Job Safety Analysis Form

Permit to Work No.

JSA No.

Work Description

Information / Specific
Documents / Drawing / 3.
Cause & Effect / P&ID
4.

5.
STEP 1: CARRY OUT AN INITIAL TASK RISK ASSESSMENT ON-SITE TO IDENTIFY ANY HAZARDOUS
CONDITIONS & ITEMS THAT SHOULD BE CONSIDERED DURING JSA. HIGHLIGHT/COMPLETE THE
NECESSARY SECTIONS BELOW. THE HEAD OF DEPARTMENT RESPONSIBLE FOR THE JOB SHALL
NOMINATE PERSONNEL TO CARRY OUT THE JOINT SITE INSPECTION.
HAZARDOUS CONDITIONS
Asbestos Ignition sources
Adjacent Work / Simultaneous Operations Manual Handling
Confined Space Noise
Chemical Exposure NORM/Radioactive substances
Dropped Objects Potential loss of containment
Dust Rotating machinery
Exposure to hazardous materials Safety System Disabled
Exposure to hydrocarbons Slip/Trip/Fall
Exposure to toxic gases Vibration
Flammable materials Weather/Sea state
High/Low Pressures Working Aloft/Over sea
High/Low Temperatures Working at Height
Inadequate guards for equipment parts Work on live systems
Others: Others:
Others: Others:
ITEMS FOR CONSIDERATION DURING JSA
Access, egress and escape routes Lifting Plan
Communication protocols Need for securing tools and equipment
Competency of personnel Pre-work inspection of area
Contractor Competence and verification of certificates Signs/barriers
Communication methods including during Emergency Supervision required
COSHH Assessment Sheet briefed to Work Party Training requirements completed (including Contractors)
Draining/Purging/Gas Freeing Tools are inspected and are in good working condition
Task familiarisation Ventilation & Lighting
Gas Testing/Gas Monitoring Working/rest hours for Work Party
Isolations in place Others:
Others: Others:
Others: Others:
We confirm that a task risk assessment was carried out on-site during a joint inspection by the following parties:
Name Position

Law M. Mechanical Supervisor

Alex A./ Egbejimi Adebayo PSC

The inspection was carried out on:

Date: 09/ 03 /2018 Time: 10:20

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2. JSA Meeting
1. JSA No.: C_2018_0032 Date: 22/01/2018

3. Additional
Information of
Relevance to the
JSA:

STEP 2: CARRY OUT A RISK ASSESSMENT OF THE JOB, CONSIDERING THE INITIAL HAZARDS AND ITEMS IDENTIFIED DURING THE JOINT SITE INSPECTION.
 The Job Safety Analysis (JSA) Form should be completed by the JSA Team Leader (HOD responsible for the job) prior to commencement of work listed as “requiring a JSA” under the Permit To Work procedures.
 JSA Form must be endorsed by JSA Team members and appended to the Permit.

4. JSA Team Participants

Name Position Signatures Refer To MS-PO01401 Risk Assessment Matrix and MS-PR00841 PTW System – Procedure- Job
Chukwuma Onwufuju Execution Team Lead Safety Analysis for guidelines on evaluating risks

Ebuka Nwankwo Installer All residual risks should be L (Low). For Medium (M) risks, reduce to ALARP. If not, the job has to be
re-classified as a Special Operation and either cancelled or a Formal Safety Assessment (FSA) must
Inimbom Michael Iwak Installer be conducted.
Nsima Inyang Akpan Installer All employees, contractors, and site visitors have the authority and responsibility to stop work or
decline to perform an assigned task, without fear of reprisal, when an imminent risk or danger exists.
Individuals calling for Stop Work should inform the Supervisor or other person in charge of the work
being performed immediately.

Hazard controls/barriers should be considered in the following order:

1- Eliminate (The task)
2- Substitute (Use a less hazardous method)
3- Engineering controls (Isolation, equipment)
4- Administrative Controls (Procedures)
5- PPE

5. Risk Assessment
Person Responsible for Control Actions in
Activity description Hazard Consequence Initial Risk Controls/Barriers Residual Risk Remarks/ Actions/Recommendations
Control Actions Place
Responsible Person to
List person(s) that will
Step Describe the controls/barriers that will reduce the possibility of a Hazard confirm that these are
(C) (P) (RL) (C) (P) (RL) Describe any Recommendations/ implement Risk Control
No. occurring in the Hierarchy of Risk Control order. Note, if the Risk Control level in place as the job
Split activity into steps. Give brief description of Describe potential remaining Actions that should be taken measures
List each hazard is not available, please state N/A within the space provided and move down progresses.
each step outcomes of the hazard prior to Job Execution with reference to the
High the Hierarchy of control order. High
Hazard
1-5 1-5 Med 1-5 1-5 Med Name Yes/No
Low Low

1 Work site preparation and Slip, Trip and fall Injury to Personnel 4 2 M Eliminate the hazard N/A 3 1 L
establishing communication with
due to wet floor Substitute with less
all work party hazardous method N/A
Wet fall should be cleaned out
Engineering Controls

Administrative
Controls
Hand gloves, ear plug & eye
PPE Minimum PPE required
protection
2 Movement of work tools and Manual handling Heavy load could 3 2 M Eliminate the hazard N/A 3 1 L
Materials to work site of work material cause sprain and Substitute with less
and equipment Injury to Personnel hazardous method N/A

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Damage to
equipment
Engineering Controls

Use proper lifting technique and

right colour coded accessories.

Lifting equipment’s and

accessories should be inspected
before been put into use

Work piece should be properly

Administrative secure before lowering / lifting.
Controls Support document filled and
signed

Lifting equipment must be in

current colour code and properly
inspected before use.

Effective communication
established among work party.
Hand gloves, ear plug & eye
PPE Minimum PPE required
protection
3 Solvent Cleaning of the Pipe Splash of solvent Personnel injury 3 2 M Eliminate the hazard N/A 3 1 L
to eyes
Substitute with less
hazardous method N/A
Work At Height

Engineering Controls

Administrative
Controls
Additional PPE Required
PPE Safety Harness

4 Application of Transfer Fillers EP- Skin Irritation Irritation to Skin 3 2 M Eliminate the hazard N/A 3 1 L
420, 400
Eye Contact Irritation to Eyes Substitute with less
hazardous method N/A
Pinch Point Injury to Personnel
Prolong Inhalation Engineering Controls N/A
Respiratory
of Chemical
irritation Work in a Properly Ventilated
Fumes
area
Administrative
Work at Height Controls
Wash hand thoroughly After
Handling
Additional PPE; rubber
PPE Additional PPE required gloves, nose mask, Safety
harness
5 Application of Base Coat PPR Skin Irritation Irritation to Skin 3 2 M Eliminate the hazard N/A 3 1 L

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 Job Safety Analysis
Substitute with less
Eye Contact Irritation to Eyes hazardous method N/A
Prolong Inhalation Respiratory
of Chemical irritation
Fumes
Work at height Engineering Controls N/A

Work in a Properly Ventilated

area
Administrative
Controls
Wash hand thoroughly After
Handling
Additional PPE; rubber
PPE Additional PPE required gloves, nose mask, Safety
harness
6 Formashield Preparation, Skin Irritation Irritation to Skin 3 2 M Eliminate the hazard N/A 3 1 L
Application and constriction wrap
Eye Contact Irritation to Eyes Substitute with less
perforation hazardous method N/A
Pinch Point Injury to Personnel
Prolong Inhalation Engineering Controls N/A
Respiratory
of Chemical
irritation Work in a Properly Ventilated
Fumes
area
Administrative
Work at height Controls
Wash hand thoroughly After
Handling
Additional PPE; rubber
PPE Additional PPE required gloves, nose mask, safety
harness
7 Removal of Constriction Wrap and Skin Irritation Irritation to Skin 3 2 M Eliminate the hazard N/A 3 1 L
Application of Top Coat.
Eye Contact Irritation to Eyes Substitute with less
hazardous method N/A
Pinch Point Injury to Personnel
Prolong Inhalation Engineering Controls N/A
Respiratory
of Chemical
irritation Work in a Properly Ventilated
Fumes
area
Administrative
Work at height Controls
Wash hand thoroughly After
Handling
Additional PPE; rubber
PPE Additional PPE required gloves, nose mask, safety
harness
8 Housekeeping Slip/Trip/Fall Personnel injury 3 2 M Eliminate the hazard N/A 3 1 L
Substitute with less
hazardous method N/A

Engineering Controls N/A

Administrative Proper housekeeping, and

Controls segregation of waste
Normal PPE; gloves, earing
PPE PPE required
protection

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