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JOB SAFETY ANALYSIS FORM

Main Activity: Work at height Plant & Location:-


Date: Day1 Day2 Day3 Day4 Day5 Day6 Day7
Permit Nos. (Day 1-
7)
Sr.No. Sub Activities Hazards Control Measures
List the tasks required to perform the (Both Existing as well as potential) List the control measures required to eliminate or minimize the risk of injury arising from the identified
activity in the sequence they are carried Against each task list the Hazards that could cause Hazard.
out injury/damage to people, equipment or the environment.
Identifying the best approach to Damage to workplace due to hitting/ climbing Approach to be identified in such a way that emergency egrees route is avilable
1 work location and scaffolding on pipes, specially SBCs in turn it release of Alternate escape route to be identified depending on criticallity of the job
preparation toxic gases / fire Scaffolding errrected should not block identified Escape routes of the plant
ALL SBCs at work location must be identified
Electrical and instrument cable must be identified and scaffolding pipes should
noy touch these cables
Adequate care must be taken to avoid hitting on SBCs
Scaffolding pipes must be atleast at least 6'' away from SBCs
JSA available for scaffolding preparation and dismantling to be referred
Scaffolding must meet all standard requirement. Scaffolding certification must be
done Scaffolding check list
must be filled.
ALL above also applies if Hyraullic platform / trolley is being used
Always see the the escape route while working at height

Tools , tackles etc are not to be carried with hands while climbing. Use pouch, belt
or other lifting / lowering device

JSA Format No. 9112-000-HSE-006-00004/Ver-2


2
Ladder must be free of oil/ greese and must be firmly placed tp prevent slip
Shifting of tools, tackles, spare Ladder to be provided perpendicular to the working platform wherever possible
Injury due to fall ( slip/trip) while climbing up
etc to work location Gloves with good grip must be used while climbing
Keep landing area near the ladder free form looses pipes and other scaffolding
material
While climbing maintain 3 point contact always

No person to be allowed to stand under weight being lifted


3 Execution of the job at height Struck by falling objects Area must be barricated. No superfluous mateiral to be kept at work site.
Use tary for small tools. Tie tools, spare wherever possible

4 All sub activities (1-3) Physically Injury while working


Use correct tools. Use mandatory PPEs

(Note:1. JSA to be done by issuer and acceptor of work permit. In case required, representative from other discipline can also join the team for JSA.
2. JSA to have approvals*(Managers) for Hot Jobs, confined space entry & Work on equipment in service
3. Minimum one hand written job specific information to be included every day by the issuer & requestor. In case of no additional information, write-“No
change from above” in the Remarks.
Note………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Name & Sig. Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Issuer

Requestor
Remarks:
*App-1 Issuer

*App-1 Requestor

Checklist of common Hazards


This should be used as an aid to identifying the hazards. This is the list for the most common hazards but is not a definitive list.
Mechanical/Equipment Thermal Ignition sources Electrical
Entanglement Hot surface Electricity Electric shock
Shearing Steam Static electricity Static electricity
Crushing Refrigerants Hot work Power failure
Striking Stored Energy Lightening Pressure
Cutting Falling material Sparks Release of energy
Mechanical failure (e.g by overloading) Springs under tension/compression Frictions Implosion
Chemical Counterweights Flames Compressed air
Flammable Radiations Auto ignition Steam
Toxic e.g. ionising radiations (X-rays) Pyrophoric material Hydraulics
Harmful Place of work Vehicles Process
Irritant Obstructions Fork lift Wrong material
Oxidising Access/egress Tankers Missed steps
Pyrophoric Work at height Reversing vehicles Instrument failure
Corrosive Falling objects Speed Interlocks
Dangerous to environment Slip/trip/fall People Control system failure
Dust explosions Housekeeping Unsafe behaviour Alarms
Gases Temperature Human errors Nature
Fumes Ventilation Training/competence Weather
Vapours Confined space Methods of work Winds/Storms/lightening
Dusts Hazards of other tasks being done simultaneously. Manual handling (lifting, carrying, pushing and pulling)
Asphyxiants Stress/workload

Biological (e.g.legionella) Noise/Vibrations/Hot work

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