Have the relevant Procedures, Standards, Guidelines, Yes N/A or Safe Work Practices been reviewed? Pending confirmation by the Task Leader of site conditions, I agree that the attached JSA identifies the significant Task Steps, Hazards, and Controls.
JSA REVIEWER (Supervisor or Designate):
RISK ASSESSMENT Must existing Procedures or Work Practices be Yes No Name / Signature: Company: modified to perform this work? After mitigation, are there any hazards that continue to WORK SITE VERIFICATION present a potentially significant risk? (Scenario-Based Yes No Risk Assessment required) The Work Team has assessed the worksite conditions and confirms: The JSA addresses the applicable hazards and necessary controls. PPE REQUIRED DURING THIS TASK The Team has the appropriate resources (people and equipment) to do the job safely. HARD HAT SAFETY GLASSES Others that could be affected by the work have been informed. FACE SHIELD TASK LEADER: SAFETY SHOES / BOOTS GOGGLES
Name / Signature: Company:
FALL PROTECTION FALL RESTRAINT COMPLETE THE SECTION BELOW IF THIS JSA IS NOT PART OF A PERMIT PACK GLOVES: COTTON Work Team Declaration: LEATHER I acknowledge that I have reviewed the attached JSA, I understand my roles and responsibilities, and I will comply with the instructions for this task. IMPACT PROTECTION Name (print): Name (print): Dust mask OTHER (specify): Work clothes
OTHER PPE (specify): High Vis Jacket
TASK STEPS POTENTIAL HAZARDS HAZARDS CONTROLS HAZARD PORT (Number) (What could go wrong?) (How can harm be prevented?) MITIGATION STATES 1. Mobilization and Driving Collision with other vehicles. Pre-deployment checklist to be issued 24 hours before Seatbelt On all the Overturning vehicle with driving off road. mobilization. time driving Driver fatigue Ensure drivers travel at safe speeds for conditions- Cars equipped with passengers to have input. first aid kits Use identified roads and tracks. Fire extinguishers Travel at suitable speed for the surface conditions. available in cars Ensure drivers take breaks Satellite phone and Use of all CONTRACTOR safe-driving procedures. GPS locator are Observe all speed limits. Vehicle to be checked before available the start of any journey to ensure safe operation. Phones and contact Rest breaks to be taken every 2 hours (15min) list available in all Journey Management Plan and convoy system in force cars Drivers to should have defensive driving certificate prior Cars equipped by to mobilization to project location IVM system The use of mobile telephones (including hands free is not permitted whilst the vehicle is in motion Emergency contact list to be posted in cars
2. Use and handling of survey Unsafe manual handling Proper handling technique MSBI Emergency station Repetitive movement Use of upper muscles response plan ( medical treatment + ambulance ) 3. Marks installation Hand injury by hammer Gloves to be worn MSBI Emergency Presence of mind at all times response plan ( medical treatment + ambulance ) 4. Housekeeping Greasing materials remaining on place Collect all remaining greasing material from work place PPE causing slip trip and fall Put back tools and equipment in the store and Trash bins Harm to environment caused by spill workshop Empty cans left at work place Put the used spares and parts into correct trash bin or Used batteries left at work place junk area Spare parts and tools left at workplace Trash, boxes remain at work place Clean work place and segregate waste 5. Working in desert Biological hazards such as reptiles Use of PPE MSBI Emergency Poison from the scorpions & snakes Close supervision response plan Personnel missing or lost in the desert Long sleeve coverall (medical treatment Personnel Protests Safety boots + ambulance ) Terrorist Attack Communication GSM Sat phone Security accompanying Provide sat phone, security spot and radio for personnel working at uncovered area by phone. Assess the situation as quick as possible and announcing the state of the emergency (Emergency or Alert). At any security threats call first the ERT leader mentioned in back of access badge and emergency contact list. In case of any Terrorism threats call first the ERT leader or the IMT Leader and the COMPANY Field Security Liaison Officer mentioned in back of access badge and emergency contact list Delegate someone to make sure that the area is evacuated. Name Position Date Signed Prepared By Checked By
