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JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
Location / Project:
ACTIVITY OR TASK: LIFT PERSONNEL IN SCISSOR LIFT
JSA Preparation & Job Number:
task work team: JSA Number: G02 JSA Revision:
Competence = Relevant Training/Qualifications + Experience
Competence/ Qualific’n
Codes of Practice &
req’d to complete work
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Legislation that are

safely
applicable:
JSA approved by Name: Position / Competence/ License: Date:
person responsible i.e.
Team Leader / Tradesman

2. HAZARD IDENTIFICATION Identify hazards that may be present by ticking items on the list below. 3. PRECAUTIONS: hard hat, safety glasses, safety boots
compulsory
WORK LOCATION HAZARDOUS AREA HIGH RISK HIGH RISK ADDITIONAL PRECAUTIONS PERMITS
Difficult Entry/Exit Hazardous Substances Falling Objects Suspended loads Gloves: type …………………. Hot Work
Oxygen Deficiency - attach MSDS to JSA Poor Lighting Poor Visibility Goggles Excavation
Oxygen Excess Working at Heights Slippery Surfaces Inhalable Dusts/Fibres Full Face Shield Confined Space
Engulfment (trench collapse) Remote Area Multiple Electrical Feeds High Noise Levels High Visibility Vest Hazardous Work Clearance
Poisonous Gas Present Motor Room Hazards Trip Hazards Use of Chemicals Harness Access to Area
Temperature Extremes Toxic Substances Electrical Hazards - LV Elevated Work Platform Fire Extinguishers High Voltage Access
Defined Confined Space Potential for Difficult Rescue Electrical Hazards - HV Difficulty to Communicate Barricades Scaffolding
Explosive Gas Present amongst workers Ventilation Other?
Manual Handling Moving Machinery Lighting
PERMIT NUMBER
HAZARDOUS SUBSTANCES in work area / to be used Sharp Materials Tools & Equipment Erect Scaffolding to access
-attach MSDS
Ladders used in the task Heat/ Sunlight/ Radiation Respirator or Dust mask
Working at Heights Traffic Movement Erect Warning signs
Working near Crane & Working near Operation Personal Locks or Tag system
Crane Runways Processing Lines Group isolation
Rail Movement Live Rails Welding screen
Pressurised Fluids Pneumatics Fall Arrest systems
Flamm. Materials Present Welding Face Shield

4. ENVIRONMENTAL HAZARDS – (IMPACTS) tick those identified Consequences: how severe an

Likelihood:
Air Pollution (dust, fumes) Spills to ground Other: RISK RATING TABLE How likely is it to injury?
Noise (plant & equipment) Soil Erosion
This table is used to calculate whether be that bad? Death Serious Medical 1st Aid
the hazard you have identified is Injuries Treatment req’d
Spills to drains/waterways Hazard to Flora /Fauna Req’d
Extreme: 9-10 High: 7-8,
Medium: 5-6 or Low: 3-4 Almost Certain - 10 9 8 7
Expected to Occur
5. EQUIPMENT REQUIRED: Likely – could 9 8 7 6
The objective of rating the risk is to lower the risk happen sometime
Static Plant & Equipment
by initiating risk control measures. The score is Moderate – could
Mobile Plant & Equipment 8 7 6 5
happen but not likely
Unlikely – could 7 6 5 4
happen but very rare

Revision Date: March 2005 ………. of ………….. Rare - could happen OHS-03-F01
6 5 4 3
but probably never will
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JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
noted in the JSA risk score column on the next
Safety / Emergency Equip’t
page – both before & after risk control measures
have been nominated.

NAME OF TASK: LIFT PERSONNEL IN SCISSOR LIFT JSA Number: G02 Rev:

Potential Safety & Risk Recommended Corrective Action or Procedure Risk

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Step Sequence of Basic Job Steps Environmental Hazards/Impacts Rating Determine what actions are necessary to eliminate or minimise all hazards that Rating
No. Break down Job into steps. Each step should Identify the hazards (health and safety or Use table on could lead to an accident, injury, illness or environmental
Of the risk
Logical accomplish a major task and environmental) associated with each step, the previous incident. The risk must be reduced or controlled to a level following
sequence
be logical. examine each to find all possible risk factors page to that is acceptable before work commences. corrective
score risk Indicate who is to perform the action where applicable against each action action
Environmental Aspects

1 Obtain PTW Injury / damage as a result of Obtain correct PTW. Training in PTW system.
incorrect information
Identify work area Risk of injury due to low awareness Operators for this task will be trained and competent in the use of
2
of work environment, Unauthorised SCISSOR LIFTS – no other person is to operate the SCISSOR
operator, Mechanical failure, Falling LIFT for this task, First task is to complete your daily checks to
from heights, Scissors lift topples, assess that the SCISSOR LIFT is in a safe working condition and
Coming into contact with complete the attached logbook for future reference. Check all oil
Instruments, Valves or other items. and fuel levels where applicable or the charge level of the
Electric type units. Prior to SCISSOR LIFT set up assess area for
obstructions, drains, uneven or unstable ground and any other
item that may raise a concern for the work crew. At all times
while driving the SCISSOR LIFT along road ways etc the
occupants of the work platform of the scissor lift must keep inside
the platforms safety rails

If the area that requires the use of a scissor lift is congested, then
it is advisable to gain the services of an observer to assist the
operator to gain access into the area with out the risk of damage
to live plant, equipment or personnel

Revision Date: March 2005 ………. of ………….. OHS-03-F01

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JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
Set up scissor lift Fire / explosion Gain a clearance and permit prior to setting scissor lift up on
3
Roadway. The small electric scissor lift is best to be transported
to the relevant work sites with the use of a Franna crane to
maintain a high battery level. Scissor lift to be directed to set up
area by competent person. Scissor lift to operated (driven) and
be set up on firm and level foundation as per manufacturers
specifications. While setting up scissor lift and equipment if
anything is assessed as a physical risk ask for assistance. If the
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scissor lift is fitted with an attachment point for a safety harness

then all occupants of the scissor lift must wear an approved
harness.

Visually monitor all scissor lift movements and ask for assistance
if vision is obscured.
4 Prepare to carry out tasks from scissor Scissor lift topples Conduct take 5 and Job Start meeting with the entire work crew
lift platform to discus tasks at hand any potential hazard that may impact on
Fire, explosion the safety of Personnel.

Collision with plant, equipment, Gain all relevant road closures to eliminate uncontrolled traffic
movement in work area.
Vehicles or personnel.
If the scissor lift is working or parked on the Refinery road
FALLING FROM HEIGHTS system then we must protect our work area, personnel and
Edge of road way collapses scissor lift by placing high visibility barricading around this
area to eliminate any access from unauthorised vehicles,
pedestrians or bicycles from entering the danger zone.

While working near the edge of Roadways keep Scissor lift a

minimum of 1 metre from the edge of the roadway and operate
under the guidance of a spotter. If during the scissor lifts
operation the supporting surface subsides or shows signs of the
scissor lift wheels penetrating and sinking into the ground or if
the work area has altered and is deemed to be unsafe, stop work
and contact the work group Supervisor. Make the area safe and
then once the concerns are discussed if there is an alternative
location the scissor lift can be positioned then conduct a new job
start meeting and continue on or if the area cannot be deemed
safe to continue, stop the work until it is deemed safe to do so.

Revision Date: March 2005 ………. of ………….. OHS-03-F01

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JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
Install and remove equipment as Falling tools – people below Barricade work area at ground level to prevent people entering in
5
required the danger zone for falling objects
Fall from Scissor lift
Position the scissor lift so that personnel working from the work
High winds platform do not have to lean out or over reach past the railing to
complete the task. If this is a requirement then stop work and
Hand or eye injury conduct another take 5 and job start to discus the risks and an
alternate method for completion of the task at hand.
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Access the risk from high winds and Electrical storms on a

regular basis. – halt the job if necessary, assess the conditions
and if cleared up conduct take 5 and job start.

Gloves and safety glasses must be worn

Placing scissor lift into lay down or Scissor lift topples When placing scissor lift into lay down or parking area maintain
6
parking area minimum of 1 metre clearance between the scissor lift wheels
Falling from heights and the edge of the roadway. As a suggestion with the small
electric scissor it is efficient to transport this unit with a franna
crane. Please note this is a guide only for firm and stable ground
and each area must be assessed on an individual basis prior to
this motion-taking place. The electric scissor lift requires that it is
placed on charge at the end of each night, gain all relevant
permits and clearances and plug in the tested electrical lead to
the end of the unit where the battery L.E.D lights a positioned.
electric scissor it is efficient to transport this unit with a franna
crane. Please note this is a guide only for firm and stable ground
and each area must be assessed on an individual basis prior to
this motion-taking place. The electric scissor lift requires that it is
placed on charge at the end of each night, gain all relevant
permits and clearances and plug in the tested electrical lead to
the end of the unit where the battery L.E.D lights a positioned.

Revision Date: March 2005 ………. of ………….. OHS-03-F01

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JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
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Revision Date: March 2005 ………. of ………….. OHS-03-F01

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JOB SAFETY & ENVIRONMENT ANALYSIS (JSA)

CONSULTATION & SIGN-OFF RECORD

I confirm by my signature below, that I have attended a briefing on the requirements of the attached Job Safety &
Environment Analysis and agree to perform the work in the manner detailed on it.
I confirm that copies of the relevant Permits, MSDS's, Isolation Plans etc. have been reviewed.

Rev:
JSA NAME JSA No:

NAME (Please print) SIGNATURE DATE

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THIS SAFE WORK BRIEFING / TRAINING WAS CARRIED OUT BY (responsible person at that location) :
Name: Signature: Date:

Client sign off (where applicable)

Site / Project Manager sign off (document reviewed)

Revision Date: March 2005 OHS-03-F01