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Project Name: Cirebon 2, 1x1000MW Coal Fired Power Plant Project, Indonesia Company:
Nama Project: Perusahaan: PT. KOIN KONSTRUKSI
Work Activity:
Pekerjaan: BOILER HYDROSTATIC TEST JSA No: KOIN/HSE/JSA/20-16 Rev 0
JSA Participants / Preparation & Review. Peserta pembuat JSA Approval/ Persetujuan
(incl. personnel consulted: e.g. workers, supervisors, foremen, HSE personnel, external parties)
Name Position Company Signature Name Date Signature
Type of Permit Required Additional PPE Requirements Special tools or equipment required:
JenisPerizinanygDiperlukan: TambahanAlatPelindungDiri yang diperlukan Alat-alatKhusus yang Diperlukan:
Excavation/ Penggalian
Hot work/ PekerjaanPanas
Confined space/Ruang terbatas
Other/ Lainnya: General Permit
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JOB SAFETY ANALYSIS (JSA)
Risk Matrix:
CONSEQUENCE
Disciplines will review likelihood and consequences in 1 = Negligible 2 = Slight 3 = Moderate 4 = High 5 = Very High
line with their specific parameters as noted
No injuries requiring any First aid treatment. Medical treatment required, Injuries resulting in; lost Single or multiple fatalities.
treatment. Restricted Work Case. time,permanent disability,
amputation, or surgery.
3=Possible Should occur at some time L-3 M-6 H-9 H-12 VH-15
2=Unlikely Could occur at some time L-2 M-4 M-6 H-8 H-10
1=Very Unlikely May occur only in exceptional L-1 L-2 L-3 M-4 M-5
circumstances
Likelihood (L) 1 = Very Unlikely, 2 = Unlikely, 3 = Possible, 4 = Likely, 5 =Very Likely Consequence (C) 1 = Negligible, 2 = Slight, 3 = Moderate, 4 = High, 5 = Very High
Risk Rating (R) LOW [ 1-3 ]Broadly acceptable - MODERATE [ 4-6 ] Tolerable – With identified HIGH [ 8-12 ] Undesirable - Additional VERY HIGH [ 15- 25 ]Intolerable - Do
Manage by routine procedures controls fully implemented controls required to reduce risk not start activity
Residual
Risk
Activity Potential Hazards /Consequences [L x C=R]
Persons Responsible
(Basic job steps) (What can go wrong) Control Measures/ Tindakan perbaikan
Penanggung jawab
Aktivitas (Langkah kerja) Potensi bahaya/ konsekwensi (Apa yang bisa salah?)
L C R
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JOB SAFETY ANALYSIS (JSA)
Residual
Risk
Activity Potential Hazards /Consequences [L x C=R]
Persons Responsible
(Basic job steps) (What can go wrong) Control Measures/ Tindakan perbaikan
Penanggung jawab
Aktivitas (Langkah kerja) Potensi bahaya/ konsekwensi (Apa yang bisa salah?)
L C R
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JOB SAFETY ANALYSIS (JSA)
Residual
Risk
Activity Potential Hazards /Consequences [L x C=R]
Persons Responsible
(Basic job steps) (What can go wrong) Control Measures/ Tindakan perbaikan
Penanggung jawab
Aktivitas (Langkah kerja) Potensi bahaya/ konsekwensi (Apa yang bisa salah?)
L C R
Page 4of 7
JOB SAFETY ANALYSIS (JSA)
Residual
Risk
Activity Potential Hazards /Consequences [L x C=R]
Persons Responsible
(Basic job steps) (What can go wrong) Control Measures/ Tindakan perbaikan
Penanggung jawab
Aktivitas (Langkah kerja) Potensi bahaya/ konsekwensi (Apa yang bisa salah?)
L C R
Page 5of 7
JOB SAFETY ANALYSIS (JSA)
Residual
Risk
Activity Potential Hazards /Consequences [L x C=R]
Persons Responsible
(Basic job steps) (What can go wrong) Control Measures/ Tindakan perbaikan
Penanggung jawab
Aktivitas (Langkah kerja) Potensi bahaya/ konsekwensi (Apa yang bisa salah?)
L C R
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JOB SAFETY ANALYSIS (JSA)
Residual
Risk
Activity Potential Hazards /Consequences [L x C=R]
Persons Responsible
(Basic job steps) (What can go wrong) Control Measures/ Tindakan perbaikan
Penanggung jawab
Aktivitas (Langkah kerja) Potensi bahaya/ konsekwensi (Apa yang bisa salah?)
L C R
Sign On: I confirm that the JSA has been explained and its contents are clearly understood. I clearly understand the controls in this JSA must be
applied; otherwise work is to cease immediately.
Saya mengkonfirmasi bahwa JSA telah dijelaskan dan isinya dipahami dengan jelas. Saya memahami dengan jelas kontrol dalam JSA ini harus diterapkan; jika
tidak, pekerjaan akan segera dihentikan
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