Form No: JAS-HSE-JSA FORM Revision No: 01

JOB SAFETY ANALYSIS

PT. JAVARO ABADI SEJAHTERA

WORK ACTIVITY (JOB) TITLE: DATE :

LOCATION : JSA NO. :
WORK TEAM REVIEWED BY: JSA PREPARED BY:
1. Signature:_____________
1 7 2. Signature:_____________
2 8 Name :__________________ 3. Signature:_____________
3 9 Signature:__________________ 4. Signature:_____________
4 10 5. Signature:_____________
5 11 6. Signature:_____________
6 12 7. Signature:_____________
8. Signature:_____________
CRITICAL QUESTIONS: Everyone Ready/Capable To Work? Potential Spill/Gas Release Addressed? Worst Case Discussed?

REQUIRED SAFETY EQUIPMENT

Hard Hats Goggles Safety Harness Hearing Protection Barricades Other (List): To provide Hi – Viz vest when working close
Safety Shoes Face Shield Cotton Gloves Flame Resistant Clothing LEL Monitor to the road________________________________
Safety Glasses Work Vests Leather Gloves Fire Extinguisher H2S Monitor _____________________________________________
_____________________________________________
APPLICABLE SAFE WORK PRACTICES/SPECIAL PRECAUTIONS
Hot Work Permit Special Pre-Job Safety Discussions Confined Space Entry Permit Pollution Prevention Measures
Energy Isolation Review Emergency Action Plans Use of Specialized PPE Redundant Protection Measures
Written Procedure Site/Job Orientation Overhead/Underground Utility Lines Simultaneous Operations
POTENTIAL HAZARDS
Lifting Hazards Short Service Employees Elec. Shock/ Flash (includes utility lines) Dropped/Falling Objects Low Lighting Ionizing
Fall Potential Water/Drowning Hazard Haz. Chemical Exposure (includes H2S) Tripping/Slipping Breathing Hazard Radiation
Skin Irritants Mech. Equip. Hazards Sharp Edges or Hot/Cold surfaces Excavation Hazard Environmental Other:_________
Confined Spaces Fire/Explosion Potential Pinch/Crush/Striking Hazards Confined spaces Extremes ________________
Elev. Load/Work High Noise Levels Potential Release of Energy Elevated load or work Vehicle Operations ________________
 Form No: JAS-HSE-JSA FORM Revision No: 01
BASIC JOB STEPS POTENTIAL INCIDENTS OR WAYS TO ELIMINATE OR CONTROL HAZARDS PIC
HAZARDS
1. Permit Holder
Form No: JAS-HSE-JSA FORM Revision No: 01