Job Safety Assessment (JSA)
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Site Name
Company Name
Operating Group
Please Select
Admin Services
Dirt Construction
Drilling
Completions
Mechanical Construction
Source Water
Production
Maintenance
Wellservice/Workover
Muster Area
Permits Required
None
Hot Work
Excavation
Lock Out/Tag Out
Confined Space
Job to be Performed
Are you submitting a written JSA
Yes
No
Job Tasks
Job Hazards & Controls
Check all that apply and give details as needed in the Tasks, Hazards and Controls section of this form. Once this form has been submitted, the submitter is able to edit and update this form as necessary by using the [Edit] option at the submission confirmation page!
Safety Orientation
Employees have completed the Pulsar Helium Safety Orientation
Delivery drivers and vendors have completed the Pulsar Helium Visitor Orientation
Contractors and Subcontractors have completed the Pulsar Helium Contractors and Subcontractor Safety Orientation
Other
Stop Work
Every worker understands the obligation to stop unsafe acts or conditions
Work Area Hazards
Confined space concerns have been addressed
Moving equipment or vehicle concerns have been addressed
Lighting levels too high/ low
Extreme heat or cold issues have been protected against
Does weather present a risk
Excessive winds (high profile structures, flying dust & debris) present a hazard
Uneven, wet, slippery, or muddy ground (unstable footing) is present
Ignition sources, static, grounding potentials have been eliminated (Hotwork)
Overhead utilities are present and managed
Underground utilities present a risk
People in proximity to dangerous conditions such as high pressure or electrical exposures
Other
Housekeeping
Job location clean, free of clutter, and known hazards are mitigated
Known or assumed hazards have been reduced to a reasonable level
Signage present as necessary
Tools and equipment are clean and orderly
Equipment is arranged in an organized and orderly fashion
Task Hazards
Ergonomic concerns (bending, lifting, etc.) Potential for slips, trips and falls have been discussed or mitigated
Caught between hazards have been discussed
Hand tool inspections are being conducted
Fire hazards are anticipated and extinguishing agents are nearby
Pressure equipment is properly secured and signage or barriers are in place
Vehicle/equipment movement hazards have been communicated
Hot/Cold weather issues have been mitigated
Hot/Cold surfaces have proper labeling
Overhead work is managed with no-go zones or other means to prevent falling object hazards
SIMOPS is properly managed
Other
Personal Protective Equipment (PPE)
Hardhat, safety glasses, safety-toed boots are in use by workers
Face shield, goggles or spoggels are in use where required
Hearing protection is available and in use where appropriate
Gloves being worn where appropriate
Respiratory protection is available where required
Eyewash station location identified and system in working order
Proper attire for the job is in use by workers (welding, snakes, etc)
Other
Emergencies & Communication
Communication resources available to call for help if needed
The County Specific Emergency Action Plan is available at www.safehe.com
Hand held radios are charged and in working order
Alarms working as required
Horns working where required
Other
Electrical Safety
Grounding and bonding
GFCI for electric power tools
Safe distance from energized lines and equipment
Power cords have been inspected
Power tools have been inspected
Water is not puddled at electric equipment
Other
Personnel Concerns
New employees/ inexperienced workers are appropriately managed
Workers are fit for duty (medications, sleep, physical limitations, distractions, etc.)
Language barriers have been addressed
Other
Heavy Equipment Concerns
Current operator certification on file where required
Equipment daily inspections have been completed
Crane and pivoting equipment swing radius is marked
Positioning and outrigger location is adequate
Overhead power lines and underground utilities are marked and signage is adequate for conditions
Air horns or other equipment communication devices are operational
Signal man or spotters are being used when/where required
Pinch points or caught between potentials have been discussed
Soft, hard, muddy, wet, sloped ground issues have been addressed
Other
Driving
Seat belts used at all times
Authorized routes have been communicated
Condition of road or route/s has been discussed where appropriate
Vehicle inspections completed as required
All loads are adequately secured
Other
Working at Heights
Man lift has been adequately inspected
Fall protection requirements understood and practiced
Proper tie-off points identified and used where appropriate
Full body harness and lanyard/lifeline in use where appropriate
Fall protection equipment inspected as required
Ladders are in safe working condition
Walking and working surfaces are restricted, narrow, wet, slippery or icy
Scaffolding is inspected and in proper working order
Other
Hot Work
Fire extinguishers are present at job location as required
Fire watch has been identified
Flammables, combustibles or LEL concerns controlled
Fire blanket is necessary for this job
The ground lead is bonded as close to the weld as possible
High wind issues have been mitigated
Other
Excavations & Trenching
Utility locate has been performed
Utility lines have been located, marked and drawings reviewed
Confined space concerns have been addressed
Approved shoring is in use
Proper sloping techniques have been used
Proper barricading around open holes or excavations as required
Proper egress provided whare required
Competent person present and performing inspections as required
Permit requirements have been met
Other
Lock Out/ Tag Out
Energy isolation (LOTO) training is current where required
Energy source is isolated and locked out
Energy isolation verification and testing has been performed
Breakers are open and locked where required
Stored energy has been released(including mechanical energy)
Someone has assured that grounding or bonding has been accomplished as required
Risk of trapped or non-isolated energy has been eliminated
Other
Environmental Issues
Spill prevention and control measures are in place and functional
Safety Data Sheets are available at www.safehe.com
Other
Hazards / Controls (Save to add additional line items)
Additional Notes
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