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HIRA Form

This document is a Hazard Identification and Risk Assessment (HIRA) form used to document a HIRA that was conducted. It includes sections to record the date, location, activity, and name and number of the document being assessed. The main body is a 5x5 risk matrix table to assess job steps, associated hazards and risks, existing controls, likelihood, consequence, and overall risk rating. Risk ratings of 13 or higher require a safe work procedure to be developed. The supervisor details are recorded at the bottom. Additional resources on hazards, risk assessment and the risk matrix are referenced.

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Francois Prinsloo
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113 views3 pages

HIRA Form

This document is a Hazard Identification and Risk Assessment (HIRA) form used to document a HIRA that was conducted. It includes sections to record the date, location, activity, and name and number of the document being assessed. The main body is a 5x5 risk matrix table to assess job steps, associated hazards and risks, existing controls, likelihood, consequence, and overall risk rating. Risk ratings of 13 or higher require a safe work procedure to be developed. The supervisor details are recorded at the bottom. Additional resources on hazards, risk assessment and the risk matrix are referenced.

Uploaded by

Francois Prinsloo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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HIRA form

Department/section: ............................................................................... Time the HIRA was conducted (e.g., 22:00) ...... H ........

Date: ...................................................................................................... Location: ............................................................................................................................

Activity: ...........................................................................................................................................................................................................................................................

Name of document: ………………………………………………………… Document number: ……………………………………………………………………………


5 x 5 Matrix

Conseque ** Risk
Job step Hazard present Risk associated Controls put in place Likelihood
nce Rating

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Job step Hazard present Risk associated Controls put in place Likelihood Consequ ** Risk
ence Rating

** Develop a SWP for Risk Ratings ≥13.

Supervisor/Team Leader:

Name: ................................................................ Pr: ............................................. Signature: .................................................................... Date: .....................................


Participants:

Name:

Pr nr:

Signature:

Date:

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Consequenc
e 1 2 3 4 5
Minor Low Medium High Major
Likelihood Elimination – the hazard is eliminated to
avoid the associated risk
5 Medium Significant Significant High High
Almost Certain 11 16 20 23 25
Substitution – the activity, process
4 Medium Medium Significant High High and/or material is substituted for one
Likely that is less hazardous
7 12 17 21 24

3 Low Medium Significant Significant High Engineering and process control –


Possible 4 8 13 18 22 redesign the equipment, work process or
automated processes to prevent
2 Low Low Medium Significant Significant interaction between the hazard and
Unlikely 2 5 9 14 19 personnel and/or the environment

1 Low Low Medium Medium Significant Separation – separate the hazard by


Rare 1 3 6 10 15 enclosing or physically guarding it. This
allows for physical barriers (human put in
place and maintain) and non-human
Figure 1: 5 x 5 Matrix interaction (interlocks, etc.)

Administration – including management


strategies, procedures (e.g. isolation,
Note: temporary barricading, spill response),
‘Documents of Interest” can be located at the following location: SWPs, training, inductions, signage etc.
Palweb > SHEQ MS > 2.1 Hazard Identification and Risk Assessment (HIRA)
< Documents of Interest Personal Protective Equipment (PPE) – in
compliance with the Palabora Personal
Examples of useful documents: Protective Equipment Standard

 A “List of Generic hazards / energy sources”


 The “5x5 Risk Matrix”
Figure 2: Hierarchy of control

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