Job Safety Analysis (JSA Checklist) - Energy Services

• Site conducted

  Select

• Facility/Pipe/Well Name

• Muster Point

• Customer Contact

• Project Location
  Address

• Description Of Work

• Date

  Date

• Prepared by

  Select

• DDS Division

  Select

Safety Equipment Required To Do this Work

• Select applicable

  Select Hard Hat Face Shield/Goggles Natural Gas Detector First Aid Kit Safety Toed Boots Gloves H2S Meter Safely Hamess/Anti-Fall Device Safety Glasses Fire Extinguisher Multi-gas Meter Rescue Lanyard & Rope FR Clothing Ground Static Cable Respirator/SCBA Eye Wash Hearing Protection Wheel Chocks Communications SDS on Site Safety Vests Lockout/Tag out Lights Other

  • Hard Hat
  • Face Shield/Goggles
  • Natural Gas Detector
  • First Aid Kit
  • Safety Toed Boots
  • Gloves
  • H2S Meter
  • Safely Hamess/Anti-Fall Device
  • Safety Glasses
  • Fire Extinguisher
  • Multi-gas Meter
  • Rescue Lanyard & Rope
  • FR Clothing
  • Ground Static Cable
  • Respirator/SCBA
  • Eye Wash
  • Hearing Protection
  • Wheel Chocks
  • Communications
  • SDS on Site
  • Safety Vests
  • Lockout/Tag out
  • Lights
  • Other

Pre-Job Hazard Assessment

• Lifting

• Manual Lifting (Body Position)

  Yes

  No

• Mechanical Lilting Equipment

  Yes

  No

• Awkward Body Position

  Yes

  No

• Slip/Trip Potential

• Lifting w/ Other Employees

  Yes

  No

• Proper Rigging Practices

  Yes

  No

• Excavation/Trenching/Drilling

• Excavation/Trenching/Drilling involved

  Yes

  No

• One Call been notified

  Yes

  No

• One Call Notification Date:

  Date

• One Call Notification #:

• Access/Exit

• Ladder Placement

  Yes

  No

• Barricades Placed

  Yes

  No

• Secure Footing

  Yes

  No

• Evacuation Routes Identified

  Yes

  No

• Handrails/Stair Rail Placement

  Yes

  No

• Environmental Concerns

• Known Contaminants on Site

  Yes

  No

• Hydrocarbon Liquids Present

  Yes

  No

• Containment/ Precautions Required

  Yes

  No

• Simultaneous Operations

• Other Operations Occurring On Site

  Yes

  No

• Coordination With Other Operations

  Yes

  No

• Others On Site:

• Confined Space Entry

• Work Involves Confined Space Entry

  Yes

  No

• If "Yes" Follow Confined Space Program

• Hazards

• Welding/Flame Cutting

  Yes

  No

• Mechanical Equipment

  Yes

  No

• Proper Tool/Material

  Yes

  No

• Hand & Finger Hazards

  Yes

  No

• Hot/Cold Surface or Material

  Yes

  No

• Working at Heights

  Yes

  No

• Electrical Hazards

  Yes

  No

• Adequate Lighting

  Yes

  No

• Containers Properly Labeled

  Yes

  No

• Hydrogen Sulfide Present

  Yes

  No

• Body Position/Movement

• Climbing

  Yes

  No

• Pulling/Pushing

  Yes

  No

• Bending

  Yes

  No

• Twisting Motion

  Yes

  No

• Walking Crawling

  Yes

  No

• Straining

  Yes

  No

• Stretching

  Yes

  No

• Reaching

  Yes

  No

• Over Extending

  Yes

  No

• Hot Work Permit

• Hot Work Permit Required

  Yes

  No

• Follow Hot Work Policy

  Yes

  No

• Lockout/Tagout (LOTO)

• Work Requires Lockout/Tagout

  Yes

  No

• Person Responsible for LOTO

  Yes

  No

Environmental Conditions

• Wind Speed/Direction:

• Weather:

• Temperature:

• Light Condition:

• Surrounding Area Use

  Undeveloped

  Residential

  Industrial

  Farm

  Other

• Location

  Elevated

  Ground Level

  Below Ground Level

  Confined Space

• Type of Work

  Routine

  Difficult

  Complex

• Work Area

  Open

  Tight

  Congested

• Supervision Availability

  None on Location

  Intermittent

  Foreman

  Supervisor on Location
JOB STEP

• Basic Job Step Sequence

• Potential Hazards

• Potential At-Risk Behaviors

• Hazard/Risk Controls

Crew Members Company Representatives & Third Party Signatures

Member

• Name and Signature

  Sign

• I have personally inspected the worksite and confirm that it is safe for the work described (Responsible Party)

  Sign