Date: June 18, 2022 MSD-WK-C-MS-GR22-005

Method Statement and Job Safety Analysis for

General Earthworks
Rev: A
1 of 14

METHOD STATEMENT AND JOB SAFETY ANALYSIS FOR

GENERAL EARTHWORKS

MS PROJECT

STATUS AUTHORIZED

NAME SIGNATURE DATE

REVIEWED/APPROVED

REVIEWED/APPROVED
WITH COMMENTS AS
MARKED

NOT APPROVED; TO BE
RESUBMITTED

(Not Applicable to IFIR)

REASON FOR NOT APPROVED

OWNER : PT. FREEPORT INDONESIA

CONTRACTOR : PT. BLACK & VEATCH CORPORATION
SUBCONTRACTOR : PT. WIJAYA KARYA (PERSERO) TBK.
MANYAR SMELTER DESALINATION PROJECT

A Issued for Approval 18-Jun-2022 MDH KN DJR

Rev. Description Date Prepared Reviewed Approved
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
2 of 14

REVISION SHEET

No. Revision Date Change

1 00 18-Jun-22 Issued For Approval
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
3 of 14

TABLE OF CONTENT

4.1 Excavation .............................................................................................................. 7

4.2 Backfill and compaction .......................................................................................... 7
4.3 Disposal .................................................................................................................. 9
4.4 Sheeting and Shoring ............................................................................................. 9

6.1 Preparation Work .................................................................................................. 10

6.2 Work Procedure .................................................................................................... 10
6.2.1 Excavation procedure .................................................................................... 10
6.2.2 Backfilling and compaction procedure............................................................ 11
6.3 Weather Condition ................................................................................................ 12

7.1 Time Available ...................................................................................................... 12

7.2 Material Resource ................................................................................................. 12
7.3 Installation Resource ............................................................................................ 13

APPENDIX

APPENDIX 1 GENERAL EXCAVATION AND BACKFILLING SCHEMATIC PROCESS

APPENDIX 2 JOB SAFETY ANALYSIS

Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
4 of 14

GENERAL
This method statement covers the procedure for the general earthworks for Area Manyar
Smelter Desalination Project. as a guideline to achieve a successful project completion
in safely manner, acceptable quality, and within target schedule.

REFERENCES
(1) Codes & Standard
a. ASTM D 422 Standard Test Method for Particle Size

b. ASTM D 698 Standard Test Methods for Laboratory Compaction

Characteristics of Soil Using Standard Effort (12,400
ft-lbf/ft3 (600 kN-m/m3))

c. ASTM D 1556 Standard Test Method for Density and Unit Weight of
Soil in Place by the Sand-Cone Method

d. ASTM D 1883 Standard Test Method for California Bearing Ratio

(CBR) of Laboratory-Compacted Soil
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
5 of 14

GENERAL LAYOUT
The proposed site location on Manyar Smelter Desalination Project Area as shown in
figure:

Figure 3: Site Location for Earthworks

Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
6 of 14

SCOPE OF WORK

The site formation work consist of construction work as follows:

Figure 1: Flowchart Excavation

Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
7 of 14

4.1 Excavation
All shallow excavation for the construction, shall be of open-cut nature and be
carried out by mechanical excavator and/or manually. The excavated sides shall
be trimmed to yield a stable slope where existing services or drains are located
close to the excavation.

Generally, excavation shall be carried out to dimensions slightly wider than the
structure so as to give sufficient working space for subsequent activities, like
formwork, say, to be set up safely. And also safe excavation slope shall be
considered depending on the soil condition.
The depth of excavation at the structure shall be up the bottom of the lean
concrete and shall be trimmed, leveled and preferably free of excess ground
water prior to lean concreting.
General excavation will be carried out up to design level. If the excavation level
is still above the ground water level, in this section shall not require installation of
a dewatering system. But if the excavation level is below ground water level In
this section requires installation of a dewatering system.
Excavation area shall be barricaded. Proper access from ground level to
designed level shall be prepared.

4.2 Backfill and compaction

Backfill materials shall be in accordance to Section 5.1 and 5.2 of MS-DD-3000-CIV-
SPE-0103. This backfill material shall be free of other unsuitable materials and shall
be placed in horizontal layers of 250 mm. Compaction shall be done using water for
narrow and hard-to-reach areas, like under existing pipes, and hand operated
mechanical tamper or vibratory tamper for normal areas. water compaction can be
allowed only for sand fill with proper water drain out system. Water compaction can
be allowed only for sand fill with proper water drain out system. Normal fill material
is not suitable for narrow zone where cannot use compacter.

Vibratory roller shall be considered for large areas which area not obstructed by other
structures. Area for compaction shall be categorized into ‘structural’ or ‘non-
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
8 of 14

structural’. ‘Structural’ shall mean areas where the backfill have to support structures
above them such as slab on grade and roads. The degree of compaction shall be
minimum of 95 % of maximum dry density (as described on Para 5.2.2. below).

The optimum moisture content and maximum dry density shall be carried out in
laboratories in accordance with ASTM D1557. For indicated area, bedding and
backfilling material shall be gravel or shall conform to ASTM C33. When flat bed is
required, steel plate can be used for bedding indicated on the drawings.

Max dry density shall be determined as per ASTM D698, and field density test shall
be carried out as per D1556, in accordance with MS-DD-3000-CIV-SPE-0103
Construction Specification for Earthwork.

Figure 2: Flowchart Backfilling

Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
9 of 14

4.3 Disposal
SUBCONTRACTOR will dispose of the unsuitable soils and excess of excavated soil
in accordance with JIIPE’s regulation and local environmental regulation.

When excess of suitable material is stockpiled temporary at laydown area where

ground improvement are not applied, maximum height of stockpiled material shall be
4m and the maximum slope ratio shall be 3 (horizontal) to 1 (vertical). If height will
be more than 2m, bench shall be provided at 2m height. Bench shall be 1m away
from edge of slope.

4.4 Sheeting and Shoring

If excavation requires sheeting or shoring, detailed installation plan of the sheeting
or shoring, with supporting design calculation, shall be submitted to CONTRACTOR
for approval prior to installation. The plan shall include details of the type and depth
of sheeting or shoring and the installation procedure.
For all excavations exceeding 1.5 m in depth below ground surface,
SUBCONTRACTOR will provide appropriate safety control measures to prevent
injury and to ensure safe working. SUBCONTRACTOR will also provide safe means
of access in and out of the excavation and movement between different levels of
excavation.
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
10 of 14

BASIC EQUIPMENT FOR EARTHWORKS

The equipment that will be used during earthworks are as follows:

(1) Excavator
(2) Bulldozer
(3) Dump truck
(4) Hand stamper or vibratory roller for compaction
(5) Dewatering pump
(6) Generator set & electrical supply
(7) Vibro-Compactor
(8) Water Tank (if necessary)

CONSTRUCTION METHOD

Activities to be done as followed to the descriptions below:

6.1 Preparation Work

Prior to the main scope of work all supporting activity and construction facility should
be well prepared.

6.2 Work Procedure

6.2.1 Excavation procedure
a. Survey
- Verify detail of excavation according to the latest IFC drawing before the start of
work
- Conduct a survey and mark the location and the limit area to be excavated
- Allowance should be provided to have enough working space between the
foundation to be constructed and the edge of the bottom of excavation for the
personnel and forms, bracing and supports to be installed. Also consider the side
slope of excavation when marking the excavation limits.
- Determine the depth of the excavation according to the latest IFC drawing
- Check with other disciplines to verify whether there is any existing service/utility
lines
- All excavation work shall be hard barricaded at all times
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
11 of 14

b. Excavation Operation
- Set up barricades and signboard to notify that there is excavation work
undergone in the area
- If any existing service/utility lines found, report immediately
- The excavation shall be done with excavator
c. Start of the Excavation
- Permit to Work for excavation work shall be obtained before the start of
excavation
- Use mechanical excavator during the excavation work
- Barricade shall be provided around the excavation and machine operation area
- Where the excavation site is close to the existing structure, sufficient shoring and
bracing system shall be planned and approved.
- Excavate up to design level, width, and length as reuired to conform to the latest
IFC drawing
6.2.2 Backfilling and compaction procedure
a. Max dry density shall be determined as per ASTM D698, and field density test
shall be carried out as per D1556, in accordance with MS-DD-3000-CIV-SPE-
0103 Construction Specification for Earthwork.
b. Backfilling will commence only after completion of inspection and test of below
grade structure is complete
c. Structural fill or backfill placed beneath footings, grade beams, mat foundations,
or any settlement sensitive structures shall be compacted to at least 95 percent
of the maximum dry density as per ASTM D1557
d. Backfill adjacent to structures and not supporting any footing, grade beams, or
mat foundations, shall be compacted and then tested for in-place density in
accordance to ASTM D1556. The tested density shall be at least 95 percent of
maximum dry density as per ASTM D1557
e. The moisture content of the material being compacted shall be within percent of
the optimum moisture content as determined by ASTM D1557
f. Structural fill or backfill adjacent to structures shall be placed in 150 mm (6 in.),
compacted in layers, or less if necessary to develop specified density. Shall be at
least 95 percent of the maximum dry density, as per ASTM D1557
g. Backfilling will be done using the approved fill material. Each layer will be
compacted to a dry density, depending on the area of works
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
12 of 14

h. Backfilling will proceed symmetrically whenever possible

6.3 Weather Condition
In the rainy season this activity will be slowing down and estimated productivity
maximum is 30% of the normal productivity.
The following task have to be taken prior to the rainy season in order to maintain the
productivity as maximum as possible.
- Prepare main temporary drainage along side of temporary road access and
sloping to the south area of plant. The drainage will be collected to existing pump
house/ temporary pit and then will be pumped
- Prepare the temporary drainage for the run off and directed to the point that
approved by the CONTRACTOR’s engineer.
- Other dewatering means such as pumping system shall be provided when
necessary.
- Prepare a proper temporary construction road in the area where the activity is
concentrated on the rainy season.
- Prepare of plastic sheet cover
- Slope of the fill area shall be maximum 2 Horizontal : 1 Vertical and shall be
compacted in the proper way to avoid the scouring caused by run off.
- Grubbing of the existing compacted layer shall be carried out prior to the filling of
following layer.
All above tasks are prepared due to the effect of rain water at least for there or four days,
filling activity will be not able fulfil properly especially the compaction. As we all know
that for compaction the moisture content in the filling material shall be maintain in such
a way to some extent so that the compaction can be done properly as specified.

CONSTRUCTION ANALYSIS
7.1 Time Available
Refer to the time schedule for each item of work. The normal working hours assumed 8
hours, and will be increased during the weather condition is good.
7.2 Material Resource
Backfill soil material is devided as follows:
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
13 of 14

a. Existing site soil, excavated soil inside of plant area will be used for filling material
that will be confirmed by laboratory check as quality of material checking.
7.3 Installation Resource
1. Laborer:
As much as possible the laborer surrounding project site will be applied for
common labor.
Skilled labor by own source.
2. Construction Equipment
Own source from Jakarta

QUALITY CONTROL

Agreement of existing ground levels with CONTRACTOR shall be reached. Survey

marks shall be set out and maintained by the surveyor, engineer or supervisor on site
indicating the extent of the earthwork. QA/QC Program manual such as QC check sheet
for main element of work.

Field and laboratory test will be done for following item:

a. Structural fill material : reach 95% of maximum dry density per ASTM D1557
Prior to first stage of compaction, a trial compaction shall be done to obtain the proper
compaction required by specification.
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
14 of 14

SAFETY

All machinery and equipment shall be checked daily by the operator prior to use and any
faulty parts reported to the immediate supervisor for appropriate action.

For excavation, suitable barricade shall be provided around all excavation areas and
appropriate signboards posted to keep unauthorized personnel out. A banks man shall
coordinate the movement of the excavator and inform him of nearby services and extent
of excavation. An appropriate ladder shall be provided and maintained for access in and
out of the excavation area.

For backfilling, material from excavation shall be re-used and placed by excavator under
supervision of banks man. For compaction, only workers familiar with the operation of
the vibrating equipment are used.

SHE plan is prepared and Main Item of SHE aspect is as follows :

a. Safety

- Heavy equipment operation

- Traffic arrangement at puublic road access

- PPE (Personal Protective Equipment)

b. Health

- Site cleaning

- Sanitair arrangement

c. Environmental

- To minimize mud from job site through tires of vehicle

Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
15 of 14

APPENDIX 1
GENERAL EXCAVATION AND BACKFILLING SCHEMATIC
PROCESS
Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
16 of 14

Hard Barricade

1.00

- All shallow excavation for the construction shall be open cut and carried out
by mechanical excavator. Allowable excavation that considered shallow is less than
or equal to 1.5 meter.
- During and after the excavation work, hard barricade shall be installed around
the area of excavation with minimum distance of 1 m from the excavation area.

- Backfilling work will be conducted with contractor’s approved material

Date: June 18, 2022 MSD-WK-C-MS-GR22-005
Method Statement and Job Safety Analysis for
General Earthworks
Rev: A
17 of 14

APPENDIX 2
JOB SAFETY ANALYSIS
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

JSA OVERVIEW
THE COMPLETION OF A QUALITY JSA HAS 4 STEPS:
STEP 1 – PLANNING & PREPARATION CHECKLIST - These items are required for a quality JSA
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 reviewed as a guide and changes can be
Is the JSA Team Leader familiar with the JSA process? √
made on by computer or hand. The JSA must involve the Supervisor and people performing the work √
STEP 2 ‐ JSA FORM
Use Section (A) and/or the Work Method Statement and JSA Team Member knowledge of the job as a
Is there an existing WMS or similar JSA for the work? √
prompt to identify hazards.
Identify the potential incidents or hazardous conditions for each step. Are chemicals or hazardous materials involved (include SDS) √
Identify controls for each step to reduce the risks to As Low As Reasonably Practical (ALARP). Work
Method Statements (WMS) can be used as a guide. Are required Permits and clearance certificates in place? √
The Hierarchy of Controls shall be applied when identifying controls.
 Eliminate Hazard
Effect to others working nearby and surrounding environment considered? √


Substitute with less hazardous alternative
Use engineering controls
Is additional PPE required? √


Use administrative controls
Use Personal Protective Equipment (PPE)
Ensure A Step Back 5x5 is completed prior to starting the task √
Use the Risk Score Calculator to calculate the residual risk after appropriate controls are identified.
Expiry and Review
STEP 3 – APPROVAL
Get approval and signature for the JSA to be used by the area Supervisor and the CONTRACTOR The JSA is to be reviewed and signed by the work party on a weekly basis or when
Construction Manager / delegate.
1 a change in the work activity occurs.
NOTE: Workgroups are not to proceed where risks are assessed as HIGH. 2 Amendments and reviews shall be reflected in section (F) of the JSA.
If a Permit to Work is governing the job, a copy of the JSA is to be provided with the
STEP 4 – DOCUMENT MANAGEMENT 3 closed out copy of the Permit
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
4 Ensure new work crew members to the job review and sign on to the JSA

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-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

JSA WORK DETAILS AND CHECKLISTS

Date: 30/5/2022 Job Title: General Earth Works
Description of Work: Excavation, Backfill, Disposal JSA Ref#
Originator: Permit# (If applicable)

(A) IDENTIFY POTENTIAL HAZARDS FOR THE JOB

Hazard Prompt List (Review the job steps and identify if any of the following hazards are applicable) Potential Hazard Exposure Mechanisms
√ Electricity
  Weather √ Excavations/Earthworks
 √ Struck – by, against

 Hot/Cold Objects  Insect/Animal Bites  Fire  Contact with
 Rotating Equipment  Lighting  Introduction of Non Native Species  Contacted by
√ Vehicles
  Driving Hazards  Harm to Flora / fauna  Caught – in, on, under, between, against
 Muscular Stress  Falling Objects  Historical Sites  Exposure – temperature, chemicals, noise, dust
 Mental Stress  Noise  Vegetation Clearing √ Slip, Trip or Fall – from heights, same level

 Repetitive Work  Radiation  Spills/Leaks  Complete Manual Handling Risk Assessment attached
 Heights  Hydrocarbon/Gas Release  Other Mobile/Stationary Equipment  Overexertion/ excessive force – lifting, pushing, pulling,
 Lone Worker  Surfaces  Pressure (Stored Energy)  Escape of Material – oil spill, gas release, light spill
 Vibration  Tools/Equipment √ Fumes/Vapor/Dust
  Human Factors
 Moving Objects  Human Factors  Light Spill incorrect use of tools or equipment
√ Confined Spaces
  Off Road  Depths repetitive strain
 Asbestos  Chemicals  Other (List additional Hazards below) perceived pressure, haste
Personal Protective Equipment arduous tasks
√ Eye/Face protection
  Hearing protection  Respiratory protection uncomfortable work position
√ Head protection
  Safety/Rescue line  Safety harness mundane work
√ Foot protection
  Hand protection  Gas detector inadequate competency
√ Body protection
  Spill prevention and clean up  Light shields communications, instruction
√ Weather conditions

hot/dry
 Other wet
windy
cold
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

JSA PREPARATION
Inherent
JOB STEPS
POTENTIAL HAZARD: fatality Responsible Person
(Sequence of work) Existing Hold Impact What What must be in place to prevent harm? Residual
Step risk? Who is responsible to
Risk point? harm could Include Rating specific responsibilities Risk
# What could hurt me / others or If 'yes' implement the
What am I going to Rating Y/N? occur? where required Rating
impact the environment? FRM control?
do?
required
1 Mobilisasi tenaga 1.1 Pekerja yang tidak terlatih dan 4 Y N Cidera Berat 1.1.1 Hanya pekerja terlatih yang boleh 3 SPV & HSE & HSE
kerja ke area kerja. Kurangnya kesadaran Major Injuries berada di lokasi
Manpower Untrained workers and Lack Only trained workers should be
mobilization into of awareness allowed on site
work area
1.1.2 Tool box meeting & pernyataan
metode kerja yang aman harus
dijelaskan kepada pekerja
Tool box meeting & safe work
method statement should be
explained to workers

1.1.3 Pastikan izin kerja harus sudah

diajukan dan disetujui
Make sure the work permit must
be applied and approved

1.1.4 Pekerjaan harus dilakukan di

bawah pengawasan berkelanjutan
Work should be carried under
continues supervision

1.1.5 APD yang tepat (Helm, sepatu

keselamatan, rompi, sarung
tangan, kacamata dll harus
disediakan
Proper PPE’s (Helmet, safety
shoes, vest, hand gloves,
goggles etc should be provided

1.2 Terpapar cuaca panas 4 N N Pingsan 1.2.1 APD yang tepat (Helm, sepatu 3
Exposure to hot weather/heat Passed Out keselamatan, rompi, sarung
stroke tangan, kacamata) harus
dsediakan
Proper PPE’s (Helmet, safety
shoes, vest, hand gloves,
goggles, etc) should be
provided
1.2.2 Menyediakan air mineral yang
cukup
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

1.3 Cuaca yang tidak sesuai
Adverse Weather (Rain/High
Winds)
Hydrated enough
1.2.3 Membuat tempat berteduh di area
aman bekerj Menyediakan shelter
dengan ukuran yang cukup untuk
menampung jumlah pekerja
Provide shelter with sufficient
sized to accommodate the
number of workers
3 N N Cidera Ringan 1.3.1 Bekerja pada hujan deras harus 2 SPV & HSE
Minor Injury dicegah
Working in heavy rain shall be
prohibited

1.3.2 Inspeksi ulang untuk kemiringan

galian oleh teknisi setelah cuaca
yang tidak sesuai
Re-inspection checklist of slope
excavation by engineer after
adverse weather

1.3.3 Menyediakan APD yang sesuai

dengan cuaca basah bila
diperlukan
Provide PPE appropriate to wet
weather when necessary

2 Meratakan/member 2.1 Adanya benda tajam 4 N N Cedera karena 2.1.1 Pastikan penggunaan APD yang 3 SPV & HSE
sihkan area kerja Presence of sharp objects benda tajam tepat oleh pekerja
secara manual Injuries due to Ensure use of proper PPE by
Leveling/clearing sharp objects workers
of the work area
by manually 2.1.2 Pastikan ketersediaan kotak
pertolongan pertama
Ensure availability of first aid
box

3 Penggalian dan 3.1 Manusia, Mesin Antarmuka
Pembuangan (Pekerja tertabrak oleh
Tanah kendaraan bergerak)
Excavation & Man Machine Interface
Earth removal Personnel struck by moving
vehicles/plant
6 Y N Cidera Berat 3.1.1 Flagman menemani kendaraan 4 SPV & HSE
Major Injuries bergerak, dengan peluit, bendera,
rompi yang dapat terlihat
Flagman to accompany moving
vehicles, with whistle, flags,
high visibility vest

3.1.2 Seluruh pekerja mematuhi jarak

aman dari kendaraan dan alat
bergerak. Berdasarkan peraturan 3
dan 5m

Doc Ref: MS-DD-3000-HSE-PLN-0007
Date: 18 June 2022
3.2 Peralatan Terguling (Tanah
yang di keluarkan terlalu
banyak/ lereng terlalu curam)
Equipment Rollover
(Excessive earth being
removed moved /Gradients
too steep)
Job Safety Analysis
Form No: MS-DD-3000-HSE-FRM-0006
MANYAR SMELTER DESALINATION PROJECT Revision No: 00
All personnel to observe safe
clearance distance from the
moving plant and machinery.
Adhere to 3 and 5m rules
3.1.3 Berhati-hati berada di dalam area
berbahaya kendaraan dan mesin
bergerak. (Terutama dalam
aktifitas mundur)
Be aware of straying into the
line of fire for moving plant and
machinery and avoid maintain
clear escape route. (Especially
during reversing activities)
3.1.4 Lampu dan alarm mundur harus
berfungsi sepenuhnya pada
kendaraan di site
Reversing lights and alarms
should be fully functioning on
vehicles on site
6 Y N Cidera Berat 3.2.1 Parameter pengoperasian 4 SPV & HSE
Major Injuries Excavator dan truk pemuatan tidak
boleh dilampaui
Operating parameters of
Excavator and loading truck
should not be exceeded
3.2.2 Jalur excavator dan truk
setidaknya 1.5m dari setiap pinggir
galian
Excavator track and truck
wheels shall be at least 1.5m
away from any excavation edge
3.2.3 Pintu belakang harus dikunci
ketika truk bergerak
Tail gate to be locked while
truck moving
3.2.4 Trucks not to be overfilled
Truk tidak boleh kelebihan
muatan

Doc Ref: MS-DD-3000-HSE-PLN-0007
Date: 18 June 2022
3.3 Dinding galian runtuh
(Longsor)
Excavation Wall Collapse
(Engulfment)
3.4 Terkena utilitas yang terkubur
Hitting buried utilities
Job Safety Analysis
Form No: MS-DD-3000-HSE-FRM-0006
MANYAR SMELTER DESALINATION PROJECT Revision No: 00
4 Y N Cidera Berat 3.3.1 Mengikuti prosedur galian untuk 2 SPV & HSE
Major Injuries untuk kemiringan atau penahan
galian sesuai klasifikasi tipe tanah
Ad here to Excavation
Procedure for sloping benching
or shoring of excavation for type
of soil classification
3.3.2 Ceklis inspeksi harian untuk
kemiringan galian dilakukan oleh
teknisi sipil
Daily Inspection checklist of
slope excavation to be
completed by civil engineer
3.3.3 Jaga jarak aman peralatan dan
material dari pinggir kemiringan.
(Minimum 1.5m)
Keep safe distance equipment &
material from edge of slope.
(Minimum 1.5m)
3.3.4 Galian harus di pasang hard
barrier untuk mencegah seseorang
terjatuh
Excavation must be hard
barriered to protect persons
from a fall
3.3.5 Ceklis galian harian di isi
Daily Excavation checklist to be
completed
3.3.6 Pegangan tangan terpasang untuk
tangga menuju galian
Handrails to be fitted to steps
into excavation
4 N Y Kerusakan 3.4.1 Cek gambar underground area 2 SPV & HSE
utilitas / property pekerjaan
Utility damage / Check the underground drawing
property on working area
damage 3.4.2 Komunikasikan dengan Kontraktor
Utama terkait dengan rencana
pekerjaan galian
Communicate with the Main
Contractor regarding the
excavation work plan
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

3.5 Pekerja jatuh kedalam galian 4 N Y Cidera berat, 3.5.1 Membuat barikade di sekeliling 2 SPV & HSE
Personnel falling into Patah anggota area galian
excavation badan, badan Barricades around the
luka-luka excavation area
Major injuries, 3.5.2 Menyediakan papan tanda
broken limbs, informasi pekerjaan galian
Wound on the Providing information signage
body for excavation work
3.5.3 Memberikan informasi pada saat
TBM terkait kondisi lingkungan
area kerja pada pekerja
Explain information during TBM
to workers regarding the
environmental conditions of the
working area
3.6 Iritasi mata dan pernafasan 4 Y N ISPA, iritasi 3.6.1 Menyediakan masker yang sesuai 2 SPV & HSE
akibat debu organ dan memadai kepada pekerja
Breathing & Eyes irritant from pernafasan, terkait dengan microparticle sekitar
dust cacat mata, area kerja.
iritasi mata Provide workers with
Acute appropriate and adequate
respiratory masks according to the
infection, microparticles around the work
respiratory area
organ irritation, 3.6.2 Menyediakan kacamata untuk
eye defects, pekerja untuk melindungi dari debu
eye irritation Provide goggles for workers to
protect against dust
3.6.3 Memastikan seluruh pekerja
memakai APD yang telah
disediakan dan disyaratkan
Ensure all workers wear the PPE
that has been provided and
required
3.7 Kerusakan pada properti 4 N Y Terhambatnya 3.7.1 Pekerja harus orang yang tepat 2 SPV & HSE
Property Damage progress sesuai dengan kompetensinya
pekerjaan Workers must be the right
Delayed work person according to their
progress competence
3.7.2 Pekerja telah mendapatkan arahan
metode kerja seperti apa yang
akan dilakukan pada pekerjaan
tertentu
Workers shall been given the
instructions on what work
methods will be carried out on
certain jobs
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

3.7.3 Memastikan bahwa alat siap untuk

bekerja
Ensure that the tool and
equipment are ready for work
3.7.4 Maintenance alat secara berkala
Maintenance the equipment
periodicaly
3.8 Peralatan / kendaraan macet di 3 N Y Terhambatnya 3.8.1 Membarikade area sekitar tanah 2 SPV & HSE
tanah lunak progress lunak
Equipment / vehicle bogged pekerjaan Barricade the area around soft
on soft ground Delayed work ground
progress 3.8.2 Menyediakan tanda informasi
kendaraan tidak boleh melintas
Provide a no-pass vehicle
information sign
3.8.3 Maintenance Ekuipmen /
kendaraan secara berkala
Equipment/vehicle maintenance
regularly
3.8.4 Driver / operator adalah orang
yang memiliki lisensi dan telah
menerima pelatihan Defensive
Driving Training
Driver / operator is a person
who has a license and has
received Defensive Driving
Training
3.8.5 Pengecekan ekuipmen /
kendaraan sebelum digunakan
untuk bekerja
Checking equipment / vehicles
before use for work
3.9 Kebisingan 4 N N Penyakit 3.9.1 Menyediakan ear plug untuk 2 SPV & HSE
Noise Gangguan pekerja
pendengaran, Providing ear plugs for workers
pecahnya 3.9.2 Pastikan pekerja memakai APD
gendang telinga sesuai dengan yang telah
Diseases disyaratkan oleh Client
Hearing loss, Make sure workers wear PPE as
ruptured required by the client
eardrum
3.10 Peralatan rusak 4 N Y Terhambatnya 3.10.1 Pekerja harus orang yang tepat 2 SPV & HSE
Equipment breakdown progress sesuai dengan kompetensinya
pekerjaan Workers must be the right
Delayed work person according to their
progress competence
3.10.2 Pekerja telah mendapatkan arahan
metode kerja seperti apa yang
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

akan dilakukan pada pekerjaan

3.11 Dampak lingkungan / tumpahan
Environment impact / spills
tertentu
Workers shall been given the
instructions on what work
methods will be carried out on
certain jobs
3.10.3 Memastikan bahwa alat siap untuk
bekerja
Ensure that the tool and
equipment are ready for work
3.10.4 Maintenance alat secara berkala
Maintenance the equipment
periodicaly
3.10.5 Menghentikan pekerjaan sampai
alat / kendaraan selesai diperbaiki
oleh mekanik / teknisi
Stopping work until the
equipment / vehicle has been
repaired by a mechanic /
technician
3 N Y Tercemarnya 3.11.1 Pekerja harus orang yang tepat 2 SPV & HSE
lingkungan area sesuai dengan kompetensinya
pekerjaan oleh Workers must be the right
bahan kimia person according to their
Pollution of the competence
work area 3.11.2 Pekerja telah mendapatkan arahan
environment by metode kerja seperti apa yang
chemicals akan dilakukan pada pekerjaan
tertentu
Workers shall been given the
instructions on what work
methods will be carried out on
certain jobs
3.11.3 Memastikan bahwa alat siap untuk
bekerja
Ensure that the tool and
equipment are ready for work
3.11.4 Maintenance alat secara berkala
Maintenance the equipment
periodicaly
3.11.5 Menghentikan pekerjaan sampai
alat / kendaraan selesai diperbaiki
oleh mekanik / teknisi
Stopping work until the
equipment / vehicle has been
repaired by a mechanic /
technician
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

4 Pengisian Kembali, 4.1 Manusia, Mesin Antarmuka 6 Y N Cidera Berat 4.1.1 Flagman menemani kendaraan 4 SPV & HSE
Pemadatan, dan (Pekerja tertabrak oleh Major Injuries bergerak, dengan peluit, bendera,
Pengembalian Site kendaraan bergerak) rompi yang dapat terlihat.
pada Kondisi Man Machine Interface Flagman to accompany moving
Semula Personnel struck by moving vehicles, with whistle, flags,
Backfilling, vehicles/plant high visibility vest
Compacting and
Site 4.1.2 Seluruh pekerja mematuhi jarak
Reinstatement aman dari kendaraan dan alat
bergerak. Berdasarkan peraturan 3
dan 5m
All personnel to observe safe
clearance distance from the
moving plant and machinery,
adhere to 3 and 5m rules

4.1.3 Berhati-hati berada di dalam area

berbahaya kendaraan dan mesin
bergerak. (Terutama dalam
aktifitas mundur)
Be aware of straying into the
line of fire for moving plant and
machinery and avoid maintain
clear escape route. (Especially
during reversing activities)

4.1.4 Lampu dan alarm mundur harus

berfungsi sepenuhnya pada
kendaraan di site
Reversing lights and alarms
should be fully functioning on
vehicles on site

4.2 Cuaca yang tidak sesuai 3 N N Cidera Ringan 4.2.1 Bekerja pada hujan deras harus 2 SPV & HSE
(Hujan/Angin kencang) Minor Injury dicegah
Adverse Weather (Rain/High Working in heavy rain shall be
Winds) prohibited

4.2.2 Inspeksi ulang untuk kemiringan

galian oleh teknisi setelah cuaca
yang tidak sesuai
Re-inspection checklist of slope
excavation by engineer after
adverse weather

4.3 Benda Terjatuh (Dari tepi atau 3 N N Cidera Ringan 4.3.1 Tidak ada material/barang 2 SPV & HSE
pinggir galian) Minor Injury disimpan pada kemiringan atau
sisi dudukan galian
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

Dropped Objects (From lip or No material/spoil should be

side of excavation) stored on the sloped or benched
sides of the excavation

4.3.2 Setiap barang/material harus

disimpan setidaknya berjarak 1.5m
dari tepi galian. Material harus
diamankan dengan baik
Any spoil / Materials should be
stored at least 1.5m away from
lip of excavation. Materials
should be suitably secured

5 Pengurasan air 5.1 Tersengat listrik 4 Y N Cidera Berat 5.1.1 Letakkan pompa terlebih dahulu di 3 SPV & HSE
Dewatering Got electrical shock Major Injuries lokasi yang ditentukan, kemudian
pasang colokan
Put the pump into the intended
location, then connect the plug /
socket

5.1.2 Selalu pakai sarung tangan karet

Always wear rubber glove

5.1.3 Selalu jaga tangan dalam kondisi

kering.
Always maintain hand in dry
condition

5.1.4 Tes fungsi setiap control

Testing the functionality of
controls

5.1.5 Semua peralatan harus diperiksa

dan diberi kode warna oleh orang
yang kompeten sebelum
digunakan
All equipment must be
inspected and color coded by
competent person prior to used

5.1.6 Sistem kelistrikan harus

menggunakan IP66
Electrical must meet IP66

6 Mengeluarkan 6.1 Tersengat listrik 4 Y N Cidera Berat 6.1.1 Lepaskan kabel sebelum 3 SPV & HSE
pompa Got electrical shock Major Injuries mengangkat pompa
Take out pump Disconnect the cable prior to
remove the pump
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

6.1.2 Selalu pakai sarung tangan karet

Always wear rubber glove

6.1.3 Selalu jaga tangan dalam kondisi

kering
Always maintain hand in dry
condition

7 Pekerjaan akhir 7.1 Terkena benda tajam 4 N N Cidera Ringan 7.1.1 Lepaskan kabel sebelum 3 SPV & HSE
pembersihan area Caught in nip points Minor Injury mengangkat pompa
kerja Disconnect the cable prior to
Housekeeping remove the pump

7.1.2 Selalu pakai sarung tangan karet

Always wear rubber glove

7.1.3 Selalu jaga tangan dalam kondisi

kering
Always maintain hand in dry
condition

7.2 Terpleset, tersandung, terjatuh 3 N N Cidera Ringan 7.2.1 Mengumpulkan material yang tidak 2 SPV & HSE
Slip, trip, fall Minor Injury dibutuhkan dan mengumpulkan di
dalam tempat
Collect all unnecessary material
& kept in bucket

7.2.2 Menyingkirkan material yang

menghalangi jalan
Remove obstructed material on
walkway

7.2.3 Pastikan pekerja menggunakan

tangga ketika dibutuhkan untuk
naik ke atas alat berat
Ensure woker to use the ladder
when nessesary to go up to
heavy equipment

7.3 Tertabrak alat berat / Dump
Truk, Mobil bak terbuka dan
Excavator, Crusher
Struck by heavy equipment /
Dump Truck, Flat Bad,
Excavator, Crusher
6 Y N Cidera Berat 7.3.1 Flagman harus siap untuk 4 SPV & HSE
Major Injuries mengontrol pergerakan dari alat
berat pada saat loading/unloading
material
Flagman shall standby to
control movement of heavy
equipment during loading /
unloading materials
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

7.4 Benda Jatuh 3 N N Cidera Ringan 7.4.1 Pastikan kunci pintu Dump Truck 2 SPV & HSE
Drop Object Minor Injury dalam keadaan terkunci
Ensure the Dump Truck pin has
been lock

7.4.2 Memastikan material tidak

ditumpuk secara berlebihan
Ensure material is not overly
stacked

7.4.3 Pastikan lasing telah diikat erat

Ensure the lasing has been tie
tightly

8 Pengontrolan 8.1 Iritasi mata dan pernafasan 4 Y N ISPA, iritasi 8.1.1 Menyediakan masker yang sesuai 2 SPV & HSE
Debu, akibat debu organ dan memadai kepada pekerja
Dust control Breathing & Eyes irritant from pernafasan, terkait dengan microparticle sekitar
dust cacat mata, area kerja.
iritasi mata Provide workers with
Acute appropriate and adequate
respiratory masks according to the
infection, microparticles around the work
respiratory area
organ irritation, 8.1.2 Menyediakan kacamata untuk
eye defects, pekerja untuk melindungi dari debu
eye irritation Provide goggles for workers to
protect against dust
8.1.3 Memastikan seluruh pekerja
memakai APD yang telah
disediakan dan disyaratkan
Ensure all workers wear the PPE
that has been provided and
required
8.2 Dampak lingkungan / polusi 3 N Y Tercemarnya 8.2.1 Pekerja harus orang yang tepat 2 SPV & HSE
udara udara sesuai dengan kompetensinya
Environment impact / air lingkungan area Workers must be the right
pollution pekerjaan oleh person according to their
bahan debu competence
Pollution of the 8.2.2 Pekerja telah mendapatkan arahan
work area metode kerja seperti apa yang
environment by akan dilakukan pada pekerjaan
the dust tertentu
Workers shall been given the
instructions on what work
methods will be carried out on
certain jobs
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

8.2.3 Membasahi area kerja bila

permukaan terlalu kering agar
pekerjaan galian tidak
menimbulkan debu terlalu banyak
Wet the work area if the surface
is too dry so that the excavation
work does not generate too
much dust
9 Pengiriman dan 9.1 Manusia, Mesin Antarmuka 6 Y N Cidera Berat 9.1.1 Flagman menemani kendaraan 3 SPV & HSE
pembongkaran (Pekerja tertabrak oleh Major Injuries bergerak, dengan peluit, bendera,
bahan pengisi kendaraan bergerak) rompi yang dapat terlihat.
kembali, Man Machine Interface Flagman to accompany moving
Delivery and Personnel struck by moving vehicles, with whistle, flags,
unloading of back vehicles/plant high visibility vest
fill material
9.1.2 Seluruh pekerja mematuhi jarak
aman dari kendaraan dan alat
bergerak. Berdasarkan peraturan 3
dan 5m
All personnel to observe safe
clearance distance from the
moving plant and machinery,
adhere to 3 and 5m rules

9.1.3 Berhati-hati berada di dalam area

berbahaya kendaraan dan mesin
bergerak. (Terutama dalam
aktifitas mundur)
Be aware of straying into the
line of fire for moving plant and
machinery and avoid maintain
clear escape route. (Especially
during reversing activities)

9.1.4 Lampu dan alarm mundur harus

berfungsi sepenuhnya pada
kendaraan di site
Reversing lights and alarms
should be fully functioning on
vehicles on site

9.2 Pekerja tertabrak Dump truk / 4 N N Cidera Ringan 9.2.1 Pastikan flagman menuntun truk / 2 SPV & HSE
Alat berat Minor Injuries alat berat saat posisi
Person hit by Dump Truck / Ensure flagman guide the truck
heavy Equipment when positioning

9.2.2 Kontak mata antara flagman dan

supir
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

Eye contact between driver and

flagman

9.2.3 Pastikan rem tangan dan ganjal

ban terpasang saat parkir.
Ensure hand brake and wheel
choke applied when park

9.2.4 Dump truck tiba di site; supir harus

mengikuti rambu-rambu dan
mengikuti arahan flagman. Tidak
ada flagman tidak ada pergerakan
Dump truck arrived at site ;
drivers must follow traffic sign
and follow flagman signal. No
flagman no movement.

9.2.5 Memastikan dump truck parkir di

tempat yang aman. Area harus di
check oleh flagman dan
mengkoordinasikan dengan kru
pompa truk.
Make sure dump truck park in
safe position. The area shall be
checked by flagman and
coordination with concrete
pump crew. The movement shall
be directed by flagman until
final position.
 Job Safety Analysis
Doc Ref: MS-DD-3000-HSE-PLN-0007 Form No: MS-DD-3000-HSE-FRM-0006
Date: 18 June 2022 MANYAR SMELTER DESALINATION PROJECT Revision No: 00

JSA APPROVAL AND REVIEW

(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.
Team Member Name Signature Date Team Member Name Signature Date
WIKA - 18/06/2022

JSA Team Name : Signature Date CONTRACTOR Name Signature Date

Supervisor : - 18/06/2022 Construction Manager
JSA AMENDMENTS AND REVIEWS
(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 Controls Residual JSA Team Signature Date CONTRACTOR Construction
Risk Supervisor Manager

JSA WORKCREW SIGN ON

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.
Date Name Signature Date Name Signature