POWER

JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
Location / Project:
ACTIVITY OR TASK: Scaffolding (Erection and Dismantling)
JSA Preparation & Job Number:
task work team: JSA Number: G20 JSA Revision:
Competence = Relevant Training/Qualifications + Experience
Competence/ Qualific’n
Codes of Practice &
req’d to complete work
Legislation that are
safely
applicable:
JSA approved by person Name: Position / Competence/ License: Date:
responsible i.e. Team
Leader / Tradesman
2. HAZARD IDENTIFICATION Identify hazards that may be present by ticking items on the list below. 3. PRECAUTIONS: hard hat, safety glasses, safety boots compulsory
WORK LOCATION HAZARDOUS AREA HIGH RISK HIGH RISK ADDITIONAL PRECAUTIONS PERMITS
Difficult Entry/Exit Hazardous Substances Falling Objects Suspended loads Gloves: type …………………. Hot Work
Oxygen Deficiency - attach MSDS to JSA Poor Lighting Poor Visibility Goggles Excavation
Oxygen Excess Working at Heights Slippery Surfaces Inhalable Dusts/Fibres Full Face Shield Confined Space
Engulfment (trench collapse) Remote Area Multiple Electrical Feeds High Noise Levels High Visibility Vest Hazardous Work Clearance
Poisonous Gas Present Motor Room Hazards Trip Hazards Use of Chemicals Harness Access to Area
Temperature Extremes Toxic Substances Electrical Hazards - LV Elevated Work Platform Fire Extinguishers High Voltage Access
Defined Confined Space Potential for Difficult Rescue Electrical Hazards - HV Difficulty to Communicate Barricades Scaffolding
Explosive Gas Present amongst workers Ventilation Other?
Manual Handling Moving Machinery Lighting
Permit Number
HAZARDOUS SUBSTANCES in work area / to be used -attach MSDS Sharp Materials Tools & Equipment Erect Scaffolding to access
Ladders used in the task Heat/ Sunlight/ Radiation Respirator or Dust mask
Working at Heights Traffic Movement Erect Warning signs
Working near Crane & Working near Operation Personal Locks or Tag system
Crane Runways Processing Lines Group isolation
Rail Movement Live Rails Welding screen
Pressurised Fluids Pneumatics Fall Arrest systems
Flamm. Materials Present Welding Face Shield

4. ENVIRONMENTAL HAZARDS – (IMPACTS) tick those identified

Likelihood: Consequences: how severe an
Air Pollution (dust, fumes) Spills to ground Other: RISK RATING TABLE injury?
How likely is it to
This table is used to calculate whether
Noise (plant & equipment) Soil Erosion be that bad? Death Serious Medical 1st Aid
the hazard you have identified is Injuries Treatment req’d
Spills to drains/waterways Hazard to Flora /Fauna Extreme: 9-10 High: 7-8, Req’d
Medium: 5-6 or Low: 3-4 Almost Certain - 10 9 8 7
Expected to Occur
5. EQUIPMENT REQUIRED:
Likely – could
The objective of rating the risk is to lower the risk 9 8 7 6
Static Plant & Equipment happen sometime
by initiating risk control measures. The score is
Mobile Plant & Equipment Moderate – could
noted in the JSA risk score column on the next 8 7 6 5
happen but not likely
page – both before & after risk control measures
Safety / Emergency Equip’t Unlikely – could
have been nominated. 7 6 5 4
happen but very rare
Rare - could 6 5 4 3
happen but probably
never will
Revision Date: March 2005 ………. of ………….. OHS-03-F01
 POWER

JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
NAME OF TASK: Scaffolding (Erection and Dismantling) JSA Number: G20 Rev:

Potential Safety & Risk Recommended Corrective Action or Procedure Risk

Step Sequence of Basic Job Steps Environmental Hazards/Impacts Rating Determine what actions are necessary to eliminate or minimise all hazards that Rating
No. Break down Job into steps. Each step should Identify the hazards (health and safety or Use table on could lead to an accident, injury, illness or environmental
Of the risk
Logical accomplish a major task and environmental) associated with each step, the previous incident. The risk must be reduced or controlled to a level following
sequence
be logical. examine each to find all possible risk factors page to that is acceptable before work commences. corrective
score risk Indicate who is to perform the action where applicable against each action action
Environmental Aspects

1 Site Inspection Injury as a result of exposure to Be aware of and plan escape routes. Be aware of wind.
substances released due to
equipment failure
Slips, Trips and Falls due to Due care and attention.
slippery surfaces, obstructions,
restricted access.
Injury due to equipment failure, Liaise with permit authority / operations to minimize exposure to
moving equipment, activity and creation of hazards.
2 Raise Permit Stress and frustration due to Ensure all information supplied is as accurate and
incorrect information misdirecting understandable as possible.
efforts
3 Transport scaffold equipment to site Injury/damage related to vehicle Use correct vehicle and handling procedures
operation and equipment handling
Injury / damage due to collision / Plan route to avoid other personnel and equipment
impact with other workgroups /
equipment
Injury / damage as a result of Use appropriate barricades and bunting to protect personnel and
dropping tools and scaffold equipment
components
4 Erect scaffolding Hot and cold burns as a result of Adequate PPE with correct instruction and use.
contact with pipework
Injury due to limited egress in Ensure scaffold has adequate egress for any situation.
emergency
Injury / damage as a result of Use appropriate barricades and bunting to protect personnel and
dropping tools and scaffold equipment
components
Injury / damage due to scaffold Erect and dismantle all scaffold to comply with all legal and site
collapse requirements.
Injury / damage due to damaged All components to be checked prior to installation
components causing equipment
failure

Revision Date: March 2005 ………. of ………….. OHS-03-F01


JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
5 Handover of scaffold
6 Dismantle scaffold
Revision Date: March 2005
Injury / damage caused by scaffold
collapse due to excessive load on
scaffold
Injury / damage due to scaffolding
erected by unauthorized personnel
Injury / damage caused by
scaffolding erected by persons with
limited competency
Injury / damage caused by
personnel falling from scaffolding
Injury / damage caused by persons
falling whilst working outside
scaffolding
Injury as a result of incomplete
scaffold, loose boards, kickplates,
etc causing slips,trips and falls
Excess scaffold components cause
clutter. Injury results.
Injury results from untidy worksite
Injury / damage caused by falling
objects
Injury / damage caused by incorrect
sequence of dismantling
………. of …………..
POWER
Check specified limits of scaffold before utilization
Scaffold must only be erected by trained personnel
Licenced scaffolder to supervise apprentices at all times
Use appropriate barricades and bunting to protect personnel and
equipment. Use IFAS harness.
Use independent fall arrest system. 1.8m fall limit and standby
person precautions
Check scaffold properly before attaching scafftag. Tag must be
signed by qualified person. Use scaffold checklist.
Stack scaffold gear in stillage and remove from site. Keep site
clean
Keep worksite clean and tidy at all times to reduce hazards to a
minimum
Inspect scaffold to ensure it is clear of debris before turning
boards and dismantling
Correct procedure for dismantling of scaffold is adhered to.
OHS-03-F01
 POWER

JOB SAFETY & ENVIRONMENT ANALYSIS (JSA)

CONSULTATION & SIGN-OFF RECORD

I confirm by my signature below, that I have attended a briefing on the requirements of the attached Job Safety &
Environment Analysis and agree to perform the work in the manner detailed on it.
I confirm that copies of the relevant Permits, MSDS's, Isolation Plans etc. have been reviewed.

Rev:
JSA NAME JSA No:

NAME (Please print) SIGNATURE DATE

THIS SAFE WORK BRIEFING / TRAINING WAS CARRIED OUT BY (responsible person at that location) :
Name: Signature: Date:

Client sign off (where applicable)

Site / Project Manager sign off (document reviewed)

Revision Date: March 2005 OHS-03-F01