GUIDANCE NOTES FOR COMPLETING A
JSA FORM
(Form can be used by a work group or individual)
STEP 1. Circle the Relevant Area
STEP 2. Write in the JSA Title
STEP 3. Write in the JSA Scope
STEP 4. Define the Job/equipment
etc.
STEP 5. List any Reference
Materials used
Date made: 10-Sep-2022
Date revised: 29- Sep- 2022
STEP 6. Fill out the JSA team details
STEP 7. Develop the procedure or Work
Instruction that includes the critical safe
behaviors to ensure that you complete the
job safely
STEP 8. Check for other documents, sign
off and give the form to your Supervisor
JSA Made by:Carlos Orasji
JSA Approved by: HSE supervisor (Sherief Rodjan)
KULDIPSING EQUIPMENT
JOB SAFETY ANALYSE
FORMULIER
STEP 1 – Circle Relevant Area:
M3 Prefab Maritiem Other: KED MTC
Step 2 JSA Title: Painting
Step 3 JSA Scope: This JSA is intended for sandblasters and
painters
STEP 4 – Define the Job/Equipment/Process/:
On regular basis we hire contractors for maintenance on our pontoons.
This includes removal of old coating and corroded spots with high
pressured sand blasting equipment. The pontoon is then again coated
with three layers of paint to keep it protected against corrosion.
STEP 5 – List Any Reference Materials/Document
Certify workers
Appropriate tools.
Operator and service manual
Document (JSA) name: Sandblasting/Painters
Version: 2.0
 STEP 6 – List the JSA Team Members:
Name Position Industry Job
Experience Experience
Carlos Orasji Fleet 14 6
Supervisor

JSA Prepared by: Signature: Date: 10 September 2022

Carlos Orasji

Authorizing HSE Signature: Date: 29 September 2022

Supervisor:
Sherief Rodjan
PLEASE RETURN THE COMPLETED AND SIGNED FORM TO YOUR SUPERVISOR
No. Activity/Task/Job Hazards/Potential Incidents Potential Existing or Current Controls Who
Steps HSEC
Consequence
List the natural What can happen at each step? Describe how defined hazards can be managed or
steps of the task (not Use following checklist: Can removed. Consider elimination/substitution, engineering
too broad and not too employee be struck by/caught controls, administrative controls, personal protective
fine) by/contacted by/struck equipment. Are there any of this controls already in
against/caught between/ exposed place?
to/have same level or different level
fall/ strained/overexerted.

Date made: 10-Sep-2022 JSA Made by:Carlos Orasji Document (JSA) name: Sandblasting/Painters

Date revised: 29- Sep- 2022 JSA Approved by: HSE supervisor (Sherief Rodjan) Version: 2.0
 1 Site preparation and Poor planning • Supervisor and Supervisor and the
Inspection contractor shall conduct joint site Contractor
inspection to identify hazards.
• The overall cable layout shall be
prepared

2 Before connecting the Trip and fall hazard • Wear appropriate PPE Sandblasters and
air hoses • Remove all obstacle /cleanup painters
procedure/inspect the hoses
• Refer to the operation and service
manuals of the manufacturer
3 Sandblasting • High pressure • Physical check on hose condition Sandblasters
• Noise • Secure hoses and relief valve in safe
• Exposure to dust working condition
• Earing protection
• Protective clothing
• Functional test (Gradually turn on)
• Blasting hood
• Workers most wear the required PPE
• Adequate ventilation
Depressurize the system , by using
4 Coating • Leaks • Ensure the correct PPE is used
manometer(testpoint), Painters
• slips • Safety classes must be worn at all time
• eye injury • Check for correct setup, tighten all
fittings
• Ensure safety trigger lock is operational
and locked machine is turned of
• Use scaffold for spraying, not ladders
• Spill kit must be always available
• Adequate ventilation
•

Date made: 10-Sep-2022 JSA Made by:Carlos Orasji Document (JSA) name: Sandblasting/Painters

Date revised: 29- Sep- 2022 JSA Approved by: HSE supervisor (Sherief Rodjan) Version: 2.0
 5 House keeping • Health hazard • Drinking location must be in Supervisor, contractor,
• Environmental pollution good hygienic conditions Sandblasters and
• Housekeeping must be done prior to Painters
closing of working permit
• All unused materials must be removed
from site daily and dispose of only in
an approved dumping area

SIGN OFF
(All personnel involved in performing the work shall enter their names below and sign to confirm they have read, understood, and will comply with
the conditions of the JSA).
Name Role in team (e.g., Company Signature Mobile #
driver)

Supervisor signature: Name: Date:

Date made: 10-Sep-2022 JSA Made by:Carlos Orasji Document (JSA) name: Sandblasting/Painters

Date revised: 29- Sep- 2022 JSA Approved by: HSE supervisor (Sherief Rodjan) Version: 2.0