An Auckland Council Organisation

Job safety analysis Phone: (09) 442 2222

Website: www.watercare.co.nz

(JSA)
Please 1 2 3 4 5
Permits and 6 7
fill in all Site and Emergency Personal Possible Steps taken Changes Sign on
certificates - and
sections project response protective hazards attach PDFs, and hazard and updates
details information equipment controls to the JSA submit
JPEGs, etc form
(PPE)

1. Site and project details

Site name Raglan Marae Project name/work order # Waikato District Network Renewals 2021

Site address: Number 69 Street name

Wainui Road
Suburb
Raglan
Postcode
3225

Work location/process area

Refer attached map Authorised access (AA) #:

HEB Construction
Service provider undertaking the works: JSA #:

Version 4 Release: 07-2019

02 / 06 / 2021 02 / 06 / 2021
Work planned start JSA developed by
Work planned end
date
Installation of a new 1500mm manholedate
to house the new 125mm PE rising main and intersect the existing 150mm gravity wastewater main outside of 69 Wainui Road.
Trench excavation to expose the existing 150mm AC wastewater main (20020831130423); replace section of the existing AC main with PVC; prepare base and pour the base
for the new 1500mm manhole riser; install ceramic channel and concrete hunching inside manhole.

Description of
the works
(Scope of work)

David Zhang

Reviewed by 31 / 05 /2021 Confirmation to proceed with work DD / MM / YYYY

(Watercare authorised person)

continued >>>
Job safety analysis (JSA) 2

2. Emergency response information

Emergency
contacts
Person in charge of the work: full nameShane RobinsonWatercare representative: full namePeter CrabbOther: full (027)222-2531(022)043-1191()
Contact
nameFacility control: full nameControl room - water treatment plant: full nameControl room - Newmarket: full name ()()()
phone

Contact

phone

Contact

phone

Contact
Nearest medical facility address and contact details: Raglan Medical - 9 Wallis Street, Raglan

phone
117 Wainui Road, empty section opposite Rakaunui Street HEB Utes & Trucks
Contact

phone

Contact

phone

Evacuation point First Aid kit location

✔ ✔ ✔ ✔
IN THE EVENT OF AN EMERGENCY DIAL 111 IMPORTANT: Injuries, incidents and near misses must be reported to your Watercare representative without delay. For
serious events, the incident scene must not be altered (unless to make it safe) and all work in the vicinity of the event must
✔ cease until permission to proceed has been granted by your Watercare representative.
✔ ✔
3. Personal protective equipment - mark all that apply
✔ Respirator
✔ H ✔ protection
High visibility e
clothing Foot protection
a
✔ ✔ ✔ d
✔ Hearing
protection
✔ Face shield
Job safety analysis (JSA) 2

2. Emergency response information

Hand protection Welding mask
Protecti Breathing
ve Dust mask apparatus
clothin
g

Eye protection Safety harness

Life vest

Gas detection

Portable
ventilation Fire extinguisher Portable Tripod and First Aid kit
radio winch

continued >>>

Version 4 Release: 07-2019

 Job safety analysis (JSA)
4. Hazards - what could cause harm? Mark all that apply
Atmospheric conditions
✔
Facility entry point (covers
and manholes etc)
✔ Hot/cold temperature
Confined space
✔ Fire / explosion
Toxic Gas (H2S, Methane etc)
Biological
Viral / bacterial
Rodents / insects
Excavation / penetration
✔ Hazardous Materials
Trench / excavation
Penetration
Tunnelling
Energy
✔ Mechanical
Electrical
Hydraulic / Pneumatic
Ultraviolet (UV)
Gravitational/Potential
✔ Underground/Overhead
Services
Other: _________________
Work environment
✔ Hazardous surface conditions
✔ Poor visibility
Unstable ground
✔ Noise
✔ Vibration
✔ Weather
Sharps, needles and broken
items
Hazardous zones
Explosive Atmosphere Zone
(EEHA)
Major Hazard Facility (MHF)
Manual Handling
Heavy Lifting
✔ Repetitive
Other: _______________
Working at Height
Structure without barrier
Ladder
Skylight or non-weight
bearing structure
Other: ________________
External
Public/Third parties
Animals
Hot works
Flammable substances
✔ Explosive gases
Hazardous Substances
✔ Chemicals (liquid/gas/fume)
✔ Asbestos
Chemical or environmental
dust
Water bodies
Dams, lakes, ponds, lagoons
Channels/aqueducts
Pipelines
Reservoirs/wells
3
Materials movement & storage
Stacking/racking
Suspended loads
✔ Lifting equipment
Loading/unloading
Plant & Equipment
Fixed plant and equipment
✔ Mobile plant and equipment
Physiological/human factors
✔ Fatigue
Impairment
Working alone
Working at Height
Road corridor traffic
Version 4 Release: 07-2019
Site traffic
continued >>>
Pedestrians
Other: __________
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 ✔
Job safety analysis (JSA) 4
✔
5. Workpack documentation - tick all that apply, attach PDFs or jpgs or physical copies to this form
✔
Regulator notification: Y/N Supporting documentation: Y/N Interaction with utilities: Y/N

✔ Worksafe notification form Electricity - what voltage? N/A

Permits to work attachments Work methodology/SOP Pressure/fluid/air - what

product?
N/A
Confined space Attached CAR form (change Gas - what pressure? N/A
entry permit
Attached
✔ Water/sewer/storm water - Water, Wastewater &
Excavation permit form) Site mains? Stormwater

Explosive atmosphere area ✔ Communication/phone - UFF, Chorus &

permit plans/drawings what type? Vodafone

High risk activity permit Lift plan

MHF regulation applies

CSRP (risk to supply)

EEHA regulation applies

Hot work permit
Safety device impairment Other (explain):
permit

Version 4 Release: 07-2019

Work at height permit
Hazardous energy permit

Isolations required: Y/N Record energy isolation/safety arrangements agreed with Watercare Operations or utility provider:

Isolation Request

Self-isolation (LOTO)

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 Consequence / potential severity
Risk matrix Minimal
Non-injury or First Aid
injury (FAI)
Minor Moderate Major
Medical treatment injury Medical treatment injury, Injury requiring hospital-
with lost time (LTI) isation/notifiable event
Catastrophic
Fatality or multiple
fatalities

Very high Almost certain: Commonly occurs 3: Medium 4: High 4: High 5: Very high 5: Very high

High Likely: Could easily happen 2: Low 3: Medium 4: High 4: High 5: Very high
Likelihoo

Medium Possible: Could happen or has 2: Low 2: Low 3: Medium 4: High 4: High
d

been known to happen

Low Unlikely: Hasn’t happened yet but 1: Very Low 2: Low 3: Medium 3: Medium 4: High
could happen

Very low Rare: Very unlikely but could hap- 1: Very Low 2: Low 2: Low 3: Medium 4: High
pen in exceptional circumstances

6. Steps taken to complete the job

Hazards (one per line) Hazard controls – what do we need to do to make it safe?
What are we doing? What could cause harm? Existing Can we eliminate If elimination is not possible, can we: If any risk still remains: Residual
risk level the risk? - substitute and/or - use admin controls and/or PPE (PPE is risk level
(step by step) (use risk - isolate and/or the least effective and should not be first
matrix) or the only control measure)
List how below - use engineering controls

Set up traffic management
Trench excavation to expose existing
150mm AC Main
Traffic 4 Set up traffic management as per approved traffic management plan, ensure work zone is isolated from the traffic 2
and the traffic is safe going around the work site
Existing Services 4 Service mark-outs prior to excavation; hand dig around the services or only use hydro-excavation. 2
Trench deeper than 1.5m 4 Batter and step the trench to make safe for access in and out of the trench. If necessary, trench shield to be utilised 2

Replace sections of AC pipe with PVC Dealing with Asbestos 4 Works to be carried out by certified personnel; AC to only be wet cut and placed in the bag as soon as possible 2
pipe while plugging upstream manhole Cement for disposal
Dealing with live 4 Only certified personnel to be working with live wastewater; up to date vaccination for hepatitis 2
wastewater
Confined space 4 Follow strict confined space entry rules; tripod & winch set up for the job and gas detector attached to the entrant 2
at all times
Manhole cover opening 3 Set up barriers to isolate the area 2

Exposure to pathogenic 4 Wash hands with disinfectant soap/handwash before consuming food 2
organisms
Manhole base preparation Dealing with cement 4 Proper PPE to be worn e.g. masks, eye protection and gloves. 2
Manhole haunching Dealing with cement 4 Proper PPE to be worn e.g. masks, eye protection and gloves. 2

Dealing with live 4 Only certified personnel to be working with live wastewater; up to date vaccination for hepatitis 2
wastewater
Confined space 4 Follow strict confined space entry rules; tripod & winch set up for the job and gas detector attached to the entrant 2
at all times
Manhole cover opening 3 Set up barriers to isolate the area 2

Exposure to pathogenic 4 Wash hands with disinfectant soap/handwash before consuming food 2
organisms
Plants Moving machinery 4 Exclusion zone; spotter on site to ensure no one is within striking distance; only certified operator to operate the 2
machine; correct PPE to be worn e.g. hi-vis vest & hard hat
Exhaust fumes 3 Ensure plants are checked regularly so no harmful fumes exhausted to the environment 2

General Slip, trip & fall 3 Site awareness; PPE to be worn e.g. safety boots 2

Weather condition – fog 4 If required, delay work until visibility has restored 2

Tracking dirt to the road 3 Wheels to be cleaned before going on to the carriageway 2

Poor lighting 3 Portable lighting or wait for daylight to come through 2

Working in noisy condition 3 Correct PPE to be worn e.g. earmuffs 2

Manual Handling 4 Use of alternative equipment such as excavator; or at least two-men lifting for anything heavier than 20kg 2

Fatigue 4 Site supervisor to ensure smoko break are being taken to keep fatigue level down 2

Version 4 Release: 07-2019

Hold point: Authorisation to start any work must be obtained from a Watercare representative or control room prior to starting the work

continued >>>
7. Changes and updates to the JSA

New hazards Hazard controls – what do we need to do to make it safe?

(one per line)
List any changes or What could cause harm? Existing Can we eliminate If elimination is not possible, can we: If any risk still remains: Residual
modifications to the job below, risk level the risk? - substitute and/or - use admin controls and/or PPE (PPE is risk level
in order (use risk - isolate and/or the least effective and should not be first
matrix) or the only control measure)
List how below - use engineering controls

Hold point: All changes and modifications to the job must be authorised by a Watercare representative or control room

JSA sign on: I have read and understood this JSA and agree to follow the plan, use the agreed hazard controls and work safely.