RETAIL PERMIT TO WORK SYSTEM –JOB HAZARD ANALYSIS

Date:
Will the work involve any of the activities below? (Circle any that apply)
Prepared by: If ‘YES’ a Permit must be obtained

Company: PCA Hot work in Hazardous areas Confined space entry Excavation >/= 1.2 m
Work on Flammable Gas
Retail Station Address: Inerting or Gas Freeing Live Electrical Work
Systems
Other (specify):
Asbestos Work Explosive Blasting

JHA Reference No.: ___SHELL-PCA-JHA 16-WORK AT HEIGHT USING SKYLIFT________________ JHA Review No.: _______3.0______________________
Making Predetermined JHA shall be verified and reviewed on site every day before performing the work

Description of work: __________________ Work at Height using Skylift___________________

Step
Job Step Job Step Hazard Job Step Control
No
1 Position the skylift according to  Skylift vehicle will hit others vehicle or people and  Ensure a flagman to guide the traffic flow
lifting plan causes injury  Ensure a worker to give signal to the skylift operator when the skylift vehicle is
reversing
2 Barricading operation area  Vehicle will hit into the working area  Wear reflective safety vest while barricading work area. Have personnel
control/direct traffic flow
3 Confirm site traffic flow  Skylift and workers knock by car  Flagman to control traffic flow

4 Accending skylift’s bucket  Tripping and fell will cause personal injury  Ensure skylift is in good condition before boarding up

5 Hauling of material and tools into  Worker fall from height.  Adjust bucket nearer to the work area.
the bucket  Falling objects  Wear appropriate gloves when handling smooth & slippery surface materials. Eg.
Glass, plates, etc.
 Carry and handle materials with care (and patience).
 Ensure no strong wind when handling large surface material
6 Working on skylift’s bucket  Fall from height  Adjust bucket nearer to the work area.
 Falling object  Wear appropriate gloves when handling smooth & slippery surface materials. Eg.
Glass, plates, etc etc.
 Carry and handle materials with care (and patience).
 Ensure no strong wind when handling large surface material
7 Descending skylift’s bucket  Tripping and fell will cause personal injury  Ensure the guard rail door has completely opened before stepping out
 Descend when the bucket platform is not 1 feet higher than the landing surface
 Ensure landing surface is free of tripping and spherical object

Shell Retail Permit to Work _ Version 5.0

Personal Protective Equipment (PPE) appropriate to the task at hand shall be worn/used at all times.
Tick box any PPE that applies to this job

Any additional PPE appropriate to the task :

List required equipment / tools (e.g fire extinguisher, barricading / signs , hand tools, mechanical tools, plant etc.):

The work crew acknowledges that they understand and will comply with the precautions listed above

NAME: SIGNATURE:

NAME: SIGNATURE:

NAME: SIGNATURE:

NAME: SIGNATURE:

NAME: SIGNATURE:

NAME: SIGNATURE:

Shell Retail Permit to Work _ Version 5.0