Csda Operator Job Safety Analysis (Jsa) Form

ADVERTISEMENT
C
S
D
A
O
P
E
R
A
T
O
R
J
O
B
S
A
F
E
T
Y
A
N
A
L
Y
S
I
S
(
J
S
A
)
F
O
R
M
C
S
D
A
O
P
E
R
A
T
O
R
J
O
B
S
A
F
E
T
Y
A
N
A
L
Y
S
I
S
(
J
S
A
)
F
O
R
M
Section 1: HAZARDS
CONCRETE CUTTING, CORING, & DEMO
TRENCHES, EXCAVATIONS, MANHOLES, &
ELEVATED WORK & WORKING
Noise / Sound
______
SEWERS
SURFACES
Slurry/Slip Hazard
______
(CONFINED SPACES)
(Open floors/Floor levels,
Vibration
______
Cave-In, Engulfment
_______
Scaffolds, JLG, Scissors Lift, and
Spark Hazard
______
Atmosphere (O
, Toxic, Flammable)
_______
Walking Surfaces)
2
Equipment Operation
______
Access / Egress
_______
Uneven Surfaces
______
Struck-By
______
Safe Work Procedures
_______
Fall Protection
______
Electrical Shock
______
Underground Utilities (gas, elec.,
_______
Work Platform
______
Respiratory Hazards
______
Fiber optic, phone, water)
Access / Egress
______
Work Area Security ______
Falling Materials
_______
Stability
______
Large Diameter Holes
______
Other: ___________________
________
Securely Attached
______
Helpers
______
Anchorage Points
______
PPE
______
Comments: ______________________________
Other: _______________
______
Overhead Work
______
Other’s in work area
______
(Public, Contractors)
Tools/Equipment
______
HUMAN FACTORS
OTHER JOB HAZARDS
CO2 Ventilation
______
Fatigue
______
Pinch Points
_______
Other: ________________
______
Heat Stress/Cold
______
Rotating Equipment
_______
Illness
______
Electrical Lines
_______
Rush / Emergency
______
Emergency Procedures
_______
HIGHWAY / ROAD WORK
work
Other (type & controls):
Traffic Hazard Control
______
Poor Housekeeping ______
______________________________________________
______
Material Handling
______
______________________________________________
Other: _______________
______
(Safe Lifting)
______________________________________________
______________________________________________
Comment: _____________________________
Section 2: ENGINEERING & ADMINISTRATIVE CONTROLS
Precautions & PPE
TRENCHES, EXCAVATIONS,
FALL PROTECTION & SCAFFOLDS
01 Visual Check
MANHOLES, & SEWERS
59 Proper ladder / secured
02 Uni-Strut Installation or Strapping
(CONFINED SPACES)
60 Body Harness / Lanyard
03 Core Catch/Proper Shoring
32 Sloping / Shoring / Shielding
61 Lifeline
04 Vacuum Slurry / Water
33 Oxygen/LEL/Toxic Gases Check
62 SRL (Self-Retracting Lifeline)
05 Protective Covering
34 Atmospheric Monitoring
63 Handrail, mid-rail, toe-boards
06 Double Anchor Large Diameter Holes
35 Body Harness / Lifeline
(if req’d.)
07 Equipment to set up and/or Dismantle Rig
36 Shielding system 18” above grade
64 Mudsills, base plates, screw jacks –
08 Housekeeping – cores, tools, equip. Trash
37 No work below 2 feet below trench
Proper Cross Bracing.
09 Barricade area (security)
box.
65 Secured Height (4X min. base
10 Area Watch / Security – Restricted Access
38 Proper Ladder
dimension)
11 Hearing Protection
39 Hole Watch / Attendant / Rescue
66 Plumb & Level
12 Proper Respirator / Supplied Air / Dust Mask
40 Entry Permit
67 Inspected
13 Safety Glasses with side protection
41 Fire Watch / Fire Extinguisher
68 Properly Cross Braced
14 Mono-goggles / Face Shield
42 Restricted Access
69 Proper Planking
15 Gloves (appropriate for work)
43 Hot Work permits
70 Anchorage Points – 5,000 lbs./person
16 Hard Hat
44 Utilities Marked or Located
17 Di-Electric Boots
45 Bottle Watch (Supplied Air), Grade D
EQUIPMENT OPERATION / JOB
18 Steel Toed Work Boots
HAZARDS
19 GFCI (Ground Fault Circuit Interrupter)
71 Competent Person
20 Water
HUMAN FACTORS
72 Lockout / Tagout
21 Hot Work &/or other permits required
46 Good / Proper Communications
73 Guards
22 Protective Clothing / NOMEX, FRC, Other
47 Maintain Attention & Awareness
74 Proper Grounding
23 Condition Inspected & Proper
48 Rest / Water Breaks
75 Emergency Stand-by, Equip., First Aid
49 Replenish Fluids / Vitamins / Minerals
76 Inform contractor to cover holes
50 Proper Housekeeping
OPERATOR - GENERAL
greater than 2” X 2”
51 Take time to do the job Safely
24 Site Specific Training Received
77 Inform Helpers of Hazards and offer
52 Expect the unexpected
25 Specialized Training required for this Job
PPE
53 Positive Hazard Intervention
26 Review of Jobsite for Unknown Hazards
54 Proper Conduct
HIGHWAY / ROAD WORK
27 Informed Contractor / Helper of OUR HAZARDS
55 Follow Safe Working Procedures
78 Proper placement of Signs – “Men
28 Emergency Plan / Evacuation Location
56 Emergency Procedures Understood
Working Ahead”, or “lane closures”,
29 Communications
57 Emergency Action Plan
etc.
30 Procedures
58 Safe Lifting Techniques-Use of
79 Arrow Boards
31 Other: _____________________________
Equipment
80 Flagmen
81 Traffic Officers
82 High Visibility Personnel Vests
It is the operator’s responsibility to inform company of any potential hazards that may be
83 Flashing lights on Vehicles/Equipment
present on a jobsite. Operator is instructed not to proceed until hazards have been
84 Barricades, Barrels, Panels, Cones, &
satisfactorily remedied.
Tapers
Operator’s name:___________________________________________ Date:__________________
Job location:_______________________________________________ Reference # ____________
C
S
D
A
O
P
E
R
A
T
O
R
J
O
B
S
A
F
E
T
Y
A
N
A
L
Y
S
I
S
(
J
S
A
)
F
O
R
M
C
S
D
A
O
P
E
R
A
T
O
R
J
O
B
S
A
F
E
T
Y
A
N
A
L
Y
S
I
S
(
J
S
A
)
F
O
R
M
Section 1: HAZARDS
CONCRETE CUTTING, CORING, & DEMO
TRENCHES, EXCAVATIONS, MANHOLES, &
ELEVATED WORK & WORKING
Noise / Sound
______
SEWERS
SURFACES
Slurry/Slip Hazard
______
(CONFINED SPACES)
(Open floors/Floor levels,
Vibration
______
Cave-In, Engulfment
_______
Scaffolds, JLG, Scissors Lift, and
Spark Hazard
______
Atmosphere (O
, Toxic, Flammable)
_______
Walking Surfaces)
2
Equipment Operation
______
Access / Egress
_______
Uneven Surfaces
______
Struck-By
______
Safe Work Procedures
_______
Fall Protection
______
Electrical Shock
______
Underground Utilities (gas, elec.,
_______
Work Platform
______
Respiratory Hazards
______
Fiber optic, phone, water)
Access / Egress
______
Work Area Security ______
Falling Materials
_______
Stability
______
Large Diameter Holes
______
Other: ___________________
________
Securely Attached
______
Helpers
______
Anchorage Points
______
PPE
______
Comments: ______________________________
Other: _______________
______
Overhead Work
______
Other’s in work area
______
(Public, Contractors)
Tools/Equipment
______
HUMAN FACTORS
OTHER JOB HAZARDS
CO2 Ventilation
______
Fatigue
______
Pinch Points
_______
Other: ________________
______
Heat Stress/Cold
______
Rotating Equipment
_______
Illness
______
Electrical Lines
_______
Rush / Emergency
______
Emergency Procedures
_______
HIGHWAY / ROAD WORK
work
Other (type & controls):
Traffic Hazard Control
______
Poor Housekeeping ______
______________________________________________
______
Material Handling
______
______________________________________________
Other: _______________
______
(Safe Lifting)
______________________________________________
______________________________________________
Comment: _____________________________
Section 2: ENGINEERING & ADMINISTRATIVE CONTROLS
Precautions & PPE
TRENCHES, EXCAVATIONS,
FALL PROTECTION & SCAFFOLDS
01 Visual Check
MANHOLES, & SEWERS
59 Proper ladder / secured
02 Uni-Strut Installation or Strapping
(CONFINED SPACES)
60 Body Harness / Lanyard
03 Core Catch/Proper Shoring
32 Sloping / Shoring / Shielding
61 Lifeline
04 Vacuum Slurry / Water
33 Oxygen/LEL/Toxic Gases Check
62 SRL (Self-Retracting Lifeline)
05 Protective Covering
34 Atmospheric Monitoring
63 Handrail, mid-rail, toe-boards
06 Double Anchor Large Diameter Holes
35 Body Harness / Lifeline
(if req’d.)
07 Equipment to set up and/or Dismantle Rig
36 Shielding system 18” above grade
64 Mudsills, base plates, screw jacks –
08 Housekeeping – cores, tools, equip. Trash
37 No work below 2 feet below trench
Proper Cross Bracing.
09 Barricade area (security)
box.
65 Secured Height (4X min. base
10 Area Watch / Security – Restricted Access
38 Proper Ladder
dimension)
11 Hearing Protection
39 Hole Watch / Attendant / Rescue
66 Plumb & Level
12 Proper Respirator / Supplied Air / Dust Mask
40 Entry Permit
67 Inspected
13 Safety Glasses with side protection
41 Fire Watch / Fire Extinguisher
68 Properly Cross Braced
14 Mono-goggles / Face Shield
42 Restricted Access
69 Proper Planking
15 Gloves (appropriate for work)
43 Hot Work permits
70 Anchorage Points – 5,000 lbs./person
16 Hard Hat
44 Utilities Marked or Located
17 Di-Electric Boots
45 Bottle Watch (Supplied Air), Grade D
EQUIPMENT OPERATION / JOB
18 Steel Toed Work Boots
HAZARDS
19 GFCI (Ground Fault Circuit Interrupter)
71 Competent Person
20 Water
HUMAN FACTORS
72 Lockout / Tagout
21 Hot Work &/or other permits required
46 Good / Proper Communications
73 Guards
22 Protective Clothing / NOMEX, FRC, Other
47 Maintain Attention & Awareness
74 Proper Grounding
23 Condition Inspected & Proper
48 Rest / Water Breaks
75 Emergency Stand-by, Equip., First Aid
49 Replenish Fluids / Vitamins / Minerals
76 Inform contractor to cover holes
50 Proper Housekeeping
OPERATOR - GENERAL
greater than 2” X 2”
51 Take time to do the job Safely
24 Site Specific Training Received
77 Inform Helpers of Hazards and offer
52 Expect the unexpected
25 Specialized Training required for this Job
PPE
53 Positive Hazard Intervention
26 Review of Jobsite for Unknown Hazards
54 Proper Conduct
HIGHWAY / ROAD WORK
27 Informed Contractor / Helper of OUR HAZARDS
55 Follow Safe Working Procedures
78 Proper placement of Signs – “Men
28 Emergency Plan / Evacuation Location
56 Emergency Procedures Understood
Working Ahead”, or “lane closures”,
29 Communications
57 Emergency Action Plan
etc.
30 Procedures
58 Safe Lifting Techniques-Use of
79 Arrow Boards
31 Other: _____________________________
Equipment
80 Flagmen
81 Traffic Officers
82 High Visibility Personnel Vests
It is the operator’s responsibility to inform company of any potential hazards that may be
83 Flashing lights on Vehicles/Equipment
present on a jobsite. Operator is instructed not to proceed until hazards have been
84 Barricades, Barrels, Panels, Cones, &
satisfactorily remedied.
Tapers
Operator’s name:___________________________________________ Date:__________________
Job location:_______________________________________________ Reference # ____________

Download Csda Operator Job Safety Analysis (Jsa) Form

312 times
Rate
4.5(4.5 / 5) 16 votes
ADVERTISEMENT