Date

Power Gen JSA Work Order #

Employee Name WWID

JSA Completed
With Co-Worker Names:
Task Category PG-Comm->200KW PG-Commercial-<200KW PG- Stitches-Switchgear Start-Up
PG-Rental PG-Consumer PG-Other PG-G Drive PM ATS Load Test
Task Description
Job Location
Specify Voltage of Equipment: Note : High Voltage > 1000 VAC
PPE
Arc Flash Warning Data Flash Hazard Boundary (where available) Level
PREPARE Yes / No / NA

If required, have you completed the safety induction and/or understand the site safety rules?
Is live electrical work being completed and a permit required?
Emergency response arrangements in place and understood?
If 'No' , Stop the
The work area is free from other activities which may impact your
Job, Contact
safety?
Your Supervisor
Correct Cummins Qualification & Authorization to complete work on this equipment?
Wiring diagram available and isolation points identified to assess Lock Out Tag Out controls?
If working with contractors, they participated in JSA & controls have been communicated?

START-UP OR LOAD BANK TEST Yes / No / NA

Are all doors closed and secured and all equipment covers in place and secured?
If battery is exposed during restart or start up, do you have the correct PPE (battery blanket, face shield, etc)?
Yes / No /
Yes / No / NA
TOOLING & EQUIPMENT LIFTING & ACCESS NA
Has the equipment been de-energized? Manual lifting of parts is within capabilities
Is Lock Out Tag Out Required and Checklist Equipment Lifting Plan in place and
completed? understood
Is there safe access to work area &
Tooling & Equipment suitable & free of damage? equipment?
PPE
PPE for task available? ☐ Is PPE Suitable & free from damage? ☐ Electrical Insulated Gloves Test Date Stamp? ☐

LONE WORKING Will the task require you to work alone or without supervision? Yes ☐ No ☐
If yes, provide details of special safety measures and emergency plan:

SERIOUS INJURY HAZARD ASSESSMENT - IDENTIFY RISK & IMPLEMENT CONTROL

RESTRICTED WORK SPACE MOVING MACHINERY WORK AT HEIGHT
WORK WITH ELECTRICITY LIFTING OPERATIONS FIRE, EXPLOSION or ARC FLASH
Serious Injury Hazards Identified Controls Put In Place What is strange, unusual or different today?
☐ RESTRICTED WORK SPACE

☐ WORK WITH ELECTRICITY

☐ MOVING MACHINERY

☐ LIFTING OPERATIONS

☐ WORK AT HEIGHT

☐ FIRE, EXPLOSION or ARC FLASH

Other :

Other :
WORKSITE HAZARD ASSESSMENT - IDENTIFY RISK & IMPLEMENT CONTROL
Each worksite is different, so identify potential hazards before you begin the task and if the task changes significantly
Hazard Identification (check if present)
Unusual Hazards Line of Fire Slips, Trips, Falls Ergonomics
☐ Natural Gas (CNG/LNG) ☐ Struck by or Against ☐ Snow, Mud or Ice ☐ Excessive Force
☐ Animals or Insects ☐ Caught or Trapped By ☐ Trailing Cables ☐ Repetitive Work
☐ Overhead Power Lines ☐ Hazardous Energy ☐ Uneven Ground/Gravel ☐ Stressful Posture
☐ Exhaust Gases ☐ Dust or Dirt ☐ Elevated Area ☐ Contact Stress
☐ High Noise Level ☐ Projectile Hazard ☐ Roof Top ☐ Kneeling/Crawling
☐ Hot Work ☐ Wet/Oily Floor ☐ Vibration
☐ Restricted Work Spaces Environmental Impact
☐ Heavy Lifting
☐ Confined Work Spaces ☐ Leaks or Spills Weather Conditions ☐ Push/Pull
☐ Hygiene Hazards ☐ Fumes or Smoke ☐ Extreme Heat
☐ Flammable Gas /Liquid ☐ Waste Disposal ☐ Extreme Cold People Interaction
☐ Compressed Air ☐ Use of Chemicals ☐ High Winds ☐ Work with Contractors
☐ Battery Safety ☐ Storm Conditions ☐ General Public
Access Equipment
☐ Rain ☐ Customer/Employees
Housekeeping ☐ Ladder or Step Ladder
☐ Snow/Ice
☐ Set to Order ☐ Static Access Platform
☐ High Altitude
☐ Dispose/Scrap ☐ Mobile Work Platform
☐ Cleanliness ☐ Step Stool

IDENTIFY ANY SPECIAL CONTROL MEASURES REQUIRED - what is strange, unusual or different today?

REPORT ALL INJURY, ILLNESS AND NEAR HIT EVENTS LOCKOUT TAGOUT CHECKLIST
In the event of a life-threatening or serious injury, contact 8 STEPS TO COMPLETE LOTO
emergency services immediately 1. Understand the equipment ☐
Report all incidents to your Manager immediately - this can be a 2. Inform Affected Employees ☐
serious or minor injury, or a near hit event 3. Shut Down and De-Energize ☐
4. Isolate the Machine from All Energy Sources ☐
Manager Name
5. Lockout the Energy ☐
Manager Contact Tel No. 6. Control Stored or Secondary Energy ☐
7. Verify the Lockout ☐
In an emergency situation, you can also contact the Cummins
Response Center for assistance on US Only +1 866.685.4313 or 8. Maintain the Lockout ☐
International +1 433.221.4877
5 STEPS TO RELEASE LOCKOUT
1. Make sure the area is clear of personnel and tools ☐
IMPROVE SAFETY TO REACH OUR INJURY FREE GOAL
2. Remove locks ☐
Is there a safer way to do this job? Share your experiences and 3. Notify the affected Employees that the Lockout has
improvement suggestions in one of these 3 ways been removed ☐
1. QSOL - Raise a Safety Help
4. Test the Machine ☐
Ticket
5. Notify Affected Employees that the machine is ready
Go to 'My QSOL Help Tickets' and select 'Safety' in the module for use ☐
dropdown box
When required, shift handover completed
2. Notify your Supervisor in person or raise a near hit report
3. Share your experience during a Job Safety Observation

THANK YOU FOR WORKING SAFELY TODAY