Job Safety Analysis (JSA) Form

1 SA B-14 form A Job Safety Analysis (JSA) 6/15 JOB Safety Analysis (JSA) Date/Time: Location: (Step 1) Work Area: Work Order No: Work Description (include Tank, Pipeline and Equipment Numbers as Practical): (Step 2) PROCEDURE REVIEW (Step 10) JSA Developer Have the relevant Procedures and Standards, been reviewed? Yes Pending confirmation by the Buckeye PIC of site conditions, I agree that the attached JSA identifies the significant Task Steps, Hazards, and Hazard Controls. (Step 8) RISK ASSESSMENT Must existing Procedures or Work Practices be modified to perform this work? (Procedure Deviation Approval Required) Yes No JSA Team Leader: Signature: PIC Name: Signature: After mitigation, are there any hazards that continue to present a potentially significant risk? If so, contact HSSE Specialist or District Advisor. Yes No (Step 11) JSA Team: I acknowledge that we have developed/updated the attached JSA.

2 Site personnel shall review and ensure that this JSA meets all current site, weather and operational conditions. Name (print): Signature: (Step 9) PPE REQUIRED DURING THIS TASK Refer to Buckeye Safety Manual Section E (Summarize PPE from the WHA and/or Hazard Management form ) Buckeye PIC: HARD HAT Safety SHOES / BOOTS Safety GLASSES W/ SIDE SHIELDS FIRST AID KIT FIRE EXTINGUISHER(S) FACE SHIELD GOGGLES WELDING SHIELD EAR PLUGS/EAR MUFFS GLOVE Type: LEATHER PRODUCT RESISTANT IMPACT PROTECTION CUT RESISTANT ELECTRICALLY CLASSIFIED OTHER (specify): intrinsically safe EQUIP. RESPIRATOR TYPE DUST MASK MASK (APR) FULL FACE SCBA/AIRLINE (Circle One) FALL PROTECTION FALL RESTRAINT FLAME RESISTANT CLOTHING (FR) DISPOSABLE FR COVERALLS FR & CHEMICAL RESISTANT SUI LIFE VEST (PFD) HI-VIS WORK VEST RAINWEAR OTHER PPE CheckPointThreatExtractionSecuredThisDoc umentGetOriginalSA B-14 form A Job Safety Analysis (JSA) 6/15 Hazard Identification and Hazard Controls Note: If the scope of work or the conditions change significantly, STOP THE WORK/SHUT DOWN.

3 Revise the JSA to address the NEW HAZARDS before proceeding. Discuss, identify and record the significant task steps, Potential Hazards and Hazard Controls PRIOR to the JSA Reviewer. Complete the Assigned Person. (Step 3) SIGNIFICANT TASK STEPS (Number/Description) (Step 4) HAZARD IDENTIFICATION (What could go wrong?) (Step 5) HAZARDS CONTROLS (How can harm be prevented?) (Step 7) ASSIGNED PERSON Name Complete SA B-14 form A Job Safety Analysis (JSA) 6/15 (Step 6) JOB Safety Analysis WORK HAZARD ASSESSMENT form This table of Hazards and Controls can assist the work group to manage hazards for the proposed work. The table does not include all possible hazards. It is expected that the required PPE for the activity and work conditions will be used.

4 Determine the Hazards that are present for the task and identify the Controls to be implemented. Pressurized Equipment Poor Lighting or visibility Personnel Confined Space Simultaneous Operations (SIMOPS) Weather Ignition Sources Perform isolation LOTO or bypassing a Safety Device Depressurize, drain, purge, and vent Relieve trapped pressure Avoid auto-refrigeration when depressurizing Anticipate residual pressure or fluids Provide alternate lighting Wait or defer until visibility improves No work over water that could require rescue (including sea state) Provide training for new workers Mentor, coach, or supervise Verify competencies, skills, and experience Address applicable limitations (fatigue, exhaustion, and restricted duty) Language Barriers Discuss confined space entry safe work practice Monitor access or entry Protect surfaces from inadvertent contact Do not locate mobile engines near confined space Provide Attendant Develop rescue plan Review SIMOPS at facility Interface between groups Communicate changes for SIMOPS restrictions Use barriers and signs to segregate activities Implement controls for slippery surfaces High winds goggles Heat hydration, breaks Cold PPE, warm up breaks, or heaters Lightning defer nonemergency work Remove, isolate.

5 Or contain combustible materials Provide firefighting equipment Construct a fire- safe work area Provide a fire watch during and after hot work Conduct continuous air monitoring Bond/Ground for static electricity or cathodic protection Hazardous Substance Potential Spills Equipment Hot or Cold High Noise Falling or Dropped Objects Lifting Equipment Work at Heights Drain or purge equipment Follow SDS controls Implement controls based on specific hazards Test or analyze material Drain equipment Provide spill containment equipment Have spill clean-up materials and equipment on hand Restrain and isolate hoses when not in use Heat or cool equipment before work starts Install barriers Provide warning signs Implement cold temperature and brittle failure controls Wear insulated gloves Noise signage in place for greater than 85 decibels Wear hearing protection Manage exposure times Shutdown equipment Use "quiet" tools Sound barriers or curtains Provide or use suitable communication techniques Use signs and barriers to restrict entry or access under work at elevation Use lifting equipment to raise/lower tools to or from the work platform Secure tools (tie-off)

6 Train personnel to avoid walking under elevated work Confirm lifting equipment condition and certification Obtain approval for lifts over processing equipment Have a documented and approved lift plan in accordance with the Rigging Policy in the Contractor Safety Manual Discuss working at heights safe work practice Verify fall restraint and arrest equipment rating and condition Consider weather conditions Portable Electrical Equipment Radiation Hazard Moving Objects or Equipment Manual Handling Equipment and Tools Vibrating Equipment Slips, Trips, and Falls Inspect equipment for condition Implement continuous air monitoring as needed Protect electrical leads from impact or damage GFCI required at source Use barriers and signs to restrict access Notify personnel who may be affected Confirm machinery guard integrity Adequate barriers and signage Observer to monitor proximity of people and equipment Shut down or lockout equipment Assess manual handling task Limit load size Manage posture Confirm stability of load and work platform Get assistance or mechanical aid to avoid pinch points Inspect equipment and tools Use protective guards Use correct tools and equipment for task Protect or remove sharp edges Get assistance or mechanical aid to avoid pinch points Manage exposure times Assess effect of vibration on equipment Use low vibration equipment Apply noise controls

7 Identify and shield uneven surface or projections Secure or cover cables, cords, and tubing Clean up liquids Barricade openings and holes High Energy or High Voltage Excavations Waste Clean Up and Disposal Other Energy Sources Mobile Equipment Other Hazards Emergency Response Observe safe work distances to exposed equipment Follow Electrical safe Work Practices ( over 50 volts) Review Electrical shock hazards Review Arc Flash hazards Hot Stick Over 600 volts- Buddy system A One-Call/Dig safe has been completed Locate underground pipes Consider sloping, shielding, or shoring measures De-energize underground services or cables by hand digging Implement confined space entry controls if over 5 feet Apply environmental management practices Follow waste management procedures Optimize task to minimize waste production Mechanical, Spring compression or expansion control Implement electromagnetic (radio) controls Manage pressure or vacuum Manage heat/cold generating processes Other.

8 Inspect equipment condition Valid Operator Certificate Limit and monitor proximity to live equipment or cables Manage overhead hazards Adhere to road and site rules Implement abrasive blasting controls Prepare a dive plan Manage potential blocked or plugged equipment MOC required for temporary/permanent connections or modifications Barricade/Warning Signs Keep egress route open Keep shower and eye wash stations accessible Have a site evacuation and muster plan in place Maintain Access to Emergency Equipment If responding to an actual emergency have SSH Plan