Da

Date : 8 Apr, 2022 MS-DD-AKPQ3-CON-PRO-1047

METHOD STATEMENT AND JOB SAFETY
Page 1 of 4
Rev. : E ANALYSIS FOR UPPER PILE SITE REPAIR

METHOD STATEMENT AND JOB SAFETY ANALYSIS

FOR UPPER PILE SITE REPAIR WIKA BETON

Issue to PTFI:

PT CII REVIEW RESULT TO SUBCONTRACTOR For Information For Approval

(Review Not Required) (Review Required)
PTFI REVIEW RESULT TO PT CII
Approved without Comments Approved by: Approved by:
A Allow to start fabrication/Construction. A Approved without Comments

Approved with Comments Reviewed by: Reviewed by:

Allow to start fabrication/Construction,
B B Approved with Comments
however, re-submit documents till code
"A" from Owner and/or Contractor.
Not Approved Checked by: Checked by:
Fabrication/Construction is not
C allowed. C Not Approved
Re-submission is required.

Reason for "(C) Not Approved" Date: Reason for "(C) Not Approved" Date:

PT CHIYODA INTERNATIONAL INDONESIA PT FREEPORT INDONESIA

CHIYODA’S APPROVAL OF ANY DRAWING SUBMITTED THERETO SHALL NOT RELIEVE THE
SUBCONTRACTOR OF ITS OBLIGATIONS OR RESPONSIBILITY FOR THE ACCURACY AND ADEQUACY
THEREOF UNDER THE SUBCONTRACT.

OWNER: PT FREEPORT INDONESIA

MANYAR SMELTER PROJECT

PT CHIYODA INTERNATIONAL INDONESIA

E For Approval Apr 8, 2022 JBI MSJ HDO

Rev. Description Date Prepared Reviewed Approved
Da
Date : 8 Apr, 2022 MS-DD-AKPQ3-CON-PRO-1047
METHOD STATEMENT AND JOB SAFETY
Page 2 of 4
Rev. : E ANALYSIS FOR UPPER PILE SITE REPAIR

TABLE OF CONTENTS

1. INTRODUCTION...........................................................................................................................3
2. TECHNICAL DATA Equipment & Material Data:........................................................................3
3. REFERENCE...................................................................................................................................3
4. SHELTER ASSEMBLY..................................................................................................................4
4.1. Equipment and Manpower Mobilization.........................................................................................4
4.2. Equipment Setting............................................................................................................................4
4.3. Repair Method..................................................................................................................................4
6. JOB SAFETY ANALYSIS....................................................................................................................4
 Da
Date : 8 Apr, 2022 MS-DD-AKPQ3-CON-PRO-1047
METHOD STATEMENT AND JOB SAFETY
Page 3 of 4
Rev. : E ANALYSIS FOR UPPER PILE SITE REPAIR

1. INTRODUCTION
This method statement was written as a guidance for the execution of temporary site facility
construction work on:
Project Name : Manyar Smelter Project – Piling & Civil Work
Location : Gresik, East Java, Indonesia
Main Contractor : PT Chiyoda International Indonesia
Owner : PT Freeport Indonesia

This method statement is a guidance to achieve a successful project completion with acceptable
quality, within specified time frame, and within a controllable budget for the purpose of Client’s
satisfaction. The following topics will be described / explained in this method statement.

To prevent un-controllable discrepancy of work performance from this method statement, this
method statement must be followed strictly. Any change or adapting action taken to anticipate job
site / work conditions, can only be performed under written notice / instruction from Site Manager
and approval of Contractor or Authorized Contractor Representative.

2. TECHNICAL DATA Equipment &

Material Data:
No. Description Specification Quantity Remark
1 Joint Plate
2 Grouting Material Sikagrout 215
3 Bonding Agent Material Consol
4 Coarse Aggregate, etc
5 Mold Materials
6 Multiplex
7 Water

3. REFERENCE

● MS-DD-3000-QUA-PRO-0201 Quality Control Requirements to Subcontractor

● MS-DD-3000-QUA-PLN-0103 Inspection and Test Plan for Concrete Work
● MS-DD-3000-CIV-SPE-0104 Construction Specification for Concrete Work
● MS-DD-3000-CIV-STA-0010 Standard Drawing for Pile Head Detail
Da
Date : 8 Apr, 2022 MS-DD-AKPQ3-CON-PRO-1047
METHOD STATEMENT AND JOB SAFETY
Page 4 of 4
Rev. : E ANALYSIS FOR UPPER PILE SITE REPAIR

4. SHELTER ASSEMBLY
4.1. Equipment and Manpower Mobilization
a. All equipment must be inspected prior to mobilize, inspection conducted on physically at
workshop along with documentation checking such as SIA, SIO, calibration certificate,
historical energy transfer of hammer and other required documents by authorized SHES
person.
b. Manpower and staff who will be assigned at project site has to conduct medical examination
and swab antigen test.
c. Submit driver register for mobilization of equipment and submit request for safety induction
for mobilization of manpower.
d. Make sure that this work is supervised by Construction and SHE team.

4.2. Equipment Setting

a. The equipment of which will be mobilized at jobsite as much as possible placed nearby
work location.
b. Setting up equipment based on manufacture standard.

4.3. Repair Method

a. Determine the part of the pile that is still intact
b. Put a circle mark on the pile as a sign of cutting
c. Cut the marked pile blanket using a grinding machine
d. Chipping the grinded part using a hammer and concrete chisel, then leave the
prestressed iron as high as 30 - 40 cm.
e. Clean the cut area of dirt and dust using a wire brush
f. Prepare multiplexes for partitions, reinforcement bar + spiral wire, grouting materials, and
molds for grouting
g. Install reinforcement bar + spiral wire
h. Apply the bonding agent material to the surface to be cast until evenly distributed
i. Install the formwork in a position perpendicular to the pile
j. Perform casting in area A and area B using grouting material with the specifications in the
Sika grout 215 material brochure.
k. Cover the casting area using a wet sack
l. Open the mold at the age of approximately 24 hours
m. Modified results can be used when the age of concrete reaches 7 days

6. JOB SAFETY ANALYSIS

 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

JSA OVERVIEW
PENYELESAIAN JSA BERKUALITAS MEMILIKI 4 LANGKAH: DAFTAR PERIKSA - Item ini diperlukan untuk JSA yang berkualitas
THE COMPLETION OF A QUALITY JSA HAS 4 STEPS: CHECKLIST - These items are required for a quality JSA
LANGKAH 1 – PERENCANAAN & PERSIAPAN
Jika tidak ada JSA yang relevan dengan pekerjaan, seluruh tim yang melakukan aktivitas pekerjaan harus terlibat dalam Apakah Ketua Tim JSA mengetahui proses JSA?
Is the JSA Team Leader familiar with the JSA process?
V
pengembangan JSA baru. JSA dapat diketik atau ditulis tangan pada template ini. Jika ada JSA yang relevan dengan pekerjaan, ini
dapat digunakan atau ditinjau sebagai panduan dan perubahan dapat dilakukan dengan komputer atau tangan. JSA harus melibatkan Supervisor dan orang-orang yang melakukan pekerjaan
STEP 1 – PLANNING & PREPARATION
The JSA must involve the Supervisor and people performing the work
V
If there is no existing JSA relevant to the work, the whole team undertaking the job activity must be involved in the development of a
new JSA. JSAs can be typed or handwritten on this template. Where existing JSAs relevant to the job exist, these can be used or Apakah ada WMS atau JSA serupa untuk pekerjaan itu?
reviewed as a guide and changes can be made on by computer or hand.
Is there an existing WMS or similar JSA for the work?
V
LANGKAH 2 - FORMULIR JSA Apakah bahan kimia atau bahan berbahaya terlibat (termasuk SDS)
Gunakan Bagian (A) dan/atau Pernyataan Metode Kerja dan pengetahuan Anggota Tim JSA tentang pekerjaan sebagai petunjuk untuk mengidentifikasi
Are chemicals or hazardous materials involved (include SDS)
X
bahaya.
Identifikasi potensi insiden atau kondisi berbahaya untuk setiap langkah. Apakah diperlukan Izin dan sertifikat izin?
Identifikasi kontrol untuk setiap langkah untuk mengurangi risiko ke As Low As Reasonably Practical (ALARP). Work Method Statements (WMS)
Are required Permits and clearance certificates in place?
V
dapat digunakan sebagai panduan.
STEP 2 ‐ JSA FORM Efek bagi orang lain yang bekerja di sekitar dan lingkungan sekitar dipertimbangkan?
Use Section (A) and/or the Work Method Statement and JSA Team Member knowledge of the job as a prompt to identify hazards. Effect to others working nearby and surrounding environment considered?
V
Identify the potential incidents or hazardous conditions for each step.
Identify controls for each step to reduce the risks to As Low As Reasonably Practical (ALARP). Work Method Statements (WMS) can be Apakah APD tambahan diperlukan?
used as a guide. Is additional PPE required?
V
Hirarki Kontrol harus diterapkan saat mengidentifikasi kontrol. Pastikan A Step Back 5x5 selesai sebelum memulai tugas
The Hierarchy of Controls shall be applied when identifying controls. Ensure A Step Back 5x5 is completed prior to starting the task
V

Hilangkan Bahaya  Eliminate Hazard
 Substitute with less hazardous alternative
 Ganti dengan alternatif yang kurang berbahaya

Gunakan kontrol teknik  Use engineering controls
 Use administrative controls
 Gunakan kontrol administrative Kadaluwarsa dan Ulasan Expiry and Review

Gunakan Alat Pelindung Diri (APD)  Use Personal Protective Equipment (PPE)
JSA harus ditinjau dan ditandatangani oleh pihak kerja setiap minggu atau bila terjadi perubahan
Gunakan Kalkulator Skor Risiko untuk menghitung risiko residual setelah pengendalian yang tepat diidentifikasi. aktivitas kerja.
Use the Risk Score Calculator to calculate the residual risk after appropriate controls are identified. 1 The JSA is to be reviewed and signed by the work party on a weekly basis or when a change
LANGKAH 3 – PERSETUJUAN in the work activity occurs.
Mendapatkan persetujuan dan tanda tangan JSA untuk digunakan oleh Supervisor area dan Manajer Konstruksi / delegasi Amandemen dan tinjauan harus tercermin dalam bagian (F) dari JSA.
KONTRAKTOR. 2 Amendments and reviews shall be reflected in section (F) of the JSA.
STEP 3 – APPROVAL
Get approval and signature for the JSA to be used by the area Supervisor and the CONTRACTOR Construction Manager / delegate. Jika Izin Bekerja mengatur pekerjaan, salinan JSA harus diberikan dengan salinan Izin yang ditutup.
If a Permit to Work is governing the job, a copy of the JSA is to be provided with the closed out
CATATAN: Kelompok kerja tidak boleh melanjutkan jika risiko dinilai TINGGI. 3 copy of the Permit
NOTE: Workgroups are not to proceed where risks are assessed as HIGH.

LANGKAH 4 – MANAJEMEN DOKUMEN

Setiap JSA akan diberikan nomor referensi, di halaman 2 formulir ini, dan masuk ke Register JSA. Selama JSA aktif, JSA harus tetap berada di
Pastikan anggota kru kerja baru untuk meninjau pekerjaan dan masuk ke JSA
lokasi pekerjaan. Daftar dan JSA yang sudah pensiun harus dipelihara oleh Subkontraktor
STEP 4 – DOCUMENT MANAGEMENT
4 Ensure new work crew members to the job review and sign on to the JSA
Each JSA shall be allocated a reference number, on page 2 of this form, and logged into a JSA Register. While the JSA is active it shall
remain at the job location. The register and retired JSAs are to be maintained by the Subcontractor
JSA akan dihentikan dan disimpan ketika pekerjaan itu selesai.
5 The JSA is to be retired and stored when that work is completed.
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

DETAIL KERJA JSA DAN DAFTAR PERIKSA JSA WORK DETAILS AND CHECKLISTS
Tanggal / Date: 8/04/2022 Judul pekerjaan / Job Title: Manyar Smelter Project
Uraian pekerjaan / Description of Work: Upper Pile Repair
JSA Ref# MS-DD-AKPQ3-CON-PRO-1047 UPPER PC PILE REPAIR
Work
MS and JSA
Pencipta / Originator: PT Adhi Karya (Persero) Tbk. Izin# (Jika berlaku) / Permit# (If applicable)
(A) IDENTIFIKASI POTENSI BAHAYA UNTUK PEKERJAAN (A) IDENTIFY POTENTIAL HAZARDS FOR THE JOB
Daftar Peringatan Bahaya (Tinjau langkah-langkah pekerjaan dan identifikasi apakah ada bahaya berikut yang berlaku) Mekanisme Paparan Potensi Bahaya
Hazard Prompt List (Review the job steps and identify if any of the following hazards are applicable) Potential Hazard Exposure Mechanisms

 Listrik / Electricity

Cuaca / Weather

Penggalian/Pekerjaan Tanah

Dipukul – oleh, melawan
Excavations/Earthworks Api Struck – by, against
 Benda Panas/DinginHot/Cold Gigitan Serangga/Hewan / Fire Kontak dengan
Objects   
Insect/Animal Bites Contact with
 Peralatan Berputar Rotating Petir / Lighting Pengenalan Spesies Non Asli Dihubungi oleh
Equipment   
Introduction of Non Native Species Contacted by
Kendaraan / Vehicles Membahayakan Flora / Fauna Harm Terperangkap – di, di, di bawah, di antara, melawan
  Bahaya Mengemudi /  
Driving Hazards to Flora / fauna Caught – in, on, under, between, against
Stres otot / Muscular Stress
  Benda Jatuh / Falling Objects 
Situs bersejarah

Paparan – suhu, bahan kimia, kebisingan, debu
Historical Sites Exposure – temperature, chemicals, noise, dust
Tekanan mental / Mental Stress
  Kebisingan / Noise  Pembukaan Vegetasi  Tergelincir, Tersandung atau Jatuh – dari ketinggian, level yang sama Slip,
Vegetation Clearing Trip or Fall – from heights, same level
Pekerjaan berulang Repetitive
 Radiasi / Radiation Tumpahan/Kebocoran Penilaian Risiko Penanganan Manual Lengkap terlampir Complete
  
Work Spills/Leaks Manual Handling Risk Assessment attached Pengerahan tenaga yang
Ketinggian / Heights Pelepasan Hidrokarbon/Gas Peralatan Seluler/Stasioner Lainnya berlebihan/kekuatan yang berlebihan – mengangkat, mendorong,
  Hydrocarbon/Gas Release  Other Mobile/Stationary Equipment  menarik,
Overexertion/ excessive force – lifting, pushing, pulling,
Pekerja tunggal / Lone Worker Permukaan / Surfaces Tekanan (Energi Tersimpan) Pelepasan Material – tumpahan minyak, pelepasan gas, tumpahan ringan Escape
   
Pressure (Stored Energy) of Material – oil spill, gas release, light spill
 Getaran / Vibration  Peralatan dan perlengkapan  Asap/Uap/Debu  Faktor manusia
Tools/Equipment Fumes/Vapor/Dust Tumpahan Human Factors
Benda Bergerak Moving Objects  Faktor manusia  Ringan / Light Spill penggunaan alat atau peralatan yang tidak benar
 Human Factors incorrect use of tools or equipment
 Off Road  Kedalaman / Depths regangan berulang
Ruang terbatas repetitive strain

Confined Spaces  Bahan kimia / Chemicals  Lainnya (Cantumkan Bahaya tambahan di bawah) tekanan yang dirasakan, tergesa-gesa
Other (List additional Hazards below) perceived pressure, haste
Asbes / Asbestos tugas berat / arduous tasks

 Pelindung pendengaran  Perlindungan pernapasan posisi kerja yang tidak nyaman / uncomfortable work position pekerjaan
Personal Protective Equipment Hearing protection Respiratory protection Tali
 Jalur Keselamatan/Penyelamatan  pengaman duniawi / mundane work
 Pelindung mata/wajah Eye/Face Safety/Rescue line Safety harness
protection pelindung tangan Detektor gas kompetensi yang tidak memadai / inadequate competency
 Pelindung kepala Head  
Hand protection Gas detector
protection Pencegahan tumpahan dan Perisai cahaya komunikasi, instruksi / communications, instruction
 Perlindungan kaki Foot protection  pembersihan  Light shields
perlindungan tubuh Spill prevention and clean up
 Body protection  Kondisi cuaca / Weather conditions
panas/kering / hot/dry
 Other basah / wet
berangin / windy
dingin / cold
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

JSA PREPARATION
Risiko Penanggung jawab
LANGKAH kematian Tindakan Kontrol Siapa yang
PEKERJAAN POTENSI BAHAYA Dampak
Peringkat bawaan? Titik Apa yang harus ada untuk mencegah bahaya? Peringkat bertanggung jawab
(Urutan pekerjaan) Apa yang dapat menyakiti saya / Jika 'ya' Kerugian apa
Risiko tunggu? Sertakan Peringkat tanggung jawab khusus Risiko untuk melaksanakan
Apa yang akan orang lain atau berdampak pada diperlukan yang bisa jika diperlukan pengendalian?
Step aku lakukan?
yang Ada FRM Y/T? Residu
lingkungan? terjadi? Control Measures Responsible
# JOB STEPS Existing Inherent Hold Residual
POTENTIAL HAZARD Impact What Person
(Sequence of work) Risk fatality point? What must be in place to prevent Risk
What could hurt me / others or harm could harm? Include Rating specific Who is responsible
What am I going Rating risk? Y/N? Rating
impact the environment? occur? responsibilities where required to implement the
to do? If 'yes' FRM
required control?
Mobilisasi material
dan alat ke lokasi 1.1. Pekerja tertabrak kendaraan Tidak Tidak
proyek Mobilization pengangkut / pick up Workers Fatality a.Operator harus berkompeten Supervisor, Rigger,
1 Low (3) Low (1)
of materials and hit by transport vehicles / pick Workers must be competent) Banksman
No No
tools up
to the project site
b.Memastikan kondisi kendaraan pengangkut
dalam kondisi layak pakai sebelum
digunakan
Ensure the condition of the transport vehicle
is in a good condition before
operating
c. Memastikan beban yang diangkut tidak
melebihi daya angkut kendaraan
Ensure the load transported does not exceed
the carrying capacity of the
vehicle
d.Bekerja sesuai IK
Working according to Working instruction
e.Melakukan safety talk sebelum bekerja
Always doing safety talk before start work

f. Memakai APD sesuai ketentuan (helm,

kacamata, masker, sarung tangan & safety
shoes)

Pemasangan Tidak Tidak

Fatality a.Pekerja harus berkompeten
2 Scaffolding 2.1 Afflicted by scaffolding Monitor (4) Low (1)
Workers must be competent)
Scaffold Installing No No
b.Memastikan scafolding beserta
aksesorisnya dalam kondisi layak pakai
Ensure the scaffolding and its
accessories are in a good condition
c. Bekerja sesuai IK
Working according to Working
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

instruction
d. Melakukan safety talk sebelum bekerja
Always doing safety talk before start to
work
e. Ada Permit To Work (PTW)
Have Permit To Work (PTW)
e. Memakai APD sesuai ketentuan (helm,
kacamata, masker, body harness, sarung
tangan & safety shoes)
Wear PPE according to the provisions
(helmets, goggles, masks, body harnesses,
hand gloves & safety shoes)

2.2 Jatuh saat install scaffolding Tidak Tidak

Falling down while installing a.Pekerja harus berkompeten
Monitor (4) Fatality Low (1)
scaffold Workers must be competent)
No No
b.Memastikan scafolding beserta
aksesorisnya dalam kondisi layak pakai
Ensure the scaffolding and its
accessories are in a good condition
c. Bekerja sesuai IK
Work according to Working
instruction
d.Melakukan safety talk sebelum bekerja
Always doing safety talk before start to
work
e.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
f. Memakai APD sesuai ketentuan (helm,
kacamata, masker, body harness, sarung
tangan & safety shoes)
Wear PPE according to the provisions
(helmets, goggles, masks, body harnesses,
hand gloves & safety shoes)

Pemotongan Tidak Tidak

3.1 Terjatuh saat proses a.Pekerja harus berkompeten
3 selimut beton Monitor (4) Fatality Low (1)
pemotongan selimut beton Workers must be competent
Spun pile Cutting No No
b.Memastikan scafolding beserta
aksesorisnya dalam kondisi layak pakai
Ensure the scaffolding and its
accessories are in a good condition
c. Bekerja sesuai IK
Work according to Working

Doc Ref: MS-DD-3000-HSE-PLN-0007
Date: 8 April 2020
3.2 Tersengat listrik saat proses
pemotongan selimut beton Got
electric shock during the
process of cutting the spun
pile
3.3 Terpapar debu saat proses
pemotongan selimut beton
Job Safety Analysis
Form No: MS-DD-3000-HSE-FRM-0040
MANYAR SMELTER PROJECT Revision No: 01
instruction
d.Melakukan safety talk sebelum bekerja
Always doing safety talk before start to
work
e.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
f. Memakai APD sesuai ketentuan (helm,
kacamata, ear plug, masker, body harness,
sarung tangan & safety shoes) Wear PPE
according to the provisions
(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes)
Tidak Tidak
a.Pekerja harus berkompeten
Low (2) Fatality Low (1)
Workers must be competent
No No
b.Memastikan alat dan aksesoris yang
digunakan dalam kondisi layak pakai Ensure
that the tools and accessories are
in a good condition
c. Memastikan area / lokasi kerja dalam
kondisi kering
Ensure the working area is dry
d.Menghentikan pekerjaan kondisi cuaca tidak
mendukung seperti hujan, angin kencang dll.
Stop work if unfavorable weather conditions
such as rain, strong winds, etc.
e.Bekerja sesuai IK
Work according to Working
instruction
f. Melakukan safety talk sebelum bekerja
Always doing safety talk before start to
work
g.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
h.Memakai APD sesuai ketentuan (helm,
kacamata, ear plug, masker, body harness,
sarung tangan & safety shoes) Wear PPE
according to the provisions
(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes)
Tidak Tidak a. Pekerja harus berkompeten
Low (2) Health Effect Low (1)
Workers must be competent

Doc Ref: MS-DD-3000-HSE-PLN-0007
Date: 8 April 2020
Got dust exposure during
cutting the spun pile
3.4 Terpapar bising saat proses
pemotongan selimut beton Got
Low (2)
noises exposure during
cutting the spun pile
Job Safety Analysis
Form No: MS-DD-3000-HSE-FRM-0040
MANYAR SMELTER PROJECT Revision No: 01
No No
b. Memastikan alat dan aksesoris yang
digunakan dalam kondisi layak pakai
Ensure that the tools and accessories are in a
good condition
c. Membasahi area yang dipotong secara
kontinyu untuk mengurangi timbulnya debu
Wet the area continuously to reduce dust
exposure
d.Bekerja sesuai IK
Work according to Working
instruction
e.Melakukan safety talk sebelum bekerja
Always doing safety talk before start to
work
f. Ada Permit To Work (PTW)
Have Permit To Work (PTW)
g.Memakai APD sesuai ketentuan (helm,
kacamata, ear plug, masker, body harness,
sarung tangan & safety shoes) Wear PPE
according to the provisions (helmets,
goggles, masks, body
harnesses, hand gloves & safety shoes)
Tidak Tidak
a. Pekerja harus berkompeten
Health Effect Low (1)
Workers must be competent
No No
b. Memastikan alat dan aksesoris yang
digunakan dalam kondisi layak pakai Ensure
that the tools and accessories are
in a good condition
c. Bekerja sesuai IK
Work according to Working
instruction
d.Melakukan safety talk sebelum bekerja
Cunduct safety talk before start to work
e.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
f. Memakai APD sesuai ketentuan (helm,
kacamata, ear plug, masker, body harness,
sarung tangan & safety shoes) Wear PPE
according to the provisions
(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes)
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

4. Pembersihan area
yang dipotong
4.1 Terjatuh saat proses
dengan alat drill Tidak Tidak
pengoperasian alat drill a.Pekerja harus berkompeten
Cleaning the Monitor (4) Fatality Low (3)
Falling down while use a Workers must be competent
cutted area using No No
drilling machine drilling machine

b. Memastikan scafolding beserta

aksesorisnya dalam kondisi layak pakai
Ensure the scaffolding and its
accessories are in a good condition
c. Bekerja sesuai IK
Work according to Working
instruction
d.Melakukan safety talk sebelum bekerja
Cunduct safety talk before start to work
e.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
f. Memakai APD sesuai ketentuan (helm,
kacamata, ear plug, masker, body harness,
sarung tangan & safety shoes) Wear PPE
according to the provisions
(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes)

4.2. Tersengat listrik saat proses Tidak Tidak

pengoperasian alat drill a. Pekerja harus berkompeten
Monitor (4) Fatality Low (3)
Got electic shock while use a Workers must be competent
No No
drilling machine
b. Memastikan alat dan aksesoris yang
digunakan dalam kondisi layak pakai Ensure
that the tools and accessories are
in a good condition
c. Memastikan area / lokasi kerja dalam kondisi
kering
Ensure the working area is dry
d.Menghentikan pekerjaan kondisi cuaca tidak
mendukung seperti hujan, angin kencang dll.
Stop work if unfavorable weather conditions
such as rain, strong winds, etc

e.Bekerja sesuai IK
Work according to Working
instruction
f. Melakukan safety talk sebelum bekerja
Cunduct safety talk before start to work
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

g.Ada Permit To Work (PTW)

Have Permit To Work (PTW)
h.Memakai APD sesuai ketentuan (helm,
kacamata, ear plug, masker, body harness,
sarung tangan & safety shoes) Wear PPE
according to the provisions
(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes)

5.1. Terjatuh saat proses pemasangan

Pemasangan Tidak Tidak
rakitan
rakitan tulangan a.Pekerja harus berkompeten
5 tulangan Monitor (4) Fatality Low (3)
Reinforce Workers must be competent
Falling down during steel No No
assembling
assembling
b.Memastikan scafolding beserta
aksesorisnya dalam kondisi layak pakai
Ensure the scaffolding and its
accessories are in a good condition
c. Bekerja sesuai IK
Work according to Working
instruction
d.Melakukan safety talk sebelum bekerja
Cunduct safety talk before start to work
e.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
f. Memakai APD sesuai ketentuan (helm,
kacamata, masker, body harness, sarung
tangan & safety shoes)
Wear PPE according to the provisions
(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes)

Tidak Tidak
5.2. Tangan tertusuk besi tulangan a.Pekerja harus berkompeten
Low (3) Minimal Injury Low (1)
Hand punctured by steel Workers must be competent
No No
b.Bekerja sesuai IK
Work according to Working
instruction
c. Melakukan safety talk sebelum bekerja
Cunduct safety talk before start to work
d.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
e.Memakai APD sesuai ketentuan (helm,
kacamata, masker, body harness, sarung
tangan & safety shoes)
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

Wear PPE according to the provisions

(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes) Wear
PPE according to the provisions
(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes)

6.1 Terpapar debu material

Pembuatan adukan Tidak Tidak
grouting
material repair a.Pekerja harus berkompeten
6 Got dust exposure from Low (2) Health Effect Low (1)
Mixing repair Workers must be competent
grouting materials No No
concrete
b.Bekerja sesuai IK
Work according to Working
instruction
c. Melakukan safety talk sebelum bekerja
Cunduct safety talk before start to work
d.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
e.Memakai APD sesuai ketentuan (helm,
kacamata, masker, sarung tangan & safety
shoes)
Wear PPE according to the provisions
(helmets, goggles, masks, gloves &
safety shoes)

6.2 Terjepit / terputar mesin mixer Tidak Tidak

Pinched by mixing machine
a.Pekerja harus berkompeten
Monitor (4) Serious Injury Low (3)
Workers must be competent
No No
b.Memastikan alat dan aksesoris yang
digunakan dalam kondisi layak pakai
Ensure that the tools and accessories
are in a good condition
c. Bekerja sesuai IK
Work according to Working
instruction
d.Melakukan safety talk sebelum bekerja
Cunduct safety talk before start to work
e.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
f. Memakai APD sesuai ketentuan (helm,
kacamata, ear plug, masker, sarung
tangan & safety shoes)
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

Wear PPE according to the provisions

(helmets, goggles, masks, gloves & safety
shoes)

Terjatuh saat proses pengecoran Tidak Tidak

Pengecoran a. Pekerja harus berkompeten
7 Falling down during pouring Monitor (4) Fatality Low (3)
Pouring concrete Workers must be competent
concrete No No
b.Memastikan scafolding beserta
aksesorisnya dalam kondisi layak pakai
Ensure the scaffolding and its
accessories are in a good condition
c. Bekerja sesuai IK
Work according to Working
instruction
d.Melakukan safety talk sebelum bekerja
Cunduct safety talk before start to work
e.Ada Permit To Work (PTW)
Have Permit To Work (PTW)
f. Memakai APD sesuai ketentuan (helm,
kacamata, masker, body harness, sarung
tangan & safety shoes)
Wear PPE according to the provisions
(helmets, goggles, masks, body
harnesses, hand gloves & safety shoes) Wear
PPE according to the provisions
(helmets, goggles, masks, body harnesses,
hand gloves & safety shoes)

PERSETUJUAN DAN TINJAUAN JSA / JSA APPROVAL AND REVIEW

(E) Semua personel yang terlibat dalam pembuatan JSA harus memasukkan nama mereka di bawah, menandatangani, dan tanggal. SUBCONTRACTOR Supervisor yang bertanggung jawab atas pekerjaan harus memastikan semua
nama dan tanda tangan dirinci.
(E) All personnel involved in the creation of the JSA shall enter their names below, sign, and date. The SUBCONTRACTOR Supervisor responsible for the work must ensure all names and signatures are detailed.
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01

Anggota tim Nama / Name Tanda tangan Tanggal / Date Team Member Nama / Name Tanda tangan Tanggal
Team Member Signature Signature Date

Bren T 8/4/2022
Alfianto Herman 8/4/2022
Pudjonarto 8/4/2022
JSA Team
Erdi Wisnu 8/4/2022 Mhd. Sallim Junjung 8/4/2022
Supervisor :
AMANDEMEN DAN ULASAN JSA / JSA AMENDMENTS AND REVIEWS
(F) JSA harus ditinjau setiap minggu atau ketika terjadi perubahan dalam aktivitas kerja. Pada setiap review dan/atau amandemen JSA, Tim Supervisor JSA harus memberi nama, menandatangani, dan memberi tanggal pada bagian di bawah ini. Perubahan JSA
harus ditandatangani oleh Manajer Konstruksi KONTRAKTOR (atau delegasi) dan pengawasan SHES. Semua perubahan harus dikomunikasikan kepada Kru Kerja yang akan masuk ke halaman berikutnya untuk mengakui dan menerima perubahan.
(F) The JSA is to be reviewed on a weekly basis or when a change in the work activity occurs. Upon each review and/or amendment of the JSA the JSA Team Supervisor shall name, sign, and date the below section. Changes to the JSA shall be countersigned by
the CONTRACTOR Construction Manager (or delegate) and SHES supervision. All changes shall be communicated to the Work Crew who shall sign on to the next page to acknowledge and accept the changes.

Key Changes / New Hazards Kontrol / Controls Sisa Pengawas Tim JSA Tanda tangan Tanggal / Date KONTRAKTOR Manajer
Mempertaruhkan JSA Team Supervisor Signature Konstruksi
Residual CONTRACTOR Construction
Risk Manager

KARYAWAN JSA MASUK / JSA WORKCREW SIGN ON

Dengan menandatangani di bawah ini, Anda menyatakan bahwa Anda telah membaca dan memahami JSA ini dan akan mematuhi tindakan pengendalian bahaya yang dijelaskan dalam dokumen ini.
By signing below, you acknowledge that you have read and understood this JSA and will comply with the hazard control measures described within this document.
Tanggal / Date Nama / Name Tanda tangan / Signature Tanggal / Date Nama / Name Tanda tangan / Signature

RAM Rating
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0040
Date: 8 April 2020 MANYAR SMELTER PROJECT Revision No: 01