Work Plan and Job Safety/Hazard Analysis
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Work Plan and Job Safety Analysis (JSA)
Project Name Date
Prepared
Client Start Date
Location Finish Date
Description
Client Facility Phone/
Manager Email
Client Facility Phone/
Operator Email
Personnel
Position Name (sign only after reading) Contact Phone/Email Training Emer. Form
Current on location
Prepared by Y N Y N
Level:
Safety Y N Y N
Supervisor Level:
Worker Y N Y N
Level:
Worker Y N Y N
Level:
Worker Y N Y N
Level:
Worker Y N Y N
Level:
Worker Y N Y N
Level:
Other Y N Y N
Level:
Other Y N Y N
Level:
Emergency Information
EMS Phone Police Phone
Fire/Rescue Phone Company Contact
Name & Phone
Emergency Access Where and how will EMS reach the worksite?
to Site
Communication: Cell Phone (Check service on site Y N)
Radio (Channel:________)
Phone (Note phone number, location, special dialing, other contacts, etc)
Tower One Inc 620 West Coliseum Blvd, Ft. Wayne, IN 46808 (317) 455-8081
Work Plan and Job Safety/Hazard Analysis
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All Tower One employees and contractors will comply fully with this work plan and job safety analysis, all client safety
programs, all site safety programs, and any other safety program deemed appropriate to Tower One Inc.
Full personnel protective equipment (PPE) will be required as deemed necessary by the site safety plan. This is to
include helmet, appropriate footwear (steel or carbon toe as required), hearing protection, eye protection, and gloves if
required.
By signing this document, the signee has agreed to these terms.
Description
of work
Work Standard practices outlined in Guidelines for Tower Work
Methods Standard practices outlined in Guidelines for Rope Access Work
Individual Helmet Connectors Protective Clothing Rope Grabs
Equipment Harness Descender Hearing Protection Cable Grab
Eye Protection Lanyards Reflective Clothing Headlamp
Foot Protection Pulleys Respiratory Protection Mutli-tool
Gloves Belay Device Other
Anchor Straps Backup Device
Group Ropes ( 11mm / 12.5mm) (Number, lengths) Connectors
Equipment Rigging Straps
Edge Protection
Other
Team Visual (Hand Signals) Verbal Radio (Note channel)
Communication
Machinery Do machinery valves, gates, or motors need to be locked out? Yes No
Lockout/tagout Machinery locked out/tagged out of service Hold order visually checked by work supervisor
Hold order number _______________
Work Supervisor__________________
Equipment/tool Squids
Management Other (describe and attach other pages if necessary)
Access zone Describe access zone and method to mark and secure entry
Hazard zone Describe hazard zone and method to mark and secure entry
Anchors Certified Anchor Straps Cable Loops
Certified Anchor Bolts Other (Specify)
Webbing
Tower One Inc 620 West Coliseum Blvd, Ft. Wayne, IN 46808 (317) 455-8081
Work Plan and Job Safety/Hazard Analysis
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Rescue
Rescue and
Retrieval
Methods
Rescue kit First Aid Kit Connectors Other
Pulleys Descenders
Rope Grabs Patient Packaging
Job Safety/Hazard Analysis
Condition Description of Hazards Control Measures
Falling Gravity induced injury or death Always use appropriate fall-protection or rope-
access equipment when 6 feet from unprotected
edge with a fall potential of 6 feet or more
All personnel must be properly trained
Human Error Rigging Errors Use 2 rope system when working line is primary
means of support
Use independent anchorages
Always do 4 point check: Ropes (including anchors),
Hardware, Harness, Helmet
Communication Loud ambient noise (traffic, machinery, running Agree upon and use standardized communication
Difficulty water, wind, etc) signals
Malfunctioning or dropped radios Check communication system
Conditions change Designate alternate communication system in case
conditions change or technical difficulties arise
Review hand signals
Sharp/abrasive Rope or anchor damage and/or failure Use proper edge protection and padding
Surfaces Abrasions or cuts to hands Use re-direct or intermediate anchors as needed
Wear gloves and proper clothing
Electrical Lines Inadvertent contact with energized lines Examine lines that might be contacted by wind-
Burns or electrocution from contact blown ropes
Get appropriate clearances
Follow lockout/tagout procedure
Machinery Inadvertent operation of machinery Get appropriate clearances
Injury sustained from machinery Follow lockout/tagout procedures
Hazardous condition created (release of water) Confirm lockout/tagout
Injury from tools Hazards depend on tools used Follow all manufacturer’s instructions and keep all
Damage to rope-access or fall-protection system protective guards in place
Separate suspension rope may be required for
tools greater that 25lbs
Dropped tools or Possible injury to personnel and public Clearly mark and barricade Hazard Zone
Materials Loss of important tools for work or egress Helmets or hard hats must be worn in hazard zone
Damage to structures or equipment Keep a clean and orderly worksite
All tools and devices must be tethered or secured
Avoid working or standing below other workers
Tower One Inc 620 West Coliseum Blvd, Ft. Wayne, IN 46808 (317) 455-8081
Work Plan and Job Safety/Hazard Analysis
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Job Safety/Hazard Analysis (continued…)
Possible injury to personnel and public Careful scaling or clearing of slope prior to work
Rock fall or Damage to structures or equipment Loose materials or rock may need to be secured
Severed ropes or anchors (either temporarily or permanently)
Loose detritus Mange ropes carefully to avoid dislodging loose
materials
Rain/wet Insulating qualities of wet clothing decreases Stop work if conditions become dangerous
Conditions Possible hypothermia (dangerously low body Wear proper footwear and clothing waterproof
temperature) rain gear should be available
Wet surfaces can be slippery Be aware of slippery conditions
Decreased friction on descent and rope grab Electrical equipment must be adequately grounded
devices and equipped with GFCI’s
Danger of stay current near improperly insulated
and grounded equipment
Decreased visibility
Snow/Ice Insulating qualities of wet clothing decreases Stop work if conditions become dangerous
Possible hypothermia (dangerously low body Wear proper footwear and clothing, including
temperature) gloves and hat
Loss of dexterity in extremities Waterproof raingear should be available
Wet and icy surfaces can be slippery Be aware of slippery conditions
Decreased friction on descent and rope grab Use appropriate equipment for conditions
devices Electrical equipment must be adequately grounded
Danger of stay current near improperly insulated and equipped with GFCI’s
and grounded equipment Hand warmers should be available in case of
Decreased visibility emergency
Water Wet surfaces can be slippery Stop work if conditions become dangerous
Potential for drowning Rescue boat shall be readily available if working
Trapped in current while tied off (drowning directly over water, especially if descent is a viable
hazard) method of egress
Fall protection or rope access equipment must now
allow worker to fall into water (especially moving
water)
Personal flotation devices not required if proper
fall protection is in place
Sun/heat Possible dehydration, heat exhaustion, or heat Stop work If conditions become dangerous
stroke Ample water and/or electrolytes must be on hand
Burns from tools, equipment, and structural steel for workers
Adhesives and first-aid supplies may be degraded Schedule proper breaks and work in morning or
by heat evening to avoid peak temperatures
Wear gloves and proper clothing to protect hands
from hot surfaces
Use and frequently re-apply adequate sunscreen
Wind Possible increased cooling or hypothermia risk, Stop work if conditions become dangerous
increased dehydration risk in dry humidity Wear proper footwear and clothing, including
Decrease in efficiency, hindrance to gloves and hat
communications between team members Secure loose materials at work site
Danger of unsecured equipment or material Be wary of wind developing slack in ropes where
being blown into the access zone they may be blown in to areas making retrieval
Difficulty communicating difficult
Lightning Possible electrocution due to lightning strike, loss Stop work when lighting threatens
of consciousness or life
Rope access equipment may provide a pathway
to the operative for electrical strikes
Tower One Inc 620 West Coliseum Blvd, Ft. Wayne, IN 46808 (317) 455-8081
Work Plan and Job Safety/Hazard Analysis
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Job Safety/Hazard Analysis (continued…)
Dimly lit or Sharp or protruding objects (metal, nails, bolts, Provide adequate lighting: area lighting and/or
Night work etc.) may not be visible to moving operatives, head and hand lamps
drowsiness of employees Provide spare batteries, light sources, and bulbs
Dust Difficulty in breathing, possible allergic reaction Provide adequate engineering controls
Possible long-term exposure hazard Provide PPE where engineering controls not
possible or impractical
Chemical Difficulty in breathing, dizziness, unconsciousness Workers must have MSDS on site for all chemicals
Exposure Chemical burns to skin, eyes, internal organs used in work
Proper PPE and engineering controls must be in
place
Respirators must be the correct type for the
exposure
Confined space Work areas may contain toxic gases or Follow confined space procedures
entry insufficient oxygen levels for work Toxic rescue plan required and in force prior to
Space may have restricted entry/exit making entry
access difficult
High noise area Permanent or temporary damage to hearing Hearing protection required, in extremely loud
Difficult communications environments (+120 dBA), multiple types of
High-noise levels may mask warning buzzers or protection may be necessary
other alert sounds Agree on hand signals before work starts
Workers may be equipped with sound-isolating
hearing protection for radios
Insect or animal Possible injury or incapacitation of personnel Careful access into areas where spiders, snakes,
bites or stings depending on severity of bite or venom scorpions, or other creatures may reside
Use of gloves at all times, equip first aid kit with
medical supplies appropriate for bites and stings
Vehicular traffic Possible impact or crushing injury Careful demarcation of access and hazard zones,
use flags, signs, flag persons, lighting as needed
Provide high-visibility clothing for personnel
Bird/animal Possible inhalation of disease carried by feces Workers may need to wear protective gloves or
feces respirators
Tower One Inc 620 West Coliseum Blvd, Ft. Wayne, IN 46808 (317) 455-8081