Job Safety Analysis (JSA) Form

Description of work
(specifically define scope of work)
Loading and Unloading using Forklift

Unit Name A61- UTILITY-1 Equipment Number #

Area where work will take place COLLECTION BASIN JSA Number #
Time and Date: DD/MM/YYYY 27-12-2024 Permit Number #
JSA Prepared By: Allan Siason JSA Approved By:
Activity Steps Hazard(s) Potential Harm Controls/Recommended Actions In Place
Being in the Area
Loading and Unloading using  Uninspected/ unapproved Severe Personnel Injury  Only certified equipment fork lift operator shall
Forklift equipment/vehicle used Damage to the property operate the equipment.
 Unlicensed/ incompetent
 No other personnel shall ride along the forklift
driver/operator
during operation.
 Unsecured/Uneven/
 Practice operation of fork lift is strictly prohibited,
Unstable Materials/Loads
 Falling materials/loads anyone found performing such act will be
 Mechanical Failure removed from the site immediately
 Traffic jam  Area of operation shall be barricaded (storage
 Equipment Stuck in the area and site location) with proper signage’s
loose soil and unsafe  Equipment shall have all its auxiliary alarm in
surface. Parking at non good working condition.
designated area  Daily pre- check shall be conducted by competent
 Uncontrolled Road closure
operator
 Vehicle collision
 Trained and competent flagman shall be assign
 Un-authorized equipment during transport operation to guide operator from
operation both traffic and pedestrians/ workers.
 Struck by moving  Forklift shall be rated based on the load that will
equipment be lifted, SWL shall be clearly posted on the
 Equipment Tipping over forklift to determine its safe operational limit.
 Collision with other moving  Maintain a slow speed while operating the forklift,
equipment never rush to finished the activity.
 Drive slowly during sharp bend.

Form No.: JIGCC-A00-HS-FRM-05002, Rev.0

Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
 Forklift to be parked in designated parking area
when not in use, apply brake and always remove
the key to prevent un-authorized use.
 Always stay clear from the working radius of the
fork lift as necessary.
 Line of fire training shall be provided to all involve
personnel.
Working under extreme conditions  Heat Stress, Personnel Injury  Heat stress related training shall be given to
i.e. Under direct Sun light, sand  Heat stroke, worker highlighting conditions and symptoms.
storm  Heat Exhaustion,  Ensure proper rest period & Drink plenty of
Dehydration water Stress management plan shall be
 Fatigue discussed among the crew by the supervisor.
 Poor visibility  Oral Re-Hydration Salts to be available in the
clinic.
 A proper drinking water station shall be
provided at the site with cold water.
 Proper rest shelters shall be provided to
workers.
 All workers should have an emergency
contact number and should be displayed at
site.
 All workers shall know about flag system and
shall be displayed in visible area.
 Workers should be properly monitored for
their health conditions and hydration.
 The construction team shall monitor the
weather conditions and suspend work when
wind speeds more than the maximum safe
working speeds are anticipated.
 All the workers must be trained and aware
through proper training, campaigns and daily
toolbox talk awareness.
 Workers shall be daily educated on their diet
as well in daily toolbox talk specially in hot
weather conditions.
 Breaks should be followed while heat index is

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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
high.
 Buddy system shall be implemented; no one
shall be allowed to work alone.
 Driving shall not be allowed during sandstorm
& zero visibility conditions.
Emergency preparedness  Missing Plan/Procedure Personnel Harm  Approved Emergency Response Plan A
 Unidentified potential Damaged to liaising to JIGPC Emergency procedures p
emergencies Assets/facilities shall be in place and communicated to all
p
 Lack of the employees.
awareness/communication  Potential Emergencies shall be identified r
 Poor Planning as per the scope of work. o
 Ensure that proper safe means of access/ v
egress are available separately for equipment e
and workforce. d
 Ensure adequate and appropriate signage’s
in the location.
 Ensure the trained flagman available for E
controlling the movement of vehicles and m
equipment around the working area. e
 Ensure that only the competent and r
trained personnel are working. g
 All employees must ensure to follow the
e
emergency alarm of the client.
 Report any accident or incident at the site n
using JIGPC emergency contact number c
 Site supervisors and safety officers must y
give information regarding emergency
evacuations in toolbox talk. R
 Follow all the JIGPC-JIGCC-000-HS-PRO-
e
06002 “Emergency response & reporting
requirements / procedures.” s
 Ensure to check the wind sack direction p
when going to assembly point area. Always o
do opposite Direction of the wind sack in n
case gas leak s
e

P
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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
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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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
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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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
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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
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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
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Reference Document: JIGCC-000-HS-PRO-05029

Job Safety Analysis (JSA) Form
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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
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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
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Reference Document: JIGCC-000-HS-PRO-05029

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Form No.: JIGCC-A00-HS-FRM-05002, Rev.0

Reference Document: JIGCC-000-HS-PRO-05029

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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
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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
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Daily Review Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Date
Reviewer
(Job Supervisor)
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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
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

□ Master the Basics communicated. □ 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

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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
Date: Date: Date:
Name ID Number Signature Name ID Number Signature Name ID Number Signature

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
o Oxygen Deficient Atmosphere o Improper tools for the job o Welding fumes
particles / objects. Struck-by hazard
o Contact, caught in or between machines
o Nitrogen Rich Atmosphere o Uncertified equipment (e.g., crane, forklift) o Exhaust fumes with moving parts, due to inadequate
guards.
o Equipment with moving or rotating parts
o Inadequate lighting o Use of non-intrinsically safe equipment in classified area o Corrosive substance
e.g., 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
o Slip/trip & falls hazard/Poor Housekeeping 5. Work at Height / Dropped Object 6. Pressure
generated by 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

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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
o Dropped object into excavation / pit or through hole opening
o Fire & explosion hazard o Working with equipment under pressure o Damaged cylinder
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.
o Poor communication
o Lack of Supervision

Page 26 of 26
Form No.: JIGCC-A00-HS-FRM-05002, Rev.0

Reference Document: JIGCC-000-HS-PRO-05029