Jobs Safety Analysis Date : 6 September 2021

JOURNEY MANAGEMENT
(JSA) PLAN
Pekerjaan Audit Energi Pertamina Lubricant Unit Gresik
JOB/ACTIVITY NAME: JSA #:
AUDIT ENERGI – PT PERTAMINA LUBRICANT PRODUCTION UNIT GRESIK
(PUG)

DEPARTMENT/GROUP NAME
Complete this BLDG/AREA
form when LOCATION(s):
driving on business either; OTHER INFORMATION:
VOKASI ITS Production Unit Gresik
• More than 400 Jl.kmHarun
(250 miles)
Tohir or
ds.4Pulo
hours a day.
Pancikan
• In areas that pose safety and security risks
Gresik - Jawa Timur 61113 due to political or social instability.
REQUIRED PERSONAL • PROTECTIVE
In unpopulated areas with
EQUIPMENT FORlimited
ENTIREcommunication
JOB infrastructure.
safety glasses • √ safety shoes
In areas where conditionschemical resistant gloves
make the travel more √ other helmet
hazardous such as: other____________________
chemical goggles >hard hat
Extensive travel welding gloves
on unpaved or unmaintained roadways;
face shield > High
harness lanyard leather
levels of wildlife gloves
interaction potential; √ other safety vest other____________________
welding goggles >hearing protection areas;
Mountainous
> Extreme weather conditions
Basic Step Potential Hazards Controls
This form should be completed at least 24 hours before travel and approved by your line or project
Perjalanan pulang – pergi dari Office ke Lokasi
manager. Kecelakaan Lalu lintas Mengikuti Prosedur Journey Plan

Aktifitas Audit Dokumen di Office Ergonomis Break setaip 45 menit untuk peregangan
Driver’s Name Totok Soehartanto
Electric Shock Memastikan kabel dan stop kontak dalam kondisi
baik.
Type & Licence Number of Vehicle Mobil Penumpang Toyota Innova

Date of Travel 11 Mei 2018

Kegiatan Audit di Lapangan
- Journey
Pengukuran Arus from
Listrik Surabaya
Electric Shock Menggunakan APD, Safety Shoes dan Gloves
Menggunakan Tangga Slip, Fall
Pertamina Lubricant Unit Gresik Memastikan Tangga dalam kondisi baik
Journey to
- Audit Proses Produksi Slip, Fall. Stuck, Fall Object Meng Menggunakan APD
Return Journey same day? Yes
Kebisingan Meng Menggunakan Ear Plug
Estimated driving time 1 jam
- Audit diPassenger(s)
Area Boiler names Herry Sufyan Hadi
Pengukuran kinerja Boiler Heat and Hot Steam Mengikuti Prosedur K3 perusahaan
Sefi Novendra Patrialova
Burn Memakai APD
Ahmad
Chemical Fauzan ‘Adziimaa
Hazzsard Mengikuti petunjuk yang ada di MSDS
Arief Abdurrakhman
Job Safety Analysis ITS Mashuri Page 1 of 2

Will the journey involve travelling through areas where there are significant security risks, where medical
I understand & will adhere to the steps, hazards & controls as described in this JSA. I
understand that performing steps out of sequence may pose hazards that have not been
evaluated, nor authorized. I will contact my supervisor prior to continuing work, if the scope of
work changes or new hazards are introduced.
I understand I have the authority and responsibility to stop work I believe to be unsafe.
Worker Name (please print) Signature Supervisor Date
Ir. Arief Abdurrakhman, S.T., MT ____ 6 September 2021

Sefi Novendra Patrialova S.Si., M.T ____ 6 September 2021

Brian Raafi’u, S.ST., M.T ____ 6 September 2021

Putri Yeni Aisyah, S.T., M.T ____ 6 September 2021

Dwi Nur Fitriyanah, S.ST., M.T. ____ 6 September 2021

I Putu Eka Widya Pratama, S.Si., M.Sc.RWTH ____ 6 September 2021

Safira Firdaus Mujiyanti, S.T., M.T. ____ 6 September 2021

I have reviewed the steps, hazards & controls described in this JSA with all workers listed above
and authorize them to perform the work. Workers are qualified (i.e. licensed or certified, as
appropriate, & in full compliance with institution training requirements) to perform this activity.
Ir .Ahmad Fauzan Adziimaa.,S.T., M.Sc ____ 6 September 2021

Leader Tim Signature Date

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