YHSS052a Job Safety Analysis Form

Record Number:
JOB SAFETY ANALYSIS FORM

The electronic version is current, or when printed and stamped with the green controlled document stamp. All other copies are uncontrolled.
Job Description: Business Unit / Workplace / Area: Work Order No: Start Date: / /
Job Residual Risk Rating:

As per highest residual risk rating listed in the job. Specify matrix cell ID i.e. L(5)
Required Documents
Permit to Work
Supervisor Review: Date: ____/_____/___ Name: Print___________________________Sign________________________________

This JSA was reviewed and accepted on the basis that; Changes were made A risk assessment must be completed prior to work commencing The JSA should be converted to a Standard Task or Safe Work Instruction
High Voltage
Hot Work
Vicinity (power lines)
Confined Space
Radiation
*Required only if the Job Residual Risk Rating is Moderate as per Queensland Nickel Risk Matrix
Superintendent Review: Date: ____/_____/___ Name: Print___________________________Sign_______________________________
This JSA was reviewed and accepted on the basis that; Changes were made A risk assessment must be completed prior to work commencing
Working at Heights
Lift Study
Excavation/Breakthrough
Rigging / Scaffold Plan
Required Competence
Electrical / Mechanical / Fabrication
Approved by Permit Acceptor: Name (print) ________________________________Sign_________________________ (All team members have the required skills and competencies to perform their job safely) Sighted by Isolation Supervisor / Permit Issuer: Name (print)_________________________________Sign_________________________ (The JSA is complete and has received Supervisor Review and Permit Acceptor approval)
Job Safety Analysis Standard
Published Date: 10 February 2012 Rev: 2.0 Next Review Date: 31 December 2013
Equipment License
Confined Space
Scaffold / Rigger
Working at Heights
Blue Card
Asbestos B Class
Other: Specify
YHSS052a
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Record Number:

WORK TEAM SIGN ON (I have read, understood and agree with the steps, hazards and controls of the JSA) NAME (Print) Trained/Competency COMPANY SIGNATURE DATE Developed JSA ( )

YHSS052a
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Record Number:

Residual Risk Ranking
No.
JOB STEPS
Required steps listed in order.
HAZARDS
Risks/hazards that could cause injury/damage to people, equipment, or the environment.
HAZARD CONTROLS
Apply the hierarchy of controls: Eliminate, Substitute, Redesign, Separate, Administrative, PPE
High / Extreme
Medium
Low
Check location and functionality of emergency equipment
Unable to access emergency equipment when required Safety equipment non-functional
Establish the location of safety showers/eye wash stations and test operation. Establish the location of fire extinguishers and check service tag.

YHSS052a
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Record Number:

The electronic version is current, or when printed and stamped with the green controlled document stamp. All other copies are uncontrolled. Residual Risk Ranking
No.
JOB STEPS
HAZARDS
HAZARD CONTROLS
High / Extreme
Medium
Low

YHSS052a
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Record Number:

The electronic version is current, or when printed and stamped with the green controlled document stamp. All other copies are uncontrolled. Residual Risk Ranking
No.
JOB STEPS
HAZARDS
HAZARD CONTROLS
High / Extreme
Medium
Low

YHSS052a
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Record Number:

Minimal
PEOPLE
First Aid Case or Report Only Spills which can be cleaned up readily or releases of less than 10 minutes in duration (AU$) up to 50,000
Minor
Medical Treatment
Moderate
Restricted Work Case Spills or releases that are limited in area but require additional effort or equipment to clean up. (AU$) 100,001 500,000 Attention from media and/or heightened concern by local community/Criticism from nonGovernment organisation Serious breach of regulation with prosecution and/or moderate fine possible
Major
Lost Time Injury or Permanent Disability Spills or releases of contamination that cannot be retrieved or require significant rehabilitation (AU$) 500,001 5 million Significant adverse national media publication-Government organisation attention Major breach of regulation. Major litigation.
Catastrophic
Fatality or multiple fatalities. Spills or releases that cause serious long term impact to environment. (AU$) >5 million Serious public or media outcry (international coverage) Significant prosecution and fines. Very serious litigation / class action
ENVIRONMENT
DEFINITIONS
Minor spills or releases with no lasting impact (AU$) 50,001 100, 000 Minor, adverse local public or media attention and complaints Minor legal issues. Non-compliances and breaches of regulation.
BUSINESS IMPACT
COMMUNITY & REPUTATION
Public concern restricted to local complaints
LEGAL
Projects Almost Certain (Once a week) LIKELIHOOD Likely (Once a month) Possible (Once a year) Unlikely (Once in 10 years) Rare (Once in 100 years) Existing operations Common or frequent occurrence
Low-level legal issue
CONSEQUENCE
M (11) L (7) L (4) L (2) L (1)

8 - 14
H (16) M (12) M (8) L (5) L (3)

Residual Risk Authority Levels
H (20) H (17) M(13) M (9) L (6)

15 - 20
High Risk; Senior management review needed. Sign-off; Area Manager, Department Manager
E (23) E (21) H (18) M (14) M (10)

21 - 25
E (25) E (24) E (22) H (19) H (15)
Likely to occur Possible to occur or has occurred in similar operations Unlikely to occur or known to happen elsewhere Very unlikely or practically impossible
1-7
Low risk; procedures. Manage by routine Sign-off; Engineer Senior Shift
Moderate Risk; Management responsibility should be specified. Supervisor, OMT, Superintendent,
Extreme Risk; Detailed review required. Sign-off; General Manager or person delegated.
Sign-off; Supervisor

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Record Number:

WORK TEAM REVIEWED CHANGES SIGN ON (I have read, understood and agree with the steps, hazards and controls of the JSA)
Sighted Changes ( ) Sighted Changes ( )
NAME (Print)
COMPANY
SIGNATURE
DATE
Time
NAME (Print)
COMPANY
SIGNATURE
DATE
Time

YHSS052a
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Record Number:

JOB SAFETY ANALYSIS FORM

Job Residual Risk Rating:

Supervisor Review: Date: ____/_____/___ Name: Print___________________________Sign________________________________

Vicinity (power lines)

Rigging / Scaffold Plan

JOB SAFETY ANALYSIS FORM

Job Safety Analysis Standard

JOB SAFETY ANALYSIS FORM

Residual Risk Ranking

Check location and functionality of emergency equipment

Unable to access emergency equipment when required Safety equipment non-functional

Job Safety Analysis Standard

JOB SAFETY ANALYSIS FORM

Job Safety Analysis Standard

JOB SAFETY ANALYSIS FORM

Job Safety Analysis Standard

JOB SAFETY ANALYSIS FORM

COMMUNITY & REPUTATION

Public concern restricted to local complaints

Low-level legal issue

M (11) L (7) L (4) L (2) L (1)

H (16) M (12) M (8) L (5) L (3)

H (20) H (17) M(13) M (9) L (6)

E (23) E (21) H (18) M (14) M (10)

E (25) E (24) E (22) H (19) H (15)

Moderate Risk; Management responsibility should be specified. Supervisor, OMT, Superintendent,

Job Safety Analysis Standard

JOB SAFETY ANALYSIS FORM

Job Safety Analysis Standard

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Supervisor Review: Date: __/_/_ Name: Print_Sign______