JOB SAFETY ANALYSIS FORM

Main Activity: Plant & Location:

Date: Day1 Day2 Day3 Day4 Day5 Day6 Day7
Permit Nos. (Day 1-7)
S.No. Sub Activities Hazards Control Measures
List the tasks required to perform the (Both Existing as well as potential) List the control measures required to eliminate or
activity in the sequence they are carried out Against each task list the Hazards that could cause minimize the risk of injury arising from the identified
injury/damage to people, equipment or the environment. Hazard.

JSA Format No. 9112-000-HSE-006-00004/ Ver-2

Note ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Name & Sig. Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Issuer
Requestor
*App-1 Issuer Remarks:

*App-1 Requestor

(Note: 1. JSA to be done by issuer and acceptor of work permit. In case required, representative from other discipline can also join the team for JSA.
2. JSA to have approvals*(Managers) for Hot Jobs, confined space entry & Work on equipment in service
3. Minimum one hand written job specific information to be included every day by the issuer & requestor. In case of no additional information, write-“No
change from above” in the Remarks.
 Checklist of common Hazards
This should be used as an aid to identifying the hazards. This is the list for the most common hazards but is not a definitive list.
Mechanical/Equipment Thermal Ignition sources Electrical
Entanglement Hot surface Electricity Electric shock
Shearing Steam Static electricity Static electricity
Crushing Refrigerants Hot work Power failure
Striking Stored Energy Lightening Pressure
Cutting Falling material Sparks Release of energy
Mechanical failure (e.g by overloading) Springs under tension/compression Frictions Implosion
Chemical Counterweights Flames Compressed air
Flammable Radiations Auto ignition Steam
Toxic e.g. ionising radiations (X-rays) Pyrophoric material Hydraulics
Harmful Place of work Vehicles Process
Irritant Obstructions Fork lift Wrong material
Oxidising Access/egress Tankers Missed steps
Pyrophoric Work at height Reversing vehicles Instrument failure
Corrosive Falling objects Speed Interlocks
Dangerous to environment Slip/trip/fall People Control system failure
Dust explosions Housekeeping Unsafe behaviour Alarms
Gases Temperature Human errors Nature
Fumes Ventilation Training/competence Weather
Vapours Confined space Methods of work Winds/Storms/lightening
Dusts Hazards of other tasks being done Manual handling (lifting, carrying, pushing
Asphyxiants simultaneously. and pulling)
Stress/workload
Biological (e.g.legionella) Noise/Vibrations/Hot work