RSA 3 PROJECT
Title Job Safety Analysis Form
SAFETY IS EVERYONE RESPONS1BLTY –SAFETY ALWAYS F1RST
Job Description: Earth dumping at Backfilling areas.
BU: STEM Area: IIP
No Basic Steps Hazards
Earth dumping at backfill locations.
0.0 UNAUTHORIZED
WORK/LACK OF JOB
AWARENESS
1 1.1 Operator / driver must carry out 360 degrees check on
1. EQUIPMENT FAILURE DUE TO
LACK OF MAINTENANCE.
ENVIRONMENTAL POLLUTION
2. EQUIPMENT /COLLISION
TO OTHER EQUIPMENT
Date: 31.12.19  New  Revised
Job Location: Cell 3 Floor and Dike Area
Control Measures SPA
0.1 Ensure required permits are obtained from authorized
permit issuers. Supervisor/
Engineer
0.2 Ensure pre-task briefing is carried out identifying risks,
their mitigation plans, traffic routes and emergency contacts.
daily basis using daily checklist of his equipment before
machine is put in operation, to ensure machine is in good Operator
condition.
Maintenance
1.2 P&M to ensure proper maintenance and upkeep of the Foreman
equipment’s as per manufacturer specified maintenance
schedule.
1.3 Ensure maintenance /oil changes /fueling is carried out in ,,,,
designated areas with spill containment.
2.1 The approved traffic Management plan to be strictly Operator/driver
followed
Supervisor
2.2 Flagman must be provided .
2.3. Follow the speed limit at construction site, 20 kph
maximum and no over speeding Ensure all personnel have Operator /Driver
completed safety orientation.
2.4 Ensure vehicles have suitable beacon lights and reverse
sirens and they are in working condition.
Safety Officer
 RSA 3 PROJECT

Title Job Safety Analysis Form

SAFETY IS EVERYONE RESPONS1BLTY –SAFETY ALWAYS F1RST

3.1 Ensure the ground is level and properly compacted.

3.2 Avoid tipping materials on inclined position to avoid tip Earthwork
over. foreman
3. VEHICLE GETTING 3.3 Make sure all materials are completely discharged and
Foreman
STUCK/TOPPLING. dump box is fully lowered prior to movement of the vehicle.
3.4 Wheel stopper or physical barriers along with high Supervisor/
visibility edge markers to be provided along with flagmen Foreman
while dumping at slopes. Minimum distance of 2m from edge
of embankment to be ensured.
4.1 No personnel to be in close to the vicinity of the
equipment. Minimum distance of 5m to be maintained. If
4. PERSONNEL INJURY DUE TO Foreman/
personnel have to move nearer than 5m equipment to be Operator
STRUCK BY EQUIPMENT
stopped .Proper communication protocol between operator,
flagman and ground personnel to be established.
4.2 Equipment to be provided with warning devices like
Safety
reverse alarm and revolving beacon. Operators and ground officer/Foreman
workers to be provided with high visibility clothing.
Required and/or Standard PPE Goggles Hearing Protection Rescue Equipment Hi-Visibility Vest Gloves__________
Recommended P.P.E
Level___ PPE Face Shield Fall Protection High Voltage PPE Disposable Coveralls Respirator________

Emergency contact name

& Number
Prepared by: JSA Team Members
Approved by:

Name ID # Position Signature Date Name ID # Position Signature Date

 RSA 3 PROJECT

Title Job Safety Analysis Form

SAFETY IS EVERYONE RESPONS1BLTY –SAFETY ALWAYS F1RST

JSA Acknowledgement Form

Date of briefing:
Conducted by:
Name: Signature
Title of JSA:
I acknowledge of the JSA briefing to me and understand its content.

No. Name Company ID# Signature

01
02
03
04
05
06
07
08
09