Job Safety Analysis (JSA)

PART A: WORK DETAILS (To be completed by permit issuer in consultation with contractor in charge of work).

Job/Task:       Date:      

Work Location:      

Description of Work:      

In case of emergency the following people are to be contacted

Name of Supervisor in Charge of Work:

      Safety Officer:      

PART B: TASKS TO BE COMPLETED (To be completed by permit issuer in consultation with contractor in charge of work)

Activity Hazard(s) Risk Control Method Who is responsible?

                       

                       

                       

                       

                       

                       

                       

                       

Examine each step carefully to find and identify hazards or potential dangers that could lead to injury, illness or damage. Consider the following:Chemical Hazard – Inhalation – Skin Contact – Absorption – Injection - Ingestion

Biological Hazards – Blood borne Pathogens – Mould – Plant/Animal/Insect

Physical Hazards – Electrical – Fire/Explosion – Noise/Radiation – Thermal Stress – Pinch Point/Line of Fall – Slips/Trips/Falls – Strike against/Struck by

Ergonomic Hazards – Repetition – Forceful/Exertion – Awkward Posture – Contact Stress – Vibration – Work Area Design

PART C: CONTROL METHOD/S REQUIRED FOR PERFORMING THE WORK

Additional Personal Protective Equipment Required

☐Face Shield ☐ Chemical Googles ☐ Chemical Protective Clothing ☐ Rubber Boots☐Chemical Resistant Gloves ☐ Leather Gloves ☐ Cut Resistant Gloves ☐ Respiratory Protection ☐Arm Protection ☐ Hearing Protection ☐ Fall Protection ☐ High Visibility Clothing ☐ Safety Boots☐ Other

☐Safe Work Method Statement Required☐Additional Permits Required

List Permits     

☐Gas Detection Required? ☐H2S Monitoring ☐ LEL, O2, CO Monitoring ☐ Other

☐List Hazardous Substances

MSDS Reviewed ☐ Yes ☐ No

Site Controls ☐Barricades ☐ Sign Posts ☐ Caution Tape ☐ Designated Area for Vehicle Parking ☐ Spotter

☐Other:      

Environmental Controls

Weather:      Terrain:       Wildlife:      

Hazardous Energy Control

☐Electrical ☐ Hydraulic ☐ Pneumatic ☐ Mechanical ☐ Thermal ☐ Chemical☐Stored Energy ☐ Line of Fire ☐ Energy Isolation Verified ☐ Lock out devices installed

Tools and Equipment

☐Pre-start inspection complete ☐ Verified as competent

QAC Document: QAC-I-FRM-003 Page 1 of 1Queenstown Airport Corporation Internal Use Only Version: 1.0