Layer of Protection Analysis Risk Assessment Checklist Form
Complete this checklist to review a process scenario, evaluate its initiating causes and protection layers, and record the final risk judgment and follow-up actions.
Assessment Details
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility / Site / Unit
*
Process / Operation / Scenario
*
Assessor / Owner Name or Team
*
LOPA Risk Review
Brief Process Description
*
Hazardous Event / Top Event
*
Initiating Cause(s) / Scenario Trigger
*
Severity of Consequence
*
1
2
3
4
5
Likelihood / Frequency of Initiating Event
*
Rare
1
2
3
4
Frequent
5
1 is Rare, 5 is Frequent
Existing Independent Protection Layers (Number/Types)
Risk Outcome and Action
Overall Residual Risk Judgment
*
Acceptable
Tolerable with Action
Not Acceptable
Required Action Recommendation / Corrective Action Summary
*
Responsible Follow-Up Owner or Department
*
Target Completion Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: