Pre-Job Safety Assessment
Instructions: The following form is to be completed “onsite” and used to communicate the potential hazards
and preventative measures to be taken prior to beginning work on critical tasks. All employees onsite must
Issued/Effective Date:
Revision Number: 1 09/08/2014review this document and sign in on the attendance section prior to beginning work.
Field Office ________________________ Date _________________________ Work Type
Person Leading __________________________________________________ ___ Construction Frac
Completion Swab
SITE INFORMATION Workover Flowback
JSA available? Yes No GPS Coordinates: LAT ____ LONG ______ Maintenance __________
Surface Location ____________________________________________________ Permits / Plans Needed?
County _____ ____________________________ State___________________ Confined Space
Hospital / Clinic Directions _________________ Excavation Permit
Critical Lift
One-Call Number _____________________ Fire Dept. _________________
Hazard Energy Control / LOTO
Smoking Area________________________ Ambulance ________________ Other ____________________
Muster Point _________________________ Sherriff ________________ Other ____________________
MINIMUM PERSONAL PROTECTIVE EQUIPMENT REQUIRED
Safety Glasses w/SS Hand Protection Fall Protection Hearing Protection
Hard Hat Respirator H 2 S Monitor Safety Boots
Chemical Prot. Clothing Other _______________________________________
HAZARD CLASSIFICATION APPLICABILITY HAZARD CLASSIFICATION APPLICABILITY
Task Hazards Yes No Material Hazards Yes No
1. OverheadUtilities 24. Flammable Atmosphere / Fire
2. Trenching/Excavation 25. Chemical Handling
3. Vehicles / Traffic 26. Dusts / Gases / Mists / Fumes
4. Scaffolding/Heights 27. Spill Potential
5. Housekeeping 28. Waste Disposal
6. WorkerProximity
7. Weather Conditions / Lightning Personal Hazards
8. Slips / Trips / Falls 29. Heat / Cold Stress
9. Welding / Grinding / Cutting 30. Communication
10. Falling Objects 31. Time Restrictions
11. Restricted Access / Egress 32. Short Service Employees
12. Confined Spaces 33. Non-English Speaking Employees
13. Noise Equipment Hazards
14. Pinch / Nip Points 34. Rotating Equipment
15. Lighting / Darkness 35. Hand / Power Tool Condition
16. Flying Debris 36. Heavy Equipment
17. Stored Energy 37. Slings / Chains / Hoists
18. Material Handling 38. Radioactive Equipment / NORM
19. Water Hazard
20. Fuel Transfer Other Hazards
21. Critical Lifts 39. Simultaneous Operations
22. Insects / Snakes 40. Other
23. High Pressure
Job Description: Describe the job that this PJSA will cover
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HAZARD CONTROL (If hazard marked “yes,” identify hazard by number and list control measure(s) implemented. Continue on back, if required.)
4. Proper P.P.E. 23. High pressure lines and awareness.
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5. Location condition and equipment. 25. Prevention measures.
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6. Location condition and equipment. 27. Prevention measures.
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8. Plastic containments and water. 30. Good communication.
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13. Proper P.P.E. 34. Placement of body and equipment.
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14. Placement of body and equipment. 36. Moving equipment.
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18. Prevention measures. 40. Reporting incidents.
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20. Prevention measures.
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Pre-Job Safety Assessment
Safety-Critical Jobs
Northeast Natural Energy,LLC
Any safety-critical jobs must have a Pre-Job Safety Assessment conducted. Examples of safety-critical jobs are listed
below. Please note this list is not all-inclusive. Each operation should be evaluated to determine if a Pre-Job Safety
Assessment is necessary.
1. Pre-move hazard assessment (condition of roads, power line clearance, etc.)
2. Raising and lower of workover rig derrick
3. BOP and casing pressure tests
4. Nipple up and nipple down BOPs on wells with open hydrocarbon zones
5. Tree removal, installation, and testing
6. Well kill operations
7. Fishing operations: back-offs, chemical cutting, jet cutting, stripping over wire
8. Perforating
9. Well stimulation: acidizing and fracturing
10. Flow-back iron and sand separator pressure testing
11. Rig up and rig down of power swivel
12. Running tubing bailer (bulldog tool) with power swivel
13. Foam-air cleanouts
14. Coil tubing operations
15. Snubbing operations
16. Plugging operations: laying down casing
17. Pumping unit operations including:
Lockout / Tagout of pumping unit counterweights
Energy isolation of electrical, mechanical, and trapped pressure
Rod jobs and stack out of rod string on stuffing box with polish rod clamp etc.
18. Permit to Work assignments (hot work, confined space, ground disturbance, etc.)
19. Hydrogen Sulfide Operations with potential exposure of 10ppm or greater to work crews
20. Simultaneous operations on well pads with drilling, completion, or construction operations
21. Critical heavy lifting operations (Permit or Plan may be needed)
A lift that presents a risk of significant property damage, or high potential of personal injury, or a lift
designated as a critical lift by the operations because of special circumstances or hazards.
Some examples are: Operator cannot see load or signal person. Lifting over energized or pressurized
equipment or occupied facilities. Lifting where power lines exist. Using two or more cranes/lifting devices. Lifts
that exceed 80% of the lifting equipment capacity. Lifting of personnel
22. Equipment hydro/pressure testing
23. Hot Tapping
HAZARD CONTROL (Continued from front.)
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TAILGATE MEETING ATTENDANCE – Please Print Meeting Conducted By: ________________________________
____________________________________ ______________________________________ _______________________________________________________
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Pre-Job Safety Assessment Page 2 of 2
