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(H) Post TSA Return to the HSE Department upon

(G) Involved Crew Members completion of this task.


Post STA
Name Sign Foreman: _____________________________________
Initial

Date: _________________ Time: __________________

Was anyone injured or did an unplanned incident occur


today. Yes No

If yes, explain: _________________________________

______________________________________________

______________________________________________

Was it reported to the HSE department?


Yes No

Is the work area clean and free of debris from the days
work? Yes No

What problems did you have with todays work


assignment?
______________________________________________

What can we do to improve performance?


______________________________________________
______________________________________________

Miscellaneous concerns:
______________________________________________
______________________________________________

Supervisor Sign: _____________________Time:______

(J) Reviewers

General Foreman: ______________________________

HSE Department: _______________________________

(K) Management Participation

Name: ________________________________________
(A) Task Safety Analysis

The Task Safety Analysis (TSA) process significantly (B) Personal Protective Equipment
impacts the success of our HSE culture and the Clothing
reduction of incidents. The interactive process Chemical Resistant Fire Retardant
requires that management / supervisors and
Reflective Vest or Hand-held signal Device
employees shall:
Define the general task for each activity. Ear Protection
Identify known and potential HSE hazards Ear Plugs Ear Muffs
associated with the task.
Eye/Face Protection
Determine work practices to complete the task
Safety Glasses with Side-shields
safely.
Goggles Monogoggles
Project Name: Kahramaa Central Workshop Address requirements for all personal protective
Welding Hood Face Shield
equipment.
Company Name: Habtoor Leighton Group Establish that all crew / department employees Fall Protection
understand the above information. Full-body Harness
Each crewmember is empowered to continuously
Foot Protection
participate in this process in an effort to promote
Steel Toed Boots Metatarsal
our Zero Incidents culture.
Rubber Boots Electrical Rated Boots
Safely execute the task as describedif
conditions change, revise accordingly. Hand Protection
Leather Rubber / Latex
TSAs will be completed daily. Post this TSA in an Kevlar Forearm Cuffs
Supervisor / Foreman: __________________________ obvious place throughout the duration of the task. Barrier Cream Chemical Resistant
Each crewmember involved with the task will sign this
First Aider : ___________________________________ TSA. Head Protection

Date: _________________ Time: __________________


KNOW THE LOCATION OF THE Hard Hat Chin Strap

NEAREST ASSEMBLY POINT Respiratory Protection


Task Location: ________________________________ Qualified to wear?
Type:
______________________________________________ (E) Joint Pre-Task Survey
___________________________________________
Joint work area survey conducted by
Task Description: ______________________________ Other: Yes
Supervisor and Safety - hazards identified and
safe work practices included in the TSA
______________________________________________

______________________________________________

______________________________________________

______________________________________________

_________________________
Name/ Signature of Supervisor
(C) Permits/Tags/Signs/Documents Hazardous Material Compliance
Required Emissions Notifications (NOC) Crane Operator Forklift Operator
Hand Rail / Grating Removal Mobile Equipment Operator Vehicle Operator
Hot Work Crane Lift Other Powder-actuated Tool User Manlift Operator
Trenching & Excavation Scaffolds Heavy Equipment Signalman Hazardous Waste
__________________________________________________ Competent Person (excavations, confined space,
Confined Space MSDS
scaffolds, hazardous material, heavy equipment)
Line Break / Hot Tapping Fire Water
Lock-Out / Tag-Out
Other:
Signs / Barricades (D) Employee Certification Required

No
(F) STA Elements
Sequential Task Steps (Steps 1, 2, 3) Potential Hazards Safe Work Practices Relevant to Hazards

_________________________________________ _________________________________________ _________________________________________

_________________________________________ _________________________________________ _________________________________________

_________________________________________ _________________________________________ ________________________________________

_________________________________________ _________________________________________ ________________________________________

_________________________________________ _________________________________________ ________________________________________

_________________________________________ _________________________________________ ________________________________________

_________________________________________ _________________________________________ ________________________________________

_________________________________________ ___________________________________ ________________________________________

_________________________________________ _________________________________________ _________________________________________

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