Job Hazard Analysis (JHA) This form involves job hazard analysis that also incorporates the Line Break and Core Drilling forms. Job and Site InfoA job hazard analysis is an objective, in-depth analysis of a specific job with the goal of finding and correcting hazards. The findings of this analysis are to be shared and discussed with the crew before the onset of a job. Employees are to sign the back of this form, and it is to be returned to the shop with all other paperwork.Job Site*Job Number*Date* Date Format: MM slash DD slash YYYY Crew Leader*Crew Leader Email* Job Description*Tools/Equipment*Potential HazardsCheck all that apply.Fall Hazards*YesNoNotes*Slips/Trips*YesNoNotes*Pinch Points*YesNoNotes*Hot/Cold Substance or Surface*YesNoNotes*Rotating/Moving Equipment*YesNoNotes*Flying Particles*YesNoNotes*Electrical*YesNoNotes*Repetitive Motion*YesNoNotes*Hot/Cold Weather*YesNoNotes*Struck by Falling/Flying Objects*YesNoNotes*Sharp Objects*YesNoNotes*Excessive Noise Levels*YesNoNotes*Energy Sources*YesNoNotes*Roof/Floor/Grating Load Capacities Adequate*YesNoNotesLift Spotter*YesNoNotes*Ground Clearance Selection as Listed in Notch Aerial Lift Policy*YesNoNotes*Proximity Hazards (sprinkler heads, electrical panels, active lines)*YesNoNotes*Other*YesNoNotes*Notes on Physical Hazards (How to Eliminate)*Chemicals/ SubstancesCheck all that apply.Flammable Materials*YesNoNotes*Corrosive Chemicals*YesNoNotes*Toxic Chemicals*YesNoNotes*Reactive Materials*YesNoNotes*Carbon Monoxide / Asphyxiates*YesNoNotes*Painted/Galvanized/Coated Surface*YesNoNotes*Dust Particulate*YesNoNotes*Spill Potential*YesNoNotes*Notes on Chemical Hazards (How to Eliminate)*PPE Equipment* Hard Hat Harness Safety Glasses Lanyard Goggles SCBA Safety Toe Tripod Face Shield Lifeline Respirator Gas Monitor Tyvek Suit Coppus Blower Gloves Hearing Protection Chemical Suit Chemical Boots Dust Mask Other Check all that ApplyOther*Line Break / Core DrillingDoes work description require a line break?*YesNoDoes work description require core drilling?*YesNoNotch Line Break PermitGood ONLY For (Date)* Date Format: MM slash DD slash YYYY Good ONLY for (Time)* : HH MM AM PM System Name*Location*Employee ID of Person(s) Doing Work*Employee 1 Line / Equipment PreparationsPre-Line Break OperationsHas correct line been confirmed?*YesNoN/AHas the Planner/Crew leader and the person working on this line as a team marked the piping all the way around, including the line contents & tie point #?*YesNoN/AIdentify contents of the piping system & obtain a copy of SDS.*YesNoN/ADoes customer / owner have a procedure for work to be done? If yes, get a copy, review with crew, and attach to this permit.*YesNoN/AHas SDS been reviewed an proper PPE been selected?*YesNoN/AHas line been flushed?*YesNoN/AHas the pipe line been traced & isolated from all lines connected to it?*YesNoN/ALine Break OperationsHas the pipe line been drained, purged, and depressurized?*YesNoN/AHave all drain valves been opened and checked to be clear of obstructions?*YesNoN/AHas a written plan been made for catching and containing material from pipe system?*YesNoN/AHas all associated equipment been de-energized, locked / tagged out & checked?*YesNoN/AHas spill potential been recognized?*YesNoN/AWill piping need temporary support?*YesNoN/AHas the nearest eye wash / safety shower been identified?*YesNoN/AIs a "HOT WORK PERMIT" required during line break?*YesNoN/ACaution tape around work area?*YesNoN/AHas an emergency response plan been reviewed with all workers?*YesNoN/APPE Requirements(Check all that apply) Goggles Face Shield Nitrile Gloves Heavy/Long Rubber Gloves Splash Jacket Splash Suit Rubber Boots Respirator - full face Further PPE may be required depending on positioning of worker at line break. Overhead line break may require additional PPE.Permit Close OutBy submitting this form, the crew leader certifies that all information is accurate to the best of his/her knowledge.Has the work area been cleaned after work was completed?*YesNoN/AHave all materials that were drained been properly disposed of?*YesNoN/ANotch Wet Core Drilling ChecklistHas the location of the hole been identified and marked above and below the floor or inside and outside of the wall, depending on where the hole is being drilled?* Yes Size of core drill bit:*Thickness of floor/wall:*Select Method for Controlling Slug*Mark out 3/4 depth on drill bit. Drill 3/4 through the floor (or wall), stop, and snap off the core with a cold chisel and 5 lb sledge. Then, remove to reduce the size of the slug, minimizing the potential impact hazard. A bucket or barrel can be located and secured as close to the penetration as possible via strapping to piping or raising in a lift as close to the ceiling as possible. Do not put person under core drill.Install a brace with wedge anchors following Notch's Silica Standard written exposure plan under the hole location to prevent the slug from falling through the floor (example: Angle iron, Unistrut, Wood).OtherOther (Please Detail)*Lower levels protected and secured?* Yes Means of communication identified:*Control method for slurry:*JHA filled for task?* Yes EmailThis field is for validation purposes and should be left unchanged.