We believe that no job is done well unless it is done safely.
Supervisor/Foreman: _____________________ Work Order No.: ___________________ Location: ____________________________________________ Date: _____/______/______Time: ______: _______ SIS Media #:_______________________________________________________________________________ Job Description from work order: ________________________________________________________________________________________________________ Initials of Technician(s) on the job:______________________________________________________________________________________ Consider and check the items that apply to the task The entire work crew shall review and be aware of this JSA Personal Protective Equipment Normal standard PPE (Safety Glasses, Leather steel toe boots)
Rubber Leather Kevlar Add Foot Protection___________ Leather / Kevlar apron/J acket NFPA 70 E equipment/ FRC Clothing Face Shield Mono Goggles Hearing Protection (Ear Plugs/Muffs) Fall Protection (inspected before use) Burning Goggles Welding Hood / hardhat Welding Hood / no hardhat Flotation Other___________________ Hard Hat Respiratory Protection Air Purified / Air Supplied HF FF Type of cartridge _____________________ (Is there a change out schedule) Tools Current Insp./Good Tool Conditions Proper Tools for the J ob Other______________________ Lockout tagout Locked and Tagged Try Start/Stop Switch/Key GFCI Test Assured Grounding____________ Extension Cord Inspection Attachments blocked, locked out? Other_______________________
Lifting and Equipment Motorized equipment:___________ Spotter needed Blocking/Cribbing____________ Crane in Area (overhead lifting) Proper Rigging Practices-barricade Manual Lifting Equ.:____________ Inspection of Equipment up-to-date Other______________________
Access Scaffold Inspected Ladder Tied Off & Inspected Man lift or J LG/Scissor lift (Current certification to operate equipment) Personnel Basket (Approved and Inspected) Special Provision____________________ Barricades Maintained & Tagged Signs (confined space, overhead work etc) Hole Cover / Gaps in scaffold deck Other Crews Working in Area Other_____________________________
Welding Welding Leads Inspected Combustibles in Area/bottles secured Spark Containment Required/ Fire Blanket Welding Screens / Blinds Required Grounding Close as possible Fire Extinguisher / Water Hose Fire watch w/ vest, horn Other_______________________
Potential Hazards (List checked items on Hazard Control) Hotwork Exposure Hazards: Is the work piece galvanized? Will there be cutting or gouging? Inside an Enclose Area?
Confined Space Inside a Confined Space? Is there a restriction to vertical airflow? Yes No Are there other workers present in the Immediate vicinity? Yes No Are there >2 Welders working in a Enclosed Area/Confined Space Respirator Required: refer to PPE
Ergonomic/Physical Fall Potential Pinch Points Slip-Trip Potential Air borne, Particles Electrical Shock Heat / Cold Heavy Objects Hot/Cold surfaces Over extension Overexertion Sharp Objects Noise Poor Access/Egress Poor Housekeeping Moving / Rotating parts Awkward body position Hands not in the line of sight Vibration Repetitive motion Prolonged twisting / Bending Working above your head Working in a tight area Handrail (missing?) Parts of body in the line of fire Suspended Other_______________________
Emergency Info/Equ. Location Fire Monitors________________________ Fire Extinguishers____________________ Safety Showers______________________ Evacuation Route____________________ Wind Direction _______________________ First aid kit _______________________
1. Think through the task If you answer no to any question, do not proceed. Contact your supervisor. Yes No N/A
Do I / we understand the scope & steps required to carry out the task?
Have I / we read and understood the procedure? Do I / we have the necessary tools to complete the job safely? Do I / we have valid training/ experience? (ie. crane/rigging, Forklift) Have I / We identified a First Aid or medical facility in area Are there any personnel in the crew that are on the job for the first time? Yes____No____
Specific Task or Segment What are the Hazards for this task? Control(s) for hazard Risk (L,M,H) 1)
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17) HAZARD CONTROL ORDER OF HAZARD CONTROL: REMOVE THE HAZARD, ISOLATE OR BARRICADE THE HAZARD, ENGINEER THE HAZARD OUT, REORGANIZE THE JOB TO MINIMIZE RISK, WEAR THE RIGHT PPE Risk Assessment Step 1 - Determine Probability Step 2 - Determine Consequences (highest of the two) People Plant, Property, Productivity or Environmental Consequences A=Practically impossible 1=First aid injury 1=Under $5K damage and minimal productivity disruption, no environmental damage B=Not likely to occur 2=Medical treatment injury 2=$5-$50K damage and/or slight productivity disruption, minor environmental damage C=Could occur or I've heard of it happening 3=Disabling short term lost time injury 3=$50-$100K damage and/or productivity disruption, reversible environmental damage D=Is known to occur or "it has happened" 4=Serious lost time injury or illness 4=$100-$500K damage and/or contingency plan required, serious environmental damage E=Common or frequent occurrence 5=Fatality or permanent disability 5=More than $500K damage and/or large reorganization of premises, major environmental damage Step 3 Calculate the Risk A B C D E 1 Low Low Low Low Low 2 Low Low Low Moderate Moderate 3 Low Low Moderate Moderate High 4 Low Moderate Moderate High High 5 Low Moderate High High High Note: Risks ranked moderate or high require supervisors involvement before work is started