**Hazard Analysis Form**

This form is to be completed by the construction subcontractor or
Fermilab Task Manager and must be accepted prior to the issuance of the
Notice to Proceed. In addition, this form is to be maintained at the
site where the work is being performed. This is a dynamic document,
which requires modifications as the project moves from start to finish.

Job Title **[Perform Survey in the Target Hall on the East and West
Walkways of the Pit Liner]{.underline}**

Contract/Change Order Number **[\_ NuMI Installation Phase\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}**

Job Location **[MI-65 Service Building]{.underline}**

Date Prepared **[January 08, 2004]{.underline}**

**[Subcontractor]{.underline}** **[Fermilab]{.underline}**

Company **[\_N/A\_\_\_\_\_ \_\_ \_ \_\_\_\_\_\_\_]{.underline}** Project
Manager **[\_\_\_\_\_ \_ \_]{.underline}**

Project Manager **[\_\_\_\_\_\_\_ \_]{.underline}** Phone

Phone **[\_\_\_\_\_\_ \_\_ \_]{.underline}** Page **[\_\_\_
\_\_\_\_\_\_\_]{.underline}** TM/CC

Superintendent **[\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_]{.underline}** Phone **[\_ \_\_]{.underline}**
Page **[\_\_\_\_\_\_\_\_ \_]{.underline}**

Phone **[\_ \_\_\_ \_]{.underline}** Page **[\_\_\_\_\_\_\_\_
\_]{.underline}** ES&H Rep. **[John P. Cassidy]{.underline}**

ESH Rep. **[\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}** Phone **[\_ \_\_\_
\_]{.underline}** Page **[\_\_\_\_\_\_\_\_]{.underline}**

Phone **[\_\_\_\_ \_\_\_\_\_\_\_]{.underline}** Page
**[\_]{.underline}** Other

**Prepared [\_\_John P. Cassidy\_]{.underline}**
**[\_\_\_\_\_\_\_\_]{.underline} Date [\_January 8,
2004\_\_]{.underline}**

**Accepted [\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}**
**[\_\_\_\_\_\_\_\_]{.underline} Date [\_\_\_ \_]{.underline}**

**Accepted as noted [\_\_\_ \_\_\_\_\_\_\_\_\_]{.underline} Date
[\_\_\_\_ ]{.underline}**

***ESH Admin Form #17 Page 1 01/2002***

**Hazard Analysis**

**Using the format below, identify hazards and safety
precautions/procedures to mitigate hazards. Use as many sheets as
necessary.**

Description of Work:

  -----------------------------------------------------------------------
  **Perform Survey in the Target Hall on the East and West Walkways of
  the Pit Liner**

  -----------------------------------------------------------------------

+-----------------------+-----------------------+-----------------------+
| **Step/Phase of Job** | **Safety Hazard**     | **Precautions/Safety  |
|                       |                       | Procedures**          |
+=======================+=======================+=======================+
| 1.  Carry survey      | Back and muscle       | Only carry what you   |
|     equipment from    | injuries.             | can without           |
|     the truck to the  |                       | overexerting          |
|     underground.      | Fall hazards when     | yourself. Use two     |
|                       | rails are removed.    | people on equipment   |
| 2.  Setting up        |                       | that is too heavy or  |
|     equipment on the  | Fall hazards          | awkward.              |
|     east and west     |                       |                       |
|     walkways.         | Muscle and back       | Set equipment up so   |
|                       | strains.              | that it minimizes the |
| 3.  Removing railing  |                       | need to remove        |
|     so survey points  |                       | railing.              |
|     can be seen.      |                       |                       |
|                       |                       | All personnel with in |
|                       |                       | six feet of the rail  |
|                       |                       | opening must use a    |
|                       |                       | body harness and      |
|                       |                       | lanyard. Retractable  |
|                       |                       | lanyards should be    |
|                       |                       | used by the Techs     |
|                       |                       | removing the railing. |
|                       |                       | The Surveys should    |
|                       |                       | use a shock-absorbing |
|                       |                       | lanyard short enough  |
|                       |                       | to keep them from     |
|                       |                       | edge of the opening.  |
|                       |                       | On the east wall      |
|                       |                       | personnel should tie  |
|                       |                       | off to the handrail   |
|                       |                       | along the wall. On    |
|                       |                       | the west side         |
|                       |                       | personnel should tie  |
|                       |                       | off to the struts     |
|                       |                       | along the wall.       |
|                       |                       |                       |
|                       |                       | Techs removing        |
|                       |                       | railing should keep   |
|                       |                       | their bodies close to |
|                       |                       | the load while        |
|                       |                       | lifting, pivot your   |
|                       |                       | feet do not twist.    |
|                       |                       | Communicate with your |
|                       |                       | partner to lift and   |
|                       |                       | move the railing at   |
|                       |                       | the same time         |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+

+-----------------------+-----------------------+-----------------------+
| **Step/Phase of Job** | **Safety Hazard**     | **Precautions/Safety  |
|                       |                       | Procedures**          |
+-----------------------+-----------------------+-----------------------+
| 4.  Surveying points  | Fall hazards          | Inspect the ladder    |
|     on the ledge of   |                       | before use to ensue   |
|     the pit liner     | Muscle and back       | there are no defects. |
|     walls with an     | strains.              | Extend the ladder far |
|     extension ladder  |                       | enough to reach the   |
|     from the bottom   |                       | top of the ledge.     |
|     of the pit liner. |                       | Make sure the pitch   |
|                       |                       | of the ladder is at a |
|                       |                       | four to one ratio.    |
|                       |                       | Hold the ladder in    |
|                       |                       | place while the       |
|                       |                       | Surveyor is making    |
|                       |                       | the survey point.     |
|                       |                       |                       |
|                       |                       | Use two people to     |
|                       |                       | move the ladder. Keep |
|                       |                       | the load close to     |
|                       |                       | your body, pivot your |
|                       |                       | feet do not twist.    |
|                       |                       | Communicate with your |
|                       |                       | partner so you are    |
|                       |                       | lifting and moving    |
|                       |                       | together.             |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+

**My supervisor has reviewed this hazard analysis with me and I
understand the hazards and required precautionary actions. I will follow
the requirements of this hazard analysis or notify my supervisor if I am
unable to do so.**

  ----------------------- ----------------------- -----------------------
  **Name (please print)** **Signature**           **Date**

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  

                                                  
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