Site: Work Area: Date:

JSA Task: Registered JSA No.: Permit No:

Supervisor (Is the reviewer): Signature:
Accountable Person (for the task): Signature:
Expiry Date (Valid for 7 days): Emergency Contact No’s
Completed By (team): Signature: Completed By (team): Signature:

Critical Control Verification: Is a fatality risk involved in this task? ☐ Yes (If yes, tick the fatality risk involved and a Critical Control Verification Form needs to be completed ☐ No
by the supervisor.)

Confined Involing Height Release of Falling Tire Ineraction Vehicle Vehicle Vehicle Lifting Rotating Fire &
Space Electricity Work Energy Objects Handling Surface Offsite Collision Rollover Work Parts Explostion
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Permits Required:
☐ Working at Heights (WAH) ☐ Confined Space (CSE) ☐ Hot Works (HW) ☐ Lifting Assessment (LA) ☐ Lockout Tagout (LOTO)
☐ Electrical work (EW) ☐ Excavation (E) ☐ Other
Personal Protective Equipment (PPE) & Other Equipment Required: (in addition to minimum site requirements)
☐ Full Face Shield ☐ Gloves (suited to task) ☐ Static Lines ☐ Inertia Reels
☐ Dust Mask ☐ Welders Apron, Sleeves & Leg Guard ☐ Barricading or Witches Hats ☐ Danger / Caution Tape
☐ Respiratory Masks ☐ Hearing Protection ☐ Fire Extinguisher (suited to task) ☐ Fire Blanket
☐ Welding Shields (welders) ☐ Safety Harnesses ☐ Radios ☐ Safety Signs
JSA Reviewed by (AML / DRA) Name & Signature:
1. 3. 5.
2. 4. 6.

List of Checklists Followed for The Job:

Sr. No. Checklist details Sr. No. Checklist details

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 Residual
Job Steps: Risk Rating:
Related Hazards: Hazard Control:
Step Break into logical steps necessary Use Risk Matrix to
Those hazards associated with each step What has been put in place to reduce or eliminate the hazards determine risk
No. to complete a job
ranking after
controls in place
Ensure safety induction to all workforce, Ensure

JSA BRIEF to all workforce about specific
hazards & preventive measures on daily basis.
 Maintenance of the crane must be done on
monthly or as need basis, daily & monthly
inspection checklist to be filled, crane must be
with valid third-party inspection certificate.
Daily Review for Management of Change: (Mark your review response  Allin riggers
YES/NO)& drivers must obtain competency
 Lack of knowledge Date: cards.
Date: Date: Date: Date: Date: Date:
Sr. No Check Point
 Unmaintained crane/trailer
Day 1 Day 2 Day 3 Day 4
 Access route must be assessed before start of Day 5 Day 6 Day 7
1. Is activity in-charge changed? Incompetent riggers & the activity, safe route must be communicated
to all, proper illumination required.
Is there change in the supervision operators
(Supervisor) of the
2.  Vehicle must be inspected before use, avoid
job?  Improper access for trailer
reversing if possible, follow the signal of banks
Is there any
Liner additionaland
lifting hazard Hit by vehicle
 identified in the job? (Via man while reversing, area to be barricaded.
3.
Lesson Learnt/Why
driving by Analysis/Root
Vibro- cause analysis,
 Damage lifting etc.)
gears  All lifting gears must be validated by third party, Low
4. hammer
Is there change in the location  ofImproper
the job? ground condition for inspect all gears before use.
positioning of crane  Check the ground condition before placing the
Is there any new activity in your area which might have
5.  Pinch point crane.
potential impact on your task?
Slip trip fall  While lowering load don't put finger below the
6. Is there any change in the job steps? load, follow proper hand signal, and deploy
Improper use of ladder competent rigger, proper supervision is
7. Is there any change in the equipment’s/tools? required.
8. Is there any change in job crew (workers)?  Maintain good housekeeping at site.
Is there change in weather conditions?  Check the ladder before use, maintain angle of
9. 75 degree.
(Sunny, Rainy, Windy, Lighting, etc.)
(SPECIAL NOTE: If any one of above check point response comes out to be “Yes”.damage
Replace Supervisor mustimmediately,
ladder “Proceed for place
Change of Management”. Change of managemen
ladder
must be recorded on
at page no 9 & 10
designated of this
place JSA)
after finishing of the activity,
always position the ladder properly.
Signature
 Sufficient working space shall be planned and
Name Date: Date: Date: placement ofDate: Date:
machine, mud pits, pile cages etc toDate:
be Date:
Day 1 Day 2 Day 3 accordingly.
placed Day 4
Vehicle movementDayshall
5 be Day 6 Day 7
Rig Machine Drilling Congested and wet workplace leading defined, firm approaches made for vehicular
Activities to trips & falls and entanglement movement.

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 Stocking the soil in designated placed in limited

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Signature
No Name Date: Date: Date: Date: Date: Date: Date:
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
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Inherent Residual Risk Review with

New/ Changed Job Steps: Risk Rating: Hazard Control: Rating: work crew:
Step Related Hazards: Use Risk Matrix to Use Risk Matrix to (Supervisor Name &
New/ Changed steps necessary to What has been put in place to reduce or eliminate
No: complete a job
Those hazards associated with each step determine risk the hazards determine risk signature and date)
ranking before ranking after
controls in place controls in place

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 NOTE: Team members must sign onto the JSA again, if a change occurred during the job task, and any additional hazards were identified, and controls implemented.

Hazards
Biological & Electrical Chemical Gravity/Height Mechanical & Motion
Environmental Arc Flash Air Emissions Equipment Being Thrown Off/Under
Altitude Buried Utilities Chemical Products Tipping/Collapsing Equipment
Animal Bite/Sting Damage to Leads/Cables  Carcinogenic Excavation/Trench Disintegration of Moving
Blood-Borne Pathogens Damage to Switches  Combustible/Flammable Falling Objects Components
Contaminated Food/Water Energized Circuits/Conductors  Explosive Floor Openings/Edges Driving/Vehicle Traffic
Insect-Borne Disease Inadvertent Energization  Toxic Grating Removed Ejection of
Pests Lack of Isolation/Grounding  Corrosive Inadequate Support Workpiece/Debris
Poisonous Plants Missing/Damaged Insulation  Reactive Lack of Access Entanglement
Precipitation Overhead Lines Client/Process Chemicals Ladders/Stairs Friction
Temperature/Humidity Overload of Circuits Lack of Containment Suspended Load Movement/Shifting
Unsanitary Conditions Stored Energy Leakage/Spills Unstable/Insecure Moving Parts
Weather (Batteries/Capacitors) Material Incompatibility Materials Pinch/Crush Points
Wind/Turbulence Water Near Electrical Produced/Disturbed by Work Above/Below Projectiles
Pressure Conductors Work Others Rotating Equipment
Abrasive Blasting Work Environment  Asbestos Work at Height/Fall Sharp Edges, Corners, or
Compressed Gases Cluttered  Lead Hazard Points
High Pressure Fluid Confined Space  Silica Walking/Working Surface Shearing

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 Pressure Testing Damaged Tools/Equipment  Welding Fumes  Slippery Stored Energy
Pressure Entrapment  Dust  Uneven (Springs/Accumulators)
Washing/Blasting Erosion Water Discharges  Obstructed Striking
Radiation Hazardous Atmosphere Wastes Generated  Steep Trapped Between
Intense Light  Oxygen Rich/Deficient  Hazardous  Moving/Swaying/Pitching Equipment and Fixed
Lasers  Contaminants  Non-Hazardous  Insufficient/Unstable Structures
Microwaves Ignition Sources Sound Ergonomic Unexpected/Uncontrolled
Naturally Occurring Inadequate Ventilation Continuous Noise Awkward Movement
Radioactivity Radioactive Poor Lighting/Glare Intermittent Noise Postures/Movement
Material Restricted Access/Egress Extreme Noise Excessive Force/ Exertion
X-Rays Runoff Impact Noise Heavy/Awkward Load
Repetitive Motion
Same Position
Vibration

Severity x Probability = Risk Rating

The severity rating shall be based on the most likely outcome, not the most extreme. For example, someone walking along a level path could slip on a spillage and fall. Whilst
the worst possible outcome is a serious or fatal injury, this outcome is extremely rare. The most likely outcome is bruising or possible fractured arm. Therefore, a severity of 3
or 4 is appropriate, but not 5.
Severity Rating Score Probability Rating Score
There is little or no risk of injury or ill health. Only under rare and unforeseen
Minor injury, such as a slight laceration or bruising
conditions is there the likelihood of injury or ill health. This should be the aim of
requiring limited medical treatment 1 1
all workplace activities.
Injury requiring medical treatment, but unlikely to Remote possibility, if other factors were present, injury or ill health might occur,
result in absence from work
2 but the probability is low.
2

More serious injury, possibility requiring hospital Possibly the incident may happen if additional factors precipitate, but is unlikely
attendance and could result in absence from work.
3 without the other factors.
3

Fracture, dislocation and attendance and possible The event is probable; the effects of humans or of other factors could cause the
attendance at hospital for treatment.
4 event (injury or ill health) but is unlikely without additional factors.
4

Serious or fatal injury 5 If the task continues, then it is certain that an injury or ill health will occur. 5

Probability Rating

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 1 2 3 4 5
1 1 2 3 4 5
Severity rating

2 2 4 6 8 10
3 3 6 9 12 15
4 4 8 12 16 20
5 5 10 15 20 25

The figure should reflect the overall assessment, however: -

 Values of 16 or above means that the task MUST NOT proceed. Measures shall be taken to reduce the risk rating.
 Values between 10 and 15 shall be reassessed and only after due consideration of the risks shall the task proceed.
 Values between 1 and 9 can proceed, provided that all practical measures have been taken to reduce the risk to the lowest practical level

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