Doc.

No : FRM/HSE/01
FORMULIR Revision :0
Effective Date : 01 APRIL 2017
JOB SAFETY ANALYSIS (JSA) Halaman : 01
Ref. SOP/HSE/02

WORK-SITE / PROJECT NAME :

LOCATION / Lokasi :

DEPT / SECTION (Penanggung Jawab Pelaksana):

NAME OF SUB-CONTRACTOR(S) : Supervisor/Leader :

TASK / ACTIVITY (Kegiatan): Supervisor/Leader :

Check all applicable anticipated or potential hazard (Centang semua bahaya potensial atau yang akan diantisipasi ):
Work affecting integrity of Critical Control System Heavy Equipment Lifting Work At Height (Scaffolds, ladders, roofs, etc…)
Electrical (Live) Traffic Pattern (Mobile Equipment / Pedestarian) Underground Tank Removal / Disposal
Electrical (Isolation) Temporary Pumping & Transfer Facilities Demolition
Hot Work Extreme Weather Exposed Handling of Petroleum Product
Confined Space Entry Pile Driving / Drilling Equipment Mobile Equipment
Equipment Handling & Dismantling Bore-hole Drilling / Test Pit Excavation Drilling, Grinding. Cutting
Excavation Pressure Testing Work in Hazardus Areas
Stored Pressure System (e.g. - Propane, NH3) Overhead Power-lines (e.g. - Designated Substances)
Radiography / X-Ray Testing Hydro-blasting / Sand-blasting Other :
Ensure that all hazards identified - are addressed in the JSA below (refer to Safety Method Statements as required)

Safety Control to Reduce or Eliminate Hazard

Sequence of Basic Job Steps (Urutan Pekerjaan) Potential Hazard (Bahaya Potensial) (Pengendalian untuk mengurangi atau menghilangkan
bahaya potensial)

1.

2.

Distribusi MSI-Master (DCR), Copy (User/Pihak Terkait)

 Doc. No : FRM/HSE/01
FORMULIR Revision :0
Effective Date : 01 APRIL 2017
JOB SAFETY ANALYSIS (JSA) Halaman : 02
Ref. SOP/HSE/02
Safety Control to Reduce or Eliminate Hazard
Sequence of Basic Job Steps (Urutan Pekerjaan) Potential Hazard (Bahaya Potensial) (Pengendalian untuk mengurangi atau menghilangkan
bahaya potensial)

3.

4.

5.

6.

7.

8.

9.

10.

Distribusi MSI-Master (DCR), Copy (User/Pihak Terkait)

 Doc. No : FRM/HSE/01
FORMULIR Revision :0
Effective Date : 01 APRIL 2017
JOB SAFETY ANALYSIS (JSA) Halaman : 03
Ref. SOP/HSE/02
Tools / Equipment (Peralatan/perlengkapan yang diperlukan, terkait dengan safety) :

Personal Protective Equipment :

PPE Specifics : Hard-hat (CSA side-protection) Eye Protection (CSA safety glasses) Safety Boots (Steel-toed CSA approved)
Hearing Protection (Class A) Gloves (puncture / cut resistant) Coveralls (Reflective - Non-Fire-rated)
Other
Outside Authorities (Pihak berwenang yang perlu diberi saran) :

Disposal of Surplus or Contaminated Materials (Metode pembuangan sampah/limbah termasuk yang terkontaminasi B3):

SAFETY PROCESS INFORMATION REGARDING THIS JSA

Prepared By : Position : Date :

Person(s) Carying Out This Process On The Actual Work-Site (personel yang akan melakukan pekerjaan ini )
Name(s) : Signed : Date :

Verified By : Position : Date :

Verified By : Position : Date :

Distribusi MSI-Master (DCR), Copy (User/Pihak Terkait)