Job Safety Analysis (JSA) Form

Description of work
Permanent Access Platform for LOX Scaffold (Erection/dismantling/modification)
(specifically define scope of work)
Unit Name ASU AREA Equipment Number # 5
Area where work will take place JSA Number # 1
Time and Date: DD/MM/YYYY 11-JUN-2024 Permit Number #
JSA Prepared By: SHOVON AHMAD JSA Approved By:
Activity Steps Hazard(s) Potential Harm Controls/Recommended Actions In Place

Who- Drivers,
 Operators, Drivers, and all personnel must undergo
Operators, Riggers,
JIGPC prerequisite training orientation to be
and Helpers
 Vehicle collision. familiarize with rules and Company policy.
How –.
 Overloading  All skilled operators/drivers must have authorization
 Incompetent drivers,
 Speeding and skill competency for each trade category.
operators
Transportation of materials  Regular inspection for preventive maintenance of the
 Operators a n d d r i v e r s  Using of damaged
(scaffolding accessories vehicles and equipment.
n o t adhering to traffic rules. tools and equipment
and components)  Ensure trailer truck/forklift/ boom truck does not
 Roll Over  Work area without exceed the rated capacity of the equipment during
 Fire proper isolation and shifting and/or lifting.
 Slip, trip barricading.  Lifting/Rigging tools must be in good condition prior to
 Materials are not the start of activity.
properly arranged  Flagger must guide all moving equipment inside
and segregated.
process area and to oversee the blind side of the
equipment.

Who- Scaffolders  Awareness on EHS – Toolbox Talks, Manual

Scaffolding Erection and
and nearby workers Handling & Lifting
Dismantling
 Only certified and competent workers are
How - allowed to do the task.
 Substandard Tool  Using of damaged  Body system must be observed when
tools and equipment carrying/lifting of heavy loads.
 Back injury
 Tool lanyard must be available to prevent
 Fall from height.  Incompetent workers falling of hands tools to ground.
 Lack of fall protection
Form No.: JIGCC-A00-HS-FRM-05002, Rev.0
Reference Document: JIGCC-ABD-A05-HS-JSA-00003
Job Safety Analysis (JSA) Form
 Noise due to hammering of equipment
scaffolding parts.  Damaged PPE
 Scattered and  Materials must be properly arranged and in
 Struck against by
placed not obstructing the access way.
 Hand injury obstructed  Proper PPE must be available and in good
 Slip, trip, fall. walkways and condition.
 Ergonomic Hazard access.  Barricade and signages must be in place.
 Earthing must be installed to prevent static
 Electric shock  Lack of isolation electricity.
and barricading of
working area.
 Awkward body
positioning

2
3

Who- Scaffolders
and nearby workers
How -  Awareness on EHS – Toolbox Talks, Manual
 Substandard Tool  Using of damaged Handling & Lifting
 Only certified and competent workers are
 Back injury tools and equipment
allowed to do the task.
 Fall from height.  Incompetent workers  Body system must be observed when
 Noise due to hammering of  Lack of fall protection carrying/lifting of heavy loads.
 Tool lanyard must be available to prevent
scaffolding parts. equipment
Scaffolding Modification falling of hands tools to ground.
 Struck against by  Damaged PPE  Materials must be properly arranged and in
 Hand injury  Scattered and placed not obstructing the access way.
 Slip, trip, fall. obstructed  Proper PPE must be available and in good
condition.
 Ergonomic Hazard walkways and  Barricade and signage must be in place.
 Electric shock access.  Earthing must be installed to prevent static
 Lack of isolation electricity.
and barricading of
working area.
 Awkward body
positioning
Page 2 of 7
Form No.: JIGCC-A00-HS-FRM-05002, Rev.0
Reference Document: JIGCC-000-HS-PRO-05029
Job Safety Analysis (JSA) Form

2
3

 While hoisting and carrying load always at

centered and never stand directly underneath a 2
3
load.
Dropped Box / Tools / Equipment's  Required to remove all unwanted and loose
materials before lifting.
 Need to perform visual inspection before lifting
Pinch points  Lifting team should identify the pinch points.
 Adequate signal man shall be used. 2
Power Failure of Lifting Equipment, 3
 Using required PPE - Helmet, Safety Glass or
Miss communication or poor rigging
goggles, Safety Shoes, and Mechanical Hand
signals
Gloves.
Damage Rigging/Lifting gears (Chain,  Routine inspection before and after use
 Quarterly color-coding inspection process
slings, belt, eyebolt, shackles act) implemented.
 On job training.
 All Rigging/Lifting Equipment are certified.
 Pre-Use Inspection of Rigging/Lifting Equipment
performed

 Uneven ground condition,

Manholes or Unstable soil,  All Rigging/Lifting Equipment, Riggers and
operators are certified.
Underground utilities, Contact
 Pre-Use Inspection of Rigging/Lifting Equipment
with power cables or other performed 3- Pre-job Briefing 4·Prior
equipment, Unsafe working Communication Complete Area Barricading/Only
authorized person can enter.
radius, Inadequate access.
 Ensure swing area is clear for movements.
Collision of crane with
 Whenever, wherever the crane must be set up,
surrounding objects/facilities.
Who- following precautions shall be adhered to:

Page 3 of 7
Form No.: JIGCC-A00-HS-FRM-05002, Rev.0
Reference Document: JIGCC-000-HS-PRO-05029
Job Safety Analysis (JSA) Form
 Falling objects, Crane Riggers / Crane Operator
 Area verification by supervisor r to confirm no
overload, Crane overturn ing, & Surrounding people. underground utilities, unstable soil, slope, or
Rigging/ Lifting Operations (Mobile Mechanical failure, How - uneven surface.
Crane) - Lifting Operation Uncontrolled movements of
Fatality, Serious personnel  In case underground utilities, unstable soil or
lifted objects, Improper
injuries, Property damage uneven surface is identified than, following

Who – Team
How –.

 Trip, slip  Poor cable  Housekeeping must be conducted from start and
management
 Access blockage in case of end if work activity.
 Scattered Materials
Poor House keeping emergency  Lack of training and  Access must be free from any obstruction.
 Poor arrangement of tools awareness for proper  Arrangement and segregation of materials must
housekeeping
and equipment be always observed and followed

Daily Review Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Date
Reviewer
(Job Supervisor)
Approver
(Shift Supervisor / Issuer)

Note:  If there is change in the Job Scope / Steps revalidate the JSA.
 JSA must be reviewed daily by the Job Supervisor & Shift Supervisor  In case of emergency, Call for EMERGENCY 911

Task Performer Sheet

Pre-Job Meeting (Toolbox Meeting) Conducted by
Name: Position: ID Number: Signature:
□ JSA Communicated to the team.
□ Master the Basics communicated. Master the Basics
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Form No.: JIGCC-A00-HS-FRM-05002, Rev.0
Reference Document: JIGCC-000-HS-PRO-05029
Job Safety Analysis (JSA) Form
□ Be aware of your surroundings.
□ Know your physical limitations.
□ Emergency Response Discussed.
□ Use the proper PPE.
□ PPE Requirements communicated □ Follow our procedures.
□ Think, think, and think again before you act
Crew Members Sign off
 We understand the hazards & controls of the Job and agree to comply with all requirements.
Date: Date: Date:
Name ID Number Signature Name ID Number Signature Name ID Number Signature

Date: Date: Date:

Name ID Number Signature Name ID Number Signature Name ID Number Signature

Page 5 of 7
Form No.: JIGCC-A00-HS-FRM-05002, Rev.0
Reference Document: JIGCC-000-HS-PRO-05029
Job Safety Analysis (JSA) Form

Hazard Reference Sheet

This is list of Hazard is to help you on hazard recognition and it doesn’t include all possible hazards
1. Worksite / Work Environment Hazard 2. Tools & Equipment 3. Chemical 4. Physical/Mechanical
o Exposure to substances hazardous to health,
o Adverse weather condition (rain, high winds, high
o Damaged/sub-standard tools through inhalation, ingestion, absorption, or o Moving vehicle, forklift
temperature /humidity)
subcutaneous routes:
o Contact with high velocity ejected particles /
o Oxygen Deficient Atmosphere o Improper tools for the job o Welding fumes
objects. Struck-by hazard
o Contact, caught in or between machines with
o Nitrogen Rich Atmosphere o Uncertified equipment (e.g., crane, forklift) o Exhaust fumes
moving parts, due to inadequate guards.
o Equipment with moving or rotating parts e.g.,
o Inadequate lighting o Use of non-intrinsically safe equipment in classified area o Corrosive substance
grinding machine
o Inadequate ventilation o Line of Fire o Pyrophoric material o Contact with sharp blade/edge
o Cave-in/collapse of inadequately
o Pinch/Nip Point o Toxic substances o Contact with excessively hot/cold surface
shored/battered/stepped excavation
o Restricted mobility due to poor access or confined
o Use of substandard/damaged ladder o Asphyxiant o Source of ignition
space
o Excessive exposure to vibration generated by
o Slip/trip & falls hazard/Poor Housekeeping 5. Work at Height / Dropped Object 6. Pressure
equipment.
o High noise (due to job location or use of o Line breaching or potential hazardous
o Dropped objects from height o Exposure to ionizing/ultra-violet radiation
tool/equipment) material release
o Dropped object into excavation / pit or through hole
o Fire & explosion hazard o Working with equipment under pressure o Damaged cylinder
opening in floor structure.
o Incorrect pressure regulator fitted to gas
7. Ergonomic o Damaged harness o Damaged/inadequate hose
cylinder
o Manual handling of heavy objects o Improper anchorage o Objects under compression e.g., spring o Improper bonding/grounding
o Stored/residual pressure after isolation of
o Awkward/cramped posture o Substandard/damaged ladder o Damaged/uncertified lifting equipment
equipment
o Excessive force 8. Miscellaneous Hazard o Incorrect pressure regulator o Unsecured load which could move
o Repetitive motion o Lack of/inadequate procedure
o Individual roles & responsibilities regarding a job not clear /
o Fatigue
understood.
o Untrained or incompetent personnel (including vendors,
subcontractors, etc,).
o Lack of experience
o Unclear interface arrangements i.e., conflicting activities
(SIMOPS)
o Equipment trip due to safety interlock unintended
activation.

Page 6 of 7
Form No.: JIGCC-A00-HS-FRM-05002, Rev.0
Reference Document: JIGCC-000-HS-PRO-05029
Job Safety Analysis (JSA) Form
o Poor communication
o Lack of Supervision

Page 7 of 7
Form No.: JIGCC-A00-HS-FRM-05002, Rev.0
Reference Document: JIGCC-000-HS-PRO-05029