JSA (Job Safety Analysis)

Start Date of Work Order: Work Order Number: Job/Task Description:

7/11/2023 za55835 change fuel pump
Name of Service Technician(s): Job Location:
g167 1b

Ye
Do I understand the scope and steps required to perform the job/task?
No If the answer is “NO” to any of these questions
✘
Have I read and/or understand the required procedure (ex. SIS)?
s
✘
NoDO NOT PROCEED. Contact your supervisor
Have I read and understand the safety policies that relate to the job/task? ✘
No
Identify and assess the risk of current job/task. Determine what control measures and PPE that must be in place to eliminate and protect yourself from the potential hazards.

1. Physical Hazards: Control Measures: PPE:

Yes No✘ Do cut hazards exist from exposed sharp edges? Sharp edges have been padded, covered, or access to area is limited Gloves:
Yes No Do pinch points/crush hazards exist?
✘
✘ Machine/parts have been blocked against motion, cribbed or chocked Cut Resistant Gloves – ANSI level 2 cut resistance

✘
Yes No✘ Do slip/trip/ hazards exist? General housekeeping; ice/mud/debris cleaned or mitigated
✘ Cut Resistant/Impact Gloves-ANSI level 4 cut resistance
Yes No✘ Do fall hazards exist? Ladders; stairs; handrails; 3 points of contact Chemical Resistant Gloves
Yes No✘ Do welding flash/radiation hazards exist? Proper screening is in place; hot work procedures are being followed Welding Gloves
Yes No✘ Are any fire hazards created by hot work? Access to fire extinguishers; hot work procedures are being followed
Yes No✘ Do any flying particle hazards exist? (Grinding, cutting etc.)
✘ Machine guarding is in place and working properly Eye/Face Protection:
Yes No✘Do electrical hazards exist? Arc flash procedure and equipment Safety Glasses–ANSI Z87.1

✘
2. Ergonomic Hazards: Control Measures: Prescription Safety Glasses with side shields
Yes No✘ Does this job/task require work in prolonged awkward positions? Changing of position and stretching Face shield
✘
No Does this job/task require bending, twisting over-reaching excessively? Changing of position and stretching
Yes
✘ ✘
✘
Yes No✘ Does this job/task require the use of excessive force or heavy lifting? Appropriate lifting device; Assistance with moving/lifting Other:
3. Chemical Hazards: Control Measures: Respirator – must be approved and fit tested
Yes No✘ Does over exposure to liquids, vapors, or dust exist? SDS are readily available and have been reviewed Hearing Protection
4. Control of Hazardous Energy (Lockout/Tagout): Control Measures: High Visibility
Yes No Are all energy sources identified and controlled? Review Lockout/Tagout procedures and implement controls Fall Protection/Fall Restraint
✘
No✘ Can equipment move unexpectedly? Proper blocking against motion procedures has been implemented
Yes
✘ Foot Protection (composite protection/slip management/shoe tread)
5. Environmental Hazards: Control Measures: Welding PPE (shaded eye protection, garments, etc.)
Yes No✘ Does severe weather create additional exposures to injury/illness? (Tornadoes, Lighting etc.) Weather conditions are being monitored; emergency plans are in place Arc Flash PPE Kits
No Do slip/trip/fall hazards exist do to ice, water, or snow? Surface ice, water, or snow have been cleared/salted
Yes
✘
✘
Yes No✘ Do spill hazards or exposures to hazardous/infectious waste exist? Controls are in place to prevent contact with chemical or waste
6. Work Condition Hazards: Control Measures:
Yes No✘ Is there a need to warn or limit access? Warning signs, caution tape, barricades, or guardrails
7. Other Hazards (List): Control Measures (List):

✘
8. Have Employees in Adjacent Work Areas Been Made Aware of and Understand Potential Hazards in Your Work Area? (Check Yes or No and Have the Employee Insert Name and Date
Name of Employee: Date:
Yes No
Yes No
Yes No
Yes No
Yes No
9. Additional Hazards Created as Work Order Progressed (List Date and Added Hazard): Added Control Measures:
Date: Hazard: Control: