Rev Dt: 18-Jan-2017
JAD CONSTRUCTION LIMITED
Permit Required: Yes/No
Company Name:
Task Location:
Task Description: SERVICING
Recognized Existing Hazards: ACCIDENTAL START UP – TOOLS AND EQUIPMENT DAMAGE – SPILLS – EYE & HAND
INJURY
Contact Emergency Response (describe how):
Evacuation Route:
Assembly Area:
Communication – Job Planning – Risk Management – Job Safety Analysis (JSA)
Task Steps
INSPECT TOOLS & EQUIPMENT
ENERGY ISOLATION
DRAIN OIL FROM SUMP
REMOVE OLD FILTERS AND INSTALL
NEW FILTERS
FILL LUBE OIL TO PROPER LEVELS
TEST RUN ENGINE
PICK UP ALL TOOPS AND EQUIPMENT
USE TO COMPLETE THE JOB
Revision No:
JOB SAFETY ANALYSIS
Job Planning
Permit No.
Dept.:
OF ENGINES / SCHEDULED MAINTENACE
Emergency Action Plan
Potential Hazards
DAMAGED TOOLS AND
EQUIPMENT CAN CAUSE
FURTHURE INJURY TO
PERSONNEL
ACCIDENTAL START UP –
INJURY TO PERSONNEL AND
DAMAGE TO ENGINE
SPILLAGE OF OIL
SPILLS, FILTER DAMAGE,
FUTURE SEAL FAILURES
SPILLS, SLIPS, TRIPS, AND
FALLS, OVER FILLING & UNDER
FILLING OF LUBE OIL
NOISE AND MOVING PARTS,
FILTER LEAKAGE, AIRLOCK
ENGINE, OR LOCK UP IN FROM
LACK OF OIL
DAMAGED TO OR LOST TOOLS,
SPILLS & TRIPS,
ENVIROMENTAL HAZARDS
A2
Document No: JAD-SMS-7F
Page 1 of 2
Date:
LIFTBOAT, INEZ H. EYMARD
Safety Shower/Eye Wash Station Located Yes No
Hazard Controls Responsible
REMOVE DEFECTIVE TOOLS &
INSURE PROPER TOOLS FOR JOB
ARE USED
REMOVE START KEY, CLOSE AIR,
OIL & FUEL VLAVES, INFORM ALL
INVOLVED PERSONNEL
DRAIN OIL INTO CONTAINER AND
DISPOSE INTO WASTE OIL TANK
USE OIL CATCH PAN, INSTALL AS
PER INSTRUCTIONS, LUBE
GASKETS, TIGHTEN WITH
APPROPRIATE TOOL
EYES ON TASK, CHECK THE
LEVEL OF OIL WITH DIPSTICK
FILL OIL TO PROPER LEVEL,
ENSURE ALL VALVES ARE OPEN,
USE EAR PROTECTION, RUN FOR
15 MINUTES TO OBSERVE FOR
LEAKS, INSURE PLUG NOT
LEAKING AS WELL AS FILTERS
INSURE PROPER FILTER
DISPOSAL, CLEAN AND PUT AWAY
TOOLS AND EQUIPMENT, GOOD
HOUSEKEPPING
 Page 2 of 2

Hazard Recognition – Hazard Considerations – Use Hazard ID Tool

Physical Hazards Physical Hazards Health Hazards
Arcing / Sparking Equipment Pinching & Crushing Airborne Particles - Task / Work Created
Electricity - Close Proximity Pressurized Systems & Equipment Chemical - Liquid / Vapor
Electricity, Loss Of Radiation - X-Ray Contaminated Soil or Water
Entanglement Sharp / Jagged Objects Fatigue
Falling Objects Slipping / Tripping Potential Fumes
Fall Potential - Same / Different Level Structural - Surface Openings Noise - Excessive: 85dB +
Fire / Explosion Tight / Close Work Quarters Oxygen Deficient Atmosphere
Flying Debris Vibration - Excessive Temperature - Extreme Heat / Cold
Heavy / Bulky Material Water - Drowning / Hypothermia UV Rays - Eyes / Skin
High Voltage Other: Other:
Hot / Cold Surfaces Environmental Hazards (Air/Soil/Water)
Lighting - Inadequate Chemical Spills / Releases
Moving Hazards Waste Water
Other: Other:
Job Planning
Standard Equipment Requirements Special Equipment / Tools Support Craft – Third Party
FILTER BELT, ½” SPANNER, ______________________________________
_____________________________________ ADJUSTABLE SPANNER, CATCH PANS ______________________________________
____________________________________ ______________________________________ ______________________________________
______________________________________ ______________________________________ ______________________________________
Example: Back Hoe; Dozer; Crane; Fork-Lift; Example: Radios; Test Meter; Special Tools; Example: Equipment; Vender; Laborers;
Truck; Compressor; Welding Mach; Compactor Gas Detector; Self Contained Breathing App. Special Hole Drilling; Testing Company
Risk Management
Safe Work Practices Basic Safeguards PPE Required
Work Permit Required Arc Shields Fire Resistant Clothing
Confined Space Entry Barricades Arc Suit
Crane Lift Study-Critical Lift Crane Suspended Work Platforms Chemical Resistant Clothing
Electrical - Close Proximity Fire Extinguishers Located Eye & Face Protection
Excavations - Shoring/Sloping/Benching Fire Watch / Flagman Fall Protection
Hot Taps Hole Covers Foot Wear
Line Breaking / Equipment Opening Hole Watch Hand Protection
Lock-Out / Tag-Out Housekeeping Head Protection
MSDS & Labeling Lighting - Additional Needed Hearing Protection
Other: Post Warning Signs Respirator
Scaffolding Weather Resistant Clothing
Tools / Equipment in Good Condition Other:
Ventilation / Exhaust Systems
Other:
Communication
Stop Work Conditions
● Adjacent Work Hazards ● Chemical Spills/Releases ● Excessive Noise ● Fires & Explosions ● Civil Disturbance
● Change in Conditions ● Evacuation ● Gas Release ● Violent Weather ● Unusual Odors ● Incident
Task Performer Comments:

I acknowledge receiving and understanding these instructions, I will fully comply with the assigned task requirements:
Name Signature. Name Signature
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________
______________________________ ______________ ______________________________ ______________

Supervisor Name (print): Signature: _____________________________

Job Monitored by Manager/Supervisor (initial): ______ ______ ______ ______ ______ ______
(Foreman will ensure completed JSA forms are given to the appropriate Supervisor at shift end)
END OF JOB: Supervisor ensures unnecessary barricades are taken down, scrap/waste placed in proper bin, and excess materials
returned to storage or properly stacked and barricaded. Submit copy to Mate.