Technical Drilling Services

Job Safety Analysis Form

Note: This JSA is valid only for the work, date, and time specified. This JSA shall be posted at the work site dring the work activity. !f the terms
noted change, work mst be stopped and the JSA reissed. "ire and#or $mergency Alarm atomatically invalidate the JSA. %hen the work is
completed or the JSA e&pires, retrn the JSA to the spervisor marked '(omplete).
Project Name and Number: Date:
Location: Supervision: Beginning Time: Expiration Time:
Crew Names:
Description of or!:

Name of Standb" Person #if re$uired%: Name of &ire atc' #if re$uired%:
Competent Persons #if re$uired%:
A. Atmosphere Monitoring Required: Yes No N/A . !ermits Required "displayed and properly signed#:
(f )es* 'ow often+ ,nit or! )es No Excavation )es No
Comb- .as / &0amm- 1apor Test 2eading: Loc!out / Tagout )es No Confined Space )es No
3x"gen Concentration 2eading: Line Brea!ing )es No 4ot or! )es No
4a5ardous / Toxic .as Test 2eading: 3t'er #specif"%:
$. %mergen&y Assembly !oint: %. 'or( !lan / )rder of 'or( / Assignments: Safest !lan*
Primar":
Secondar": F. +raining:
ind Direction:
,. Safety ,he&(list Requirements: #See Page 6 for items c'ec!ed be0ow-% -. !otential .a/ards:
7ccess )es No
E0ectrica0 )es No
Excavation )es No .. A&tions +a(en to %liminate .a/ards:
Emergenc" E$uipment Locations )es No
4a5ards #bod"% )es No
New or!er )es No
Pipe0ine )es No 0. +ools1 Materials1 and Safety %quipment Required:
4a5ards #environmenta0% )es No
E$uipment / Lifting )es No
3ver'ead or! )es No J. )ther Spe&ial !re&autions:
Process / E$uipment )es No
Too0s )es No 2. Signatures sho3ing a&&eptan&e of this safe 4ob plan:
Persona0 Protective e$uipment )es No &oreman:
Stand8B" Person )es No Crew:
e0ding / Burning )es No
4a5ards )es No
Technical Drilling Services
Job Safety Analysis Form
Note: (heck off and discss all pertinent items from the attached checklist that apply to the scope of work being performed. The items that are checked
are to be discssed with the crew performing the work to ensre that they nderstand the safety re*irements necessary to safely perform this task.
A,,%SS
Scaffo0d #proper0" inspected%
Date: 9999999999999999
Scaffo0d #comp0ete 'andrai0s*
toeboards* so0id0" dec!ed%
Ladder #condition* secured*
p0acement%
a0!wa"s and 4andrai0s
&a00 protection
%5%,+R0,A5
Loc!out / tagged #Tr" start / stop
Switc'%
Disconnected #if re$uired%
Proper0" .rounded
.ood Condition
7ut'ori5ed
%6,A7A+0)N
Proper0" S'ored / S0oped or Benc'ed
Escape Ladder Provided
Competent Person on Site
Entr" Permit 2e$uired
Soi0 T"ped / Documented
Dai0" (nspection #Documented%
Barricaded Proper0"
%M%R-%N,Y %890!M%N+
5),A+0)NS
&ire :onitors 0ocated at
99999999999999999999999999999
&ire Extinguis'ers 0ocated at
99999999999999999999999999999
Safet" S'ower 0ocated at
99999999999999999999999999999
E"e as' 0ocated at
99999999999999999999999999999
:edica0 at
99999999999999999999999999999
Emergenc" P'one No-
99999999999999999999999999999
.A:ARS "body#
&a00 Potentia0
Pinc' Points
E0ectrica0 S'oc!
4ouse!eeping
S0ip / Trip #Cords* Pipe* etc-%
&0"ing Partic0es
T'erma0 Burns
S'arp 3bjects
N%' ')R2%R
Site 3rientation
Budd" 7ssigned
!0!%50N%
Poison (v"
Sna!es
4ornets / asps
Tic!s
700igators
:ac'ete
7T1
a0!ing Surfaces #:ud%
.A:ARS "%n;ironmental#
7irborne Particu0ate #&umes* :ists%
4eat Stress #4ot / Co0d Surfaces%
:ateria0s
7de$uate Lig'ting
Noise
7ccess / Egress
2adiation from 2adiograp'"
2adiation from 3t'er Source
%890!M%N+ / 50F+0N-
3perator Certified / Licensed
.ood E$uipment Condition
Bac!up arning Device
&or!0ift
:an0ift
Boom Truc!
Crane
Load C'arts
Position
Proper 2iggings
C'ainfa00
Las'ing 2e$uired
Personne0 Bas!et Permit
)7%R.%A ')R2
Barricades / Tags
Signs
4o0e Cover
4andrai0
.rating Secured
&a00 Protection in P0ace
Life Lines Proper0" (nsta00ed /
(nspected
!R),%SS / %890!M%N+
1a0ves B0oc!ed (n
Tags 4ung
E$uipment C0eared
B0inds (nsta00ed and Tagged
B0ind List
4a5com Summar"
Loc!out Comp0ete
+))5S
Current (nspection
Proper Too0s
.ood Too0s Condition
Too0 ,se (nstructions
!%RS)NA5 !R)+%,+07%
%890!M%N+
4ard'at
Safet" .0asses
:ono .ogg0es
Ear Protection
&ace S'ie0d / Burning .ogg0e
Proper T"pe 2espirator
&res' 7ir
.0oves
Safet"8Toe S'oes
:etatarsa0 .uards
2ubber Boots
3t'er Safet" &ootwear
&ire 2etardant C0ot'ing
S0ic!er Suit
7cid Suit
Safet" 4arness / Lan"ard
46S :onitor
3t'er #List%: 9999999999999999999
S+AN<$Y !%RS)N
Confined Space Entr" #4o0e8atc'%
&res' 7ir or! #Bott0e atc'%
&ire atc'
E0ectrica0
Traffic &0agman
'%50N- / $9RN0N-
&0as'burns
Combustib0es
Spar! Containment
S'ie0ds
.rounding
ater 4ose
&ire Extinguis'ers #(nspected /
Nearb"%
&ire B0an!et
C"0inders Secured
C"0inder Caps in P0ace
.A:ARS
4"giene
C'emica0 Burns
S!in / E"es
&0ammab0e
(n'a0ation
S!in Contamination
Technical Drilling Services
Job Safety Analysis Form
efinitions
.a/ard ; Potentia0 to cause 'arm or injur" to peop0e* t'e environment* or e$uipment-
Super;isor ; 2esponsib0e for direct supervision of personne0 wor!ing on a job site- Examp0es are Crew Leader* Crew C'ief* <ob &oreman* or
Construction Supervisor-
JSA !reparation
T'e Supervisor s'ou0d 'ave a0read" met wit' t'e Project :anager or designee to p0an t'e wor!- T'e minimum re$uirement is t'at t'e Supervisor
'as <S7 training* or anot'er person is present to assist w'o is <S7 trained- T'e Supervisor wi00 p0an for active participation b" t'e wor!ers-
&i00 out t'e top portion of t'e <S7 form wit' project name and number* Supervisor name* etc- rite out t'e crew names 0egib0"- (f more room is
needed* write t'e names across t'e top of t'e form or attac' a s'eet-
JSA !ro&ess
T'e goa0 is to use t'e form as a too0 to ensure wor!er safet"- T'e identification of a00 'a5ards is t'e essentia0 first step* t'en p0an for e0imination of
t'e 'a5ards or ensure protection against t'e 'a5ard- Encourage wor!ers to state 'a5ards t'e" cou0d expect and as! t'em w'at t'e" wi00 do to
protect against 'a5ards* suc' as t'e use of PPE- .uide t'e discussion to ensure a00 'a5ards are considered-
Start b" writing t'e description of t'e wor! and 0isting eac' tas! to be performed- ,se a sufficient0" detai0ed tas! 0eve0 to identif" 'a5ards
comp0ete0"-
(dentif" if specia0i5ed competent persons are needed for excavation* scaffo0ding* etc and write down t'eir names in t'e stated p0ace- (f confined
space is performed* write down t'e names of t'e attendant and a0so t'e name of a fire watc'* if needed for 'ot wor!-
Discuss t'e emergenc" assemb0" points and write t'em down on t'e form- List t'e wind direction if app0icab0e and discuss 'ow to judge t'e wind
direction b" windsoc!s or steam-
&or confined space entr" w'ere identified as re$uired* enter t'e atmosp'eric testing resu0ts-
,sing t'e bac! of t'e form* go t'roug' t'e c'ec!0ist identif"ing eac' t"pe of 'a5ard- C'ec! t'e item= c'ec! t'e corresponding box on t'e front of
t'e form under Section C- T'en 0ist t'e 'a5ard under Section 4-
List t'e permits re$uired-
P0an t'e wor! to minimi5e 'a5ards and ris! to persons and propert"-
(dentif" a00 training re$uired and confirm t'at eac' person 'as t'e training- &or examp0e* specia0 training is re$uired for confined space entr"*
scaffo0ds* fa00 protection* c'emica0s* and respirators-
List a00 steps ta!en to e0iminate* contro0* or protect against 'a5ards- T'is is often PPE but can be a0ternate wor! met'ods-
List too0s* materia0s* and safet" e$uipment re$uired- &or examp0e* for confined space t'is cou0d be a rescue 'oist* venti0ator* atmosp'eric
monitor* etc-
List an" ot'er specia0 precaution ta!en* suc' as spotter* f0agger* water remova0* etc-
Technical Drilling Services
Job Safety Analysis Form
T'e Supervisor wi00 sign t'e form and a00 crew members wi00 sign as we00- (f t'ere is not room* t'en sign at t'e bottom of t'e page and on t'e
bac!-
!osting
Post t'e <S7 &orm at t'e wor!site near t'e wor!* if possib0e- (f not possib0e= p0ace t'e form on a c0ipboard and 'ang on TDS 0ogging unit bu00etin
board-
Follo3<up and ,losure
'en t'e time period for t'e <S7 is comp0eted but no more t'an one wee! 0ater* t'e <S7 &orm wi00 be turned in to supervisor to fi0e for t'e duration of
t'e project-