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Date: Project # and Name: 1321771104 VC PM/HSO: JHA#:
Work Type (Task):
Development Team: Master Revision Rev#: 0
(maintain hard copies on site
for audit)
Equipment / Tools / Materials Personal Protective Equipment Reason for JHA Revision

Potential Risks /
Step Job Steps Corrective Actions / Mitigation



CMS-710-05-FM-01700-VCS Page 1 of 5

NO negative repercussions will result from this action. and have the responsibility to stop their own work and the work of co-workers. CB&I – JOB HAZARD ANALYSIS Step Job Steps Potential Risks / Corrective Actions / Mitigation Hazards 4 5 6 Stop Work Authority – All on-site personnel are empowered. Chemicals Description/Health Hazards CMS-710-05-FM-01700-VCS Page 2 of 5 . expected. or other contractors if any person’s safety or the environment is at risk.

CB&I – JOB HAZARD ANALYSIS Required Training: Required Permit(s): Other Information: CMS-710-05-FM-01700-VCS Page 3 of 5 .

jagged objects? protruding objects. OR BETWEEN – Can you be caught in. SLIPS. PUSHING) – Does the fall? Will the fall be to the same level or a task involve lifting. TRIPS. pulling or pushing? Is there a lower level? possibility for over exerting or straining yourself? Is the CMS-710-05-FM-01700-VCS Page 4 of 5 . against stationary. or poor air quality? STRIKE AGAINST – Can you strike your body CAUGHT IN. sharp or on. moving. chemicals. CB&I – JOB HAZARD ANALYSIS JSA Hazard Checklist Potential Hazards Chemical Exposure Ignition Sources Fire/Explosion Hazardous Atmosphere Pressure Spills Confined Spaces Lifting Slips/Trips Noise Overhead Chips/Slivers Working/Walking Surfaces Falls Pinch Points Environment/Weather Machinery Hot Surface Arc/Flash Heat Stress Simultaneous Open Hole Other - Hazard Controls and Emergency/Contingency Plans Personnel Protective Equipment Spill Control/Contingency Plan Physical Barriers Fire Fighting Safety Equipment Emergency Evacuation Procedures Ignition Source Controls Eyewash/Safety Shower Location Lock Out Tag Out Material Safety Data Sheets Required Work Permits Simultaneous Operations Fall Protection/Open Hole Policy Hot Bolting Policy Other – Describe: Safety Equipment Required Hard Hats Work Vest/Life Jacket Respirator Safety Shoes Full Body Harness Fire Extinguisher Safety Glasses Double Lanyard w/ Shock Fire Retardant Tarps Face Shield Absorber Life Line Lock Out Tag Out Devices Goggles Safety Cable Gas Detector Cotton Gloves Safety Barricade Hearing Protection Leather Gloves Caution Tape Adsorbent Pads Rubber/Chemical Clothing Containment Pans Chemical Apron Work Permit Proper Tools Other – Describe: CONTACT WITH – Will the task put you in STRUCK BY – Can you be struck by moving objects. contact with hazardous energy/materials. cold radiation. or between anything? Look for pinch points. moving and fixed objects. ON. OR FALL – Can you slip. PULLING. flying objects or falling material? electricity. water. gases or fumes. protruding. trip or OVEREXERTION (LIFTING. heat. steam.

CB&I – JOB HAZARD ANALYSIS job highly repetitive? CMS-710-05-FM-01700-VCS Page 5 of 5 .