Project Manager Representative
Resume:
JOB SAFETY ANALYSIS
JSA # / Name:
Date:
Contact #:
Proposed End Date:
Name(s) of supporting engineer or qualified / competent person (if necessary): SFMEA
Score 0
KEY STEPS IN THE
TASK
CRITICAL
HAZARDS HAZARD CONTROL AND SAFE WORK PRACTICES
Use this symbol in the Critical Cross column for those steps that involve a Severity Potential of 15 as scored on the SFMEA indicating that the hazard could result in a FATALITY. These steps have controls that must be emphasized to the worker. At a minimum, consider the following key information:
1. Key steps, hazards, and control / safe method for the work to be performed 2. Emergency response plan
3. Pre-work task steps and Post-task cleanup activities that may be hazardous Project / Task Description:
EMERGENCY
RESPONSE PLAN
Company Name:
Prepared by:
Proposed Start Date:
Supervisor:
2. JSA INSTRUCTIONS
If situations arise that fall outside the scope of this JSA or if there are any questions or concerns, STOP work and contact your Supervisor and/or Safety Person. Re-evaluate the JSA and make changes as necessary on the Worker Safety Engagement - Daily Review Sheet. SAFE018 REV13 05/19
Risk Assessment / Safety FMEA
Company Name: JSA # / Name:
Date:
Contact #:
Proposed Start Date:
Project/Task
Description:
SP
Score
P
Score
F
Score
NP
Score
RISK
Score
0
0
0
0
0
0
SCORE RISK
0 TO 50 LOW
51 TO 160 MEDIUM
161 - 500 HIGH
500 AND
ABOVE
UNACCEPTABLE
1. PROJECT / TASK DESCRIPTION
2. SAFETY FMEA (Failure Modes Effects Analysis)
Instructions: Complete a Risk Assessment / Safety FMEA for hazards identified with the Critical Cross from the Job Safety Analysis (JSA) and that would result in a Critical or Life Altering Injury as described in the Severity Potential section below . Determine the risk score based on the "SFMEA Instructions" page for Severity Potential, Probability of Occurance, Frequency of Exposure and # of People Exposed. The minimum actions required will always include all three parts of the PTP document 1) Safety FMEA, 2) JSA, and 3) Worker Safety Engagement Process. Highest risk score number will determine reviews/approvals needed prior to work starting.
HAZARD
(Identifed w/Critical Cross on JSA)
1. Confirm workers received Orientation Training
2. Review Job Safety Analysis and Review at Start-of-Shift Meeting 3. Complete Planning & Review Section
4. Establish Planned Inspection / Safety Observation Tour Process 5. Ensure All Worker(s) Perform Worker Engagement During Each Shift 6. Execute Management Of Change if Changes Occur
All Low & Medium Requirements PLUS a Secondary Signature in Review Section MINIMUM ACTION SUMMARY
Risk Assessment / SAFETY FMEA CALCULATION
RISK = SP (Severity Potential Score) X P (Probability Score) X F (Frequency of Exposure Score) X NP (# of People Exposed Score) 3. MINIMUM ACTION SUMMARY - BASED ON HIGHEST RISK SCORE FROM ABOVE 0
1. Risk score must be reduced below 500 prior to starting work using the hierarchy of safety controls. 2. Based on a second S-FMEA calculation follow the minimum action summary for either Low, Medium, or High Risks ALL Pre-Task Plans require completion of the "Planning and Review" section regardless of the calculated SFMEA Score. HIGHEST RISK SCORE
0
0
0
Name(s) of supporting engineer or qualified / competent person (if necessary): 0
0
0
0
0
Prepared by:
Supervisor:
Proposed End Date:
0
SAFE018 REV13 05/19
Risk Assessment / Safety FMEA
SCORE
15 FATALITY
10 Critical Life
Altering Injury
6 Major Life Altering
Injury
4 Life Altering Injury
2 Reversible Injury
1 Minor Reversible
Injury
SCORE
15 Certain
8 Possible
2 Unlikely
SCORE SCORE
5 12
4 8
2.5 4
2
1
ONE TIME ONLY (exposed to the hazard once during the task) Typically risks in this category are mitigated solely with administrative controls such as standardized work, pre-task plans, warning signs, or PPE. The injury will occur if a single person fails to follow directions or follow procedures. 5 to 80% chance an injury will occur due to the hazards. An injury may happen if additional factors precipitate it, but it is unlikely to happen without them. In the presence of the hazard, an additional factor such as vibration, wind, or human carelessness will cause the injury. An incident occurs if a single person fails to follow directions or procedures.
Typically risks in this category have NO or Minimum controls in place. 80-to 100% chance an injury will occur due to the hazards. An injury will occur immediately when a person comes into contact with the hazard. A person is in the danger zone, or it is highly likely that an incident will happen, such as in the case of a mezzanine without handrails, or a live wire exposed in an occupied area. JUSTIFICATION OF SCORE
Note: Only values listed above can be used for SFMEA calculations INTERMITTENLY (exposed more than once to the hazard throughout the task) 16 TO 50 Laceration or minor ill-health effect or Partial-thickness/First degree burn <1% of body. First Aid only. 1 TO 2
Loss of digits (fingers/toes), break of major bone (e.g. skull, arm, back, pelvis, leg, rib) or minor permanent illness (e.g. mild hearing loss). Full- thickness/second degree burn of <9% of body. Any injury requiring a hospital overnight stay. Loss of one limb/eye, a hand, a foot. Partial-thickness/Second degree burn of >9% of body. Any injury requiring 2-7 days in the hospital. Loss of two limbs/eyes, both hands, both feet, Paralysis, or serious permanent illness (permanent loss of respiratory function, above mild hearing loss, non terminal disease). Full-thickness/third degree burn of > 9% of body . Any injury requiring greater than a week-long hospitalization.
(F) - FREQUENCY OF EXPOSURE (to the hazard DURING the TASK, not the shift) (NP) - NUMBER OF PEOPLE EXPOSED Typically risks in this category are mitigated with engineering controls, and / or several administrative controls (standardized work, pre task plans, training, warning signs, and/or PPE) that rely on more than one person or checking processes are in place (e.g. safety observation tours, high risk safety equipment inspections.) 1 to 5% chance an injury will occur due to the hazards. If multiple factors are in place an injury may occur, but the probability is low. Multiple people would need to fail to follow directions or follow procedures. For example a person is in an aerial platform without being tied off and the spotter does not remind the worker to use fall protection.
(P) - PROBABILITY OF OCCURANCE (Layers of Control in Place) 8 TO 15
3 TO 7
MORE THAN 50 PEOPLE
CATEGORY CATEGORY
CONSTANTLY (exposed to the hazard throughout the task) Break of minor bone (fingers, hand, toes, foot) or minor temporary illness (e.g. concussion, sprain or repetitive strain injury). Partial-thickness burn 1% to 9% of body. No overnight hospitalization required.
(SP) - SEVERITY POTENTIAL (WITHOUT Controls in Place) SFMEA Instructions
JUSTIFICATION OF SCORE
Death of one of more people
PAGE 2
SAFE018 REV13 05/19
Planning and Review
YES or NO
6. Is there a need for engineering drawings, rigging calculations, anchorage point calculations, assessment of critical equipment, licenses/certifications/evaluations, Safety Data Sheets (SDS's), or other supportive documentation to be attached to this JSA? HIGHEST RISK SCORE (FROM SFMEA) 0
12. Is a rescue plan necessary and detailed on the JSA? Is any required Safety Critical Equipment for rescue available and inspected? YES or NO YES or NO
2. TASK RISK CONTROL PLANNING QUESTIONS
If "YES" describe action or documentation
required / referenced
1. PROJECT / TASK DESCRIPTION
3. Are there any Risk Mitigation Requirements included in the Owner's Safety Minimum Requirements for this activity?
4. Are there any Safety Specifications included in the contract for the work to be performed?
9. For work involving hazardous energy, have you considered all energy sources and the safe method of control/verification? YES or NO
YES or NO
11. Does the task involve the use of a Powered Industrial Vehicle? If YES, is verification of Annual and Daily inspection available for all Safety Equipment (brakes, lights, horn, siren, etc.)? Does the JSA include mitigation if working or parked on an incline? Question
YES or NO
5. Does this work require assistance or support from an engineer, professional engineer, or safety professional?
13. Does the task include activities that will produce crystalline silica dust? If "YES", is an Exposure Control Plan completed and attached to this JSA?
YES or NO
8. Does this activity require a permit (e.g. confined space, roof access, hot work, etc.)?
7. For any critical equipment or personal protective equipment used, have you verified that required preventive maintenance has been completed? If pre-use or pre-operational inspection is required, is it a part of the work instructions?
1. Is there any way to eliminate, substitute, or to use engineering controls to eliminate or restrict exposure to the hazards? 10. Is there a need for specialized training AND have the assigned workers received such training?
YES or NO
YES or NO
0
YES or NO
Answer (Yes/No)
YES or NO
2. Are there work instructions, previous JSA's, or standardized work for this activity?
Supervisor:
Proposed Start Date: 0
YES or NO
YES or NO
Proposed End Date: 0
Name(s) of supporting engineer or qualified / competent person (if necessary): 0 Project / Task 0
Description:
Company Name: JSA # / Name: 0
Date: 0
Contact #: 0
Prepared by: 0
0
PAGE 4
SAFE018 REV13 05/19
Planning and Review
#
1
2
3
4
5
Action Date Completed
Instructions: Based on the planning questions above, list additional documentation or actions necessary to complete prior to the start of the job.
Responsible
3. PLANNING ACTION SUMMARY
SAFE018 REV13 05/19
Planning and Review
DATE:
DATE:
Date:
2
3. Contractor Safety Representative:
Low Risk
(Score 50)
CONTRACTOR REVIEW OWNER REVIEW
ROLE SIGNATURE BLOCK
3.
Name:
3. When new contractor workers are assigned to the work 1. During the Start of Shift meeting
OWNER REVIEW: Persons authorized to review Job Safety Analysis (JSA) include Contract/Project Manager, Field Safety Resource, Site SCM Champion, the Site Global Workplace Safety Leader/Resource, or anyone trained and authorized by the site champion to review JSAs.
OWNER Representative’s review of a Contractor’s JSA, or any safety measure proposed or implemented by the Contractor, is intended for the sole and exclusive benefit of the OWNER. Contractor may not rely upon OWNER’s review as constituting validation of the means, methods, techniques, procedures or equipment. Note: Low & Medium Risk section must be completed. Contractor must reduce risk below 500, using the hierarchy of safety controls and then conduct a second Safety FMEA to determine new risk score. Note: Low, Medium, & High Risk sections must be completed. High Risk
(Score 161 - 500)
When the JSA changes
2
nd
person to review:
OWNER will not accept Risk
level
4. At least monthly
Name:
1
st
person to review:
2. Prime Contractor Representative:
5. WORKER TRAINING & COMMUNICATION
Instructions: Direct Contractor Supervisor must review the Job Safety Analysis, at a minimum, at the following times: RISK LEVEL
2.
4.
Unacceptable Risk
4. CONTRACTOR / OWNER PROCESS REVIEW
1. Direct Supervisor:
SIGNATURE:
Date:
SIGNATURE:
1.
Medium Risk
(Score 51 - 160)
4. Prime Contractor Senior Leader on
Site:
SAFE018 REV13 05/19
Planning and Review
DATE:
DATE:
Date:
2
1. During the Start of Shift meeting
When the JSA changes
3. When new contractor workers are assigned to the work 4. Subcontractor Senior Leader on
Site:
4. Name: CCC REVIEW: CCC Persons authorized to review Job Safety Analysis (JSA) include CCC Project Manager, Superintendent, or Site Safety Representative.
CCC Representative’s review of a Subcontractor’s JSA, or any safety measure proposed or implemented by the Subcontractor, is intended for the sole and exclusive benefit of CCC. Subcontractor may not rely upon CCC’s review as constituting validation of the means, methods, techniques, procedures or equipment. 7. WORKER TRAINING & COMMUNICATION
High Risk
(Score 161 - 500)
Instructions: Direct Subcontractor Supervisor must review the Job Safety Analysis, at a minimum, at the following times: SIGNATURE: 2
nd
CCC person to review:
3. Subcontractor Safety
Representative:
3.
4. At least monthly
Note: Low, Medium, & High Risk sections must be completed. Unacceptable Risk
Subcontractor must reduce risk below 500 using the hierarchy of safety controls and then conduct a second Safety FEMA to determine new risk score. Risk Level NOT Acceptable Note: Low & Medium Risk section must be completed. 2. Subcontractor Representative: 2. Date: 1. Subcontractor Direct Supervisor: 1. Name: Low Risk
(Score 50)
Medium Risk
(Score 51 - 160)
SIGNATURE: 1
st
CCC person to review:
6. SUBCONTRACTOR / CCC PROCESS REVIEW
RISK LEVEL ROLE SUBCONTRACTOR REVIEW SIGNATURE BLOCK CCC REVIEW SAFE018 REV13 05/19
Contact this candidate