Operation's Procedure Variance Form
Established policies, procedures and operating practices cannot be written or implemented to address all situations. It is therefore necessary to originate a method of authorized deviation from policy, procedure, or practice to assure job execution in a fashion that achieves the high level of safety desired by all. This form is intended to document variances and to insure that “equivalent or greater” job safety is maintained in every case. Variances must not be interpreted in a general sense; rather they shall apply to the specific job in question. Past approvals do not guarantee a repeat approval.In all cases, the person requesting consideration of the variance shall bring it to the attention of his supervisor. The requester is responsible for completing this form in sufficient detail to adequately describe the variance desired. All variances will be approved by (1) Management, (2) Corporate Safety and (3) Customer Management, if the customer’s safety program is involved. Safety Variances take time to review and approve and must be used as a pre-planning process when possible. Work is not to begin until the variance has been approved.
Supervisor Requesting the Variance
Date of Request
-
Month
-
Day
Year
Date
Date Approval Needed for the Variance
-
Month
-
Day
Year
Date
SES Region requesting the variance
Please Select
East
West
North
South
R1 Prod Dest
R1 Waste & Recycle
Other
Other Region requesting the variance
Branch requesting the variance
Please Select
Appleton
Ashville
Chicago
Chillicothe
Cincinnati
Dayton
Dearborn
Decatur
Delta
Dundee
EMR
Hoosier
Indianapolis
Loudon
Loudon EMR
Louisville
Miami Fort
Middletown
Monroe
Moscow
NAS
Owensboro
Peoria
ES - Bellefontaine
ES - California
ES - Cincinnati
ES - Covington
ES - North Carolina
ES - Raymond
ES - Tennessee
Tate & Lyle - Decatur
Tate & Lyle - Lafayette
Tate & Lyle - Loudon
Three Rivers
Toledo
Travel Team
Waterloo
Other
Other Branch requesting the variance
Client location
Phone Number of Supervisor requesting the variance
Please enter a valid phone number.
Description of equipment needing to be cleaned
(Ex: Evap, Pipes, etc...)
Job Type
Please Select
Flex Lancing
Floor Drain Cleaning
Line Mole
Rigid Lancing
Other
Other Job Type
Equipment to be cleaned
Please Select
1"-8" Pipe
8"-24" Pipe
Evap/Exchanger Tube bundles
Hose type
Please Select
15K: 3/2 = 1/16" NPT
15K: 4/2 = 1/16" NPT
15K: 5/2 = 1/8" NPT
15K: 6/2 = 1/4" NPT
15K: 8/2 = 3/8" NPT
15K: 13/2 = 1/2" NPT
20K: 4/2 = 9/16" MPT
20K: 5/4 = 9/16" MPT
20K: 6/4 = 9/16" MPT
20K: 8/4 = 3/4" MPT
20K: 13/4 = 1" MPT
20K: 20/6 = 1 5/16" MPT
Tooling type
Please Select
Badger
Banshee
Beetle
Button tip
BJV
Gopher
Orbital
Raptor
Other
Other tooling type
Explain Why The Variance Is Necessary?
Potential Automated Solutions
Potential Automated Solutions
Application Tool 1"-8" pipes Pro Drive
Potential Automated Solutions
Application Tool 8"-24" Pipe Pro Drive 8"-24" Pipe ABX 500 (Autobox)
Potential Automated Solutions
Application Tool Floor drain/small bore pipe Pro Drive Floor drain/small bore pipe Navigator
Potential Automated Solutions
Application Tool Rigid Lance Pro Drive Rigid Lance StoneAge Stiff Lance
Potential Automated Solutions
Application Tool Evap/Exchanger Pro Drive/ Pro Positioner Evap/Exchanger ABX2L
Explain why the designated automated solution cannot be used
Controls to be used to reduce risk (Check all that apply)
All components rated for pump MAWP
Anti-Withdrawal Devices (AWD) Secured
Cut Cards on hand with operator
Cut Suit/Turtle Suit to be used
Rated hose shroud over connection between rigid and flex lance
Lance supports used with rigid lance
Trained/Experienced Operator
Whip checks in place
Stinger used (length at least diameter of piping)
Metal metatarsal and shin guards used
Lance operator controlling own foot pedal
Safety Observer being used
Specific Written procedure in place
Grounding of system
List additional steps to minimize the risk
Submit
Should be Empty: