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 – 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 : Recon SPV
Sarana Utama Chief/HSE Manager CM
Scope of Work/Pkg :
JSA No. : RDMP /
JSA / ............. / ...............
Position : Civil Supervisior
Job Activity : Bundwall
Area : 55 / Gasoline Tank
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 of work Potential the tool Tools cannot be Injuries to body 4 3 M Make sure the machine or 2 1 L
tools, conducting has a problem controlled and can parts and can equipment must be ready
periodic / daily running or not injure workers damage the work for use and have gone
checks and checking suitable for use area through the inspection
documents Incompetent process as evidenced by
operators and lack (marking) and the
of supervision operator has a valid
operating permit
Persiapan alat kerja , Alat tidak dapat Cedera pada bagian Pastikan mesin atau
melakukan Potensi Alat dikontrol dan dapat tubuh dan dapat peralatan harus siap pakai
pengecekan berkala / mengalami melukai pekerja merusak area kerja dan sudah melalui proses
harian dan kerusakan pada saat pemeriksaan yang
pengecekan dokumen di oprasikan, atau dibuktikan dengan
tidak layak untuk (penandaan) dan operator
digunakan memiliki izin operasi yang
Operator yang tidak berlaku.
kompeten dan
kurangnya
pengawasan
3. Implementation of Potential poor soil Tools are mired, Suffered heavy 3 5 H Make sure there are 1 3 L
Work conditions dropped and slipped damage, the supervisors in the work
operator was injured field
Alat terperosok, to death Memastikan ada pengawas
Pelaksanaan Potensi kondisi terjatuh dan Mengalami / supervisor di bidang kerja
Pekerjaan tanah yang kurang tergelincir kerusakan berat,
baik operator terluka Does not allow the tool to
hingga meninggal operate on sloping land
dunia Tidak mengizinkan alat
Dust inhaled by beroperasi di lahan miring
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
workers, Workers experience
Potential dust crushed by falling respiratory problems Keep the machine
flying, material fell material working so that workers
from the excavator do not cross the working
tub Debu terhirup oleh Pekerja mengalami radius of the tool by
pekerja, kejatuhan gangguan pada giving a sign that the tool
material yang tidak Pernafasan is in operation
Potensi debu disengaja Jaga agar mesin tetap
berterbangan dan bekerja agar pekerja tidak
kejatuhan material Damage to tools and Incident Fatality, melewati radius kerja alat
dari baket excavator crushed by material loss of time, work dengan memberikan tanda
progress bahwa alat sedang
Potential excavator kerusakan alat dan beroperasi
is used to lift tertimpa material Kejadian fatal,
material kerugian waktu, Use a mask that suits your
kerugian progress job
pekerjaan Gunakaan masker yang
Potensi excavator seuai dengan pekerjaan
digunakan untuk anda
mengangkat
material Make sure to use a tool
that is suitable for its
function
Pastikan untuk
menggunakan alat yang
seusai dengan fungsinya
If using a truck, make
sure the truck access road
is suitable for the vehicle
to pass and the location of
temporary shelter / shelter
does not interfere with
access to other jobs
jika menggunakan truck,
pastikan jalan akses truk
layak untuk dilalui
kendaraan dan lokasi
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
pembungan / tempat
penampungan sementara
tidak mengganggu akses
pekerjaan lainnya
4. Finished working Tool returns to the Hit other workers, Damage, loss to 3 4 M Make sure if the tool 1 2 L
parking location via break materials, hit other workers' returns from work always
Pekerjaan selesai another worker other vehicles & facilities in the orient it with a spv and if
area / not in its lane work facilities surrounding area necessary add a mark to
give a signal
Alat kembali ke menabrak pekerja kerusakan, pastikan jika alat kembali
lokasi parkir melalui lain, merusak kehilangan fasilitas dari tempat kerja selalu
area pekerja lain / material, menabrak pekerja lain di mengarahkannya dengan
tidak di jalurnya kendaraan lain & sekitarnya spv dan jika perlu
fasilitas kerja tambahkan penandaan
untuk memberi sinyal
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
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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