Job Safety Analysis Worksheet

Project Information
Project Name: Date:
Project Location: Work Area:
Permit(s) Required Y/N: Permits Attached Y/N
Adjacent Work Y/N
See Permit Checklist Link to Permit List
JSA Type
Operations: New:
Transport: Revised:
Office: Other:
Construction:
Remediation:
Work Type: Work Activity:
Equipment Checklist
Goggles: Lifeline/Body Harness: Supplied Respirator: Gloves:
Face Shield: Hearing Protection: Air Purifying Respirator: Other:
Safety Glasses: Hard Hat: Welding / Pipe Clothing: Other:
Safety Shoes: Welding Mask / Goggles: Life Vest: Other:
See Equipment Checklist Link to Equipment List Modify equipment list as needed
Job Steps Potential Hazard Hazard Mitgation Steps Required Tools / Material for Safe Work
Link to Hazard Checklist
Equipment Mob Setup Slips, Trips Secure area from trip hazards
Rebar puncture hazard Mark locations of rebar
Pinch Point Pinch point from equpment
Blind spots on equipment Maintain visual contact with operation
Excavation Swing / hit hazard Maintain safe distance from bucket
Pinch points Maintain clearance from equipment and drums
Chemical hazards Vapor and odor monitoring maintained as per workplan
High noise Hearing protection.
Trackhoe stability Maintain rig on stable ground
Utilities Utility clearance OK
Vehicle traffic Maintain 10 MPH on all roads. Tire puncture hazard.
Hole collapse Maintain exclusion zone distance for work area
IDW handling Splatter from handling waste. Control splatter TEP
Bucket sampling Operate in visual contact with operator
Hole stability clearing debris Maintain safe WD with backhoe for clearing hole
Stockpile monitoring Stop excavation, maintain contact with operator
Foam Application Compressed air lines Secure lines from compressor
Spray hazard from foam Maintain spray away from personnel.
High noise Hearing protection.
Hazards of waste loading Maintain distance from equipment while loading waste
Environmental Control Limit waste generation as low as reasonably achievable
Team Member Signatures
Supervisor Signature: Date:
Instructions: Write the name of the job or task in the space provided.
Conduct a walk-through survey of the work area
Write work steps in a safe sequence
List all possible hazards in each step including possibility for failure
In the Hazard Mitigation Checklist (page 2) provide actions taken to keep the hazard from resulting in accident or injury
List tools and additional equipment needed for safe work.
Have teammembers sign in spaces provided
Review Task Analysis for changes and improvements
Stop Work and complete new safety analysis if conditions change or deficient safety observation is noted.
Permit Checklist Potential Hazard List
Utility clearance obtained Appearance neat & orderly o Passageway & walkways clear o Wash station available o
Soil excavation Regular removal of trash o Portable toilets maintained o
Critical lift Inspect for Hazards o Hazards marked o
Request for shutdown Work zone free of debris o Cords secured o
Hot work List potential pinch points o Hand, body position o Additional information below o
Confined space entry Working near equipment o
Concrete scructure penetration Safety glasses o Goggles o Other information below o
Boom assembly, breakdown, proximity Face shield o Eye wash station available o
Scaffold Erection plan Proper extinguishers and number o Safety cans for gas/diesel o Smoke detectors in buildings o
Steel erection/decking/flooring/grating checklist Extinguishers inspected & visible o Smoking area assigned o
Hoisting & rigging safety review Potential for contact, inh, injest o Identified proper PPE o
Electrically hazardous work Identified chemicals o Identified proper monitoring o
Pneumatic test Sharp tools, materials, equip o Safety equipment o
Radiation work permit PPE, gloves, guards in place o
Ear plugs o Monitoring equipment o
Ear muffs o
Required PPE Reviewed proper lifting o Hand protection required o
Hard hat Weight for mechanical lifting o
Ear protection H/C Temperature monitoring o Cool-down / warm-up period o Additional information below o
Eye Protection Review heat/cold symptoms o Break area / fluids available o
Safety glasses Animal, insect hazards o Poison plants o o
Face shield Snake chaps required o Lightning / weather o
Chemical goggles Bloodborne pathogens o Sewage or medical waste o Disease causing pathogens o
Welding hood Mold, fungus, spores o Animal / human waste / carcasses o
Hand Protection Traffic cones & signs o Flagmen o Additional information below o
Cut resistant gloves Communication with operator o Lane closure o
Welding gloves First-Aid Kit o Emerg nbrs / directions posted o Rally point identified o
Rubber gloves Hospital / clinic secured o FA/CPR Competent person o Additional information below o
Electrical insulated gloves Spill plan in place o Fuel and chem tanks bermed o Additional information below o
Arm sleves Booms and absorbent o ESD identified o
Foot Protection Gates and fences secure o Security devices and alarms o Chemicals locked and secure o
Safety shoes Security services secured o Locks and chains o
Rubber boots One call performed o Subsurface survey complete o Reviewed as-builts o
Boot covers Dig permit received o Safe zone marked o
Dielectric footware Permit required o Confirm de-energized o Down electrical lines o
Fall protection Lockout - Tagout o Review safety procedures o
Harness Safe use reviewed o Guards OK o
Double lanyard required GFCI in use o Additional information below o
Anchorage point available Understand machine process o Training and working procedures o Guards in place o
Respiratory Protection Identify and mark hazards o Emergency shut off identified o Additional information below o
Dust maks Equipment in good order o Hazards identified o Ground stable / level o
Air purifying respirator Safety equipment in place o Support equipment ready o Additional information below o
Supplied air respiator Safety harness o Warning signs required o Lanyards required o
SCBA Rigid railing required o Barricade tape o
Emergency escape respirator De-energization required o Wire watcher required o Additional information below o
Protective Clothing ____(ft) Clearance distance o Safe zone marked o
Coveralls Inspect for general conditions o Tags in place o Guard rails and toe boards o
Tyvek Proper placement / angle / tieoff o Footing sound and level o Additional information below o
Nomex Lifting equipment inspected o Personnel clear of overhead load o Work area barricaded o
Rainsuit Tag lines in use o Signalman assigned o
Acid suit Permits in place o Proper sloping / shoring o Inspected prior to entry o
Confined Space Barricades o Protection from water o Access / egress provided o
Atmosphere Monitoring Personal floatation devices o Liferafts / lifeboat available o Additional information below o
Rescue Equipment Safety / lifelines o
Rescue Service Permit in place o Safety watch in place o Hazards marked and barricaded o
Monitoring Equipment LEL / O2 meters o Rescue in place o Additional information below o
PID/FID Permits in place o Flammable debris removed o Hot areas / items identified o
O2/LEL Fire extinguishers o Fire watch o Proper PPE identified o
IH sampling Work permit in place o Survey / monitoring instruments o Additional information below o
Respirable dust Isotopes identified o Dosimetry required o
Forms and Documents
Training records
Worker certifications and medical clearance
Written programs
Hazard assessments
Required OSHA postings, fact sheets, guides
Right to Know - MSDS - Hazcom - Prop 65 (CA)
OSHA Tracking and compliance forms
DAILY TASK ANALYSIS WORKSHEET
o Hot Work / Welding
o Radiation
o Work Over/Near Water
o Confined Space Entry and Floor / Wall Openings
Housekeeping
Additional Information
Roadway / Traffic / Heavy Equipment o
o Electrical Hazards / Pressurized Lines
o Machines & Rotating Equipment
o
Spill Control and Containment
Site Security
o
o
o
o
Hazard Mitigation Checklist
Slips/Trips/Falls
Chemical Hazards
Medical Emergency
Manual Lifting
o
o
o
o
o
o
o
o
o
Pinch Points
Biological Hazards
Eye Hazards (i.e. projectiles, dust, gas)
Noise
Natural Hazards
Fire Hazards
o
o
Scaffolds & Ladders
Hand/Power Tools
Hand / Foot Hazards
Overhead Hazards
Heat/Cold Stress
Overhead Work
Drilling and boring
o Crane and Lifting Equipment
o Excavation/Trenching Activities
o
o
o
o
o
Underground Utilities
Project:
Task Location :
Task Description:
Observed by:
(1) ASSESS the risk.
What could go wrong?
What is the worst thing that can happen if something goes wrong?
(2) ANALYZE how to reduce the risk.
Is all necessary training and knowledge available to perform work safely?
Is all proper safety equipment, tools and PPE available?
(3) ACT to ensure safe operations.
Take necessary action to ensure the job is done safely.
Follow written procedures. Ask for assistance if necessary.
Cab cleanlieness Exiting cab
Window cleanliness Turning / cornering
Sounding horn Safe speed
Looking in reverse Dumping / lowering bed
Actions when approached Bucket actions
Seatbelt use Comm and eye contact
Follow pertinent procedures Material handling / locding
Proper PPE Follow pertinent procedures
Proper tool Awareness of equipment
Proper use of tools Housekeeping practices
Undersanding task
Working surfaces
Activities planned adequately Pre-task inspection
Crew prepared / briefed / trained Permits obtained as required
Hazards controls adequate Traffic controls / signs / route
Behavior Based Safety Observations
Safety Assessment Checklist
Risk Severity Scale
Additional Hazards / Observations
Safe = 1 2 3 4 5 = At Risk
Rate each observation below for risk potential (1 to 5) 0 = not applicable
Operators
Field Crew and Labor
Supervisors and Managers
Explanation of At-Risk Behaviors
Explanation of Good Behaviors
Corective Actions
Date:
Duration Observed:
Proper PPE
Working on slopes
Awareness of surroundings
Walkaround / inspections
Turn signal use
Qualified on equipment
Distractions
Approaching equipment
Grasping / handling
Balance / body position
Lifting
Task simple by design
Adequate safety administration
Ergonomics
Behavior Based Safety Observations
Safety Assessment Checklist
Risk Severity Scale
Additional Hazards / Observations
Safe = 1 2 3 4 5 = At Risk
Rate each observation below for risk potential (1 to 5) 0 = not applicable
Operators
Field Crew and Labor
Supervisors and Managers
Explanation of At-Risk Behaviors
Explanation of Good Behaviors
Corective Actions
Safety Prevention Checklist (Daily Completion by Supervisor) Supervisor:
Contractor
Number of Employees for the
day:
Site:______________________________________________
Frequency Saturday, May 17, 2014
Ensure Project Safety Plan is in place Daily y
Understand Scope of Work Daily y
Identify all hazards Daily y
Complete all required permits Daily y
Ensure crew is properly trained Daily y
Communicate hazards to all crew members Daily y
Ensure any required hazardous energy control Daily y
Ensure equipment is available and in proper working order Daily y
Hold morning safety meeting Daily y
Ensure staffing is adequate Daily y
Ensure other employers are informed of potentially hazardous activities that might affect them Daily y
Ensure locator services have been contacted to identify any underground obstructions Daily y
Supervisor's Daily Safety Prevention Score: 0
Employee's Daily Safety Card Date
Card Holder:
Company:
Supervisor:
Do you understand the Project Safety Plan? (y/n)
Do you know the Scope of Work? (y/n)
Have you identified all hazards? (y/n)
Are all work permits completed for your work?
Are you properly trained for safety?
Do you know all the potential hazards around you?
Is hazardous energy control complete?
Is your equipment available and working properly?
Did you attend the morning safety meeting?
Do you have sufficient co-worker assistance?
Have you informed employees of your potentially hazardous work?
Have locator services been informed of your underground work?
Employee's Daily Safety Card
Card Holder:
Supervisor:
Contractor:
Do you understand the Project Safety Plan? (y/n)
Do you know the Scope of Work? (y/n)
Have you identified all hazards? (y/n)
Are all work permits completed for your work?
Are you properly trained for safety?
Do you know all the potential hazards around you?
Is hazardous energy control complete?
Is your equipment available and working properly?
Did you attend the morning safety meeting?
Do you have sufficient co-worker assistance?
Have you informed employees of your potentially hazardous work?
Have locator services been informed of your underground work?
Employee's Daily Safety Card
Card Holder:
Supervisor:
Contractor:
Do you understand the Project Safety Plan? (y/n)
Do you know the Scope of Work? (y/n)
Have you identified all hazards? (y/n)
Are all work permits completed for your work?
Are you properly trained for safety?
Do you know all the potential hazards around you?
Is hazardous energy control complete?
Is your equipment available and working properly?
Did you attend the morning safety meeting?
Do you have sufficient co-worker assistance?
Have you informed employees of your potentially hazardous work?
Have locator services been informed of your underground work?
No. Contractor List
Employees Company
1
2
3
4
5
Add additional lines as needed. Link to individual sheets for summary tabulation by contractor.
Company Acronym Title Supervisor
Date Hours Worked
Injury Reports 2005
Case No. Injured Company Date of Injury
Nature of Injury Severity Days of Work Missed
Responsible Manager
Injury Report for:
Company Name:
Supervisor:
Site:
Case No.#:
Injury Date:
Nature of Injury:
Severity:
Treating Clinic:
Hospital Physicians Contact Information:
Days of Work Missed:
Location of Injury:
Specific Work Being Performed at Occurrence:
Nature of Supervision at Accident:
Causal Factors (Events and conditions that
contributed to the accident):
Corrective Actions (Actions that have or will be
taken to address the hazard and prevent
reoccurrence):
Prepared By:
Title:
Date:
Signature:
Responsible Manager:
Title:
Date:
Signature:
Safety Statistics 2005
Site Name
Contractor____________
Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids Cases
Reportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event
Contractor____________
Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids Cases
Reportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event
Contractor____________
Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids Cases
Reportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event
Contractor____________
Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids Cases
Reportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event
Contractor____________
Category Jan Feb March April May
Contractor Days Away From Work Rate 2005
Contractor OSHA Recordable Rate 2005
Total Contractor On-Site work hours
Total Sub Contractor On-Site work hours
Total Contractor Off-Site work hours
Number of OSHA Recordable Incidents for Contractor
Number of Days Away from Work (DAWF) for Contractor
Number of OSHA Recordable Incidents for Subcontractors
Number of Days Away from Work (DAWF) for SubContractor
Fatalities
First Aids Cases
Reportable Spills
Fires
Motor Vehicle Accidents (MVA)
Notice of Violations (NOV)
Media Coverage
Repetitive Stress Injury (RSI)
Third Party Liability Event

June July Aug Sept Oct Nov Dec Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
June July Aug Sept Oct Nov Dec Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
June July Aug Sept Oct Nov Dec Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
June July Aug Sept Oct Nov Dec Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
June July Aug Sept Oct Nov Dec Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0