Document No: 700-FOR-001

Revision: 0
Job Safety Assessment Worksheet Issue Date: 05-Jul-2013
Page: Page 1 of 4

JSA No. JSA Developed by Reviewed by

Location
Equipment Date
Task Description Risk Rating (highest of individual steps)
Initial (before controls) Residual (after control)
Date
Permit required Special PPE required Special tools or equipment required (gas detection, ventilation fans, lighting, scaffolding etc.)
No Permit Required

Confined Space Excavation

Hot Work Group Isolation

Fire/Emergency equipment requirements (Fire extinguishers, rescue gear etc.) Hazardous materials (List any hazardous materials to be used and attach MSDS)

POTENTIAL HAZARDS / RISKS WHICH MAY BE PRESENT

Heat Confined Spaces Engulfment Interruption to Services

Noise Access/Egress from confined spaces Explosive Atmosphere Lifting Equipment
Asphyxiation Dusts Fire/Explosion Lighting
Atmosphere/Gases Electric Shock Molten Metal Manual Handling
Chemical/Biological Chemicals Weather Conditions Oxy Welding & Cutting
Mobile Equipment Environmental damage Waste Pinch Points
Stored Energy Tools Working at Heights Slips/Trips
Poor Housekeeping Excavations Parked in a Safe Condition Equipment suspended or likely to move
Other

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 Document No: FOR-012-008
Consequence and Revision: 1.0.1
Issue Date: 01-Apr-2009
Likelihood Page: Page 2 of 4

CONSEQUENC Insignificant Minor Moderate Major Catastrophic

E A B C D E
Health &
First aid injury Medical Treatment Injury Lost Time Injury Permanent Disability Fatality
Safety
Less than one shift Up to one day production Up to one week One week to one Greater than one
Operational
production disruption production disruption. month production month production
Loss or disruption disruption. disruption.
Damages,
Less than US$50,000 - $500,000 loss. US$500,000 - $5 million US$5 million - $20 US$20 million loss.
Liability US$50,000 loss. million loss.
loss.

Little or no impact Minor impact immediate Substantial impact. Serious impact that Major/Disastrous
Immediate containment/control. within the project area may extend beyond and/or widespread
containment and Impact contained to area (e.g. unapproved the project boundary impact (can cause
Environmental control, (e.g. minor currently impacted by clearing of vegetation (e.g. uncontrolled Immediate and/or
contained spill, operations.(e.g. large or disturbance of fire, destroying long-term harm)
report/procedure contained spill, incorrect heritage site) heritage site). (E.g., tailings dam
breach). waste disposal) breach).

The management Non-compliance not Management and Management and Prosecution will
and control of the causing any issues (e.g. no control of the impact is control of the impact occur and result in
impact is not environment harm), the subject of is required by process halt and
required by prosecution will not occur. regulatory inspection, legislation or loss of production.
Compliance
legislation, corporate policy, statutory obligations
statutory however, unlikely that and it is likely that
obligations or prosecution will occur. prosecution will
corporate policy. occur.

The issue has not Localized complaint with The issue has been The issue is or could Significant
been raised as a no media coverage. raised as an area of be of primary complaints and
concern and concern for the concern to the local, national and/or
Community complaints are immediate community national community international media
rare. or public with with significant coverage.
Impact
possibility of complaints and wide
occasional complaints local and/or national
or minor media media coverage.
coverage.

Rare Unlikely Possible likely Certain

LIKELIHOOD
1 2 3 4 5
The event may occur The event has The event could The event is The event will
in exceptional happened elsewhere occur under some expected to occur occur
circumstances yet, yet, circumstances
All Rarely occurs in the is unlikely to occur
industry
Incidents
The event could occur The event could occur The event could The event could The event could
once every 100 years once every 10 years occur once every 5 occur twice per occur once per
years. year month

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 Document No: 700-FOR-001
Revision: 0
Risk Matrix Issue Date: 05-Jul-2013
Page: Page 3 of 4

Consequence
The intersection of the Consequence and the
Likelihood A B C D E likelihood on the Risk Matrix gives you a Risk Rating
1 1 3 6 10 15

2 2 5 9 14 19 The highest Residual Risk Rating determines who will

3 4 8 13 18 22
take action to correct the hazards identified
4 7 12 17 21 24

5 11 16 20 23 25

Risk Ranking Priority Action

Extreme 18 25 1 Cease activity or task, detailed research and planning required

High 11 17 2 Senior Management attention required, immediate corrective or preventative action required

Moderate 6 10 3 Management responsibility assigned, corrective and preventative action plan including JSA

Low 15 4 Manage by routine procedures, e.g. JSA or SOP

NOTE: After Hazard control measures have been implemented, the highest residual risk score shall determine who shall action this JSA

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 Document No: 700-FOR-001
Revision: 0
Worksheet Issue Date: 05-Jul-2013
Page: Page 4 of 4

STEP JOB STEP POTENTIAL HAZARD INITIAL HAZARD CONTROL MEASURES RESIDUAL RESPONSIBLE PERSON
No. List the steps required to perform the job For each step list the potential hazards RISK For each hazard identified list the control RISK List the person responsible
in the sequence it is carried out that could cause injury or damage when RATING measures required to eliminate or RATING for implementing the
each job step is carried out minimize the risk of injury or damage After required hazard control
Before
controls measures
controls
1. 1
2. 4
3. 5
4. 6
5. 7
6. 8
7.
8.
9.
10.
11.
12.
13.
14.

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