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JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
Location / Project:
ACTIVITY OR TASK: Scaffolding (Erection and Dismantling)
JSA Preparation & Job Number:
task work team: JSA Number: G20 JSA Revision:
Competence = Relevant Training/Qualifications + Experience
Competence/ Qualific’n
Codes of Practice &
req’d to complete work
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: Scaffolding (Erection and Dismantling) JSA Number: G20 Rev:

Potential Safety & Environmental Risk Recommended Corrective Action or Procedure Risk
Step Sequence of Basic Job Steps 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 that following
sequence
be logical. examine each to find all possible risk factors page to score is acceptable before work commences. corrective
risk Indicate who is to perform the action where applicable against each action action
Environmental Aspects

1 Site Inspection Injury as a result of exposure to Be aware of and plan escape routes. Be aware of wind.
substances released due to
equipment failure
Slips, Trips and Falls due to slippery Due care and attention.
surfaces, obstructions, restricted
access.
Injury due to equipment failure, Liaise with permit authority / operations to minimize exposure to
moving equipment, activity and creation of hazards.
2 Raise Permit Stress and frustration due to Ensure all information supplied is as accurate and understandable
incorrect information misdirecting as possible.
efforts
3 Transport scaffold equipment to site Injury/damage related to vehicle Use correct vehicle and handling procedures
operation and equipment handling
Injury / damage due to collision / Plan route to avoid other personnel and equipment
impact with other workgroups /
equipment
Injury / damage as a result of Use appropriate barricades and bunting to protect personnel and
dropping tools and scaffold equipment
components
4 Erect scaffolding Hot and cold burns as a result of Adequate PPE with correct instruction and use.
contact with pipework
Injury due to limited egress in Ensure scaffold has adequate egress for any situation.
emergency
Injury / damage as a result of Use appropriate barricades and bunting to protect personnel and
dropping tools and scaffold equipment
components

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

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JOB SAFETY & ENVIRONMENT ANALYSIS (JSA) / SAFE WORK METHOD STATEMENT
Injury / damage due to scaffold Erect and dismantle all scaffold to comply with all legal and site
collapse requirements.
Injury / damage due to damaged All components to be checked prior to installation
components causing equipment
failure
Injury / damage caused by scaffold Check specified limits of scaffold before utilization
collapse due to excessive load on
scaffold
Injury / damage due to scaffolding Scaffold must only be erected by trained personnel
erected by unauthorized personnel
Injury / damage caused by Licenced scaffolder to supervise apprentices at all times
scaffolding erected by persons with
limited competency
Injury / damage caused by Use appropriate barricades and bunting to protect personnel and
personnel falling from scaffolding equipment. Use IFAS harness.
Injury / damage caused by persons Use independent fall arrest system. 1.8m fall limit and standby
falling whilst working outside person precautions
scaffolding
5 Handover of scaffold Injury as a result of incomplete Check scaffold properly before attaching scafftag. Tag must be
scaffold, loose boards, kickplates, signed by qualified person. Use scaffold checklist.
etc causing slips,trips and falls
6 Dismantle scaffold Excess scaffold components cause Stack scaffold gear in stillage and remove from site. Keep site
clutter. Injury results. clean
Injury results from untidy worksite Keep worksite clean and tidy at all times to reduce hazards to a
minimum
Injury / damage caused by falling Inspect scaffold to ensure it is clear of debris before turning boards
objects and dismantling
Injury / damage caused by incorrect Correct procedure for dismantling of scaffold is adhered to.
sequence of dismantling

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

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

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