JOB SAFETY ANALYSIS

JOB DETAILS:

Location: Start Date: Finish Date: JSA #: Permit #:

Job Description: Risk Assessment Level: 1 2 3
Estimated No. of Employees: Site Visited? : Yes No Are there any SIMOPS? : Yes No Emergency Response Known? : Yes No

Prepared by 1. Signature Approved by: 1. Signature

(BLOCK (BLOCK
LETTERS) 2. Signature LETTERS) 2. Signature
3. Signature 3. Signature
4. Signature 4. Signature
SAFETY EQUIPMENT REQUIRED:

Safety hard hat Safety Glasses Face Shield Barricades Goggles Cotton Gloves Fire Blanket Fire
extinguisher
Safety Harness Hearing Vessel Entry Hot work permit Leather gloves Chemical Resistant Lock Out / s
Chemical
Protection permit gloves Tag out mask
Safety Boots Fire resistant Fire watch Rope off area Gas detectors Lifting precaution Dust mask Other
clothing
HAZARD CHECKLIST:

Falls from heights Falling objects Collision Access/Egress Moving Machinery Liquid or Gas under Pressure
Noise Chemical exposure Illumination Flammable Materials Environmental Impact Electricity
Oil/ Chemical Competence of Confined Space Corrosive Material Manual Handling Naked Flames
personnel
RISK RANKING MATRIX:

RISK ASSESSMENT (Insert value based on Risk Grid)

Severity (S) x Likelihood (L) = Risk value or Risk Level (R)

Risk definitions:
Severity of an accident which may occur
1 - Negligible, No first aid treatment necessary, Minor Loss/ Injury (E.g. Scratches to equipment, Minor dents etc), No visible impact to the environment.
2 - Marginal Damage (not affecting the performance of equipment or systems or injury) (Minor first aid treatment/damage). Cost
effective applications can be applied to control effluent from processes that can cause damage to the environment
3 - Medium Damage to equipment of systems likely to be in the range of US$ 1,000 to $10,000 or injury. Injury requiring medical treatment. Could
cause LTI (Loss Time Injury), monitoring and recording needs to be undertaken from effluent emitted from processes
4 - Major, Results in critical injury but not death, Damage to Equipment of systems in excess of US$ 10,000 or Major injury, may result in
destruction of habitats and death of some terrestrial and aquatic life
5 - Catastrophic, Results in death of person(s), Damage resulting in the loss of essential equipment, resulting in substantial financial loss and
decline in production, widespread death of terrestrial and aquatic life and contributes significantly to ozone depletion

Likelihood of an accident which may occur

1 Unlikely not expected to occur in 5 years
2 Improbable not expected to occur in 2 to 3 years
3 likely - not expected to occur once per year
4 Probable - could occur once per year
5 Frequent Likely to occur any moment

*L Likelihood after Corrective Measures

ACTS-HSE-FORM-0001-JSA-20120405-REV-1
 R *RR *ALARP
Item Job Steps Hazards Identified Hazard Effect S L Corrective Measures *L
=SxL =Sx*L (Y/N)

ACTS-HSE-FORM-0001-JSA-20120405-REV-1