Rev Dt: 18-Jan-2017

JAD CONSTRUCTION LIMITED Revision No: A2

JOB SAFETY ANALYSIS
Document No: JAD-SMS-7F
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Job Planning
Permit Required: Yes/ No Permit No. Date:
Company Name: Dept.: LIFTBOAT, INEZ H. EYMARD
Task Location:
Task Description: FUELING DECK EQUIPMENT
Recognized Existing Hazards: LEAKS, SPILLS, SLIPS, TRIPS, FALLS
____________________________________________________________________________________________________________
Emergency Action Plan
Contact Emergency Response (describe how):
Evacuation Route:

Assembly Area: Safety Shower/Eye Wash Station Located Yes No

Communication – Job Planning – Risk Management – Job Safety Analysis (JSA)
Task Steps Potential Hazards Hazard Controls Responsible
PRE-JOB HAZARD ASSESSMENT OF WORK PERSONNEL NOT FOLLOWING ESTABLISH SITE SPECIFIC JOB
AREA. ESTABLISHED SAFETY PROCEDURE, PLANNING, DISCUSS ANY HAZARDS IN
CREW MEMBER NOT COMPETENT THE WORK AREA AND SORROUNDING
FOR THE JOB, UNFAMILIAR WITH AREAS ADJACENT TO OR IN THE
SAFE USE OF EQUIPMENT, NOT VICINITY OF THE JOB AREA, USE
AWARE OF THE DANGER OF PROPER TOOLS FOR THE JOB
PETROLEUM PRODUCTS USED, NOT
AWARE OF HAZARDOUS
SURROUNDING.
STRETCHING OUT FUEL LINE TO THE SLIPS AND TRIPS, PINCH POINTS BE SURE OF THE SURROUNDINGS
EQUIPMENT WITH EQUIPMENT ON DECK, WHEN STRETCHING OUT FUEL HOSE
STRAINS FROM STRETCHING OF ON DECK BETWEEN THE EQUIPMENT,
FUEL HOSE TO THE EQUIPMENT, SEE WHERE YOU GOING TO PASS THE
PINCH POINTS BETWEEN HOSE AND MAKE SURE THE DECK HAS
EQUIPMENT. A CLEAR WALKWAY, HAVE SOMEONE
TO HELP YOU STRETCH OUT THE HOSE
IF NEEDED, WATCH OUT FOR PINCH
POINTS BETWEEN EQUIPMENT.
FUELING UP OF EQUIPMENT OVER FILLING TANK AND CAUSING A CHECK THE FUEL LEVEL IN EQUIPMENT
SPILL, SKIN AND EYE CONTACT WITH TANK BEFORE FILLING IT; MONITOR
FUEL HOSE BURSTING AND THE FUEL LEVEL IN TANK WHILE
CAUSING SPILLS, TRIPPING ON FUEL FUELING TO MAKE SURE NOT TO OVER
HOSE FILL CAUSING A SPILL. MAKE SURE ALL
VALVES ON FUEL LINE ARE OPEN SO
NOT TO CAUSE BUILDUP OF PRESSURE
CAUSING HOSE TO BURST. MAINTAIN
GOOD COMMUNICATION BETWEEN THE
PERSON AT THE EQUIPMENT AND THE
PERSON AT THE START BUTTON FOR
THE FUEL PUMP. HAVE ABSORBENT
PADS AND RAGS READY IN CASE
THERE IS A SPILL. READ SDS ON
DIESEL IN CASE FUEL GETS IN EYES OR
ON SKIN, SECURE THE HOSE SO IT WILL
NOT FALL. WATCH YOUR STEP AROUND
THE EQUIPMENT.
ROLLING OF FUEL HOSE BACK ON IT’S RACK SLIPS FROM SLIPPERY SURFACE ON CLEAN UP ANY DIESEL THAT IF IT IS
AFTER FUELING EQUIPMENT DECK, ENVIRONMENTAL CONCERN SPILLED, DISPOSE OF THE PADS OR
FROM ANY FUEL THAT MAY HAVE RAGS IN A PROPER ENVIRONMENTAL
BEEN SPILLED, STRAINS FROM DRUM, WATCH YOUR FOOT
CARRYING AND ROLLING UP OF PLACEMENT BETWEEN EQUIPMENT,
HOSE. USE PROPER MANUAL LIFTING
TECHNIQUES WHEN HANDLING HOSE,
MAKE SURE ALL VALVES ON FUEL
HOSE AND LINES ARE CLOSED, CHECK
AND DOUBLE CHECK VALVES AND BE
SURE NO FUEL IS ON DECK.
 Page 2 of 2

Hazard Recognition – Hazard Considerations – Use Hazard ID Tool

Physical Hazards Physical Hazards Health Hazards
Arcing / Sparking Equipment Pinching & Crushing Airborne Particles - Task / Work Created
Electricity - Close Proximity Pressurized Systems & Equipment Chemical - Liquid / Vapor
Electricity, Loss Of Radiation - X-Ray Contaminated Soil or Water
Entanglement Sharp / Jagged Objects Fatigue
Falling Objects Slipping / Tripping Potential Fumes
Fall Potential - Same / Different Level Structural - Surface Openings Noise - Excessive: 85dB +
Fire / Explosion Tight / Close Work Quarters Oxygen Deficient Atmosphere
Flying Debris Vibration - Excessive Temperature - Extreme Heat / Cold
Heavy / Bulky Material Water - Drowning / Hypothermia UV Rays - Eyes / Skin
High Voltage Other: Other:
Hot / Cold Surfaces Environmental Hazards (Air/Soil/Water)
Lighting - Inadequate Chemical Spills / Releases
Moving Hazards Waste Water
Other: Other:
Job Planning
Standard Equipment Requirements Special Equipment / Tools Support Craft – Third Party
______________________________________ ______________________________________ ______________________________________
______________________________________ ______________________________________ ______________________________________
______________________________________ ______________________________________ ______________________________________
______________________________________ ______________________________________ ______________________________________
Example: Back Hoe; Dozer; Crane; Fork-Lift; Example: Radios; Test Meter; Special Tools; Example: Equipment; Vender; Laborers;
Truck; Compressor; Welding Mach; Compactor Gas Detector; Self Contained Breathing App. Special Hole Drilling; Testing Company
Risk Management
Safe Work Practices Basic Safeguards PPE Required
Work Permit Required Arc Shields Fire Resistant Clothing
Confined Space Entry Barricades Arc Suit
Crane Lift Study-Critical Lift Crane Suspended Work Platforms Chemical Resistant Clothing
Electrical - Close Proximity Fire Extinguishers Located Eye & Face Protection
Excavations - Shoring/Sloping/Benching Fire Watch / Flagman Fall Protection
Hot Taps Hole Covers Foot Wear
Line Breaking / Equipment Opening Hole Watch Hand Protection
Lock-Out / Tag-Out Housekeeping Head Protection
MSDS & Labeling Lighting - Additional Needed Hearing Protection
Other: Post Warning Signs Respirator
Scaffolding Weather Resistant Clothing
Tools / Equipment in Good Condition Other:
Ventilation / Exhaust Systems
Other:
Communication
Stop Work Conditions
● Adjacent Work Hazards ● Chemical Spills/Releases ● Excessive Noise ● Fires & Explosions ● Civil Disturbance
● Change in Conditions ● Evacuation ● Gas Release ● Violent Weather ● Unusual Odors ● Incident
Task Performer Comments:

I acknowledge receiving and understanding these instructions, I will fully comply with the assigned task requirements:
Name Signature. Name Signature
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________

Supervisor Name (print): Signature: _____________________________

Job Monitored by Manager/Supervisor (initial): ______ ______ ______ ______ ______ ______
(Foreman will ensure completed JSA forms are given to the appropriate Supervisor at shift end)
END OF JOB: Supervisor ensures unnecessary barricades are taken down, scrap/waste placed in proper bin, and excess materials
returned to storage or properly stacked and barricaded. Submit copy to Mate.