Job Safety Assessment Form

By Russell Porter,2014-10-17 13:07
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Job Safety Assessment Form

    Job Safety Assessment Form


    2009 Regional Competition Updated January 2009

University: Vehicle Name:

    JSA Author Contact Name: Author Email:

    Faculty Supervisor: Supervisor Email:

    Revision #: Revision Date:

    Date and location of required ChemE car safety training for current team and advisor:

    Advisor ____________________________ Team___________________________________

    Approval to Begin Construction: Advisor: _________________ Date: _______________

    Approval to Operate: Advisor: _________________ Date: _______________

Purpose of Experiment / Equipment: Briefly describe your Chem-E-Car’s design, intended

    mode for operation (source of power), intended mode for control (stopping), and major hazards

    and their control.

Expected Operating Conditions:

    Temperature Pressure

    Normal: Normal:

    Minimum: Minimum:

    Maximum: Maximum:

    1 Ver. 1, January, 2009

    Disallowed Activities: All activities listed below are not allowed and will result in a multi-year disqualification of your university from ChemE car competition and possible fines. Item

     (a) No transport of chemicals in private, university or rental vehicles either to or from the competition.

    (b) Chemicals must not be stored in hotel rooms or other facilities not rated for chemical storage.

    Approved chemical storage will be provided at the host site.

    (c) No vehicle testing in hotel or dorm hallways, warehouses, or other facilities that are not

    designed for chemical handling. This includes your university and the competition site.

    (d) No improper disposal of chemicals at the conclusion of the competition. All chemicals

    shipped to the competition site must be disposed of in a safe and environmental fashion following all local, state and national regulatory measures. Chemical disposal will normally be provided by the host site.

Disallowed Vehicles: All of the items listed below are not allowed.

    Item Explanation

     (a) Flames and/or smoke Both inside and outside the vehicle, except for commercial

    internal combustion engines. See ChemE car rules for using

    commercial internal combustion engines.

    (b) Liquid Discharge Liquid may not be discharged under normal operating


    (c) Open and/or Containing chemicals having an NFPA rating of 2 or greater.

     improperly All containers with these chemicals must have secure lids and

     secured containers must be secured to the vehicle. All containers brought to the

    starting line must have lids, be properly labeled, and proper

    personal protective equipment must be used.

    (d) Chemical pouring at Any chemicals with an NFPA rating of 2 or greater. Use a

     starting line holding vessel on vehicle, with valve, to load starting chemicals.

    (e) Regulated Chemicals A number of chemicals are listed by OSHA as a special hazard.

    See list below. OSHA has a special regulation for each

    chemical. See for details.

    (f) Highly Reactive / Any chemical, raw material, intermediate or product with an

     Unstable Chemicals NFPA reactivity / instability rating of 4.

    Regulated chemicals: asbestos, coal tar pitch volatiles, 4-nitrobiphenyl, alpha-napthylamine, methyl chloromethyl ether, 3,3'-dichlorobenzidine, bis-chloromethyl ether, beta-naphthylamine, benzidine, 4-aminodiphenyl, ethyleneimine, beta-propiolactone, 2-acetylaminofluorene, 4-dimethylaminoazo-benezene, n-nitrosodimethylamine, vinyl chloride, inorganic arsenic, benzene, 1,2-dibromo-3-chloropropane, acrylonitrile, ethylene oxide, formaldehyde, 4,4'-Methylenedianiline, 1,3-butadiene, methylene chloride.

    2 Ver. 1, January, 2009

     Personal Protective Equipment (PPE) : Check all PPE worn during operation of this Chem-E-Car. Do not list these in the procedure section.

     Long Pants Safety Glasses Hard Hat Apron

     Long Sleeves Splash Goggles Insulated Gloves Ear Protection

     Non-porous Shoes Face Shield Chemical Gloves Other:

Available Safety Equipment Provide the location of each item shown below at your home

    institution where your vehicle will be operated and tested. Show the location of this equipment

    on your provided floor plan. If not available, type “NA” in the field.

    Item Location

    Fire Extinguisher:


    Safety Shower:


    First Aid Kit:

    Spill Containment


Spill Response Supplies - Provide the location of each item shown below at your home

    institution where your vehicle will be operated and tested. Show the location of this equipment

    on the attached floor plan. If not available, type “NA” in the field.

    Item Location

    Spill Kit:


    Spill Dikes:

    Sodium Bicarbonate:

    Drain Plugs:

    Spill Pillows:

    Mercury Spill Kit:



    3 Ver. 1, January, 2009

Vehicle Primary Hazards Checklist: Check the left hand column box if the hazards listed

    below exist on the vehicle. Then check the applicable means of control for each hazard.

    Hazard Control

    (check if present)

     (a) Pressure Anything greater than 1 psig? Must meet all requirements below:

     Pressure gauge (must read to 2x max. operating pressure)

     Emergency relief device set to no more than 1.1 times max. operating

    pressure. Relief sizing calculations must be provided.

     Emergency relief device in proper location.

     Pressure certification see Pressure Vessel Testing Protocol

     Proper management system to prevent over or mis-charging.

    Must have measurements or calculations to prove maximum

    operating pressure.

    See ChemE car rules for more details on these requirements.

     (b) Toxic Any chemicals with an NFPA toxicity of 2 or greater?

     Doubly contained and handled properly.

     (c) Flammable Any chemicals with an NFPA flammability rating of 2 or higher?

     Doubly contained and handled properly

     (d) Reactive Any chemicals with an NFPA instability / reactivity rating of 2 or 3?

    Chemicals with a 4 rating are not allowed.

     Doubly contained and handled properly.

     (e) Temperature Any exposed surface greater than 150 deg. F or under 32 deg F?

     Insulation or barrier to prevent contact.

     (f) Electrical Exposed wiring and electrically energized components are ignition,

    electrocution, and a shorting / fire hazard. Alligator clips and twisted wire

    connections are not allowed use binding posts or banana plugs for a

    more secure connection.

     Proper electrical insulation and connections provided.

     (g) Mechanical Any fast moving parts (meshing gears, belts or chains) that are pinch


     Guards present and adequate.

    4 Ver. 1, January, 2009

Fabrication & Operation Additional Hazard Detail Check List: Check all hazards that are likely to be encountered during your Chem.-Car

    construction and operation. List the major source(s) of the hazard and describe how the hazard(s) will be controlled. If both construction and

    hazard columns are checked in an individual row, then the hazards should be identified separately for both the construction and operation.

    11Hazard Present During Control Method(s) PPE Required

    Construction? Operation?

    Pressure Toxicity Flammability Reactivity / Instability Hot Surfaces/ High Temp > 150 F

    Cold Surfaces/ Low Temp < 0 C

    Electrical Arc welding Gas welding Lathe Milling machine Handheld power tools Drill press Other mechanical


    Paint spraying Ionizing radiation Laser radiation Asphyxiates Open flames Potential Spills Other: Other:

    5 Ver. 1, January, 2009

    Required Attachments: All attachments must be provided to the JSA reviewers and to the on-site inspectors. For electronic transfers, use only a .doc, .pdf, or .ppt file formats. Submit

    pictures in jpeg format.

     Picture of your vehicle. For electronic file transfers use jpeg format.

     Flow diagram of vehicle process

    Label all valves and identify all equipment for reference in procedure.

     Laboratory Floor Plan at your home institution where the car will be tested.

    Identify the location of your experiment and all safety and spill response equipment.

     Equipment Specifications

    Include materials of construction, maximum temperature and pressure, standard operating

    values, and any other specifications important to the safe operation.

     Pressure documentation, if pressure hazard checked on page 3. This should include pressure

    calculations, pressure testing, relief sizing calculations, pressure vessel certification and any other materials required to demonstrate that these hazards have been addressed properly.

     Material Safety Data Sheets (MSDS)

    Include for all reactants, products and any intermediate or other chemicals which may occur.

Additional Attachments: As necessary to support safety.

    6 Ver. 1, January, 2009

    Chemical Information Page

    Fill in as much data below as available. If data are not available, leave the field blank.

    Chemical Quantities: List below the chemical names, concentrations, and total quantity of chemical required for the competition.

     Chemical State Concentration Required Total Quantity Required for Competition

    Chemical Name Solid, Liquid, Gas Be sure to list units! Be sure to list the units!

Chemical Properties and Hazards for ALL CHEMICALS, including reactants, intermediates and products.

     Physical Incompatible Chemicals Flash Flammability * List chemicals present within the laboratory, and Chemical Name State NFPA RatingsPoint Limits

    any others that may come in contact. S, L, G Temp. H F S Sp. LFL UFL

*NFPA Ratings: H Health, F Flammability, S Stability, Sp. Special


Chemical Toxicology, Regulation and Disposal: List the same chemicals that appear above, in the same order.

     Toxicology Hazardous OSHA

    Chemical Name Waste Regulated? Personal Protective Equipment TWA PEL Other Number Specific to this Chemical

Chemical Reactions: Provide details below on any chemical reaction(s) that occur in your process. Please show the species involved, the

    stoichiometry and the heat of reaction, if available. Also list side reactions and any other reactions that may impact safety.


    Job Safety Assessment Form

    Safe Operating Procedures Page

    Provide step-by-step details for each of the sections shown below. Identify the hazards, the control methods and the personal protective equipment

    (PPE) required. Provide adequate detail so that the reviewers of this document will have adequate understanding of your procedure to pass judgment

    on the safety of your vehicle.

    The Emergency Shutdown section should have only one or two steps required to stop your vehicle and bring it to a safe state. The Start-Up Procedure section should list all the steps required to prepare your chemicals and vehicle. The Run Time Procedure should describe all steps to operate your vehicle at the starting line of the competition. The Shutdown Procedure should describe the steps normally taken to shutdown your vehicle at the end of your competitive run. The Cleanup / Waste Disposal section should list all the steps required to clean your vehicle of all chemicals and proper chemical disposal.

     PPE or Equipment

    Sequence of Steps Potential Hazards Procedure to Control Hazard Required

    Emergency Shutdown

Start-up Procedure

Run Time Procedure

Shutdown Procedure

Cleanup / Waste Disposal


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