HSE-SAF-SFM-00-0018

SAFETY
Rev. 8
15-May-2018
JOB SAFETY ANALYSIS (JSA) FORM
Page 1 of 13

JSA GENERAL INFORMATION

Unit: 32 Area: ISBL Equipment Involved: N/A
Work Scope / Job Activity: Road (Asphalt) Cutting & Excavation Activity In New LD line Project

Original JSA Date: 25 Nov 2018 High Risk Activity: NO YES (HSE Rep. required) High Risk Activity Job Step Nos. :
Maruthu Basith Aswin Janarthanan JSA Facilitator Name:
JSA Participants
Name Ralph Abreu

REVALIDATION DATE
(JSA IS VALID FOR 3 MONTHS. REVALIDATION TO BE DONE AFTER 3 MONTHS IF SAME JOB CONTINUOUS OR IF ANY CHANGE IN JOB SCOPE OR JOB CONDITION).
No. DATE NAME SIGNATURE No. DATE NAME SIGNATURE
1 4
2 5
3 6

JSA PRE-CHECKS
YES NO QUESTION
 Is the JSA Team sufficient (Area Owners, Job Performers, HSE Rep, Technical, etc.)?
 If contractor is involved, contractor participated in JSA?
 Is Job Scope clear and well defined?
 Visit to the job site has been made?
 If a similar activity was performed in past, a copy of previous JSA is available?
Is team aware of any history of incident / near-miss on similar job at Q-Chem? If YES, lesson learned report (LLR) should be reviewed and
 attached to JSA?
 Are any unique SDS’s required for this job? If YES, SDS’s should be reviewed by JSA Team?

HSE-SAF-SFM-00-0018 Rev.8 Date: 15-May-18 Page 1 of 13 Ref. KBD: HSE-SAF-PRO-00-0009

 HSE-SAF-SFM-00-0018
SAFETY
Rev. 8
15-May-2018
JOB SAFETY ANALYSIS (JSA) FORM
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JSA HAZARD CHECKLIST

YES NO Work Environment / Personal
Rain High Winds Dust Poor Visibility Lightning Storms Birds, animals,
 insects Bacterial / Viral Plants Others (please mention if any other)…………………………
 Heat Stress
 Language / Communication barriers
 Fatigue
 Oxygen Deficient Atmosphere / Poor Ventilation
 Nitrogen Rich Atmosphere
YES NO Excavation
 Fall into open hole
 Collapse of excavation walls
 Underground utilities (live cables, pipelines etc.)
Unstable adjacent structures
 Heavy equipment park or movement near excavation
 Water/ Toxic material accumulation in excavation
 Falling hazard/ uneven surface
YES NO Electrical
 Working on energized equipment
 Un-insulated live conductors or damaged cables
 Electrocution/ Electric Shock due to lack of protective system like GFCI etc.
 Arc Flash Hazards
 Static electricity
YES NO Thermal (high/low temperature) / Radiation
 Contact with excessively hot (more than 500C) or cold equipment/ surface.
 Exposure to ionizing radiation from x-ray, gamma rays or laser etc.
 Exposure to non-ionizing radiation e.g. ultraviolet, welding rays, infrared etc.
 Metal Fire from metal packings in columns or vessels over packed beds (also having flammable
material coating)
 Scaffold Materials Exposed To Hot Surface or Potential Hot Surfaces
 Source of ignition / hot work/PWHT
 Exposure to high temperature water (more than 500C) (i.e.; high pressure hydro-jetting activity,
condensate draining)
YES NO Moving Machinery/Tools/Equipment
 Contact with high velocity ejected particles / objects. Struck by moving (e.g. broken, flying) object
 Inadequate machine/ equipment guards.
 Wearing clothes or jewellery that could get caught in the machinery
 Moving vehicle, forklift
 Homemade/ poor condition / damaged/ uninspected tools (including hand tools), machines and
equipment
 Contact with sharp blades/edges
 Struck by tools/ equipment
 Exposure to excessive vibration
 Non intrinsically safe equipment
 Mechanical stops or limits missing or damaged
 Pinch / nip points

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 HSE-SAF-SFM-00-0018
SAFETY
Rev. 8
15-May-2018
JOB SAFETY ANALYSIS (JSA) FORM
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JSA HAZARD CHECKLIST

 Heavy equipment movement
 Equipment noise level at or above action level.
YES NO Pressure
 Damaged hose on gas cylinders
 Damaged/corroded/ Inadequately stored gas cylinders.
 Failure of plant or equipment causing release of stored pressure (behind non-return/check valves, etc.).
 Incorrect pressure regulator fitted to gas cylinder.
 Objects under compression/ tension e.g. spring, wire rope, polyester slings and chains
YES NO Slips, Trips, Falls
 Slick working surface or uneven working surface or tripping hazards
 Substandard / damaged ladders and steps
 Housekeeping
YES NO Working at Height / Dropped Object
 Uncertified fall arrest system inappropriate anchorage point inadequate fall clearance
 No guardrail No barricade No toe board
 Working on walking and working surfaces within 1.2 meters (04 feet) of a leading edge or brittle surface
with a fall potential of 1.8 meter (06 feet) or greater.
 Person working alone no buddy system to initiate rescue
 Dropping objects from height (Refer to Appendix 8.11)
 Working under suspended load
 Risk of fall to personnel from 1.8 meters (06 feet) or greater height?
Rescue Plan Assessment
YES NO NOTE: If below conditions meet, prepare the job specific rescue plan (Refer to Work at Height Procedure
Appendix D)
 Additional hazards in fall path hot surfaces live electrical conductors drowning hazards
 Rescue of the fallen person is excessively difficult. no means of egress available specialized
rescue equipment required rescue team cannot reach the location easily
YES NO Egress / Ingress / Restriction
 Restricted / unsafe access or egress Struck against fixed object Struck by mass
acceleration
YES NO Chemical
Hazardous Chemical
Pyrophoric Explosives Flammable Liquids Flammable solids Oxidizing
 Organic peroxides Poisonous (Acute) Infectious substances Radioactive
Corrosives Toxic (Delayed or chronic) Asphyxiant Lead
Carcinogenic Cryogenic Any other …………………………………….
 Improper container, lack of secondary containment, inadequate labelling, etc.
 Exhaust fumes e.g. forklift, generator
YES NO Ergonomics Hazards
 Unusual / awkward or cramped positions to perform the job
 Manual handling for heavy objects
 Accessibility to the equipment
 Excessive force
 Repetitive motion

Physiological/ Psychological Hazards

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 HSE-SAF-SFM-00-0018
SAFETY
Rev. 8
15-May-2018
JOB SAFETY ANALYSIS (JSA) FORM
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JSA HAZARD CHECKLIST

 Stress Peer Pressure
YES NO Waste Handling/ Disposal
 Generation of hazardous waste
 Hazardous Waste handling, segregation and disposal
 Improper waste containers
 Poor housekeeping due to material presence in job area
YES NO Working in a Confined Space
 Potential hazard of the Confined Space, including identity and nature of material last contained in the
space and potential NORM concentration
 Hazard caused due to material brought inside the Confined Space such as fumes, toxicity, flammability,
lead exposure etc.
 Hazard caused due to equipment brought inside the Confined Space such as noise, electrocution,
radiation etc.
 Hazards of the concurrent works planned inside the Confined Space
 External hazards like traffic
 Inadequate Lighting / Additional Lighting requirements
 Inadequate ventilation / Additional ventilation requirements
 Inadequate PPEs / Specialised PPE requirements
 Permit to work requirements not identified
 Blinding is not done at the flange that is closest to the equipment
 Communication method of hole watch with entrants are inadequate
 Continuous Gas monitoring requirements not identified
 Periodic monitoring of Toxic Substance not identified
 Safeguard against temperature extremes not identified
 Maximum number of persons inside confined space not identified in rescue person
 Training qualifications of ‘Confined Space Entrants’ for employees and contractors not identified
 Backup Hole Watch requirement identified
 Installation of physical barrier at the entry point of confined space identified.
YES NO Miscellaneous Hazards
 Adjacent jobs or activities
 Alarms or signals not audible
 High noise above100dB
 Substandard / damaged / inadequate PPE
 Unavailability of SOP, SMP or method statement.
 Job required MOC
 Pressurized hoses in work area
 Stop/Start switches that could be inadvertently contacted
 Equipment trip due to safety interlock unintended activation.
 Will a road be completely blocked? (If YES, then a Road Blocking Permit HSE-SAF-SFM-00-0044 is
required)
 Damaged/Inadequate/insufficient communication equipment
 Lack of special training or certification requirement

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SAFETY
Rev. 8
15-May-2018
JOB SAFETY ANALYSIS (JSA) FORM
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YES QUESTION
 The JSA Hazard Checklist is filled and attached with the JSA?
NOTE: If any point ticked “YES” in JSA HAZARD CHECKLIST above, its mitigation shall be mentioned in JSA JOB STEPS below.
JSA - JOB STEPS
JOB STEP JOB STEP DESCRIPTON POTENTIAL HAZARDS REQUIRED MITIGATIONS
1  Vehicle movement only at permitted areas
 Access concern/damage to existing  Vehicle movement path for adequate ground and
Site preparation and mobilization. facilities overhead clearance
Loading, unloading, shifting of  Equipment to move with spotter signal
materials, Generator and other  Gas test shall be done prior to vehicle entry and
tools. gas monitoring to continue at work site.
 Spark due to vehicle entry.  Check vehicle/equipment condition daily prior to
each use.
 Keep RLOC certified fire extinguisher with vehicle.
 Assign material storage location in field to avoid
blockage of plant operation/maintenance
 Blocking of essential area by stored activities/vehicle movement. (Take assistance of
materials operator)
 Access should not block to safety or plant
equipment
 Proper manual handling techniques shall be
followed with proper body ergonomics.
 Avoid twisting or awkward body postures.
 Handling heavy loads
 Always keep the load close to your body
 Maximum lifting for any person shall not exceed 20
kg
 Boom truck tilting/collapsing  Ensure outriggers are fully extended and the boom
truck should park only on even surface.
 Use RLOC certified Boom truck and lifting tackles.
 Don’t stand under suspended load.
 Barricade and provide barricade tag for the work
area.
 Ensure operator have valid 3rdparty certificate for
boom truck operation.

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JOB SAFETY ANALYSIS (JSA) FORM
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 Road Block
 Obtain Road Block permit from FSC prior starting
the activity.
 Use calibrated surveying machine.
 Use of uninspected /calibrated  Use appropriate drawings for survey
surveying machine which can cause  Survey machine must be inspected and approved
2 Surveying and marking the area improper survey, damage of by RLOC with inspection stickers.
underground pipe /cable (equipment  Continuous gas monitoring to be done
damage/personal injury)  Obtain PTW prior to start work
 Use calibrated scanning instrument
Scanning to identify by  Use of uninspected/calibrated scanning  Scanning instrument must be inspected and
3
underground utilities instrument. approved by RLOC with inspection stickers.
 Continuous gas monitoring to be done
 Proper manual handling techniques shall be
followed with proper body ergonomics.
 Handling heavy loads
 Avoid twisting or awkward body postures.
 Always keep the load close to your body
 Maximum lifting for any person shall not exceed 20
kg
 Lead Worker should identify pinch points in the
Hard Barricading with scaffolding
 Pinch points while erecting barricades activity and it should be discussed during TBT
4 pipes around the area to be
 Keep body parts away from line of fire.
excavated.
 Hard barricade the area and put barricade tags.
 Do not park or move any equipment or vehicle near
the edge of the excavation.
 Fall of person / materials into excavated
 Beware of excavation edges while building hard
area barricade
 Hard barriers shall be erect not less than 2 meters
from the edge of the excavation.
5 Cutting of existing Asphalt  Personnel injury due to sharp edges  Keep away from line of fire.
Pavement and Concrete by using  Keep eyes on task.
concrete cutter and Asphalt  Wear cut resistant gloves while handling sharp
demolition edges.
 Ensure the asphalt cutter having safety guard.
 Eye injury due to flying objects while  Use face shield with safety glass while using cutting
core cutting machine

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JOB SAFETY ANALYSIS (JSA) FORM
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 Heat produced by cutting wheel.  Ensure continuous coolant(water) supply while

cutting
 Ensure the asphalt cutter having continuous coolant
supply device that functioning properly.
 Ensure machine guard in place.
 All underground identified areas shall be marked
with depth on Road cutting areas.
 Damage of underground services  Asphalt cutting depth shall not exceed 100mm.
(Pipelines, cables, etc.)  Underground utilities identified areas less than
300mm depth shall be marked at span of 1 meter
from both side and concrete cutting limited up to
50mm in that areas.
 Static electricity / Electrocution  Ensure Generator is properly grounded.
 Barricade the generator with barricading tag.
 Check for any visible damage on the wiring and
make sure there are no splices or temporary joints.
 Disconnect asphalt cutting machine when not in
use.
 Injuries while operating rotating  Ensure adequate machine guarding in place.
machines (E.g. Concrete cutting  Keep hands away from the moving parts.
machine)  Do not wear any jewellery while working
 Contact with high velocity ejected  Use face shield with safety glass while cutting, the
particles / objects. concrete. Use approved dust mask (i.e.3M 8210)
 Avoid unauthorised entry
 Line of fire  Area must be barricaded, and only authorized
personal is allowed.
 Keep body parts away from the cutting blade.
 Secure tools and cables away from work area.
 Slips/trips
 Cables should be laid properly to avoid trips.
 Maintain good housekeeping throughout the job.
 High Noise
 Use double hearing protection while using concrete
cutting machine .
 Use approved dust mask(i.e.3M 8210)
 Dust  Ensure work crew attended RPP training and Fit
test

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6  Excavation Clearance Certificate to be obtained

prior to the start of the work.
Manual & Mechanical Excavation  Properly mark and provide identification for
using jackhammer / Hilti breaker & identified underground services.
 Damage of underground and above
Backhoe loader  Only manual excavation near identified facilities
ground services (Pipelines, cables, etc.)
until hard rock appears
 Use plastic shovel near live facilities
 Stop excavation when underground facilities are
spotted (Dune sand or indication tapes) notify the
area authority/permit issuer/operator.
 Use only RLOC inspected Equipment and
extension cables.
 Faulty Equipment.
 Check and ensure no splices/damage on cables.
 Electrocution from power cable
 Ensure all equipment is inspected before use
 Disconnect electrical equipment and tools when not
in use/changing drill bit.
 Obtain contained hot PTW prior to starting the work.
 Fire hazards (Non-intrinsically safe  Initial gas test and continuous gas monitoring
equipment).  Fire extinguisher must be provided near by the
working location.
 Clear plan route for the movement of vehicle.
 Do not place hands/fingers in trap points
 Only authorized personals shall operate equipment.
 Moving equipment
 Control vehicle/equipment movement by banks man
 Ensure Outriggers of Backhoe are placed

 Ensure safety guard properly fixed on equipment.

 Keep safe distance from equipment
 Moving parts
 Stop equipment, if any abnormalities identified and
report.
 Fall into Excavation  Provide hard barricade and sign boards around
excavation
 Provide access to enter and exit the excavation
 Hard barriers shall be erect not less than 2 meters
from the edge of the excavation.
 Reflector/warning light shall be provided.

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 Keep finger, hand and foot clear from line of fire.

 Pinch point  Lead worker should identify the pinch point and
communicate to work crew through TBT.
 Work - Rest cycle to be agreed and followed
 Fatigue, Cramp, Vibration  Workers to be rotated to avoid fatigue.
 Use Leather heavy duty Hand Gloves to avoid
vibration exposure.
 Stack materials / excavated soil must be moved at
least 2 meters away from the edge of excavation.
 Remove the excess soil from work place
 Cave in / Soil collapse  Shoring to be provided (if required).
 Nearby existing foundations shall be considered
before starting excavation works for shoring and
securing.
 Wear double hearing protection while using the
vibrator/jack hammer
 Noise
 Barricade the area with Signages to Restrict un
authorized entry ( Noise Exposure )
 Keep safe distance between work crew and lead
worker. It should be communicate with work crew in
 Line of fire, foot injury tool box talk.
 Metatarsal foot protection must be worn while using
the jack hammer.
 Sharp edge (steel rode / concrete)
 Cut the steel rode with hacksaw completely up to
the concrete side level.
 Personnel injury  All tools & materials should be handled carefully.
 Sharp edges/ Cut injury  Only experienced Carpenter/steel fixers should be
 Hand injury/pinch points utilized for the job.
 Line of fire  Barricade the area and restrict un-intended
personal entry.
 Always maintain good housekeeping.
 Use cut resistant / Leather gloves while handling
Installation/removal of form work, sharp edges.
7 reinforcing steel work, rebar  Electrical blower should be inspected and approved
cutting using hand tools and by RLOC.
cleaning by electric air blower.  Use dust mask and face shield while using air

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blower.
 Maximum lifting for any person shall not exceed 20
kg
 Use manual handling techniques.
 Use of rebar caps for projection from pinch points
 Use nail holder while hammering nails
 Keep hands away from pinch points

 Hot work permit to be obtained

 Keep fire extinguisher standby near the vehicles.
 Clear plan route for the movement of vehicle.
 Vehicle movements shall be controlled by Banks
man.
Concrete pouring for civil works by  Do not place hands / fingers in trap point.
8 concrete mixing truck, concrete  Moving vehicle/Rotating parts  Only authorized personnel to operate vehicles with
pump truck, hand trolleys, chute & valid driving license and third-party certificates.
vibrator  Park vehicles on roadside always or Obtain road
block permits if vehicles are blocking the road
 Use buddy system while handling heavy loads in
trolleys and while shifting concrete with hand
trolleys

 Vibrator must be inspected & certified by RLOC

 Vibrator machine failure
 Electrocution  Obtain contained hot work permit for the job.
 Use only RLOC inspected grinding machine.
 Check for any visible damage on the wiring and
make sure there are no splices or temporary joints.
 Disconnect power tools when not in use.
 Personal injury due to sharp edges  Ensure grinding machine have safety guard.
 Do not use mushroom-headed chisels
 Contact with high velocity ejected  Use face shield with safety glass while using drilling
particles / objects. machine or manual chipping.
 Dust  Use dust mask while drilling/chipping. Use
approved dust mask (i.e.3M 8210)
Concrete repair and finishing using  Line of fire  Avoid unauthorized entry

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9 Grinding machine, manual chisel  Area must be barricaded and only authorized
and cement application. personal should be allowed to enter.
 Keep body parts away from rotating parts.
 Slips/ trips  Secure tools and cables away from work area.
 Cables should be laid properly to avoid trips.
 Maintain good housekeeping throughout the job.
 High noise  Use double hearing protection while using grinding
machine
 Use adequate PPE.
 Use rubber gloves, dust mask (3m 8210)
 Skin contact with concrete material  Maintain good housekeeping.
 SDS must be available at work site
 Housekeeping shall be done to ensure work place
 Slip / Trip is clear all the time.
 All materials shall be removed from site to a safe
area immediately after the work.
10 Housekeeping  All the wastes generated must be collected and
 Waste accumulation disposed of in the designated collection points on
every day basis.
 Use of 3M 8210 dust mask in case of dust
 Dust environment

JSA Facilitator JSA Facilitator

Date
Name Signature
Job Performer Job Performer
Date
Supervisor Name Supervisor Signature
Area Owner Area Owner
Date
Supervisor Name Supervisor Signature

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JSA RECURRING APPROVAL

(FOR HIGH RISK ACTIVITY BY AREA OWNER SUPERVISOR)

Unit: Area: Equipment Involved:

Work Scope / Job Activity:

No. DATE NAME SIGNATURE No. DATE NAME SIGNATURE

1 18
2 19
3 20
4 21
5 22
6 23
7 24
8 25
9 26
10 27
11 28
12 29
13 30
14 31
15 32
16 33

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17 34

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