Fe a sa” \/ JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM PERTAMINA REMe ane rea) [ora ee ENGNEERNGPROCUREMENT consToUCTIONonsernexy __|EYedtve DS TS Janay 2022 pevr1SPHEMT MASTER PLAN GPCFOR NOTE) HU MCMEAARSROnECY Hee Pe oe Project RDMP JO PERTAMINA ai Frepared By “Reviewed By ‘Approved By | Company ‘PT Berdikari Pondasi SPV, es aa | Scope of WorkdPig_| - | Pilling Work Package 6 Name Eke nt i em TeAN, MP [ISA SITET T|{ siemens osupeyanto oH 2 | ig0g Aw iy Ae Poston | Job Activity _ us are Dae [iicdeavaet sat | ap fon [aU E=V=aI ? a i Status ‘| Status No Permit Registry No No | Permit Regi: No | Open O | Close 0 ‘ormit Registry Ne [Copent | Close a SI 1 — — | | 1 I 1 \ Ve t 1 \ Sequence of Basic : onseque Risk th No | "TobStepe | Hazard Be Conaueee/ | aseument’ | itecommend Penge Tahapan pekerjaan hayes esl Akibat pr | sv | nr | Bxdston Java i Persiapan/Preparatio Cidera, Berkelahi 3\s \ H_ | Lakukan Toolbox meeting)2\s |i an 4 “iu sah mem ( tahapan —pekerjaan | Communication pekerjaan ered Diesel Hammer _ | tidak diketahui oleh Pekerjaan terhenti Ensure Doing Toolbox seluruh pekerja, | Pekerja cedera working stop Meeting before start work Ceev) "All of workers | “Injury | don’t know about lain —_ pemilik Koordinasi dengan pemilik scope of work and | Alat Rusak ( trailer SOP tusak, crane rus? owner always, “Broken Equipment | complained Coordination with ut Bahaya dalam suatu | owner pekerjaan lak | Alat bantu kerja | Kerusakan alat kerja diketahui oleh | rusak (lifting gear) | *Broken Tools ISA. di bacakan pada seluruh pekerja *Broken Tools crew "Workers don’t Kerusakan_peralatan_ *Pastikan_semua_tools Scanned with CamScanner— 0 = " PERTAMII x maura, RR o MPO OB SAFETY ANALYSIS USA) AND RISK ASSESSMENT Fomyy ENGINEERING PROCUREMENT co; a on SSE saeco rota [sete ons] ea ee ee a : dergatot =] ass SS nts |g ee ai a aja oe ie a ace Dekat dengan perasional Bie ope | ee ay Spee er equipmentitools existing ‘dan di buatken BA ditanda tangani Bersama dan di lampirkan dam permit 2 | Pengangkatan Trang | Bahaya Tenimpa material | Coder, Fatality Takukan koorlinast | Pancang ke lat | pengangkatan “Falling of Material | "Injury, Fatality 4 [5 ]H | dengan semus im sebsiom|2 (5 |x | uae angkut mat pekerjaan kepiatan Lifting Nuade *Lifting pile "Potential hazard | Ter Pekerjaan —_techenti dilskakan ri dn material using lifting material “Pintch by material | dan tertunda “Ensure always Coeernter) cra *Stop working and coordinated about iting faut Bahaya material | Material rusak delayed progress ‘work jatuh *loss material Glowereiyadi “Hazard of falling Kerugian material Pastikan sem C Rigger) material Crane rusak © Loss material support pekerjaan lifting i “Broken equipment gear dalam Kondisi baik Bahaya crane | crane dan dapat digunakan tumbang —ataupun “Make sure all off lifting amblas ‘gear on good *hazard of crane can be use collapse Pastikan_membuat isolasi Scanned with CamScannerns RBMP. yo REMENT COMET THEA FO ESTSERY “Fee bee PLAN aN rom eanar te \ ee LAN 0 A RAUMAPAN wa Hepes ee ——————— Gupakan sling yang sewai (mebbing sling ), dengan ‘spasitas yang benar \ ‘Ensure using webbing | | sling Correctly capacity Gunakan tagline untuk meagostrel material yang | diangkat \ *Use tagline for contrat when litting Scanned with CamScanner— | &* PERTAMINA JOB SAFETY ANALYSIS USA) AND Ris ASSESSMENT FORM ‘sane pen, ROM tsa MPO CLOMID RING PROCUREMENT coy DEVELOPMENT MASTER PLAN FOR Da, Saag EOR RETINERY | Bakaya angkut “Hazard when a *Dectease the decrease material rt on Ott agwahyes - Pekerja i fore start of we material pile from dan tenia, TH ‘foe sta of work Cofecator) aa Nebbing sting purus | Syne Sop and Qanan APD yay atnghet webbing | dlayea pee, lengkap dan seu dae ay sling ekerjaan qoute Material rus Sens PPE Completeand aerial rua *Loss f “Broken, ‘material ae Chm Lakukan isolasi area saat Penurunan material Pile Tidak | bisa “Isolated — area when operasional decrease the pile materi ‘Loss Time | ‘lakukan —mintenance/ service bila iy ejanggalan pads alat "Check posisialat equipment saat akan dilakukan perbaikan, kan seat moving, ot tidak sampai_ ‘exjadi blind spot (Gunakan HT/alat komunikasi) pamukulesTiang | Babaya —pocahan Tertinpa, Cidera | aq | Pash mistaken fotar yw Pancang material saat | *Falling Material Pekerjaantertunda | 4 | 3 He | area sebelum pekerjaan | 2 30 IL a “Hit pile material | pemuulan “Injury, progress Pemukulantiang pancang horidin by hammer “Hazard spark from Terpaper kebisingan | delayed “ensure doing isolation | Coftetor) | 4 ‘material when hit | *Noise Exposed ‘area before activity start Diesel Bahaye debu *sediaken blower untuk aot “hazard of dusk Sara Peete Glodat inate ‘nak dari dalam tana | Sita ain ares Be Jerk dite ot ty os. Hy, Scanned with CamScannerAP” cere vemos RBMEJO {ENT-CONSTRUCTION FOR RE! FOR RDM) RUSV BALIKPA! FINN PROSECT [Rwsion NO. cel aby aya) fest Gunaken APD yang. Tengkap dan sesuai dengan pekerjaan Fuse PPE Completeand suitable for the job Mengaunakan ear plug dan ‘ear muff wajib ‘Test Vibrast Noise monitoring “Hazard of welding | *Burnt smoke Terpapar sina las Bahaya kebakaran | “Exposed from “Hazard offre | welding Light Bahaya percikan las | Terpapar asap las *hazard of spark | "Exposed welding smoke Bahaya peralatan "Hazard tools ie | Bahaya Listrik Cidera, Fatality Takukan Ko ‘Mazard of etre ‘injury, Fatality scum a |v ody Bahays Asap “Doing coordination QyalawssiP before start of work Currder) Gunakan APD__yang engkap dan sesuai dengan pekerjaan *Use PPE Completeand suitable for the job Pastikan peralatan selalu di cek dan dapat berfungsi *Ensure tools always check and can be use Fire watcher standby di Jokasi dan gunakan vest Scanned with CamScanner[AND RISK ASSESSMENT FORM JOB SAFETY ANALYSIS USA) FEOTTIONSEOLA PERTAMINA Ri Bp. sires BME JO ecive DA 3 anwar) 2070 | x I STE SETAE AN OT evision NO. oot —T YT First aller standby di rea dan. menggunakat azm band perhatikan — Kondist pawahtanah yah ‘erpotensi mengeluarkan aroma tidak enak, di prepare masker catridge Sengan jumlah yang ‘mencukupi Jarak existing area 40m. ‘Menggunakan Fire screen Hanging, Cut off pile | -Terjepit Terlepas ~Cidera Susan material dengan Taydown broken | ah (Kkemungkinana) 3 | 5 | # | tapi y {5s |e yr --Material jatul -Pekerjaan ai Arrange all tools neath . ne -Terkena Material | hentikan J Gow (a abaya Peralstan | Pile Potongan Kawat Las di tor . -Patah tulang tempatkan terpisah cot ) Nei j -Pekerja cidera dalam = wadah khusus ial jatu (box/kaleng) ye ‘Alat bantu kerja | Kerusakan alat kerja ® Bahaya runk poeks pengangkatan | Kerusakan alat $k material Pokerja cidera existing cage) ‘Terjepit material Pekerjaan terhenti Pekerja cidera Pekerj Memastikan alat potor eke ra ng eae sudah di inspeksi dan Texjepit material c aman untuk bekerja Spun pit Ne Ran) ‘ Me PD [mete in di bming degen CR on a In Scanned with CamScanner__ ——_. CERAM ROMP JO onan cron FOR REEINERY pave NENT MASTER PLAN “re FOR RON ee PO a ea housekeeping: ‘*fell down Pomser of fowctening work | Tp ahaya material sisa pekerjaan ANB ‘erserakan ‘Material hazards ‘Area kerja tidak rapi uncluttered work area, vst ragcuREMENT CONSTR Gi BALINFAPAS PROJECT Ciera Pekerjaan tertunda Mnjury work is delayed {JOB SAFETY ANALYSIS U! TESTE IONSEOL ag January 2024 Takukan -Roordinast untuk Melakukan |) | Housekeeping _secelal pekerjaan berakhir Doing coordination for housekeeping before end of work Buang sisa material hasil pekerjaan ——_divempat pembuangan yang disediakan put the remai ‘material resulting, work area to place provided JA) AND RISK ASSESSM! ining, isposal ENT FORM from Risk Ranaking (RR) Recommendation Action Probability (PR) Severity / cons | x sequence | = tat Risiko Ti | ‘Keparaba a nga Rist Tindakan Pengendal |__| Catastrophic _= 5 19-25 B Les Tingkat pengendalian ‘Hierarchy of Control aa =3 135 reme High [B= H#243-485 i “Moderate / Serious = High He 34445 ious = 3 6-12 Medium, Ma 435. [improbatie = 1 = 15 Low L=5 Ne : Without Control / Tang ipa control »): With Control / Dengan control Scanned with CamScannerte ~ JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM. REMPJO ew BeOTETOREDTA ln TS Joy 2077 AE AG a NRE TCT TEN AR uonecr [REN BE ISANo. sare Scanned with CamScanner ATTENDANCE LIST - PRE-JOB SAFETY MEETING (JSA SOCIALIZATION) Signature \ same Peston | Campy |= i | | \ i a |EI ROMPJO JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM Dos. No. 26071-JO-HSE-014 er oe 7 te toner [ee ass JSANO. : ROMP /JSA/..S2C(L2) $09 +. JSA Title ATTENDANCE LIST —JSA PREPARATION \ NO NAME POSITION COMPANY SIGNATURE | tlkro. S stv IT. Berd kerf =f | 2 | Nundin oft ye =U 2:| Pando Hse TM —b | 4 Slanot riyodd Ligger che ar \ \ \ Scanned with CamScanner= Ss” REMPO JOB SAFETY ANALYSIS (ISA) AND RISK ASSESSMENT FORM. Fiuwac PERTAMING BatnSaran SKS ENGINEERING PROCUREMENT CONSTRUC' _— 2607 JO-HSEOI Ree ee eeepc FOR RDM) RUN ALIKEAPANTROUECT [ETeeNe OO 3 Jano 2023 a Revision No. Be | Project RDMP JO PERTAMINA, ‘Compan PT Berdikari Pondasi Prepared By Reviewed By [Approved By Scope of WorlPkg |: | Pilling Work Package 6 Name SS leg | a ISA No. a 7 ISA / SE{ N27 |\ signature a mg | wees epspann Position Supervisor he = Tob Activity Pilling work z Area B) Date. 6 OL ote Date 15 Januari 2021 4b : for fou t W rs i ic Status i i No Permit Registry No Open ¥ | Close 7 No Permit Registry No | | iC | - ; Consequence / ‘Sequence of Basic Hazard Risk severity NO Job Steps baka Resiko ‘Akiba rahapan pekerjaan ee i i ‘Lakukan Toolbox meeting | 2 I ; | senig | Miss Komunikasi | Cidsrs. Berkelabi sebelum memulai Persiapan/Preparatio: eis a *Miss “Injury pekerjaan - a pekerjaan . r ; Ensure Doing Toolbox fabapan pekerjaan Communication Pekerjaan techentt TE betore start work i tidak diketabui ole ; eorking stOP Diesel Hammer | #00 ceria. | Pekera ove : coordina dengan weil =A of — ‘Injury Complain pemilik ‘utilitas erat on’t know about ster ‘Ensure S ai of work and | Alat Rusak ( oy Utility owner Coordination wit wtllts oe rusak, crane TUSK) | complained ownet : Broken Equipment yon . vaca i boca rrahava dalam suatl | pany Kerja | Revues aackes sa a be \ ca ~" | sRiroken Too SW an serun_t00's Lh — Scanned with CamScannerRTAMINA =~ OD] PE RI Pp JOB SAFETY ANALYSIS (ISA) AND RISK ASSESSMENT FORM | RANT AMINA BMPO | _ a Dos. No 2eOTEORSEOTE ENG ROCAREMENT CONSTHUCTION FOR RERINERY __ | Effecive DaX january 2023 LDEVIDOPMENT MASTER FLAW ne FOR NDNA ey NE ie 33 ienvery 20 i ff r ow, poten | Nateal yang equipment Toosinspekah | Peart se | ag mak "Lakukan observas) pada | “Broken Material area Kerja sebum | Behaya peralatan | memulai pekerjaan agar | #Potenta hazard of | dapat menceeah edi nya | tools potensi kecelakaan kerja Gangguan le cat faa = Sebrlaon mall catidyd urd operational | Kerusakan : Siar gon piping usddepronn equipmenttools [)Maber cotrdge rastlien operation | “Lakukan joint ivestigas | Bersama RU-V-KPB dan JO untuk memastkan area aman equipmenttonls exising dan i buatkan BA. yang ditanda tangent Bersama ddan permit ] Tertimpa material Cedera, Fatality ‘Lakukan | coordinasi [ | ‘Falling of Material | *Injuy, Fatality 4 |S | H_ | dengan semua tim sebelum | 2 | pekerjaan kegiatan Lifting “Lifting pile hazard | Texepit material | Pekerjaan—terhentt dilakakan it lifting material “*Pintch by material dan tertunda “Ensure always mateo ey | an ei ce a | ee | Bahaya material | Material rusak delayed progress work | Jjatuk “loss material “Hazard of falling Kerugian mat Pastikan semua lifting gear ‘material ‘Crane rusak © Loss material support pekerjaan | “Broken equipment gear dalam ond | Bahaya crane | crane ne Pa tumbang —ataupun Make sue all off ting | amblas ‘gear on good condition and. | “hazard of crane can be use collapse Pastikan_membuat isolasi | Scanned with CamScannerL: wae ENGIN: EVELOP ME PERT, ST MNS PROCUREMENT Com: NT MASTER PLAN (ee oe RAMEO STRUCTION FoR REFINERY. DM Doe. No, 108 SAFETY ANALYSIS USA) AND RISK, ASSESSMENT FORM [20rd sO RSEOT Effective Date | January 2000 Mt) RU-V BALIKPAPAN PROJECT Revision ne toor ‘area sebelum telah Dekesjaan vem, vain, amet | \ | ing yang sesuai sling ), dengan Teapasitas yang benar ‘Ensure using webbing a capacity | \ \\ when lifting Scanned with CamScanner= = PERTAMINA KILANG PERTAMINA BAURDAP AN RBMEO JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM Dos. No. ENGINEERING PROCUREM: 1 2607 LJOHBE-OIA DEVELOPMENT MASTER PLAN (EP€ FOW ADM) RES woe EY gone [Eos Date 5 January 2021 Revision No, oor * | pamcang as a | penne ma ae Te ats angkut Saeed aera injury, Fatality | 3 setclum pekxan im *Decrease the | decrease material Pot Daina a osetia material pile from - dan tertunda crane Webbing sting putus |*work stop and Gunakan APD yang “Broken webbing | delayed progress Jengkap dan sesuai dengan sling pekerjaan Kerugian material "Use PPE Completeand Material rusak “Loss material suitable forthe job \ “Broken material “Lakukan isolasi area saat | penurunan material Pe Tidak bisa isolated area when operasional decrease the pie materi \ Loss Time : \ ‘akakan maintenance! | service bila ada ‘ejanggalan pada slat \ Check posisi slat / \ | ‘equipment saat akan \ dlilakukan perbskan \ *pastikan saat moving, operator tidak sampai teria blind spot (Gunakan H1/alat komunikasi) | \ | | 7 Pastikan mata sles | 5 ie Ga = Cidera_ ebelum —pekerjaan ; ctim| : area sebelur \ [ Pemukulan Trang | Bahaya —pecahan | TOTS ateial | Pekerjaanterunda | 4 pemukulan tang pancang | i Pancang material a “Injury, progress ensure doing isolation \ara re i ; vty start *Hit pile material ea from | Terpapar kebisingan | delayed area before activity st |coteete) by hammer material when hit | *Noise Exposed sedikan blower nti \ Diesel meniup aroma = eo Bahaya debu ‘enak dari dalam tana! _— *hazard of dusk foo | Scanned with CamScanner= M&F ~PERTAMINA end ROMP 1D 408 SAFETY ANALYSIS USA) AND ISK ASSESSMENT FORM -NGINEERING PROCUREM Dos. No. DEVELOPMENT MASTER PLAN (EPC FOR RDM GI EOE ; 260TEIOHSEOT RDMP) RUS BALIKPAPAN PR Effective Data, 33 Janvai | KPAPAN PROJECT [Revision No- Er \ i} *Kemunglinan —tancul nya aroma tidak enak dari dalam tanah saat memancang, sediakan ‘apr untold tabu pada ‘agian celab-eeah pile Gomkan APD yang lengkap dan sesuai dengan pekerjaan "Use PPE Completeand suitable forthe job | “Menggunakan ear plug dan car mofT wajib ‘Test Vibrasi | Nese mentorne 5] Pengelasan Joint Pile | Bahaya Listrik Seirum Cidera, Fatality Takaakan koordinasl y_\ *Welding joint pile | *Hazard of electric _| *Induction “Injury, Fatality [4 |3 |H scblum pekerjaan {2 [3 \L \Mde mula Bahaya Asaj ‘Terbakar Pekerjaan Tethenti, ‘Doing coordination \ ; "Hazard of welding *Burnt Progress tertunda before start of work Yobiv smoke work stop, delayed Gunakan APD yang Cunidee) ‘Terpapar sinarlas | progress "egkap an seinen \ottee “1 ekerjaan Bahaya kebakaran E: oan ft from Perle PPE Completeand “Hazard of fire welding Ligh suitable for the job Bahaya percikan las | Terpapar asap las Pastikan peralatan selalu *hazard of spark “Exposed welding & dan dapat angst ‘Ensure tools always Bahaya peralatan check and can be wse ya ps *Hazard tools Fire watcher standby ¢i Jokasi dan gunakan vest Scanned with CamScannerTAMIA, pxcinerning PROCES constRUCTION FOR RENE xc FRING ER PLA ee FOR NON? GUS BALIKTAPAN peveor" =perhatiker ‘bawah berotensi mengeluastar berpereridak ema “Ferlepas (kemunekinana) pekerjaan -Terkena Material ‘hentikan Pile ‘potongan Kawat Las di Pata tlang, aoe tee _Pekerja cidera dalam husus (box/kaleng) Kerusakan alat kerja ow cow) ‘Atat panty Ked® rusak Kerusakan. existing alat Pekerja cidera ‘Memastikan alat, potons Terjepit material Pekerjaan terhenti Pekerja cidera Pekerjaan Sodah di inspeksi_ dan terhenti ‘aman untuk beker}? Scanned with CamScanner "4108 SAFETY ANALYSIS ( TEOTEIOHSEOSS Ts january 2024, (008 cof work BBuang sisa material basil ditempat work area, Probability (PR) ‘Kemungkinan p: = Probable = 4 place provided ‘Recommer Tindakan Tingkat pengendalian Fess He 35445 M45 L=5 ‘Occasional =3 | Moderate / Serious = 3 | Unlikel =2 [improbable = 1 Note: * thout Control / Tanpa control '): With Control / Deagan contro! Scanned with CamScannerpee = LIF— PERTAMINA KIN TNA. = RD MPs 108 SAFETY ANALYSIS USA) AND RSK SESSMENT FORM | BAGRSAES oO ENGINEERING PROCUREMENT Com Doe. No. eOTEIONSEDIA DEVELOPMENT MASTER PLAN ate FOR KORE Ee a EA . eheaive Bate 33 January 2023 mI ‘orret Revision No- 00a JSA No. : RDMP/JsA/..., = ISA Title ne ATTENDANCE LIST - PRE-JOB SAFETY MEETING (JSA SOCIALIZATION) | Signature ne. eee ees Date: Date: [Date:___| Date: fae Pp \ i \ \ ; \ 3 [4 Scanned with CamScanner[= Pe PERTAMINA R EN waa ov DEVELOPMENT MG ERO MASTER MEO | \CUREMENT con; moana Oe Eee ete Bas Sion ao Revision Na co JSA No. : RDMP / Jsa SL osseee JSA Title : ee os | L ATTENDANCE LIST — JSA PREPARATION \ [No ~_NAME POSITION SS \ \ Nuvain ort Berd kan 2z.| Eleo.s sev Berd kon \ 3. | Vosiv wwe ons Pager — [Sf Romine se | \ 7 | | | | \ “es Scanned with CamScanner