Phase Condition Risk Assessment

Pollard Wireline Safety Management System

Assessment Information

Name of Assessor(s) *

Date *

Location *

Company *

Personnel Information

Number of People at Location *

Number of People on Ice Road

Supervisor in Charge *

Names of Crew Members Involved *

Work Scope

Task/Work Scope *

Weather Conditions

Weather (Temp, Wind Speed, Visibility, Wind Chill) *

Hazards & Risk Controls

Hazards & Risks (select all that apply) *

Extreme ColdHigh WindsLow VisibilityWhiteout ConditionsIce Road ConditionsBlowing SnowFrostbite RiskHypothermia RiskEquipment MalfunctionCommunication LimitationsLimited Evacuation OptionsWildlife

Risk Controls & Mitigation Measures (select all that apply) *

Warm-up Shelter AvailableBuddy System in PlaceCold Weather PPERegular Warm-up BreaksEmergency CommunicationVehicle Staged for EvacuationMedic On-SiteWeather MonitoringWork/Rest RotationHot Beverages AvailableReduced Work ScopeAdditional Supervision

Emergency Preparedness

Evacuation Vehicle(s) ID & Driver Name(s) *

On-Site Medic Contact *

Verify Medic Has Care Capabilities *

Yes - VerifiedNo - Not VerifiedN/A

Muster Locations *

Re-Evaluation

Re-Evaluation Frequency *

Every 30 MinutesEvery HourEvery 2 HoursEvery 4 HoursAs Conditions Change

Phase Work Plans

Phase 2 Available Work (Describe)

Phase 3 Workplan (Describe)

Status & Approval

Work Suspended? *

No - Work ContinuingYes - Work SuspendedModified Work Only

Phase Management Team Approves Plan? *

Yes - ApprovedNo - Not ApprovedPending Review

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