JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

JSA No. : RDMP / JSA /......................... / .....................

JSA Title : Install Rebar & Formwok

ATTENDANCE LIST – JSA PREPARATION

NO NAME POSITION COMPANY SIGNATURE
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Project : Prepared
RDMP By
Balikpapan JO Reviewed By Approved By
Company : AGCIASPV
PERTIWI Chief/HSE Manager CM
Scope of Work/Pkg :
JSA No. : RDMP /
JSA / ............. / ...............
Position : Supervisior
Job Activity : Install Rebar & Formwork
Area :
Date :

Name
Signature

Date

Status
Status
No Permit Registry No
Open 🗸 Close 🗸

Permit Registry No
Open 🗸 Close 🗸

No

Sequence of Basic Consequence / Risk PIC

Hazard Risk Recommendation action Result Risk*)
NO Job Steps severity Assessment* Penanggung
Bahaya Resiko Tindakan Pengendalian
Tahapan pekerjaan Akibat PR SV RR PR SV RR Jawab
1. Briefing Jobdesc Potential workers do Miss Accidents of during 4 4 H Make sure the scope of 1 1 L
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

not understand the Communication work and hinder field work is clear, and if
work to be carried progress anything is not
out understood ask
Pengarahan Miskomunikasi Kecelakaan saat Pastikan ruang lingkup
Pekerjaan Potensi para pekerja sedang bekerja dan pekerjaannya jelas, dan
tidak memahami menghambat kemajuan jika ada yang tidak
pekerjaan yang harus lapangan dipahami, tanyakan
dilakukan

2. Preparation to work The potential for Work is stopped, injuries, loss of work 3 4 M Make sure the permit is 2 2 L
incomplete work workers are injured, time, hindered work taken care of 1 day before
equipment and progress carrying out the work
Persiapan pekerjaan personal protective Pekerjaan dihentikan, Pastikan pengurusan
equipment (PPE) pekerja mengalami Pekerjaan / progress permit 1 hari sebelum
not feasible, as well luka terhambat, Cidera , pekerjaan dilaksanakan
as a work kehilangan waktu
environment with bekerja Use apd in accordance
potential hazards with the work being done,
Tool repair costs make sure the work
Potensi peralatan Biaya perbaikan alat equipment is tagged
kerja dan alat through inspection
pelindung diri Gunakan apd sesuai
(APD) yang tidak dengan pekerjaan yang
lengkap / tidak dilakukan, pastikan
layak digunakan, peralatan kerja telah diberi
serta lingkungan tag melalui inspeksi
kerja yang tidak
nyaman / berbahaya Ensure the work place is
free from hazardous
Permit to work not materials / equipment that
accepted or not could potentially cause
making accidents
Memastikan tempat kerja
Permit tidak di bebas dari bahan /
setujui / belum di peralatan berbahaya yang
buat berpotensi menimbulkan
kecelakaan
Potential workers
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

are dehydrated /
passed out Prepare sufficient
drinking water and always
Potensi pekerja active supervision of
mengalami workers
dehidrasi / pingsan Siapkan air minum yang
cukup dan selalu
pengawasan aktif terhadap
pekerja
3. Installation rebar & Potential pinched, Workers suffered Delay and loss of 3 3 M Make sure to use 2 1 L
formwork proccess beaten, and sink on minor to severe work time due to a adequate personal
soft ground at injuries shortage of workers protective equipment and
Proses instalasi besi installation who are injured tools and the installation
dan bekisting Pekerja mengalami process is carried out by
Potensi terjepit, cidera ringan samapi keterlambatan dan workers who are experts /
terpukul dan berat kerugian waktu if the workers are not
terperosok di tanah pekerjaan skilled, make sure they
yang lunak saat dikarenakan are accompanied by field
melakukan kekurangan tenaga supervisors and give
pemasangan kerja yg mengalami directions to these
cidera workers

Pastikan menggunakan
peralatan kerja dan apd
yang memadai serta proses
pemasangan di lakukan
oleh pekerja yang sudah
ahli / jika pekerja belum
terampil pastikan di
dampingi oleh pengawas
lapangan dan berikan arah
kepada pekerja tersebut
4. Work at night Potential visibility Tripping due to Work stops, workers 4 3 M Do TBM before working 2 2 L
and ineffective / unseen material, suffer minor - severe and socialize the potential
Pekerjaan dimalam limited lighting holes from spun pile injuries are greater dangers that will occur
hari potensi jarak pieces, crashing into because the risk of lakukan TBM sebelum
pandang serta lampu project assets due to working at night is bekerja dan sosialisaikan
penerangan yang limited vision, bitten greater potensi bahaya yang akan
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

kurang, tidak efektif by animals that are pekerjaan terhenti, terjadi

/ terbatas active at night pekerja mengalami
tersandung akibat cidera ringan - berat Check workers who are at
material yang tidak lebih besar high risk
terlihat, lubang bekas dikarenakan resiko lakukan pemeriksaan
Potential for potongan spun pile, bekerja di malam terhadap pekerja yang
animal disturbance, menabrak aset hari lebih besar memiliki resiko tinggi
the generator set proyek dikarenakan
runs out of diesel pandangan yang Use personal protective
potensi gangguan terbatas,tergigit equipment
binatang, genset binatang binatang Gunakan alat pelindung
kehabisan solar yang aktif dimalam diri
hari
Potential electrical Pay attention to working
short circuit hours, make 2 shif if
Potensi konsleting doing emergency work (24
listrik hours)
perhatikan jam kerja,
buatlah 2 shif jika
melakukan pekerjaan
darurat ( 24 jam )
5. House keeping and Potential equipment wretched the Loss of working time 4 2 L Do not leave the work 2 1 L
finished worked and remaining workers, interfere and delays in the location before the
materials scattered with access to other work process the equipment and materials
Pembersihan dan in the field work next day are placed in a safe place,
pekerjaan selesai ask the field supervisor
peralatan dan membuat celaka para kerugian waktu kerja for directions, do cleaning
material yang tersisa pekerja dan keterlambatan for 10-15 minutes after
tersebar di lapangan mengganggu akses proses kerja each work
untuk pekerjaan keesokan harinya Jangan meninggalkan
lainnya lokasi kerja sebelum
peralatan dan material di
tempatkan pada tempatnya
/ tempat yang aman, minta
arahan pengawas
dilapangan, serta lakukan
pemberishan selama 10 -
15 menit setiap selesai
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

bekerja

Make sure to save the

work permit for the next
day
Pastikan untuk menyimpan
surat ijin kerja untuk ke
esokan harinya

Risk Rangking (RR) Recommendation Action

Probability (PR) Severity / consequence Tingkat Risiko Tindakan Pengendalian
x =
Kemungkinan Keparahan
Score Level Tingkat pengendalian Hierarchy of Control
Frequent =5 Catastrophic =5 19-25 Extreme high E= 1+2+3+4+5 1= Elemination
Probable =4 Major =4 13-18 High H= 3+4+5 2= Substitution
Occasional = 3 Moderate / Serious = 3 6-12 Medium M= 4+5 3= Engineering Control
Unlikely =2 Minor =2 1-5 Low L=5 4= Administration
Improbable = 1 Negligible =1 5= PPE

Note : * : Without Control / Tanpa control

*) : With Control / Dengan control
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

JSA No. : RDMP / JSA /......................... / .....................

JSA Title :

ATTENDANCE LIST – PRE-JOB SAFETY MEETING (JSA SOCIALIZATION)

Signature
No Name Position Company
Date: Date: Date: Date: Date: Date: Date:
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 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

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