PMO

JOB SAFETY ANALYSIS (JSA) FORM

PROJECT PD#3 PROJECT DATE : 13 Maret 2025 JSA NO.:08/HSPD/PMO/JPN/25 REV. 00
JSA TEAM
CONTRACTOR PT. Jaya Pondasi Nusantara
(First Named – JSA Team Leader)
PDA (Pile Driving Analyzer)
JOB TITLE
Test & Lateral Pile Loading Test
NAME POSITION SIGNATURE

LOCATION PD#3 Upgrade Putra Sinuhaji Site Manager PT JPN

ITEM Fahmi Candra HSE PT JPN
JOB DESCRIPTION: Imannuel Sitepu/Sahat Silalahi T Supervisor PT JPN
- Preparation
- Mobilisasi Alat PDA (Pile Driving Analyzer) Test Imam Ghazali Civil PMO
- Loading & Unloading alat PDA(Pile Driving Analyzer)
Indra Sitorus / Andri S HSE PMO
Test
- PDA (Pile Driving Analyzer) Test Edbert Gozali PD Operation
- Excavation
- Lateral Pile Loading Test Arry Susanto PD Project Leader
- Housekeeping Della OHS LPnC
- Emergency Respon Team

REFERENCE AND OTHER RELEVANT

INFORMATION : NAME Putra Sinuhaji
e.g. ERP required, Competency requirements, Tools &
equipment, PTW, Drawings, Lifting Plan, Procedures, POSITION Site Manager PT JPN
P&IDs, Certificates, PPE required, etc.
1.Tools 2. PPE 3. Equipment SIGNATURE Date:
- Shackel -Helmet -Excavator Pc200
I am satisfied that the controls measures identified when put into place will reduce the risk to tolerable level. The job/action change is permitted to
- Webbing sling -Safety Glasses -CRANE 30 Ton proceed. CONFIRMED & APPROVED BY PROJECT/SITE MANAGER/HSE MANAGER
- Wire sling -Safety Shoes -Genset
- Hook -Ear Plug -Instrument PDA NAME Ajis Ismail
-Hammer (5,5T) -Hand Gloves -Lateral Test POSITION Manager HSE PMO
-Tiang uji (rumah base plate/Hammer)
-Chain Block (If Needed)
-Bor SIGNATURE Date:
-Hydraulic Jack
# STOP Work if Found Un-Safe #
 JSA WORK SHEET
JOB TITLE
Hazard Identification Risk Evaluation Risk Control
Seqience of Job Hazard Description Hazard Effect Done by Check
No. Control measures
(Urutan Pekerjaan (Penjelasan Bahaya) (Dampak Bahaya) (Dilakukan Oleh) ()
 1. Persiapan Kerja Tidak kompeten  MTI 1. SPV harus memastikan kru yang terlibat memiliki pengetahuan, - HSE PT JPN
JSA WORK SHEET dan keterlibatan  LTI kompetensi dan diberikan otoritas untuk melaksanakan aktivitas (Fahmi)
pekerja yang tidak diarea PD#3. - SPV PT JPN
JOB TITLE memiliki otoritas 2. SPV harus melakukan pendampingan dan memberikan arahan dan (Imannuel)
instruksi sesuai dengan aktivitas di area PD#3. - HSE PMO
Hazard Identification Risk Evaluation Risk Control (Andri
3. Pastikan sebelum pekerjaan di mulai PERMIT dan JSA sudah
Seqience of Job Hazard Description Hazard Effect S)/(KevinF)
Done by Check
No. tersedia dan sudah di approved oleh
Control User, HSE PMO, LPnC dan
measures
(Urutan Pekerjaan (Penjelasan Bahaya) (Dampak Bahaya) - Civil PMO
(Dilakukan Oleh) ()
team Proses.
(Imam)
4. Pastikan melakukan Tool Box Meeting sebelum memulai - OHS LPnC
pekerjaan. (Aspi
5. Pastikan Heavy Equipment sudah diperiksa dan diinspeksi dalam Nasution)
keadaan bagus/lulus inspeksi. - Team Proses
6. Pastikan operator atau rigger bersertifikat dan kompeten yang (Edbert)
diizinkan untuk mengoperasikan Heavy Equipment.
7. Pastikan alat PDA test sudah terkalibrasi.
8. Pastikan hanya pekerja yang berkepentingan (ditunjuk) yang
diizinkan berada di area kerja. Jika dibutuhkan, maka akan ada
seorang flagman/signalman untuk mengamankan area kerja dan
memberikan sinyal kepada operator HE.
9. Pastikan semua kru mendapatkan informasi yang tepat dari SPV
lapangan.
10. Pastikan signboard/Traffic corn terpasang untuk memberikan
peringatan bahaya kepada pekerja.
11. Pekerja harus selalu menggunakan APD mandatory (Safety
Helmet, Safety Shoes, Safety Glass, uniform, sarung tangan sesuai
jenis pekerjaan.
Pekerja tidak fit MTI Pastikan pekerja dalam keadaan sehat, fokus pada saat bekerja dan - HSE PT JPN
melakukan komunikasi yang baik dan tepat. (Fahmi)
- SPV PT JPN
(Imannuel)
Cuaca Buruk MTI Stop pekerjaan saat kondisi cuaca hujan, petir, angin kencang dan - HSE PT JPN
gempa bumi. (Fahmi)
- SPV PT JPN
(Imannuel)
2. Mobilisasi alat PDA Test Tertimpa material /  LTI 1. Pastikan alat PDA test harus terikat kuat dengan rantai saat - HSE PT JPN
kegagalan pada  Fatality mobilisasi. (Fahmi)
saat mobilisasi 2. Pastikan ikatan rantai terpasang tiga jalur (depan, tengah dan - SPV PT JPN
belakang). (Imannuel)
3. Pastikan Guide post pada trailer sudah terpasang. - Driver PT
4. Pastikan Susunan dan muatan tersusun rapi. JPN (Jhon)
5. Pekerja harus selalu menggunakan APD mandatory (Safety
Helmet, Safety Shoes, Safety Glass, uniform, sarung tangan sesuai
jenis pekerjaan.
Tabrakan  MTI 1. Pastikan Sopir harus memiliki keahlian dan memiliki surat ijin - HSE PT JPN
 Property mengemudi (SIM dan Kimper). (Fahmi)
Damage 2. Patuhi rambu-rambu lalu lintas & batas kecepatan di mill area. - SPV PT JPN
3. Unit harus dipandu pada saat mundur dan pastikan diberikan safety (Imannuel)
 JSA WORK SHEET
JOB TITLE
Hazard Identification Risk Evaluation Risk Control
Seqience of Job Hazard Description Hazard Effect Done by Check
No. Control measures
(Urutan Pekerjaan (Penjelasan Bahaya) (Dampak Bahaya) (Dilakukan Oleh) ()
Hazard Check List

GENERAL CONFINED SPACE ENTRY PROCESS

No Hazard Description No Hazard Description No Hazard Description
1 Asphyxiation 1 Adequacy of lighting within the CS 1 Asbestos gaskets
2 Barriers/access restrictions 2 Adequacy of ventilation 2 Chemical hazards
3 Biological agents 3 Comm. Difficulties within the CS or with the standby man 3 Chemical reactions with cleaning materials
4 Chemical hazard 4 Competency of standby man 4 Chemical reactions with cleaning materials
5 Cold/Heat 5 Danger of falling into CS boots or sumps 5 Electrical risk of using portable tools
6 Collision (impact from moving object to fixed object) 6 Disposal of CS cleanings 6 Environmental impact of spills or emissions
7 Electricity 7 Falling from height Residual gases/ vapors 7 Flammable or toxic vapors arising from sludge in vessel
8 Falling from height 8 Frequency of gas testing 8 Hazardous substances trapped around bends, linings etc.
9 Falling object/Drop Object 9 Ingress of gases/vapors from other nearby activities/systems 9 Inert atmospheres
10 Open flame 10 Ionizing radiation; nucleonic instrumentation 10 Liquids remaining from flushing
11 Flammable gas 11 Location of rescue kits 11 Hazardous Chemical Scale
12 Flammable liquid 12 Hazardous Chemical scale 12 Pyrophoric scale
13 Fume/dust 13 Need for air movers during entry. 13 Residual heat
14 Grit blasting 14 Noise when using power tools 14 Residual pressure
15 Hand tools 15 Noise, general 15 Trapped pressure
16 Ignition 16 Oxygen deficiency
17 Impact (force full contact) 17 Oxygen enrichment
18 Inert gas 18 Slip hazards within the CS or at the point of entry
19 Ionizing Radiation 19 Sludge which may give rise to vapors/gases when disturbed
20 Lifting operations 20 Standby man communication with the ERP
21 Lighting 21 Temperature effects
22 Machinery 22 Use of mechanical tools/power tools/electrical equipment
23 Manual Handling 23 Visibility within the Confined Space
24 Mental Stress
25 Noise
26 Potential for ignition
27 Power tools
28 Pressure
29 Static Electricity
30 Slip, Trip and Fall
31 Working at height
32 Bad Weather