Example JSA

The items highlighted in yellow are examples of data that could be documented on a library JSA. All other fields on the standardized JSA form must be documented onsite
(handwritten) where the work will be conducted. It is critical that all fields of the form be discussed and/or reviewed during the JSA meeting as they may need to be
edited/changed based on situational details of the task specific to this date, time, place, etc. the task is being performed.
Upstream Gas Job Safety Analysis
Work Location: Organization:
FPSO – Module 15 Laydown Area - This should be filled out onsite when the JSA discussion takes Cargo and Electrical Department
place
Task Description: Date:
Ventilation (includes rigging up, ventilating, and rigging down the ventilation). Note: This task does April 20, 2015 - This should be filled out onsite when the JSA
not require entry into the vessel (no confined space entry – work will take place in front of the entry discussion takes place
point).
Required PPE: In case of emergency
Hard hat, coveralls (FRC), safety glasses, ear plugs, leather gloves, steel-toed boots, fall protection Contact the following:
Required Tools: Company Rep: Phone #:
Basic hand tools (screwdriver, pliers, bag to hold tools, small hammer, etc.), rope, electrical current Control Room (Any CR operator) 23456
meter
Required Equipment: Contractor Rep: Phone #:
Fan and (ventilation) hose This should be filled out onsite when 081X-XXXX-XXXX
the JSA discussion takes place
Required Procedures (e.g. Operating, Maintenance, Safety, D&C, etc.): Emergency Responder: Phone #:
Confined Space SOP – Section 2.4.3 Response team 0-800-1-800-123

General Hazards: List SIMOPs Representatives for all applicable

Slips, trips, falls Hot/cold surfaces SIMOPs work crews:
Pinch points Extreme weather SIMOPs Reps - This should be filled out onsite when the
JSA discussion takes place
Low lighting Fauna/wildlife/insects
Lifting/bending/twisting/stretching Noise PMCoW - This should be filled out onsite when the JSA
discussion takes place
Uneven walking/working surfaces Vibration
Moving parts/rotating equipment Vehicular traffic      

No. PPHA: 050

No. General PTW: GPTW/XXX/YYY/2015/075
No. Specialized Permit:
Page 1 of 9
 Taskfirst
The steps listed in sequential
3 columns could be documented in a library Hazard
JSAInformation
but must always be reviewed – by the entire work crew during the onsite JSA discussion. Any revisions, additional
order Complete the following for each task step:
information, added steps, etc. should be documented
 Document potential hazards
in handwriting during the onsite JSA discussion with the work crew.
Person Check all Critical
 How could a team member be seriously injured or killed Person Responsible Steps where work
conducting this step? Responsible for
Safeguards/Mitigations for Safeguard MUST be Stopped if
 Could the hazards associated this step lead to property damage? Safeguard not executed exactly
Implementation
How? Verification as planned
 Could the hazards associated this step lead to loss of
containment? How?
 List potential dropped objects associated with this step:
Step 1: Pre-use inspection of N/A N/A N/A N/A
hose and fan

Step 2: Conduct initial gas Exposure to gas Use a gas testing meter Qualified Gas Task PMCoW –
testing at ground level fitted with an extension Tester - Safety Juan Carlos
(Qualified Gas Tester will wand to allow for Technician
determine testing frequency atmospheric monitoring Leandro
of atmosphere at ground level without having to
– hourly). personally enter the
monitoring area
Fixed gas monitoring is Control room
continuous at ground level operator
(monitored by control
room)
Step 3: Position the fan and See general hazards documented on page 1 of this Standard PPE Everyone Task PMCoW –
hose at ground level JSA Take frequent breaks (due Juan Carlos
to heat)
Drink water during breaks
(hydration)
Individual Hazard
Assessments (be mindful
of potential pinch points
and slipping/tripping
hazards)

No. PPHA: 050 These 3 columns cannot be completed in a library JSA. They will be specific to the crew
performing the work and must be documented onsite (in handwriting) at the time the JSA
No. General PTW: GPTW/XXX/YYY/2015/075
is conducted.
No. Specialized Permit:
Page 2 of 9
Step 4: Conduct initial and Exposure to gas Use a gas testing meter Qualified Gas Task PMCoW –
continuous gas testing at vessel fitted with an extension Tester - Safety Juan Carlos
opening (where hose will be wand to allow for Technician
installed). Continuous monitoring is atmospheric monitoring Leandro
required as long as a crew member is without having to
working in front of the vessel personally enter the
opening. monitoring area
Fixed gas monitoring is Control room
continuous at ground level operator
(monitored by control
room)
Have escape SCBA gear Safety Technician
available at the vessel level - Leandro

Fall from height Fall prevention device Scaffolding crew

(railing) attached to
scaffolding
Qualified gas tester and Safety Technician
hose installer will wear fall - Leandro and
protection and tie off when Carlos
climbing up and down
scaffolding
Step 5: Position and secure the hose Fall from height Fall prevention device Safety Technician Task PMCoW –
at the vessel level. (railing) attached to - Leandro and Juan Carlos
scaffolding Carlos
Qualified gas tester and
hose installer will wear fall
protection and tie off when
climbing up and down
scaffolding

See general hazards documented on page Standard PPE Safety Technician

1 Individual hazard - Leandro and
assessments (be mindful of Carlos
potential pinch points and
slipping/tripping hazards)

No. PPHA: 050

No. General PTW: GPTW/XXX/YYY/2015/075
No. Specialized Permit:
Page 3 of 9
 Discuss and document potential scenarios and conditions that will trigger Stop Work Authority.
     
It is recommended that all mandatory stop work requirements (listed in the applicable MSW standards) be included in this section if the SBU is building a
library JSA. The work crews are expected to document additional scenarios/conditions that they all agree will trigger the use of SWA during the completion
of this task (these additional scenarios/conditions should be documented onsite (in handwriting) at the time the JSA is conducted).

Discuss and document performance influencing factors that could potentially impact the safe completion of the task.
(e.g performance modes, mental state, error traps, etc.)
     
This entire section should be documented onsite (in handwriting) at the time the JSA is conducted. This information cannot be pre-documented in a library
JSA as it must be specific to the crew performing the task.

Work Team Acknowledgement & JSA Approval

I acknowledge that I understand the contents of this JSA (work team members):
Printed Name: Signature and Date:

     

     

     

     

     

     

No. PPHA: 050

No. General PTW: GPTW/XXX/YYY/2015/075
No. Specialized Permit:
Page 4 of 9
JSA Approval by Person Managing Control of Work:
Name: Signature and Date:
     
In event of change in Person Managing Control of Work berganti, new Person Managing
Control of Work must sign on the JSA:
Name: Signature and Date:
     
Other Approvers/SMEs as required per PPHA:
Name: Signature and Date:
     
     
     

No. PPHA: 050

No. General PTW: GPTW/XXX/YYY/2015/075
No. Specialized Permit:
Page 5 of 9
 Work completion & Lesson Learned Discussion
Discuss and document the following:
 What went well?
 Opportunities for improvement (e.g. use of additional procedures, missed task steps, missed hazards, missing approvals, etc.)
     

This entire section should be documented onsite (in handwriting) immediately after the task has been completed and the worksite has been restored to
normal operating conditions. Lessons learned cannot be pre-documented in a library JSA. Lessons learned should be specific to this task, this day, this work
crew, this time.

This section will not contain pre-populated lessons learned. If the SBU or profit center maintains a JSA library, the JSAs in the library should be updated to
reflect the lessons learned (i.e. update hazards, safeguards, etc. as applicable).

No. PPHA: 050

No. General PTW: GPTW/XXX/YYY/2015/075
No. Specialized Permit:
Page 6 of 9
 Hazard Information
Complete the following for each task step:
 Document potential hazards
 How could a team member be seriously injured or Check all Critical Steps
killed conducting this step? Person Responsible Person Responsible where work MUST be
Task steps listed in sequential order  Could the hazards associated this step lead to Safeguards/Mitigations for Safeguard for Safeguard Stopped if not
property damage? How? Implementation Verification executed exactly as
 Could the hazards associated this step lead to loss of planned
containment? How?
 List potential dropped objects associated with this
step:
Step 6: Connect to power supply and Electrocution Conduct test of circuit Electrician - Joe Paulo
conduct startup test (to ensure fan prior to connecting fan
works) and start ventilation

Step 7: Continue ventilating vessel for N/A N/A N/A N/A

24 hours (prior to authorization for
cleaning task to begin).
Keep ventilation in place and working
for duration of vessel cleaning and
inspection tasks.
Step 8: Disconnect fan from power Low voltage shock Simple plug/cord Electrician - Joe Paulo
supply disconnection - keep
hands away from power
source (plug)
Step 9: Remove hose from vessel Fall from height Fall prevention device Safety Technician Task PMCoW –
(railing) attached to - Leandro and Juan Carlos
scaffolding Carlos
Qualified gas tester and
hose installer will wear
fall protection and tie off
when climbing up and
down scaffolding

See general hazards documented on page Standard PPE Safety Technician

1 Individual hazard - Leandro and
assessments (be mindful Carlos
of potential pinch points
and slipping/tripping
hazards)
No. PPHA: 050
No. General PTW: GPTW/XXX/YYY/2015/075
No. Specialized Permit:
Page 7 of 9
Step 10: Return fan to equipment See general hazards documented on page Standard PPE Everyone Task PMCoW –
storage area 1 Take frequent breaks (due Juan Carlos
to heat)
Drink water during breaks
(hydration)
Individual hazard
assessments (be mindful
of potential pinch points
and slipping/tripping
hazards)
Step 11:                              

Step 12:                              

No. PPHA: 050

No. General PTW: GPTW/XXX/YYY/2015/075
No. Specialized Permit:
Page 8 of 9
 Work Team Acknowledgement & JSA Approval

I acknowledge that I understand the contents of this JSA (work team members):
Name: Signature and Date:

     

     

     

     

     

     

     

     

     

     

     

     

     

     

No. PPHA: 050

No. General PTW: GPTW/XXX/YYY/2015/075
No. Specialized Permit:
Page 9 of 9