TYPICAL JHA FORM

COMPANY NAME JHA # CLIENT NAME

Rev: XXX

JHA NO.: REVISION NO.:0 AREA: JOB LOCATION: DATE:

Hazardous Area Classification: Zone 0  , Zone 1 , Zone 2  , Non Hazardous
Job Ref (Project No./Work Order No.: GC12107100-EPIC FOR 20” WET GAS PIPELINE

Job Description: Activities for Cutting Of Asphalt Road for Placemen/fixing of Protection Slabs Permit Type & No. :________________ _____________

Risk Assessment Matrix (RAM)

INCREASING LIKELIHOOD & PROBABILITY

Consequences A B C D E
Occurs
Potential Occurs Risk/Signific
Assets damaged Never heard of in Has occurred in Has occurred in several
Severity Environmental Reputation several times
ance Zone
People & Business
Effect
industry industry the industry
a year
times a year
Losses Impact in this Site
Rarely Unlikely Possible Likely Almost certain
I
N 0 No injury No damage No effect No impact A0 B0 C0 D0 E0
C Low
R Risk/Impact
E Slight injury or Slight damaged
1 Health effect (< 35,000 QR)
Slight effect Slight impact A1 B1 C1 D1 E1
A
S Minor damaged
Minor injury or E2
I 2 Health effect
(Between 35,000 Minor effect Minor impact A2 B2 C2 D2
N to 350,000 QR)
Medium
G Minor damaged
Risk/Impact
Major injury or (Between
3 Health effect 350,000 to
Moderate effect Moderate impact A3 B3 C3 D3 E3
S
E 3,500,000 QR)
V Major damaged
Single fatality or
E (Between 3.5
4 Permanent total
million to 35
Major effect Major impact A4 B4 C4 D4 E4
R disability
million QR) High
I
Risk/Impact
T Massive
Multiple
Y 5 damaged (> 35 Critical effect Critical impact A5 B5 C5 D5 E5
fatalities
million QR)

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 Risk Rating Residual
Activities (Job Action Party /
S/N Potential Hazard Before Controls/Mitigation Measures Risk /
Steps) Remark
Mitigation Rating
Work Permit  Unauthorized commencement of works Medium= C2  Authorized work permit holders shall ensure obtaining Low=C1 Site Supervisor
 May result in exposing people and/or potential and maintaining valid work permits. and
to harm or danger.  The supervisor responsible for this activity has to Safety Officer
check the PPE of his staff to ensure that all required
items are available and properly used.
1
 Inform all people regarding permit conditions before
work starts.
 Supervisors must conduct daily toolbox talk about
nature of work and associated potential hazards and
their essential precautionary measures.
Gas test  May found toxic gas or H2S gas leak or extreme Medium= C2  Carryout gas test by Authorized gas tester time to time if Low =C1 Site
oxygen limit in air required. Supervisor/PTW
2
 All groups working in different area inside station shall
have H2S personal gas monitor/Toxic clips
Using of hand tools  Body pain Medium= C2  All operatives shall be trained for proper handling of Low= C1 Site Supervisor
 Risk of injury due to use of hand tools tools. and
 Safety Officer
 Risk of striking hand Appropriate tools only have to be used and its
 Risk of striking others requirements
 Risk of eye injury from metal chips  All operatives shall wear their PPEs without fail.
 Cuts From Sharp Objects  Keep only required amount of tools at site.
3
 Fall, hit and strip  All tools shall be kept clean for easy use.
 Ensure other personnel are well clear.
 Beware of sharp edges on tools
 The right tool for the job should always be used to
decrease the chances of injury, incidents, or damage
to a tool through improper use
HSE check list &Prior  Lack of safety awareness Medium= C2  Obtain work permits/ All personnel shall be H2S Low= C1 Site supervisor &
to commencing trained safety officer
mobilization to site  Comply with all general job requirements mentioned
on PTW
4
 Toolbox Talk on possible emergency and response
procedure and work activities.
 All safety requirements stated on the work permit
must be fulfilled
5 General  Faulty Equipment Medium= C2  Survey the work area and check utilities that need to Low =C1 All
safety/Emergency  Health Hazards / Heat Stress turn off
condition 
 Back-strain Ensure equipment is maintained in good working
 Emergency condition order and properly used .check equipment before
use.
 Work in confined space
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  Block of emergency access by excavated  Ensure that proper barricade and sign have been
materials OR trenches placed around the working areas
 Provide drinking water at the jobsite according
weather condition.
 QP work and rest procedure shall be followed.
 Follow summer period working law and procedures
 Each employee should be instructed in safe working
procedure/technique and emergency procedure and
what they should to do in case of emergency inform
every one about the emergency exit and assembly
points and emergency contact numbers.
 Provide proper access and ladders
 If excavation dept. more hen 1.20 meter confined
space procedure to be followed
 Follow the security rules and regulation .using proper
gate and exit for entering and exit.
 Don’t block operation access and emergency access
OR access to fire equipment.
 Provide proper access to emergency gates
 Lack of safety awareness Medium= C2  Obtain all required work permits/ Low= C1 Site supervisor &
HSE check list &Prior  Comply with all general job requirements mentioned safety officer
to commencing on PTW
mobilization to site
6  Toolbox Talks on possible emergency and response
procedure.
 All safety requirements stated on the work permit
must be fulfilled
Site preparation and  Personal injury Medium= C2  Inspect all tool and equipment Low= C1 Site supervisor &
movement of  Manually handling injury  Observe proper manual handling techniques safety officer
personnel, tools
equipment
 Uninspected tools equipment  Provide adequate amount of cold drinking water
7
 Over exhaustion/extreme weather condition  Maintain work rest period
 Slips ,trips and falls  Suitable access and egress to be provided
 Sharp object  Wearing of PPE
Medium= C2  Working area shall be barricaded and access shall be Low= C1 Site supervisor &
Barricading and Accidents and incidents may take place as a restricted. safety officer/ALL
setting warning sign result of lack of attention.  Use safety cones bounded by safety caution tape to
8
cordon the working area.
 Warning signs will be settled in place of work for
attention
9 Asphalt Cutting Using  Concrete or other debris embedded in eyes. Medium= C2  Area cordon off. Low= C1 Site Supervisor,
Jack Hammer  Loss of hearing.  Know your weight lifting capacity and get help if and
Safety Officer
 Back strain needed. Lift using leg muscles. Keep back straight.
 Body vibration  Maintain work and rest period
 Personal injury  All operatives shall be trained for proper handling of

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  Body pain task.
 Risk of striking hand  Jack Hammer shall use only for Asphalt cutting
 Risk of striking others  Al people working for jack hammer shall always use
 Cuts From Sharp Objects ear plugs and proper PPE
 Fall, hit and strip  All operatives shall wear their PPEs without fail.
 Fire ignition.  Beware of sharp edges on tools
 Electric shock.  Provide proper fitting, safety whips and safety
requirements for air hoses.
 High Water Table.
 Continuously checking of hoses for damaged or leaks
 Equipment In Unsafe Operating Condition
 Continuously checking of compressor
 Damaging Buried Utilities
 Remove soil/ stock pile material maximum away from
edge.
 Fire extinguisher
 Thoroughly Inspect Equipment Before Use. Make
Sure All Safety Devices And Guards Are Intact And
Operable.
 All equipment must be diesel fuel driven with spark
arrestor
 Use Extreme Caution Around Existing Utilities,
Medium= C2  Inform control room on end of the day /shift Low =C1 Site Supervisor,
 Complete the task on daily base .doesn’t leave any and
cut OR excavated road without proper arrangement Safety Officer
 Falling hazards and inform to control room.
10 Post Asphalt Cutting  Traffic hazards  Use warning signs & lights if work not competed
 Backfill and compact the area daily bases.
 Don’t block operation access/Road and emergency
access OR access to fire equipment.
 Provide proper access to emergency gates
Housekeeping.  Debris causing Slips, trips and falls. Medium=  Regular housekeeping at site shall be performed. Low= C1 Site Supervisor,
 Fire risk due to presence of combustible C2  Adequate and correct stacking of materials. Workers
and
11 materials / debris.  Regular inspection and immediate corrective action.
Safety Officer
Keep always clear of obstruction.
 Regular clearing of work site shall be implemented.

TEAM MEMBERS & ENDORSEMENT

POSITION /REF POSITION /REF
NAME SIGN S/N NAME SIGN
INDICATOR INDICATOR

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JHA Team Leader Authorization: Ref Indicator: Sign:

JHA Approval (Permit Authority / Asset Holder): Ref Indicator: Sign:

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