KA-1 JSA

• Conducted on

  Date

• Job: KA-1 Exposure Remediation

• Completed by: Ronnie Wallace (Foreman)

• Job location: 37.627571, -83.961517 (Murphy Flat Road)

• Cross Road : KY-594

• Onsite Contact: Ronnie Wallace (304) 494-8118

• Muster Area: Parking Area

• Emergency Location (H): Mercy Health - Marcum and Wallace Hospital 60 Mercy Ct. Irvine KY 40336 (606) 723-2115

• Form must be revisited if any conditions change on scope or new hazard exists, Make sure to inspect all ppe daily and use the buddy system. Pre-inspect equipment/vehicles before use.

• Potential Hazards (Check all that apply to specific job)

  Select Lifting Hazards Fall Potential Electrical Shock Environmental Hazard Confined Spaces Water Hazard Excavation Hazard High Noise Levels Pinch, Crush, or Struck by Sharp edges or Cold/Hot surfaces Fire/Explosion Hazards Slips, Trips, Falls Other

  • Lifting Hazards
  • Fall Potential
  • Electrical Shock
  • Environmental Hazard
  • Confined Spaces
  • Water Hazard
  • Excavation Hazard
  • High Noise Levels
  • Pinch, Crush, or Struck by
  • Sharp edges or Cold/Hot surfaces
  • Fire/Explosion Hazards
  • Slips, Trips, Falls
  • Other

• List other

• Personal Protective Equipment (PPE) Assessment

  Select Hard Hat Safety Glasses Safety Vest Disposable Over Suit Face Shield Hearing Protection Steel Toe Boots Goggles Gloves Respiratory (Masks) FR Clothing Other:

  • Hard Hat
  • Safety Glasses
  • Safety Vest
  • Disposable Over Suit
  • Face Shield
  • Hearing Protection
  • Steel Toe Boots
  • Goggles
  • Gloves
  • Respiratory (Masks)
  • FR Clothing
  • Other:

• List other

Job Tasks

• Job Task: Drive to and From Work

• Potential Hazards and Consequences: Traffic/Weather/Wildlife/Distractions

• Actions Taken to Eliminate Hazards: Defensive Driving/Obey Speed limits/Maintain Safe Following Distances/Eliminate Distractions(put cells on do not disturb)/Be aware and attentive of surroundings

• Job task: Housekeeping

• Potential Hazards and Consequences: Slips/Trips/Falls

• Actions taken to Eliminate Hazards: Keep tool, supplies, and materials organized, Keep trash picked up, Keep walkways and travel lanes clear

• Job Task: Mounting and Dismounting Equipment

• Potential Hazards and Consequences: Slips/Trips/Falls

• Actions taken to Eliminate Hazards: Always face equipment when mounting/dismounting, Use 3-points of contact

• Job Task: Working in Hot Weather

• Potential Hazards and Consequences: Heat Exhaustion, Dehydration, Heat Stroke

• Actions taken to Eliminate Hazard: Water on site, Take breaks to cool down, Monitor crew members for signs and symptoms

• Job Task: Fueling Equipment

• Potential Hazards and Consequences: Fuel spilling onto the ground, explosion/fire due to ignition source

• Actions taken to Eliminate Hazards: Have spill kit readily available, Do not leave equipment while fueling, Do not use trigger locks on handles, No smoking or cell phone use while fueling, Ensure tanks and equipment are grounded and bonded

Additional Job Tasks

• Job Task

• Potential Hazards and Consequences

• Actions Taken to Eliminate Hazards

Crew Members Attending Signatures

• Ronnie Wallace

  Sign

• Jeremy Bolyard

  Sign

• Andrew Robinson

  Sign

• Gavin Barke

  Sign

• Sam Bopp

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• Michael Kidwell

  Sign

• Garett Civiello

  Sign

• Josh Heter

  Sign
Additional Individuals' Signatures

• Individual's Name

  Sign