DeepCor Marine, Inc.

JSA Hazard Checklist / Worksheet PRINT IN BLOCK LETTERS Scan This END DOWN
(MM) (DD) (YY) Vessel/Facility Code Brief Task Description (single line)
Date 06 26 15 FRE CHOP SAW - HOT WORK
Client: Arena Job Number: 1083-67 Location: ST-161-C

Comments:
Supervisor: Snyder/Sheaves Approved by:

Note: This JSA is a written Workplace Hazard Assessment

Discuss STOP Work Authority (SWA) at EVERY JSA Review -

Potential Hazards Pressure Chips / Slivers Key Focus Behaviors

Chemical Exposure Gravity Pinch Points Are employees in Line Of Fire?
Hazardous Atmosphere Lifting Temperature Do Employees Have Their Eyes
Confined Spaces Overhead Heat Stress / Humidity on Path?
Noise / Sound Falls Hot Surface Are Proper Techniques Being
Working/Walking Surfaces Open Holes Cold Used for Lifting / Pulling / Pushing
Motion Mechanical Dust / Fumes Tasks?
Environment / Weather Machinery Radiation Are Employees Protecting Their
Electrical Fire/Explosion Biological Hands?
Arc/Flash Spills Lighting Other Describe
Ignition Sources Slips/Trips Simultaneous Operation

Hazard Controls and Plans Weather Emergency Evacuation / Path Required Work Permits
Personal Protective Equipment Simultaneous Operation Eyewash / Safety Shower Lock Out Tag Out
(PPE) Management of Change Lift Plan Confined Space
Physical Barriers / Tape Fall Protection/Open Hole SWL rated rigging for load Hot Work
Safety Equipment Spill Control/Contingency Diving Operations Working At Height
Ignition Source Controls Spill Kits Other Controls Describe Basket Transfer
Fire Fighting MSDS reviewed Other-

Safety Equipment / PPE Gloves Full Body Harness Fire Extinguisher / Hose
Hard Hats Type - 1,3,5,7 Fall System w/Tie-off Fire Retardant Tarps
Safety Shoes Goggles Life Line Fire Retardant Clothing (FRC)
Safety Glasses Chemical Apron Retrieval Equipment Adsorbent Pads
Face Shields Respirator Gas Detector Containment Area/Pans
Hearing Protection Type- Burning Goggles/Shield Other Equipment Describe;
Work Vest / Life Jacket Protective Clothing Barriers / Access Control

DeepCore Marine, Inc. Cover Page FORM ID 06141989

Page __ of __ EHS-F-347 REV 1 - 07/31/14 Scanning Instructions, Insert this end into scanner FACE DOWN
Do Not Copy, SCAN PRINTED Pages ONLY --Scan Page one FIRST, then scan Page two./ three, etc.

DeepCor Marine, Inc. JSA Hazard Checklist / Worksheet PRINT IN BLOCK LETTERS Scan This END DOWN
Date: (MM) (DD) (YY) Vessel/Facility Code: Brief Task Description:

6 26 15 FRE CHOP SAW - HOT WORK

# SEQUENCE OF BASIC JOB TASKS
Discuss STOP Work Authority (SWA) at EVERY JSA Review -
RESPONSIBLE PERSON (NAME)
IF SSE IS NOTED AS THE RESPONSIBLE
POTENTIAL INCIDENTS OR HAZARDS RECOMMENDATIONS TO ELIMATE OR REDUCE POTENTIAL HAZARDS PERSON THE ASSIGNED MENTOR MUST
BE NOTED AS WELL

CHOP SAW SET UP DAMAGED EXTENTION CORDS INSPECT ALL EXTENTION CORDS FOR
1 DAMAGE PRIOR TO USE
WATER ON DECK OR TRIP HAZARDS KEEP EXTENTION CORDS HIGH AND OUT
OF WATER
NO HOT WORK PERMIT OPEN HOT WORK PERMIT, HAVE ALL
REQUIRED PARTIES SIGN
NO GFI VERIFY GFI IS ON OUTLET

IGNITION SOURCES REMOVE ANY IGNITION SOURCES OR

COVER WHAT CANT BE REMOVED

CHOP SAW NO OR DAMAGED PPE INSPECT AND DON ALL REQUIRED PPE,
2 INCLUDING FACE SHIELD
NO FIRE WATCH PRESENT HAVE FIRE WATCH PRESENT AND REMAIN
FOR 30MIN AFTER
STORED ENERGY BE MINDFUL OF POSSIBLE STORED
ENERGY IN MATERIAL BEING CUT
LINE OF FIRE STAY OUT OF THE LINE OF FIRE

HOT SURFACES BE MINDFUL THAT SURFACES WILL BE HOT

AFTER CUT
CHIPS, SLIVERS, DUST, AND SPARKS WATCH FOR CHIPS, SLIVERS, DUST, AND
SPARKS
If this is a printed JSA, leave blank spaces between each task step for site specific conditions, equipment, or personnel changes.
IF CONDITIONS CHANGE OR NEW HAZARDS ARE IDENTIFIED, STOP WORK. CONTACT YOUR SUPERVISOR TO EVALUATE.
CREW SIGNATURES

Page __ of __ EHS-F-347 REV 1 - 07/31/14 Scanning Instructions, Insert this end into scanner FACE DOWN
Do Not Copy, SCAN PRINTED Pages ONLY --Scan Page one FIRST, then scan Page two./ three, etc.

DeepCor Marine, Inc. JSA Hazard Checklist / Worksheet PRINT IN BLOCK LETTERS Scan This END DOWN
Date: (MM) (DD) (YY) Vessel/Facility Code: Brief Task Description:

6 26 15 FRE CHOP SAW - HOT WORK

# SEQUENCE OF BASIC JOB TASKS
Discuss STOP Work Authority (SWA) at EVERY JSA Review -
RESPONSIBLE PERSON (NAME)
IF SSE IS NOTED AS THE RESPONSIBLE
POTENTIAL INCIDENTS OR HAZARDS RECOMMENDATIONS TO ELIMATE OR REDUCE POTENTIAL HAZARDS
PERSON THE ASSIGNED MENTOR MUST
BE NOTED AS WELL

CHOP SAW CONT. POSSIBLE FUMES MAKE CUTS IN WELL VENTALATED

LOCATION
LOOSE CLOTHING OR LANYARDS TUCK IN OR REMOVE ANY LOOSE
CLOTHING OR LANYARDS

If this is a printed JSA, leave blank spaces between each task step for site specific conditions, equipment, or personnel changes.

CLEAR FORM
Page __ of __ EHS-F-347 REV 1 - 07/31/14 Scanning Instructions, Insert this end into scanner FACE DOWN
Do Not Copy, SCAN PRINTED Pages ONLY --Scan Page one FIRST, then scan Page two./ three, etc.