FENJ JSA 12/9/15

• Document No.

• Job Site & Number

• Conducted on

  Date

• Prepared by

• Job Description

• Emergency Numbers

• Current temperature

• Current weather condition

  Select Sunny Overcast Rain Snow Ice Windy

  • Sunny
  • Overcast
  • Rain
  • Snow
  • Ice
  • Windy

General Housekeeping

• Slip/Trip Hazards Abated

  Yes

  No

  N/A

• Why Aren't Hazards Abated

• Aisle Ways Clear

  Yes

  No

  N/A

• Why Aren't Hazards Abated

• Pinch Points Eliminated

  Yes

  No

  N/A

• Why Aren't Hazards Abated

• Loose Material/Debris Removed

  Yes

  No

  N/A

• Why Aren't Hazards Abated

PPE Required

• Head Protection required

  YES

  NO

• hard hat

  bump cap (MUST BE AUTHORIZED)

• Why is head protection not required

• Eye Protection/Face Protection required

  Yes

  No

  N/A

• Why Isn't Eye Protection Required

• Select safety glasses goggles face shield

  • safety glasses
  • goggles
  • face shield

• Hand Protection required

  Yes

  No

  N/A

• Why isn't hand protection required

• What hand protection is required

  Select cut 3 gloves cut 5 gloves insulating gloves rubber gloves leather gloves cut resistant sleeves leather apron

  • cut 3 gloves
  • cut 5 gloves
  • insulating gloves
  • rubber gloves
  • leather gloves
  • cut resistant sleeves
  • leather apron

• Fall Protection required

  Yes

  No

  N/A

• What fall protection is required

  Select harness with retractable harness with lanyard fall arrest system safety monitor system temporary handrail

  • harness with retractable
  • harness with lanyard
  • fall arrest system
  • safety monitor system
  • temporary handrail

• Arc rated clothing

  Yes

  No

  N/A

• What calorie rating is required

  Select 8 cal 11 cal 31 cal 40 cal 75 cal 100 cal

  • 8 cal
  • 11 cal
  • 31 cal
  • 40 cal
  • 75 cal
  • 100 cal

• Hearing Protection required

  Yes

  No

  N/A

• What type of hearing protection required

  Ear plugs

  Ear Muffs

• Foot protection required

  Yes

  No

  N/A

• What type of foot protection is required

  Select hard toed boots EH rated over boot insulating over boot spikes rubber mud boots

  • hard toed boots
  • EH rated
  • over boot insulating
  • over boot spikes
  • rubber mud boots

• Welding leathers

  Yes

  No

  N/A

• Respiratory protection

  Yes

  No

  N/A

• What type of respiratory protection is required

  dust mask

  half face respirator (FIT TEST/MED CLEARANCE REQUIRED)

  full face respirator (FIT TEST/ MED CLEARANCE REQUIRED)

Tools

• Proper tools for job

  YES

  NO

• THEN DO NOT DO JOB

• Visual inspection and in good condition

  YES

  NO

• THEN DO NOT USE TOOL

• Other

Emergency Equipment

• Fire extinguisher

  Yes

  No

  N/A

• Fire monitor

  Yes

  No

  N/A

• Is the monitor trained

  YES

  NO

• MUST GET TRAINED MONITOR DO NOT DO WORK UNTIL THEN

• Safety shower

  Yes

  No

  N/A

• Evacuation route

  YES

  NO

• MUST HAVE EVACUATION ROUTE

• Are Emergency Phone Numbers Posted

  YES

  NO

• MUST HAVE EMERGENCY PHONE NUMBERS POSTED

Access/Overhead Work

• Scaffolding inspected/tagged

  Yes

  No

  N/A

• Handrails/Toe Boards

  Yes

  No

  N/A

• Ladders inspected and approved

  Yes

  No

  N/A

• DO NOT USE LADDER AND TAKE OUT OF SERVICE

• Are the tags legible

  YES

  NO

• Get new tag that is legible prior to use

• Ladders tied off

  Yes

  No

  N/A

• Overheard work signs

  Yes

  No

  N/A

• Barricades utilized

  Yes

  No

  N/A

• Holes in deck covered

  Yes

  No

  N/A

• MUST COVER HOLES CAN NOT LEAVES HOLES IN DECK UNCOVERED

• Climbing hazards abated

  Yes

  No

  N/A

Confined Space

• Has confined space training be completed as required by a competent person

  Yes

  No

  N/A

• STOP!!! All parties must be trained by a competent person prior to entry

• If required has emergency response been identified and available

  Yes

  No

  N/A

• Emergency response must be identified and informed prior to beginning

• Who was the contact you spoke to

• Authorized entrants

  Yes

  No

  N/A

• CAN NOT DO WORK WITHOUT AUTHORIZED ENTRANTS

• Authorized attendants

  Yes

  No

  N/A

• CAN NOT GO IN CONFINED SPACE WITHOUT AUTHORIZED ATTENDANTS

• Communication with entrants

  Yes

  No

  N/A

• What is type of communication

  Select verbal line of site electronic (radio/phones)

  • verbal
  • line of site
  • electronic (radio/phones)

• CAN NOT GO IN CONFINED SPACE WITHOUT PROPER COMMUNICATION

• Was confined space tested with a calibrated LEL meter

  Yes

  No

  N/A

• MUST TEST CONFINED SPACE PRIOR TO ENTERING

• Completed entry permit

  Yes

  No

  N/A

• PERMIT MUST BE FILLED OUT AND APPROVED PRIOR TO ENTERING CONFINED SPACE

Welding/Burning

• Combustibles eliminated

  Yes

  No

  N/A

• Remove combustibles prior to doing any burning or welding

• Fire extinguisher in place where work is to be preformed

  Yes

  No

  N/A

• Must have fire extinguisher in close proximity prior to work

• Adequate ventilation

  Yes

  No

  N/A

• Take the appropriate measures to adequately ventilate area

• Is there an active fire alarm system where the welding/burning is taking place

  Yes

  No

  N/A

• Inform building that you will be welding/burning prior to doing any work so that they may take appropriate measures

Electrical

• Are GFCI protection devices used

  Yes

  No

  N/A

• Have they been inspected and tested as required

  YES

  NO

• Must be inspected and tested prior to use

• GFCI's must be used at all times during work. Don't proceed with work until GFCI's are used

• Are all cords inspected

  Yes

  No

  N/A

• All cords must be inspected prior to use to verify its free of defects

• Is LOTO required

  Yes

  No

  N/A

• Verify that there is a zero energy state

• Is there any stored energy

  YES

  NO

• Go back and verify that the LOTO is in the correct location.

Are Hazards Associated With The Following Conditions Eliminated

Work Area

• Radiation

  Yes

  No

  N/A

• Do not enter area until radiation hazard is eliminated or reduced to acceptable levels

• Dusts

  Yes

  No

  N/A

• Do not enter work area until dust hazard is eliminated or reduced to acceptable levels

• Electrical shock

  Yes

  No

  N/A

• Do not work on until shock hazard is eliminated

• Heat stress

  Yes

  No

  N/A

• Develop adequate measures to reduce heat exposure

• Heavy objects

  Yes

  No

  N/A

• Get help or use mechanical assistance

• Surface temperatures

  Yes

  No

  N/A

• Develop adequate measures to reduce heat exposure

• Inadequate lighting

  Yes

  No

  N/A

• Take appropriate measures to increase lighting to acceptable levels

• High noise levels

  Yes

  No

  N/A

• Take appropriate measures to eliminate noise or reduce to acceptable levels

• Poor access/egress

  Yes

  No

  N/A

• Take appropriate measures to increase access or egress

• Poor housekeeping

  Yes

  No

  N/A

• Take appropriate measures to improve housekeeping

• Sharp objects

  Yes

  No

  N/A

• Take measures to eliminate contact with sharp objects

Bodily Hazards

• Falls

  Yes

  No

  N/A

• Take the appropriate measures to mitigate fall hazards

• Pinch points

  Yes

  No

  N/A

• Take the appropriate measures to avoid pinch points

• Slips/trips

  Yes

  No

  N/A

• Take the appropriate measures to prevent slips and/or trips

• Manual lifting

  Yes

  No

  N/A

Chemical

• Burns

  Yes

  No

  N/A

• Flammability

  Yes

  No

  N/A

• Absorption

  Yes

  No

  N/A

• Ingesting

  Yes

  No

  N/A

• Inhalation

  Yes

  No

  N/A

Verification of Review

• Have lines been purged

  Yes

  No

  N/A

• Purge lines prior to working on

• Have lines been marked

  Yes

  No

  N/A

• Prior to working on any lines that are not marked trace lines to verify the lines are what you you have locked out

• LOTO complete

  Yes

  No

  N/A

• We're all permits reviewed

  Yes

  No

  N/A

• Pre-shift job instructions

  YES

  NO

• Work scope covered with crew

  YES

  NO

• SDS location/access

  YES

  NO

• Hot work permit #

• 70 E Permit/ MOP #

• Confined space permit #

• General work permit # (if required)

• Other

Steps

• List job steps

• List of hazards present

• Corrective actions/ controls

• Equipment required for job

Employee signatures

• Formen's signature

  Sign

• Employee #1 signature

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• Employee #2 signature

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• Employee #3 signature

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• Employee #4 signature

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• Employee #5 signature

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• Employee #6 signature

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• Employee #7 signature

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• Employee #8 signature

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• Employee #9 signature

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• Employee #10 signature

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• Employee #11 signature

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• Employee #12 signature

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• Employee #13 signature

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• Employee #14 signature

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