JOB SAFETY ANALYSIS - JSA JSA No:

Rev: 01
ABG/JSA005
Issued: ___ /___/_____

TASK TASK
TASK: form work
LOCATION: SUPERVISOR:

WORKSITE HAZARD IDENTIFICATION

Working at height (>1.2 m) Equip. moving, rotating parts Lightning discharge Hot surfaces Adverse weather conditions
Dropped objects Using hand tools Hydrocarbon’s leaks/spills Manual handling (pinch points) Snakes/spiders/scorpions
Confined space Use of knifes/sharp objects Ignition source Loud steady noise (>85Dba) Biological hazard (COVID-19)
Excavation Gas/liquid under pressure Fire / explosion Vibration Simultaneous Ops (SIMOPS)
Ground / slope stability Objects under tension Radiation work Dust (including abrasive blasting, silica) Remote location (< supervision)
Slips, trips, and falls Electricity (low voltage) Chemical (diesel / engine oils) Overexertion Inadequate lighting
Overspeed (driving) Electricity (medium-high voltage) Welding fumes Awkward posture Struck by objects or equipment
Transient vehicles Electrostatic energy Toxic materials (lead painting) Heat stress Others_______________

WORKSITE HAZARD CONTROLS + REQUIRED DOCUMENTATION

Work Permit Support system/shoring Equipment isolations (LOTO) Hot work permit HSE induction training

Scaffold check (tagging system) Journey Management Plan Proper tool for the job Continuous gas testing MOPO (Matrix of Permitted Operations)

Scissor lift requirements Worksite Traffic Plan Housekeeping standards Temporary lighting COVID-19 Management Plan

Lifting Plan Work Method Statement Rigging assessment Adequate air ventilation Fatigue Management Plan

Dropped objects inspection Inspect tools / equipment Safety Data Sheet (SDS) Secondary containment Buddy system

Barrier & warning signs Body positioning (line of fire) Ignition source controls Weather monitoring Gas testing

Maintain 3-point contact Pressure control / relief valve Non-sparking tool Ground wetting Others: ______________

RECOVERY MEASURES (PPE & SAFETY EQUIPMENTS)

Basic worksite PPE Rubber/chemical gloves Harness lanyard w/ Shock Absorber Lock Out / Tag Out Devices Access and egress plans

Safety glasses + face shield Cotton gloves Horizontal lifeline Chemical apron Spill kit
Chemical splash goggles Heat resistant gloves Self-retracting lifeline Tyvek suit / chemical suit
Others: ______________
Double hearing protection Dust mask Hard safety barricade Eyewash / emergency shower
Others: ______________
Coveralls (antistatic/flame retardant) Respirator mask (cartridge) Caution tape Fire Fighting / ERT standby
Others: ______________
High visible vests SCBA mask Fire extinguisher First aid kit
Others: ______________
Heavy duty gloves Safety harness (> 1.8m) Fire blankets Radio communication Others: ______________

TASK SUPERVISOR CONSTRUCTION MANAGER SITE HSE MANAGER

Name& Signature Name& Signature Name& Signature

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 POTENTIAL RESPONSIBILITY
# JOB STEP CONTROL MEASURES / HAZARD CONTROLS
HAZARD
1. Incident due to lack of 1. Perform Toolbox talk – discuss this JHA and task specific requirements. All people PICW/EHS
knowledge, experience including housekeeping team are to attend and sign attendance sheet.
or understanding 2. Correct PPE checked before starting work. Hard Hat, safety glasses or goggles, ear
protection for when using power saw/tools or within 3mtrs, SB3 boots (must have
Task Planning + puncture proof sole and toe-tector) coverall, cut and puncture resistant gloves
1
Pre-start task
3. Check training and experience is valid for the task
4. Check power and hand tools and equipment before use. (Condition and color
coding as required)
Procedures
PTW
JSA
1. Formwork workshop area to be fenced and signs posted to avoid any PICW/EHS
unauthorized entry. Qualified carpenters and experienced helpers only
2. Power tools, power cords, junction boxes or supplies to be inspected and color
coded by a qualified electrician.
1. Personal injury, 3. Hand tools to be in good serviceable condition
puncture wounds, 4. No home-made, improvised or, modified tools are allowed
lacerations,splinters, 5. Do not allow yourself to be distracted. Eyes on the job
freign objects in eyes.
Formwork fabrication 6. Good housekeeping to be maintained to avoid trip and slip hazards and maintain
2 2. Impact injuries (line
clear access and egress.
of fire)
3. Electrical shock 7. All waste material to be de-nailed and removed from the workshop continuously,
4. Slips trips and falls and not allowed to build up
5. Fire hazard 8. All fabricated formwork to be stacked in a stable way.
9. Qualified and skilled carpenters only allowed to work in the fabrication workshop.
10. Fire extinguisher to be available at site and a trained fire watch to be ready in case
of fire.
11. First aid and eye wash to be available
1. All the above control measures in section 2 apply PICW/EHS
1. Slips trips and falls 2. WAH will require safe access using scaffold or ladder. Harness to be worn where
Formwork outside
2. Work At Height necessary (see WAH JSA)
workshop area
3. Confined space entry 3. Some excavations will be considered confined spaces e.g. slit trenches >1.2 mts
deep. (see CSE JHA

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 WORK TEAM SIGN ON / JSA no:
NEW ON HEREBY I CONFIRM THAT I HAVE READ, UNDERSTOOD, AND WILL

MENTOR
THE ADHERE TO THE REQUIREMENTS TO THIS JSA TO PERFORM THE TASK
NAME TASK FUNCTION TASK? SAFELY.
(< 90 days)
YES NO SIGNATURE DATE

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