Job Safety Analysis Form

JOB SAFETY ANALYSIS FORM
Site: Civil Works -6084 Work Area: Yekepa Camp Date:

JSA Task: Registered JSA No.: Camp/01 Permit No: Camp/01
Supervisor (Is the reviewer): Signature:
Accountable Person (for the task): Signature:
Expiry Date (Valid for 7 days):
Emergency Contact No’s 0775599999
Completed By (team): Signature: Completed By (team): Signature:
Fatality Risk Management: Is a fatality risk involved in this task? ☐ Yes If yes, tick the fatality risk involved and a Fatality risk ☐ No
Evaluation Form needs to be completed by the supervisor.
Confined space Work at Height Isolation Vehicle & Driving Cranes & Rigging Rail Work Tree Felling
ww c
c c c c c
Permits Required:
☐ Working at Heights (WAH) ☐ Confined Space (CSE) ☐ Hot Works (HW) ☐ Lifting Assessment (LA)
☐ Electrical work (EW) ☐ Excavation (E) ☐ Other__________________________
Personal Protective Equipment (PPE) & Other Equipment Required: (in addition to minimum site requirements)
☐ Full Face Shield ☐ Gloves (suited to task) ☐ Static Lines ☐ Inertia Reels
☐ Dust Mask ☐ ☐ Barricading or Witches Hats ☐ Danger / Caution Tape
☐ Respiratory Masks ☐ Hearing Protection ☐ Fire Extinguisher (suited to task) ☐ Fire Blanket
☐ Welding Shields (welders) ☐ Safety Harnesses ☐ Radios ☐ Safety Signs
Revision 00 Page 1 of 9
Doc Number JSA/6084/SF/01 UNCONTROLLED DOCUMENT WHEN PRINTED
Inherent Residual Risk

Risk Rating: Rating:
Use Risk Matrix Use Risk Matrix to
Job Steps: Related Hazards: to determine Hazard Control: determine risk
Step Break into logical steps necessary to risk ranking ranking after
Those hazards associated with each step What has been put in place to reduce or eliminate the hazards
No. complete a job before controls controls in place
in place
Signature
Name
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Signature
Name
Signature
Name
JSA REVIEW AND CHANGE MANAGEMENT

This section is to be completed by the Supervisor in Table 1 – Supervisor Daily Review
control of the task and in consultation with the Team Da Supervisor Name Signature
Members performing the task. y
The Supervisor directly in control of the task must D/S N/S D/S N/S
review the original JSA and any additions with the Team 1
Members performing the task and update details when 2

conditions change. 3
4
Following the daily review, the Supervisor directly in
control of the task must complete Table 1. 5
Inherent Review
Risk Residual with work
Rating: Risk crew:
Step New/ Changed Job Steps: Use Risk Matrix Hazard Control: Rating: (Supervisor
Related Hazards: Use Risk Matrix
New/ Changed steps necessary to complete a to determine What has been put in place to reduce or eliminate signature and
No: job
Those hazards associated with each step risk ranking the hazards to determine date)
before controls risk ranking
in place after controls in
place
NOTE: Team members must sign onto the JSA again, if a change occurred during the job task, and any additional hazards were identified, and controls implemented.
Hazards
Biological & Electrical Chemical Gravity/Height Mechanical & Motion
Environmental Arc Flash Air Emissions Equipment Being Thrown Off/Under
Altitude Buried Utilities Chemical Products Tipping/Collapsing Equipment
Animal Bite/Sting Damage to Leads/Cables  Carcinogenic Excavation/Trench Disintegration of Moving
Blood-Borne Pathogens Damage to Switches  Combustible/Flammable Falling Objects Components
Contaminated Food/Water Energized Circuits/Conductors  Explosive Floor Openings/Edges Driving/Vehicle Traffic

Insect-Borne Disease Inadvertent Energization  Toxic Grating Removed Ejection of
Pests Lack of Isolation/Grounding  Corrosive Inadequate Support Workpiece/Debris
Poisonous Plants Missing/Damaged Insulation  Reactive Lack of Access Entanglement
Precipitation Overhead Lines Client/Process Chemicals Ladders/Stairs Friction
Temperature/Humidity Overload of Circuits Lack of Containment Suspended Load Movement/Shifting
Unsanitary Conditions Stored Energy Leakage/Spills Unstable/Insecure Moving Parts
Weather (Batteries/Capacitors) Material Incompatibility Materials Pinch/Crush Points
Wind/Turbulence Water Near Electrical Produced/Disturbed by Work Above/Below Projectiles
Pressure Conductors Work Others Rotating Equipment
Abrasive Blasting Work Environment  Asbestos Work at Height/Fall Sharp Edges, Corners, or
Compressed Gases Cluttered  Lead Hazard Points
High Pressure Fluid Confined Space  Silica Walking/Working Surface Shearing
Pressure Testing Damaged Tools/Equipment  Welding Fumes  Slippery Stored Energy
Pressure Entrapment  Dust  Uneven (Springs/Accumulators)
Washing/Blasting Erosion Water Discharges  Obstructed Striking
Radiation Hazardous Atmosphere Wastes Generated  Steep Trapped Between
Intense Light  Oxygen Rich/Deficient  Hazardous  Moving/Swaying/Pitching Equipment and Fixed
Lasers  Contaminants  Non-Hazardous  Insufficient/Unstable Structures
Microwaves Ignition Sources Sound Ergonomic Unexpected/Uncontrolled
Naturally Occurring Inadequate Ventilation Continuous Noise Awkward Movement
Radioactivity Radioactive Poor Lighting/Glare Intermittent Noise Postures/Movement
Material Restricted Access/Egress Extreme Noise Excessive Force/
X-Rays Runoff Impact Noise Exertion
Heavy/Awkward Load
Repetitive Motion
Same Position
Vibration
Severity x Probability = Risk Rating
The severity rating shall be based on the most likely outcome, not the most extreme. For example, someone walking along a level path could slip on a spillage and fall. Whilst
the worst possible outcome is a serious or fatal injury, this outcome is extremely rare. The most likely outcome is bruising or possible fractured arm. Therefore, a severity of 3
or 4 is appropriate, but not 5.
Severity Rating Score Probability Rating Score

There is little or no risk of injury or ill health. Only under rare and unforeseen
Minor injury, such as a slight laceration or bruising
conditions is there the likelihood of injury or ill health. This should be the aim of
requiring limited medical treatment 1 all workplace activities. 1
Injury requiring medical treatment, but unlikely to Remote possibility, if other factors were present, injury or ill health might occur,
result in absence from work
2 but the probability is low.
2
More serious injury, possibility requiring hospital Possible the incident may happen if additional factors precipitate, but is unlikely
attendance and could result in absence from work.
3 without the other factors.
3
Fracture, dislocation and attendance and possible The event is probable; the effects of humans or of other factors could cause the
attendance at hospital for treatment.
4 event (injury or ill health) but is unlikely without additional factors.
4
Serious or fatal injury 5 If the task continues, then it is certain that an injury or ill health will occur. 5
Probability Rating
1 2 3 4 5
1 1 2 3 4 5
Severity rating
2 2 4 6 8 10
3 3 6 9 12 15
4 4 8 12 16 20
5 5 10 15 20 25
The figure should reflect the overall assessment, however:-

 Values of 16 or above means that the task MUST NOT proceed. Measures shall be taken to reduce the risk rating.
 Values between 10 and 15 shall be reassessed and only after due consideration of the risks shall the task proceed.
 Values between 1 and 9 can proceed, provided that all practical measures have been taken to reduce the risk to the lowest practical level

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Job Safety Analysis Form

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JOB SAFETY ANALYSIS FORM

Site: Civil Works -6084 Work Area: Yekepa Camp Date:

Inherent Residual Risk

JSA REVIEW AND CHANGE MANAGEMENT

Members performing the task and update details when 2

Contaminated Food/Water Energized Circuits/Conductors  Explosive Floor Openings/Edges Driving/Vehicle Traffic

Severity x Probability = Risk Rating

Severity Rating Score Probability Rating Score

The figure should reflect the overall assessment, however:-

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