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Job Safety Analysis (JSA) Worksheet

For use by all Technicians working at: LMC


We believe that no job is done well unless it is done safely.

Supervisor/Foreman: _____________________ Work Order No.: ___________________ Location: ____________________________________________
Date: _____/______/______Time: ______: _______ SIS Media #:_______________________________________________________________________________
Job Description from work order: ________________________________________________________________________________________________________
Initials of Technician(s) on the job:______________________________________________________________________________________
Consider and check the items that apply to the task The entire work crew shall review and be aware of this JSA
Personal Protective Equipment
Normal standard PPE
(Safety Glasses, Leather steel toe boots)

Rubber Leather Kevlar
Add Foot Protection___________
Leather / Kevlar apron/J acket
NFPA 70 E equipment/ FRC Clothing
Face Shield
Mono Goggles
Hearing Protection (Ear Plugs/Muffs)
Fall Protection (inspected before use)
Burning Goggles
Welding Hood / hardhat
Welding Hood / no hardhat
Flotation
Other___________________
Hard Hat
Respiratory Protection
Air Purified / Air Supplied
HF
FF
Type of cartridge _____________________
(Is there a change out schedule)
Tools
Current Insp./Good Tool Conditions
Proper Tools for the J ob
Other______________________
Lockout tagout
Locked and Tagged
Try Start/Stop Switch/Key
GFCI Test
Assured Grounding____________
Extension Cord Inspection
Attachments blocked, locked out?
Other_______________________
















Lifting and Equipment
Motorized equipment:___________
Spotter needed
Blocking/Cribbing____________
Crane in Area (overhead lifting)
Proper Rigging Practices-barricade
Manual Lifting Equ.:____________
Inspection of Equipment up-to-date
Other______________________

Access
Scaffold Inspected
Ladder Tied Off & Inspected
Man lift or J LG/Scissor lift
(Current certification to operate equipment)
Personnel Basket
(Approved and Inspected)
Special Provision____________________
Barricades Maintained & Tagged
Signs (confined space, overhead work etc)
Hole Cover / Gaps in scaffold deck
Other Crews Working in Area
Other_____________________________

Welding
Welding Leads Inspected
Combustibles in Area/bottles secured
Spark Containment Required/ Fire Blanket
Welding Screens / Blinds Required
Grounding Close as possible
Fire Extinguisher / Water Hose
Fire watch w/ vest, horn
Other_______________________










Potential Hazards
(List checked items on Hazard Control)
Hotwork Exposure Hazards:
Is the work piece galvanized?
Will there be cutting or gouging?
Inside an Enclose Area?

Confined Space
Inside a Confined Space?
Is there a restriction to vertical airflow?
Yes No
Are there other workers present in the
Immediate vicinity?
Yes No
Are there >2 Welders working in a
Enclosed Area/Confined Space
Respirator Required: refer to PPE

Environmental Hazards
Spill / Leak
Weather conditions
Waste
Noise
Bacteria
Light levels low
Other____________________________

Chemicals
Chemical Burns Skin/Eyes
Flammable
Ingestion
Inhalation (Fumes, Smoke, Dust)
Skin Contamination
Cleaners / Degreasers
Compressed Chemicals
Radiation
Electrical
Other_______________________












Ergonomic/Physical
Fall Potential
Pinch Points
Slip-Trip Potential
Air borne, Particles
Electrical Shock
Heat / Cold
Heavy Objects
Hot/Cold surfaces
Over extension
Overexertion
Sharp Objects
Noise
Poor Access/Egress
Poor Housekeeping
Moving / Rotating parts
Awkward body position
Hands not in the line of sight
Vibration
Repetitive motion
Prolonged twisting / Bending
Working above your head
Working in a tight area
Handrail (missing?)
Parts of body in the line of fire
Suspended
Other_______________________


Emergency Info/Equ. Location
Fire Monitors________________________
Fire Extinguishers____________________
Safety Showers______________________
Evacuation Route____________________
Wind Direction _______________________
First aid kit _______________________













1. Think
through
the task
If you answer no to any question, do not proceed.
Contact your supervisor. Yes No N/A

Do I / we understand the scope & steps required to carry out the task?

Have I / we read and understood the procedure?
Do I / we have the necessary tools to complete the job safely?
Do I / we have valid training/ experience? (ie. crane/rigging, Forklift)
Have I / We identified a First Aid or medical facility in area
Are there any personnel in the crew that are on the job for the first time? Yes____No____

Employees Signature: ________________________________________________


Supervisors Signature: ________________________________________________












Specific Task or Segment What are the Hazards for this task? Control(s) for hazard
Risk
(L,M,H)
1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

12)

13)

14)

15)

16)

17)
HAZARD CONTROL
ORDER OF HAZARD CONTROL:
REMOVE THE HAZARD, ISOLATE OR BARRICADE THE HAZARD, ENGINEER THE HAZARD OUT, REORGANIZE THE JOB TO MINIMIZE RISK, WEAR THE RIGHT PPE
Risk Assessment
Step 1 - Determine Probability Step 2 - Determine Consequences (highest of the two)
People Plant, Property, Productivity or Environmental Consequences
A=Practically impossible 1=First aid injury 1=Under $5K damage and minimal productivity disruption, no environmental damage
B=Not likely to occur 2=Medical treatment injury 2=$5-$50K damage and/or slight productivity disruption, minor environmental damage
C=Could occur or I've heard of it happening 3=Disabling short term lost time injury 3=$50-$100K damage and/or productivity disruption, reversible environmental damage
D=Is known to occur or "it has happened" 4=Serious lost time injury or illness 4=$100-$500K damage and/or contingency plan required, serious environmental damage
E=Common or frequent occurrence 5=Fatality or permanent disability 5=More than $500K damage and/or large reorganization of premises, major environmental damage
Step 3 Calculate the Risk
A B C D E
1 Low Low Low Low Low
2 Low Low Low Moderate Moderate
3 Low Low Moderate Moderate High
4 Low Moderate Moderate High High
5 Low Moderate High High High
Note: Risks ranked moderate or high require supervisors involvement before work is started