Event Date: 1/12/2020
FIELD SERVICE JSA Work Order# SR-DS-UD-2021-001896
Employee Name KISHAN LALMEGHWAL WWID 15246190LHAC
JSA Completed with Co-Worker Names: Mr. Hukam Singh Chouhan
Task Catagory Ind-Agriculture Auto-Truck- Bus Fire Pump Ind-Other
Ind-Constr-Logging Oil-Gas HHP PM Mining HHP-Rail HHP-Other
Task Description REPI A CHECK
Job Location Birla Corp.,Chanderiya
PREPARE Yes / No / NA
If required, have you completed the safety induction and/or understand the site
Yes If 'No' , Stop the
safety rules?
Emergency response arrangements in place and understood? Yes Job, Contact
The work area is free from other activities which may impact your safety? Yes Your Supervisor
TOOLING & EQUIPMENT Yes / No / NA LIFTING & ACCESS Yes / No / NA
Tooling & Equipment suitable & free of damage? Yes Manual lifting of parts is within capabilities Yes
Equipment Lifting Plan in place and understood NA
Is Lock Out Tag Out Required and Checklist
NA Is there safe access to work area & equipment? Yes
completed?
PPE
PPE for task available? Is PPE Suitable & free from damage?
LONE WORKING Will the task require you to work alone or without supervision? Yes No
If yes, provide details of special safety measures and emergency plan:
SERIOUS INJURY HAZARD ASSESSMENT - IDENTIFY RISK & IMPLEMENT CONTROL
MOVING VEHICLES MOVING MACHINERY WORK AT HEIGHT
WORK WITH ELECTRICITY LIFTING OPERATIONS FIRE, EXPLOSION
Serious Injury Hazards Identified Controls Put In Place What is strange, unusual or different today?
MOVING VEHICLES
WORK WITH ELECTRICITY
MOVING MACHINERY Hydraulic Locked
LIFTING OPERATIONS
WORK AT HEIGHT
FIRE, EXPLOSION or ARC FLASH
Other :
Other :
WORKSITE HAZARD ASSESSMENT - IDENTIFY RISK & IMPLEMENT CONTROL
Each worksite is different, so identify potential hazards before you begin the task and if the task changes significantly
Hazard Identification (check if present)
Unusual Hazards Line of Fire Slips, Trips, Falls Ergonomics
Natural Gas (CNG/LNG) Struck by or Against Snow, Mud or Ice Excessive Force
Animals or Insects Caught or Trapped By Trailing Cables Repetitive Work
Overhead Power Lines Hazardous Energy Uneven Ground/Gravel Stressful Posture
Exhaust Gases Dust or Dirt Elevated Area Contact Stress
High Noise Level Projectile Hazard Roof Top Kneeling/Crawling
Hot Work Wet or Oily Floor Vibration
Restricted Work Spaces Heavy Lifting
Environmental Impact
Confined Space Entry
Leaks or Spills People Interaction
Hygiene Hazards
Fumes or Smoke Work with Contractors Weather Conditions
Flammable Gas or Liquid
Waste Disposal General Public Extreme Heat
Compressed Air
Use of Chemicals Customer/Employees Extreme Cold
Battery Safety
High Winds
Storm Conditions
Housekeeping
Access Equipment Rain
Set to Order
Ladder or Step Ladder Snow/Ice
Dispose/Scrap
Static Access Platform High Altitude
Cleanliness
Mobile Work Platform
Step Stool
IDENTIFY ANY SPECIAL CONTROL MEASURES REQUIRED - what is strange, unusual or different today?
LOCKOUT TAGOUT CHECKLIST
REPORT ALL INJURY, ILLNESS AND NEAR HIT EVENTS 8 STEPS TO COMPLETE LOTO
In the event of a life-threatening or serious injury, contact emergency 1. Understand the equipment
services immediately
Report all incidents to your Manager immediately - this can be a serious or 2. Inform Affected Employees
minor injury, or a near hit event 3. Shut Down and De-Energize
Manager Name Mr. Mahesh Vyas 4. Isolate the Machine from All Energy Sources
Manager Contact Tel 5. Lockout the Energy
9414165571
No:
6. Control Stored or Secondary Energy
7. Verify the Lockout
8. Maintain the Lockout
IMPROVE SAFETY TO REACH OUR INJURY FREE GOAL
Is there a safer way to do this job? Share your experiences and
improvement suggestions in one of these 3 ways 5 STEPS TO RELEASE LOCKOUT
1. QSOL - Raise a Safety Help Ticket 1. Make sure the area is clear of personnel and tools
2. Remove locks
Go to 'My QSOL Help Tickets' and select 'Safety' in the module dropdown 3. Notify the affected Employees that the Lockout has been
box
removed
2. Notify your Supervisor in person or raise a near hit report 4. Test the Machine
3. Share your experience during a Job Safety Observation 5. Notify Affected Employees that the machine is ready for
use
When required, shift handover completed
THANK YOU FOR WORKING SAFELY TODAY
