Job Hazard Analysis (JHA) Form - Notch Mechanical Constructors

Job and Site Info

A 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*

Crew Leader*

Crew Leader Email*

Job Description*

Tools/Equipment*

Potential Hazards

Check all that apply.

Fall Hazards*

Yes
No

Notes*

Slips/Trips*

Yes
No

Notes*

Pinch Points*

Yes
No

Notes*

Hot/Cold Substance or Surface*

Yes
No

Notes*

Rotating/Moving Equipment*

Yes
No

Notes*

Flying Particles*

Yes
No

Notes*

Electrical*

Yes
No

Notes*

Repetitive Motion*

Yes
No

Notes*

Hot/Cold Weather*

Yes
No

Notes*

Struck by Falling/Flying Objects*

Yes
No

Notes*

Sharp Objects*

Yes
No

Notes*

Excessive Noise Levels*

Yes
No

Notes*

Energy Sources*

Yes
No

Notes*

Roof/Floor/Grating Load Capacities Adequate*

Yes
No

Notes

Lift Spotter*

Yes
No

Notes*

Ground Clearance Selection as Listed in Notch Aerial Lift Policy*

Yes
No

Notes*

Proximity Hazards (sprinkler heads, electrical panels, active lines)*

Yes
No

Notes*

Other*

Yes
No

Notes*

Notes on Physical Hazards (How to Eliminate)*

Chemicals/ Substances

Check all that apply.

Flammable Materials*

Yes
No

Notes*

Corrosive Chemicals*

Yes
No

Notes*

Toxic Chemicals*

Yes
No

Notes*

Reactive Materials*

Yes
No

Notes*

Carbon Monoxide / Asphyxiates*

Yes
No

Notes*

Painted/Galvanized/Coated Surface*

Yes
No

Notes*

Dust Particulate*

Yes
No

Notes*

Spill Potential*

Yes
No

Notes*

Notes on Chemical Hazards (How to Eliminate)*

PPE Equipment*

Check all that Apply

Other*

Line Break / Core Drilling

Does work description require a line break?*

Yes
No

Does work description require core drilling?*

Yes
No

Notch Line Break Permit

Good ONLY For (Date)*

Good ONLY for (Time)*

: HH

MM

System Name*

Location*

Employee ID of Person(s) Doing Work*

Employee 1

Line / Equipment Preparations

Pre-Line Break Operations

Has correct line been confirmed?*

Yes
No
N/A

Has 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 #?*

Yes
No
N/A

Identify contents of the piping system & obtain a copy of SDS.*

Yes
No
N/A

Does customer / owner have a procedure for work to be done? If yes, get a copy, review with crew, and attach to this permit.*

Yes
No
N/A

Has SDS been reviewed an proper PPE been selected?*

Yes
No
N/A

Has line been flushed?*

Yes
No
N/A

Has the pipe line been traced & isolated from all lines connected to it?*

Yes
No
N/A

Line Break Operations

Has the pipe line been drained, purged, and depressurized?*

Yes
No
N/A

Have all drain valves been opened and checked to be clear of obstructions?*

Yes
No
N/A

Has a written plan been made for catching and containing material from pipe system?*

Yes
No
N/A

Has all associated equipment been de-energized, locked / tagged out & checked?*

Yes
No
N/A

Has spill potential been recognized?*

Yes
No
N/A

Will piping need temporary support?*

Yes
No
N/A

Has the nearest eye wash / safety shower been identified?*

Yes
No
N/A

Is a "HOT WORK PERMIT" required during line break?*

Yes
No
N/A

Caution tape around work area?*

Yes
No
N/A

Has an emergency response plan been reviewed with all workers?*

Yes
No
N/A

PPE 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 Out

By 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?*

Yes
No
N/A

Have all materials that were drained been properly disposed of?*

Yes
No
N/A

Notch Wet Core Drilling Checklist

Has 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).
Other

Other (Please Detail)*

Lower levels protected and secured?*

Yes

Means of communication identified:*

Control method for slurry:*

JHA filled for task?*

Yes

Name

This field is for validation purposes and should be left unchanged.