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                                  JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
                                                                                                                                         Location / Project:
ACTIVITY OR TASK:
JSA Preparation &                                                                                                                        Job Number:
task work team:                                                                                                                          JSA Number:                                     JSA Revision:
Competence = Relevant Training/Qualifications + Experience
Competence/ Qualific’n
                                                                                                                                         Codes of Practice &
req’d to complete work
                                                                                                                                         Legislation that are
safely
                                                                                                                                         applicable:
JSA approved by                Name:                                  Position / Competence/ License:                Date:
person responsible i.e.
Team Leader / Tradesman

2. HAZARD IDENTIFICATION Identify hazards that may be present by ticking items on the list below.                                              3. PRECAUTIONS: hard hat, safety glasses, safety boots compulsory
     WORK LOCATION                     HAZARDOUS AREA                          HIGH RISK                         HIGH RISK                       ADDITIONAL PRECAUTIONS                                PERMITS
Difficult Entry/Exit              Hazardous Substances                Falling Objects                   Suspended loads                        Gloves: type ………………….                      Hot Work
Oxygen Deficiency                 - attach MSDS to JSA                Poor Lighting                     Poor Visibility                        Goggles                                    Excavation
Oxygen Excess                     Working at Heights                  Slippery Surfaces                 Inhalable Dusts/Fibres                 Full Face Shield                           Confined Space
Engulfment (trench collapse)      Remote Area                         Multiple Electrical Feeds         High Noise Levels                      High Visibility Vest                       Hazardous Work Clearance
Poisonous Gas Present             Motor Room Hazards                  Trip Hazards                      Use of Chemicals                       Harness                                    Access to Area
Temperature Extremes              Toxic Substances                    Electrical Hazards - LV           Elevated Work Platform                 Fire Extinguishers                         High Voltage Access
Defined Confined Space            Potential for Difficult Rescue      Electrical Hazards - HV           Difficulty to Communicate              Barricades                                 Scaffolding
Explosive Gas Present                                                                                   amongst workers                        Ventilation                                Other?
                                                                      Manual Handling                   Moving Machinery                       Lighting
                                                                                                                                                                                          PERMIT NUMBER
HAZARDOUS SUBSTANCES in work area / to be used -attach MSDS           Sharp Materials                   Tools & Equipment                      Erect Scaffolding to access
                                                                      Ladders used in the task          Heat/ Sunlight/ Radiation              Respirator or Dust mask
                                                                      Working at Heights                Traffic Movement                       Erect Warning signs
                                                                      Working near Crane &              Working near Operation                 Personal Locks or Tag system
                                                                      Crane Runways                     Processing Lines                       Group isolation
                                                                      Rail Movement                     Live Rails                             Welding screen
                                                                      Pressurised Fluids                Pneumatics                             Fall Arrest systems
                                                                      Flamm. Materials Present                                                 Welding Face Shield

4. ENVIRONMENTAL HAZARDS – (IMPACTS) tick those identified                                                                                                                             Consequences: how severe an injury?
                                                                                                                                                             Likelihood:
Air Pollution (dust, fumes)       Spills to ground                 Other:                                                    RISK RATING TABLE               How likely is it to        Death   Serious     Medical    1st Aid
                                                                                                           This table is used to calculate whether           be that bad?                       Injuries   Treatment    req’d
Noise (plant & equipment)         Soil Erosion                                                                                                                                                               Req’d
                                                                                                                  the hazard you have identified is
Spills to drains/waterways        Hazard to Flora /Fauna                                                           Extreme: 9-10         High: 7-8,          Almost Certain -            10        9          8          7
                                                                                                                                                             Expected to Occur
                                                                                                                  Medium: 5-6        or Low: 3-4
                                                                                                                                                             Likely – could               9        8          7          6
5. EQUIPMENT REQUIRED:                                                                                                                                       happen sometime

Static Plant & Equipment                                                                            The objective of rating the risk is to lower the risk    Moderate – could             8        7          6          5
                                                                                                     by initiating risk control measures. The score is       happen but not likely
Mobile Plant & Equipment                                                                              noted in the JSA risk score column on the next         Unlikely – could
                                                                                                    page – both before & after risk control measures                                      7        6          5          4
Safety / Emergency Equip’t                                                                                                                                   happen but very rare
                                                                                                                                 have been nominated.        Rare - could happen          6        5          4          3
                                                                                                                                                             but probably never will


Revision Date: March 2005                                                                   ………. of …………..                                                                                        OHS-03-F01
                                                                                                                                                                                                    POWER

                                  JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT

 NAME OF TASK:                                                                                                                                      JSA Number:                           Rev:

                                                                Potential Safety &                        Risk                Recommended Corrective Action or Procedure                                  Risk
 Step          Sequence of Basic Job Steps                Environmental Hazards/Impacts                  Rating    Determine what actions are necessary to eliminate or minimise all hazards that        Rating
 No.        Break down Job into steps. Each step should    Identify the hazards (health and safety or Use table on could lead to an accident, injury, illness or environmental incident. The risk must   Of the risk
 Logical      accomplish a major task and be logical.      environmental) associated with each step, the previous be reduced or controlled to a level that is acceptable before work commences.          following
sequence
                     Environmental Aspects                examine each to find all possible risk factors page to      Indicate who is to perform the action where applicable against each action         corrective
                                                                                                         score risk                                                                                        action


   1       Obtain PTW                                     Injury / damage as a result of                              Obtain correct PTW. Training in PTW system.
                                                          incorrect information
   2       Identify work area                             Risk of injury due to low awareness                         Take 5, be aware of hazards
                                                          of work environment




 Revision Date: March 2005                                                              ………. of …………..                                                                                     OHS-03-F01
                                                                                                               POWER

                                     JOB SAFETY & ENVIRONMENT ANALYSIS (JSA)

                              CONSULTATION & SIGN-OFF RECORD
I confirm by my signature below, that I have attended a briefing on the requirements of the attached Job Safety &
Environment Analysis and agree to perform the work in the manner detailed on it.
I confirm that copies of the relevant Permits, MSDS's, Isolation Plans etc. have been reviewed.

                                                                                                            Rev:
  JSA NAME                                                               JSA No:


               NAME      (Please print)                             SIGNATURE                            DATE




THIS SAFE WORK BRIEFING / TRAINING WAS CARRIED OUT BY (responsible person at that location) :
Name:                                        Signature:                                      Date:

Client sign off (where applicable)


Site / Project Manager sign off (document reviewed)



Revision Date: March 2005                                                                                  OHS-03-F01

				
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