Classification: Tasnee - Confidential Information

JOB SAFETY ANALYSIS (JSA)

DOCUMENT No: IMRS 02-04-01-01 MOC No: MOC-DOC-TQM-19-654 REVISION No: 05

TASK DESCRIPTION: JSA SAP #: DEPARTMENT OR COMPANY NAME (if Contractor):

6781 LDPE Mechanical
Rotary Feeder Cover remove to Grease the chain/Sprocket
DATE: A joint site visit conducted prior to the JSA session

Yes No
TASK SUPERVISOR OR PTW RECEIVER EXECUTING THE TASK: PTW ISSUER:

NAME: SIGNATURE: NAME: SIGNATURE:

Responsible Signature after

Task Steps Description of Hazard Control Measures Required
Person Implementation
Nr.
The signature
Consider Safety, Health, Damage, Consider Design, Procedure, Practices, Skill Training, Special Responsible person
List the basic shall reflect the
Fire, Quality, Production Problems, Rules, health & Hygiene Control, Personal Protective to implement
steps for the task implemented
etc. Equipment, etc. control measures.
control measures.
 Wear PPE as mentioned in the permit
 Use only suitable tools for the job.
Chain Cover Rotary Feeder is offline Personal
1  Losing of cover must be hold properly.
Opening injury
 Supervise the activities while removing cover.

Inspection &  Inspection of Chain/ Sprocket if they have grease or not

Rotary Feeder is offline Personal
2 apply grease of  If not have grease , I will apply grease.
injury
Chain/ Sprocket
 Wear PPE as mentioned in the permit
 Use only correct tools for the job.
Rotary Feeder is offline Personal
3 Box up the Cover  Supervise the activities while removing cover.
injury
 Install the cover properly.

Date Printed: 19 May 2024 TASNEE Page 1 of 2

Classification: Tasnee - Confidential Information
JOB SAFETY ANALYSIS (JSA)

DOCUMENT No: IMRS 02-04-01-01 MOC No: MOC-DOC-TQM-19-654 REVISION No: 05

I acknowledge and fully understand JSA contents and I am fully aware and responsible to implement stated control measures and satisfied that task can be carried out safely.

JSA CROSS FUNCTIONAL TEAM MEMBER (ATTENDANCE SHEET): CRAFTSMEN CARRYING OUT THE TASK (ATTENDANCE SHEET):
JSA briefing by Task Supervisor/ craft man to Team who did not attend the JSA
meeting

NAME MEMBER SIGNATURE NAME Position SIGNATURE

1. Task Supervisor (Mandatory) 1.
2. Craftsperson 2.
3. PTW Issuer (Mandatory) 3.
4. Other: 4.
5. Other: 5.
6. Other: 6.

Review Quality Check of the JSA

NAME Position Quality Check Date SIGNATURE
1. JSA is completed by cross functional teams. □ Yes □ No
2. All Task and Work Area Hazards and associated controls are
Task
1. identified. □ Yes □ No
Specialist /Engineer
3. This Task with the same conditions is repeated twice within a
period of 3 years. □ Yes □ No
PTW Area Owner
2. 1. PTW Package and JSA are reviewed. □ Yes □ No
Specialist /Engineer

Approval

NAME:
Area Owner Manager or Delegated: Date:
Signature:

Date Printed: 19 May 2024 TASNEE Page 2 of 2