JOB SAFETY & ENVIRONMENT ANALYSIS (JSA)

ACTIVITY OR TASK: Location / Project:

JSA Preparation & Job Number:

task work team: JSA Number: 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 Name: Position / Competence/ License: Date:
person responsible i.e.
Team Leader / Tradesman

2. HAZARD IDENTIFICATION Identify hazards that may be present by checking 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: typ0e: 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) check those identified Consequences: how severe an injury?
Likelihood:
Air Pollution (dust, fumes) Spills to ground Other: RISK RATING TABLE How likely is it to Death Serious Medical 1st Aid
This table is used to calculate whether be that bad? Injuries Treatment req’d
Noise (plant & equipment) Soil Erosion Req’d
the hazard you have identified is
Spills to drains/waterways Hazard to Flora /Fauna Extreme: 9-10 High: 7-8, Almost Certain - 10 9 8 7
Expected to Occur
Medium: 5-6 or Low: 3-4
Likely – could 9 8 7 6
5. EQUIPMENT REQUIRED: happen sometime

Static Plant & Equipment The objective of rating the risk is to lower the risk Moderate – could 8 7 6 5
by initiating risk control measures. The score is happen but not likely
Mobile Plant & Equipment noted in the JSA risk score column on the next Unlikely – could
page – both before & after risk control measures 7 6 5 4
Safety / Emergency Equip’t happen but very rare
have been nominated. Rare - could happen 6 5 4 3
but probably never will

Revision Date: January 2013 ………. of …………..

 JOB SAFETY & ENVIRONMENT ANALYSIS (JSA)
NAME OF TASK: JSA Number: 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 incident. The risk must Of the risk
Logical accomplish a major task and be logical. environmental) associated with each step, the previous be reduced or controlled to a level that is acceptable before work commences. following
sequence
Environmental Aspects examine each to find all possible risk factors page to Indicate who is to perform the action where applicable against each action corrective
score risk action

Revision Date: January 2013 ………. of …………..

 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: January 2013