JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

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

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

LOADING – UNLOADING CONTAINER
JSA Title :
AND SITE OFFICE INSTALLATION

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
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No.

Project : Prepared
RDMP – HVAC By Package 2 Reviewed By Approved By
Company : PT.PP SPV
Urban Chief/HSE Manager CM
Scope of Work/Pkg : HVAC Package 2
JSA No. : RDMP /
JSA / ............. / ...............
Position : Supervisor
Job Activity : Loading – unloading container
Area :
Date :

Name
Signature

Date

Status
Status
No Permit Registry No
Open 🗸 Close 🗸

Permit Registry No
Open 🗸 Close 🗸

No

NO Sequence of Basic Hazard Risk Consequence / Risk Recommendation action Result Risk*) PIC
Job Steps Bahaya Resiko severity Assessment* Tindakan Pengendalian Penanggung
Tahapan pekerjaan Akibat Jawab
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

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

PR SV RR PR SV RR

1. Persiapan 1.1 Tidak 1.1 Komunikasi yang 1.1 Kesalahan prosesur 3 2 M 1.1 Pastikan semua pekerja 2 1 L Supervisor
Preparation Memahami gagal. kerja. ikut ToolBox Meeting
Materi Yang Miss Erroneous work sebelum Pekerjaan akan
Disampaikan communication. procedures. dilakukakan dan
Oleh Supervisor mengisi attendent list
saat ToolBox 1.2 Human Error. 1.2 Koordinasi kacau, bagi yang terlambat
Meeting Human error Erroneous tidak diijinkan mengisi
Not coordination attendent list.
Understanding 1.3 Pekerja tidak Make sure all workers
the Material memahami step 1.3 Kecelakaan kerja. join the Tools Box
pekerjaan. work accident Meeting before the
Presented by the
Workers do not
Supervisor on Work will be done
understand the
ToolBox Meeting work steps
1.2 Tool box meeting
1.2 Pekerja Tidak 1.4 Pekerjaan tidak dipimpin oleh
diawasi dengan supervisor.
Memahami
benar. Tool box meeting are
Tugas – lead by supervisor
Work not control
Tugasnya
properly
Workers do not 1.3 Pastikan semua peserta
understand their TBM memahami
duties. prosedur dan jalur
komunikasi saat terjadi
1.3 Pekerja tidak kondisi emergency .
ikut TBM. Ensure for all TBM
Workers do not attendance is know for
join TBM emergency procedure
and emergency
1.4 Ijin kerja tidak evacuation route
ada.
No Work Permit 1.4 Pastikan semua
memahami isi dari
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

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

toolbox meeting.
Ensure all attendance is
know content of TBM

1.5 Pastikan radio

communication tersedia
channel internal JO dan
RU V.
Ensure the radio
communication is
provide with JO
internal and RU V
channel

1.6 Pastikan kepada pekerja

kondisi kesehatan
terakhir sedang fit untuk
bekerja dengan
melakukan DCU oleh
team medik dan
terdokumentasi.
Ensure that workers of
the latest health
condition are fit to work
as per newest DCU.

1.7 Sosialisasi JSA / WMS

daftar hadir terlampir
Socialization of JSA /
WMS attendance list
attached

1.8 Pastikan dokumen ijin

 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
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kerja (SIKA),
pernyataan metode
kerja, jsa, dan sertifikat
alat dan kompetensi
sudah ada, valid dan
disetujui
Ensure the work permit
(SIKA), work method,
JSA, and certificate is
valid and approved

2 Persiapan pekerjaan, 2.1 Alat belum 2.1 Alat rusak 2.1 Pekerjaan tidak 3 3 M 2.1 Periksa alat kerja 2 1 L Supervisor
pemeriksaan alat – diperiksa dan Tool or equipment bisa dikerjakan/ sebelum memulai
alat kerja broken or dilanjutkan pekerjaan.
diberi tanda
Prepare for work, Stop work or cant Tool and equipment
pemeriksaan disfunction
tool and equipment continue check before start
checking Tool and working.
equipment work
is not checked 2.2 Pastikan alat dalam
yet and give keadaan fit dan telah di
sign check periksa oleh tim
RDMP JO.
Ensure for tool and
equipment is on good
condition and already
checked by RDMP JO
inspection team.

2.3 Mengikuti prosedur

yang berlaku terkait
pemeriksaan/inspeksi
equipment dan alat
kerja
Following to standard
procedure of tool and
equipment inspection.
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

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

2.4 Gunakan checklist

inspeksi harian JO
untuk Crane dan alat
berat lainnya
Using JO daily
inspection for crane
and other heavy
equipment.

3 Bongkar – muat 3.1 Gagal memahami 3.1 Terkena fasilitas 3.1 Kerusakan 4 4 H 3.1 Hanya operator yang 2 1 L Operator
container fasilitas eksisting eksisting property memiliki SIO MIGAS Crane (SIO
Loading - unloading Exposed to Property damage dan bersertifikat yang must be
Failed to
container existing facilities dapat mengoprasikan included)
understand 3.2 Ganti rugi alat berat.
existing facilities 3.2 Kebocoran pipa Compensation Only operator that
minyak, gas, uap, already have SIO
3.2 Terkena manuver & air. 3.3 Kebakaran/ledak MIGAS and certified
alat Leak of oil, gas, anFire and that can operate
Exposed with explosion equipment
steam or water
lifting equipment
pipe line
3.4 Luka Memar dan 3.2 Pastikan prosedur
3.3 Tumpahan sobek berkendara yang aman
minyak atau oli 3.3 Kebocoran gas
Bruises and torn terlaksana / peraturan
pada mesin beracun wounds lalu lintas dalam
Oil spill to Leak of poisonus kilang.
machine gas 3.5 Tertimpa, terjepit, Ensure the safety
terbentur driving and traffic
3.4 Peralatan angkat 3.4 Kebakaran mesin Struck down, regulations in refinery
angkut terbalik Auto ignition pinched, hit procedure is already
Lifting Gear done
collapse 3.5 Kerusakan alat 3.6 Kematian
Equipment broken Fatality 3.3 Komunikasi dengan
HSSE RDMP dan JO
3.6 Tertimpa dan saat akan mobilisasi
Comunicate with
terjatuh
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

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

dikarenakan gagal HSSE RDMP and JO

angkat before and during
Struck down cause mobilization
of lifting fail
3.4 Flag man standby saat
proses mobilisasi alat
dan material ke dalam
site
Flagman shall be
standby when
mobilization

3.5 Pastikan prosedur

kerja instalasi alat
berat terlaksana
dengan benar.
Tepasang pelindung
pada alat yang
berputar.
Ensure work
procedure, equipment
installation is doing
right, installed with
swinging protection.

3.6 Pastikan barricade

area kerja di sekitar
mesin crane, dump
truck dan flagman
tersedia.
Ensure baricade on
work area around
crane and flagman is
available

3.7 Lakukan pemeriksaan

harian kondisi mesin
dan sediakan
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

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

penampungan kedua
di bawah mesin yang
digunakan.
Doing machine
condition daily
checklist and provide
spill storage under the
machine

3.8 Pastikan spill kit

tersedia di area kerja
Ensure spill kit is
provide on work area

3.9 Pastikan pekerja

memahami prosedur
evakuasi ketika terjadi
kebocoran gas.
Ensure the worker is
know the evacuation
procedure when leak
gas is happen.

3.10 Lakukan koordinasi

dengan kontraktor lain
dan pertamina jika
bekerja di area
eksisting.
Doing coordination
with other contractor
and Pertamina if work
on exixsting area.

3.11 Proses loading /

unloading material
pastikan didampingi
oleh rigger.
Ensure rigger is stand
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
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by when loading and

unloading material
process.

3.12 Pastikan untuk

personil yang
berhubungan dengan
alat angkat adalah
orang yang fit untuk
bekerja sesuai dengan
pengecekan kondisi
harian, kompeten dan
bersertifikat begitu
pula dengan alat yang
akan digunakan
bersertifikat dan telah
dilakukan checklist
sebelum digunakan.
Ensure all lifting work
personil shall fit for
work following to
DCU, competent and
certified, and for tool
and equipment is
certified and already
inspect and checklist
before start operated..

3.13 Jauhkan anggota tubuh

dari titik jepit
Keep away from pinch
point.

3.14 Pastikan proses

loading dilakukan
pada permukaan yang
keras dan rata.
Ensure the loading
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

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

process on hard and

flat ground surfaces.

3.15 Pastikan radius aman

terhadap fasilitas
eksisting
Ensure the safe radius
from existing
facilities.

3.16 Pastikan operator telah

mengikuti training di
JO
Ensure for operator is
already trained by JO

4 Pekerjaan selesai, 4.1 Bekerja dengan 4.2 Area kotor dan 4.3 Kebersihan yang 3 2 M 4.4 Pastikan area bersih Supervisor
Housekeeping peralatan berantakan buruk dan rapi sebelum
Finishing work,
angkat angkut Dirty and Bad meninggalkan area
houseeping
Working with crowded housekeeping pekerjaan
lifting gear Ensure the location is
neat and clean before
leaving work area
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
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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
JSA No. : RDMP / JSA /......................... / .....................
LOADING – UNLOADING CONTAINER
JSA Title :
AND SITE OFFICE INSTALLATION

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

N Signature
Name Position Company
o Date: Date: Date: Date: Date: Date: Date:
1
2
3
4
5
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7
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

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

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