JOB SAFETY ANALISYS FORM

PROJECT : Pembuatan Pagar teralis rumah tinggal DATE : 19 Jun 2024 JSA NO.: PT.ABC/001

TASK / Job : Pengelasan JSA Team

LOCATION Gudang A NAME POSITION SIGNATURE

NO. OF PERSONS INCLUDED IN TASK 5 Orang Yesi Yulaintika Team JSA Leader

TASK DESCRIPTION / Job step:

Nisa Indriani Production Team Leader
1. Menyiapkan bahan las + alat kerja
2. Memasang peralatan kerja sesuai dengan rancangan awal ( MS)
Rivka Dinda Annisa S. HSE / Team K3
3. Uji coba alat dan bahan
4. Set up material yang akan di las
Muhammad Ikhsan Engineer
5. Pengelasan
6. Menggerinda untuk merapikan titik las
7. Membersihkan peralatan kerja dan tempat kerja setelah pekerjaan selesai Aridestriadi Supervisor
pengelasan
REFERENCE: JSA Team Leader confirm that the risk for task describe have been reviewed and the controls measures which are
recommended reduce the risk to tolerable level and I consider it is safe so the task can be proceed
1. Model Rancang ( Method statement )
2. SOP & IK NAME SIGNATURE
3. Standard Pegelasan DESIGNATION
4. MSDS – Spec Material
5. Certificate welder Date:

I am satisfied that the controls measures identified when put into place will reduce the risk to tolerable level. The
task/action change is permitted to proceed. CONFIRMED & APPROVED BY PROJECT MANAGER

NAME SIGNATURE
DESIGNATION PM

Date:
JSA WORK SHEET
TASK DESCRIPTION
Hazard Identification Risk Evaluation Risk Control
Ver.
Hazard Effect: Initial
Hazard Description TYPE Control measures: Residual Responsible Actions
No. Task Activity : SD Manusia, Aset, Risk/ Resiko
Potensi Bahaya Cidera, Loss, pencemaran E, S, RE, DC, APD Risk Person Closed
Lingk Awal
(Y/N)
S P R S P R

1 Menyiapkan
bahan las + alat
kerja

2 Memasang
peralatan kerja
sesuai dengan
rancangan awal
( MS)

3 Uji coba alat

dan bahan

4 Set up material
yang akan di las

5 Pengelasan Kebakaran Manusia , Cidera Menggunakan APD Pelindung Yes

Aset, Loss mata & wajah), kaki , tangan, Yes
Lingkungan Pencemaran wear pack No
Menggunakan celemek anti Supervisor/
E 4 H6 panas A 1 L1 Leader
No
Menyiapkan APAR Pengelasan No
Membersihkan area kerja dari
dari benda, cairan dan gas
mudah terbakar
Percikan panas Manusia Cidera D 4 H2
Mata silau – Arch Manusia Cidera
Sengatan listrik Manusia Cidera
Gangguan pernafasan Manusia Cidera

2
JSA WORK SHEET
TASK DESCRIPTION
Hazard Identification Risk Evaluation Risk Control
Ver.
Hazard Effect: Initial
Hazard Description TYPE Control measures: Residual Responsible Actions
No. Task Activity : SD Manusia, Aset, Risk/ Resiko
Potensi Bahaya Cidera, Loss, pencemaran E, S, RE, DC, APD Risk Person Closed
Lingk Awal
(Y/N)
S P R S P R

6 Menggerinda
untuk
merapikan titik
las

7 Membersihkan
peralatan kerja
dan tempat
kerja setelah
pekerjaan
selesai
pengelasan
8

10

11

3
S = SEVERITY = TINGKAT KEPARAHAN
P = PROBABILITY = TINGKAT KEMUNGKINAN
R = RISK = RESIKO