Activitate/ Departament/ Coordonator activitate/

Amplasament/ Loc lucrare/

Activity Department: Activity coordinator:
Location: Worksite:
Data JSA/ Data urmatoarei rev./ JSA aprobata de/
JSA revizuita in data/ Revizie JSA Specifica condusa de/
Date of JSA: Date of next review: JSA approved by:
JSA revised / reviewed on (date): Review of Specific JSA led by:
r Casca / Hard hat Cerinte specifice amplasamentului / r Indicatoare SSO / Safety signs
r Incaltaminte de protectie / Safety footwear Site specific requirements r Tag out / lock out
r Ochelari de protectie/ Safety glasses r Stingatoare de incendii tip....nr. /Fire
EIP necesar /
r Manusi de lucru / Work gloves extinguishers type ....... no. ...
PPE required
r Salopeta / Overalls r Hidrant / Hydrant
r Work vest r Bariere (de acces) / Barricades (at access openings)
r Safety harness r Bariere anti-incendiu / Barriers against fire
Abbreviations:
Afectarea
Poluarea Apei / Poluarea Aerului Epuizarea Resurselor / Ranire/ Calitatea serv./ Reputatie
Detaliile impactului Poluarea Solului / Poluare Sonora / Florei/Faunei / Imbolnavire / Ill Dauna proprietatii /
Water Pollution / Air Pollution Resources Depletion Injury Service Quality /Reputation
Details of impact Land Pollution (LP) Noise Pollution (NP) Effects on Flora / health (IH) Property Loss (PL)
(WP) (AP) (RD) (IN) (SQ) (R)
Fauna (FF)
Normal/ Rutina/ Normal / Routine(N) Urgenta / Emergency (E)
Anormal/ NonRutina / Abnormal / NonRoutine (A)
Conditii/ Frequent activities, continuous and Exceptional situation, having the potential to generate disastrous, catastrophic effects. If the aspect/
Low frequency activities, undesired, but necessary for normal, routine
Conditions normal for daily operations hazard from which the impact derives from occurs in an emergency situation, risk level is considered
operations
High, even if in normal conditions it would be low.
Project Manager Project HSEQ Man. Project Site Manager Project Dive Supervisor Party Chief Project ROV Supervisor ROV Lead Piot
Operator Other-specify
Responsabilitati/ (PM) (PHSEQM) (PSM) (PDS) (PC) (PRS) (RLP)
Responsibilities Vessel Operator Vessel Captain Chief Eng. Client A Rep.
OIM Client (C) Other-specify Other-specify Other-specify
(VO) (VC) (CE) (CAR)
TBT = Toolbox Talk LMRA = Last Minute Risk Assessment (informal; Step back 5x5)

Etapele activitatii /Job Pericole Impact posibil Contingenta

No. Masuri de control / Control measures
steps / Hazards / Possible impact / Contingency
1. Controls applicable for all below risks:

All XXX personnel adequately trained (PSM)

All ship personnel adequately trained (VM)
All activities performed only by certified /authorized/ competent/ experienced personnel (PSM; VM)
Adequate on-site supervision of activities (PSM)
Toolbox-talks (TBT)- at the beginning of work day and whenever necessary (PSM; VM)
Last Minute Risk Assessment (LMRA) before hazardous activities
All equipment fit-for-purpose and adequately certified
Stop Work Authority (all personnel)
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 Etapele activitatii /Job
No.
steps
Work place maintained clean & tidy (all personnel)
Power source placed on rubber or wooden support (PSM)
Use adequate PPE: diving personnel and non-diving personnel; Check PPE before use! (PSM/ operator)
Preparation
Ensure everyone is trained
and knows the task
Ensure relevant vessel /rig
personnel are aware of the
tasks to be conducted
Ensure worksite is free of
obstructions and hazards
are known /marked
Ensure the right tools and
2. equipment are at hand
Ensure adequate
communication
Confirm location of
equipment and cable
routes with relevant
personnel
Assess environmental
conditions ( weather- rain,
heavy fog, wet ground etc.
3. Use of electrical tools &
equipment
Plug equipment
Use equipment
Unplug/ disconect
equipment
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Pericole Impact posibil Contingenta
Masuri de control / Control measures
/ Hazards / Possible impact / Contingency
Planning of activity: Specific Task Plan (DM)
Specific Equipment layout (DM)
Everyone aware of the task TBT and LMRA (PSM)
Ensure all portable tools are regularly inspected and maintained
(PSM)
Electroshock (N)
Certified and trained electricians/operators (PM)
Touching hot parts (N) Sprv to ensure communication with relevant vessel / rig personnel
Burns, injury, death due to (PSM)
electroshock (IN) Sprv to obtain confirmation that the task can be safely conducted on
Fumes (N)
board (PSM)
Operator error (N) Respiratory disorders (IH) Ensure vessel power system adequate (PSM)- premob:
o .400 V/ 50Hz; Output voltage (socket): 230 V; Sockets:
Dropping equipment (N) Hand injury (IN) European type
o ..; Output voltage (socket): 230 V; Sockets:
Contact with pointy Feet injury (IN) European type
objects, sharp surfaces o ; Output voltage (socket): 230 V; Sockets: Emergency Response
(N) Damage to equipment (PL) European type Plans- Vessel / Rig and
Verify the voltage provided to each equipment (operator) XXX
Sparks (N) Delay in ops (SQ) Power sources/plugs compliant with the equipment to be connected Project incident reporting
(operator)- available transformers and adaptors and investigation
Injury/damage due to Use of UPSes (PSM) procedure
incorrect supply of Verify that all equipment/pieces of equipment and plugs are dry and Contingency plan
voltage (N) clean (operator)
Verify that area is dry and clean (operator)
Injury/damage due to Clearly marked and well defined electrical disconnects (PSM)
plugs and sockets in
Ensure safety devices are not bypassed or removed (operator)
poor condition (N)
Consideration given to environmental conditions prior to starting work
No work to be undertaken in adverse weather conditions ( wind, rain
Injury/damage due to
etc.).
exposure of electrical
Daily and whenever necessary - reinforcement of safe working
part to sea water (N)
procedures for the use of electricity and wearing of adequate PPE-
Power distribution during JSA and TBT (PSM)
system overload (N) On .: HWM and LP compressor supplied from .
generator (PSM)
Rubber mat in front of all equipment supplied with 440 V/ 60 Hz (hot
water machine & HP compressors 2 & 3) (TM)
Supplemented Project Inventory: additional spares on board for HWM
(TM)
Hand Pinching (N) Everyone aware of the task TBT and LMRA (PSM) Emergency Response
Ensure all portable tools & equipment are regularly inspected and Plan - Vessel and XXX
Contact with pointy maintained (PSM) Project incident reporting
objects, sharp surfaces Limb/torso/head/internal Certified and trained electricians/operators (PM) and investigation
(N) organs injury due to fall (IN) Ensure safety devices are not bypassed or removed (operator) procedure
Ensure safety devices are maintained as operational and that operators Contingency planning -
 Etapele activitatii /Job Pericole Impact posibil Contingenta
No. Masuri de control / Control measures
steps / Hazards / Possible impact / Contingency
Electroshock (N) Burns, injury, death due to
electroshock (IN)
Tripping / severing know the location of these devices and how to use them.
cables (N) Musculoskeletal disorders Inspect electrical equipment before use- Verify that all
(IH) equipment/pieces of equipment and plugs are dry and clean. Look for
Dropping equipment (N) damage to the lead or the plug. Also check condition of the socket. If adequate supply of
Equipment loss (PL) damage is present, do not proceed youre your work- ask for
spares on board (VO;
Ensure worksite is left safe Incorrect installation / specialized help (ETO).
XXX)
and clear rigging (A) Do not work where water is present. (all)
Damage to equipment (PL) As far as possible, try to keep the cable runs out of the way (all)
Cable runs should be identified as a trip hazard (PSM)
Malfunctioning Visual checks of equipment and tools before operations power lead
equipment (A) Delay in ops (SQ) (operator)
No use of electricity in wet environment (operator)
Mutual hindrance- XXX
and Vessel personnel (N)

Echipa JSA / JSA Team

Functie/Companie Nume/Semnatura Functie/Companie Nume/Semnatura
No. No.
Position / Company Name/Signature Position / Company Name/Signature
1. 7.
2. 8.
3. 9.
4. 10.
5. 11.
6. 12.

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