JSA Title: SCAFFOLD ERECTION / DISMANTLING JSA No.

: JSA- Date: Jan-2024

Work Location: Company: Supervisor:

B
Name Signature Date Name Signature Date Name Signature Date
REV
Prepared By: Reviewed By: Approved By:

Please tick () appropriate boxes

1.0 Permit(s) Required:  Cold  Hot  Confined Space Entry  Energy Isolation  NDT  Night Work  Hot works Checklist
 Hard Hat  Clear Safety Glasses  Dark Safety Glasses  Chemical Goggles  Cutting Goggles
 Dust Mask  Face Shield  Welding Screen  Welding Aprons  Welding Leggings
2.0 PPE Required:  Ear Plugs  Earmuffs  Cartridge Respirator  Escape Respirator  SCBA
 Cotton Gloves  Leather Gloves (rigging)  Leather Gloves (welding)  Rubber Gloves  Rubberized Cotton
 Coverall  Disposable Coverall  Full Body Harness  Hi-viz Vest / jacket  Safety Shoes
 Gas Badge  Multi-Gas Monitor  Gas Detective  Light Meter  Anemometer
3.0
Special Tools and  Dosimeter  Thermometer  Ventilation Fans  Air Blowers  Fire Extinguisher
Equipment Required:  Lifeline  Retrieval Line  Padlock, Hasp, Tags  Lighting (low voltage)  Lighting (high lux)
 Air Horn  Whistle  Traffic Flags  Traffic Cones  Spill Kits
Potential  Noise  Air Pollution (dust)  Air Pollution (smoke)  Air Pollution (vapor)
4.0 Environmental
Hazards  Soil erosion  Spills (to ground)  Spills (wadi)  Hazards to Flora & Fauna
Hazardous Materials
5.0
(attach MSDS)  Carcinogen  Irritant  Highly Flammable  Toxic  Explosive

6.0
Other Potential  Electrical  Pressure (air, water, gas)  Mechanical (crush points)  Ergonomics  Temperature (±)
Hazards  Light / Dark  Ignition Sources  Dust / Vapor  Suffocation  Other Trades
Additional
7.0
Instructions
CONSEQUENCES INCREASING LIKELIHOOD
SEVE
RITY Never heard of Heard of in Incident has occurred Happens several Happens several times
People Assets Environment Reputation
in EPC Industry EPC Industry in Petrofac Projects times / year in PUL / year in a location
1 Slight health effect / injury Slight Damage Slight Effect Slight Impact 1 2 3 4 5
2 Minor health effect / injury Minor Damage Minor Effect Minor Impact 2 4 Low Risk 6 8 10
3 Major health effect / injury Localized Damage Localized Effect Localized Impact 3 6 9 Medium Risk 12 15
Permanent Total disability
4 Major Damage Major Effect Major Impact 4 8 12 (ALARP) 16 High Risk 20
or 1 Fatality
5 Multiple Fatalities Extensive Damage Massive Effect Massive Impact 5 10 15 20 25
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 JSA Title: SCAFFOLD ERECTION / DISMANTLING JSA No.: JSA-2024 Rev.: B
Risk Residual
Step Activity Hazards Risk / Consequences Control Measures
Rating Risk

1. Off loading / - Defective equipment Injury to personnel, damage to 12 Certified equipment/ crane to be used 6
stacking the - Incompetent operators property Deploy competent operator to operate the equipment
scaffolding - Defective rigging tools
material - Suspended load Inspect all rigging tools before use.
Barricade loading/ unloading area to prevent entry of
 Using crane/ unauthorised personnel
fork lift No standing under the load

 Manual Handling - Trapping hands/ fingers Personnel injury/ Ergonomics Training for manual handling techniques
between the material problem (WRULD) Toolbox talks
- Repetitive movements

2. - Uneven ground Collapse of scaffold structure 12 Ground condition (ground must be firm and levelled) to 6
- Defective scaffolding Personnel falling from heights be inspected prior to erecting the scaffold by
materials competent supervisor
- Defective tools Falling objects
Scaffolding material/ tools to be inspected prior to use
- Untrained personnel Injury to personnel/ fatality and
property damage Full body harness and other PPE to be used
Deploy trained scaffolders
Competent supervision
Toolbox talks
Training for working at heights
Area to be barricaded and warning signs to be
displayed.

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 JSA Title: SCAFFOLD ERECTION / DISMANTLING JSA No.: Rev.:
PRE-START TOOLBOX TALKS Worksite Supervisor Conducting JSA Talks

NOTE: As the worksite Supervisor, my signature (next column) confirms that I understand the hazards and control
measures on the previous page(s) and have communicated all requirements with my work crew and will abide by
______________________ _________________ ________
all conditions and restrictions stated therein. List of names of work crew detailed below. Name Signature Date
No. Name Designation Company Signature Date
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