JOB SAFETY ANALYSIS [JSA] FORM

JSA
BMC-JSA-109
Project Name Number
Date
Location Client
Activity SITE MOBILIZATION Equipment
Work Details
Installing Formwork for Concreting Works
Description

Check all applicable anticipated or potential hazards

Work At Height [Scaffolds, ladders, roofs,
 Electrical [ Live ]  Heavy Equipment Lifting  etc...]
 Electrical [ Isolation ]  Traffic Patterns [ Mobile Equipment / Pedestrian ]  Underground Tank Removal / Disposal

 Hot Work  Temporary Pumping & Transfer Facilities  Demolition

 Confined Space Entry  Extreme Weather  Exposed Handling of Petroleum Products

 Equipment Handling & Dismantling  Pile Driving / Drilling Equipment  Mobile Equipment

 Excavation  Bore-hole Drilling / Test Pit Excavation  Drilling, Grinding, Cutting

Stored Pressure Systems [ e.g. - Propane, NH3
 ]
 Pressure Testing  Work in Hazardous Areas

 Radiography / X-ray Testing  Overhead Power-lines  Other:

Tools, Equipment, Interfaces, or Job Aids needed to perform Work Upgraded PPE needed to address Potential Risks identified in this
Task JSA
Hard Hats, Safety Shoes, Safety Goggles, Safety Gloves and Coverall

Reviewed By Organization Position Date

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 JOB SAFETY ANALYSIS [JSA] FORM

Sequence of Basic Job Potential Hazard Responsibility

Control Measures
Identify potential risks [safety, process safety, Personnel directly
Steps environmental, reliability, and business
Explain critical actions to prevent/ manage potential
responsible to
List key and critical job steps risks.
Inefficiencies]. supervise the task
1. Site Setup  The entire site shall be barricaded and
warning signs displayed prominently around
the perimeter of site with security personnel
stationed at entry and exit points.
 Unauthorized Entries  Stay alert, observant, and maintain effective HSE Officer
communications between all team members
on-site.
 Heed all CAUTION, WARNING, and DANGER
decals
2. Site Personnel  Ensure all workers undergo mandatory
Mobilization safety orientation and brief safety training
 Un-oriented Workers prior to mobilization HSE Officer
 Untrained personnel should be assisted and
trained by a qualified operator.
 Ensure that all site personnel undergo
medical checkup that include general
checkup and specialized checkups for
specific diseases prior to resuming work on Project
 Medically Unfit
site. Manager
 The mandatory medical screening forms
should be duly filled and endorsed by the
site in-charge.
 Struck-by/Crushed by Site specific  All PPE mentioned on this JSA with additional
HSE Officer
hazards task specific PPE should be worn at all times.
3. Transporting Vehicles  Ensure all vehicles are fit for purpose, fitness
Mobilization certificate is issued by a certified and
recognized 3rd party authority
 Vehicle Fitness HSE Officer
 Ensure that seatbelts are installed, all lights
including signal lights are operable at all
times.
 Ensure that the driver has valid driver’s
license that certifies his eligibility to drive
the type of vehicle assigned to him.
 Incompetent Driver HSE Officer
 Make certain that the driver is medically fit.
 The driver shall be fully trained to combat
situations in case of emergencies
 Fire  The vehicle should be equipped with HSE Officer
minimum 4.5kg DCP Fire extinguishers with
valid service certificate.

Page 2 of 4
 JOB SAFETY ANALYSIS [JSA] FORM

Sequence of Basic Job Potential Hazard Responsibility

Control Measures
Identify potential risks [safety, process safety, Personnel directly
Steps environmental, reliability, and business
Explain critical actions to prevent/ manage potential
responsible to
List key and critical job steps risks.
Inefficiencies]. supervise the task
 The vehicle should be installed flame
arrestor.
 Ensure that the electrical wiring is safe and
as per standards. All naked electrical wiring
should be covered.
 Stay alert, be aware of traffic around you.
Obey all traffic laws, reduce speed for
inclement weather conditions; do not use
 Vehicle Accidents All Personel
mobile phones while driving; preferably, stop
at appropriate location to make phone calls
and check messages.
4. Heavy Equipment  Awareness of surroundings/work area; keep
Mobilization  Slip, Trips and Falls staging, loading, unloading area organized HSE Engineer
with clear paths to vehicles or trailers
 Increase stopping distance if you have a
heavy trailer load. Be aware of restricted
vision with a tall trailer.
 Suitable training and/or experience for
towing trailer; pre-trip check of trailer/hitch
 Unsecured or improperly secured load. Operator
for road-worthiness; spare tire & jack
present and functional; all equipment &
materials stowed & secured.
 Ensure all items are secured and will not
become untied or bounce of trailer.
 Complete trailer pre- check of lights, tire
 Breakdowns Operator
pressure
 Stay alert, be aware of traffic around you.
Obey all traffic laws, reduce speed for
inclement weather conditions; do not use
 Accidents Operator
mobile phones while driving; preferably, stop
at appropriate location to make phone calls
and check messages.
 Vehicle Fitness  Ensure all equipment are fit for purpose.
 Ensure that Fitness certificate is issued by a
certified and recognized 3rd party authority
 Ensure that seatbelts are installed, all lights
including signal lights are operable at all
times.
 Ensure equipment are armed with warning
signs clearly displayed and Warning Strobe

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 JOB SAFETY ANALYSIS [JSA] FORM

Sequence of Basic Job Potential Hazard Responsibility

Control Measures
Identify potential risks [safety, process safety, Personnel directly
Steps environmental, reliability, and business
Explain critical actions to prevent/ manage potential
responsible to
List key and critical job steps risks.
Inefficiencies]. supervise the task
Light Beacon installed.

Safety Process Information Regarding this JSA

Prepared by Position Date

Person[s] Carrying Out This Process On The Actual Work-Site

Names: Signed Date

Verified by Position Date

Use back of the sheet if additional names and signatures are required in this section of JSA.

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