PT.

MBI

JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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Catatan:
Setiap ada perubahan pekerja, kondisi area kerja, metode
kerja, peralatan kerja, dan / atau material, JSA harus
:
diperbarui. Registrasi terhadap perubahan JSA harus
dilakukan sekurang-kurangnya setiap minggu

Company: : LEHUI Disiapkan Oleh Direview Oleh Diverifikasi Oleh Disetujui Oleh
Project : Work Leader Superintendent Konstruksi HSE officer HSE Client
Name Person In Charge : NAMA
Position :
TANDA TANGAN
:
:
Working activity
PPE Required : Safety glasses Mask dust/ Weld Coverall Safety helmet Safety shoes
Goggles/Faceshield Mask Filter-Catridge Hand gloves SCBA/SABA Earplug/Earmuff

Sequence of Basic Hazard/Aspect Risk/Impact Consequence / severity Risk Last Minute Risk
Recommendation action Result Risk*) Assessment (LMRA)
NO JobSteps Bahaya/Aspek Resiko/Dampak Akibat Assessment*
Tindakan Pengendalian PR SV RR
Tahapan pekerjaan PR SV RR STATUS TTD
1.  1. • Control of the covid
Preparation • • Health Check •  • Exposure to • Suspected
Preparation of rapid test protocol,
MP(Manpower) •
Exposure to tools covid • History of covid, death /
PCR, quarantine,
Unskill and • Expiry date, new other diseases • fatality • consultation with site
Negligence • employee, Injuries and Contagion to doctors • Attendance
Employee identity
admin • Materials
lost/damaged ID, damaged other workers • is present during TBM,
and work equipment. and emergency equipment • Illness and Loss Induction and training
• Health Check • date • Materials • Safety and work Progress • Can status checks. • ID
Exposure to tools • check during TBM,
Expiry date, new
Working tool progress • not work • Sick • periodic monitoring •
employee, Pinched, Injuries to body Communicate with
lost/damaged ID, scratched. parts colleagues all
and emergency date activities carried out •
Stumble

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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• Materials • Working Wear proper gloves •

tool • Pandemic Use appropriate PPE.
covid • Exposure to
covid • History of
other diseases •
Injuries and
damaged equipment
• Safety and work
progress • Pinched,
scratched. •
Stumbled •
Suspected covid,
death/ fatality •
Contagion to other
workers • Illness and
Loss Progress • Can
not work • Sick •
Injuries to body parts
4 4 H • Control of the
covid rapid test
protocol, PCR,
quarantine,
consultation with the
site doctor •
Attendance is
present during TBM,
Induction and
training status
checks. • ID check
during TBM, periodic
monitoring •

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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Communicate with
colleagues all
activities carried out
• Wear proper gloves
• Use appropriate
PPE.

2
 • Use the Stoel
Lifting Material Plate on the out
TANK PARTS rigger base. •
Using Ensure that the soil
(KOBELCO 50 T conditions are able
to withstand the
Crane) 1. •Tipping/  • Crane not level • Overturned crane • load of the crane. •
Positioning collapsed crane
 • Pinched hands Property Ensure that the
crane • Narrow Side
damage • method of
Fatality • Lifting fastening the
at Stop • Body
2. Installing / webbing sling on
injury • Property
Take off Lifting  the Material and
damage •
Equipment is
Gear Fatality
correct according
to the lifting
plan/drawing. •
Avoid pinch points.
• Crane does not
boom when setting
webbing. • The
binding is carried
out by a certified

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 PT. MBI

JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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and valid rigger,

only the rigger
gives the signal to
the operator
(attached rigger
certificate). •
Coordinate well
between operator
and signal man. •
Use radio for
communication
with crane
operators in out of
 Biological hazard sight areas. • Use
weather Leather
factor(Wind or
lightning)
 Property damage glove/heavy duty
 Fatality Gloves when doing
.3. Activity Lifting work • Make sure
of TANKS • The material the sling setting
PARTS material being lifted swings, has a readable
material hitting the labile that indicates
surrounding the maximum
workers/Equipmen lifting capacity. •
t Install Softerner
when transporting
sharp-edged
materials •

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
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Operators are
prohibited from
making
sudden/surprised
lifts • Define COG
(Ceter of Graffiti).
Before the load is
lifted • Use 2
taglines to direct
the load. • Make
sure the weather
conditions are
good and lifting
activities can be
carried out •
Perform a Weather
check with a
predefined tool for
measuring
weather/lightning
that has been
calibrated and can
be used
3 4. Activity TANK  3 4. Activity TANK   Body injury •  • Make sure the
PARTS material PARTS material Fatality • material is well
lifting material • Property
material lifting The material is damage •
laid out and not

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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lifted at an angle. • Material loss skewed. •

Lack of Perform a 5-10
coordination
between crane
cm lift from the
operators and surface, to
riggers • Materials check the level
fall/slipped and hit of inclination of
workers. • Body the material
injury • Fatality •
Property damage •
being lifted. •
Loss of material 4 Not near
5 E • Make sure the material when
material is boom up sling.
arranged properly • Communicate
and not tilted. •
Perform a 5-10 cm
clearly between
lift from the the signalman
surface, to check and the
the level of operator. • Only
inclination of the one signalman
material being
lifted. • Not near
can signal the
material when operator. • Stop
boom up sling. • work if
Communicate conditions are
clearly between the not safe, hold a
signalman and the
operator. • Only
short meeting

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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one signalman can with the work

signal the operator. team. •
• Stop work if
conditions are not
Workleaders
safe, hold a short are always in
meeting with the the work area
work team. • and supervise
Workleaders are the work in
always in the work
area and supervise
progress. •
the work in Ensure that the
progress. Hook Block
crane is
perpendicular
to the point of
gravity. lifted
item • Ensure
the stability of
the lifting point
of the
equipment
load. • Perform
a load
test/slope by
lifting 5-10 cm

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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from the
surface. •
Ensure that the
method of
binding and
lifting is in
accordance
with the
approved lifting
plan. • Use tag
lines in both
directions to
control the
load. • The
lifting gear
used has been
certified by the
3rd Party and is
still valid. •
Check the
actual goods
being lifted, and
do not exceed

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 PT. MBI

JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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the design
lifting plan. •
The lifting
radius is in
accordance
with the lifting
plan. • Use
champions to
protect the
webbing from
being
damaged. •
Install
barricades and
sign boards in
the lifting area.
• Identify the
fall zone area
(the size of the
boom length
area). • Clear
communication
by signalman

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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including
signaling by
hand when
work is in
progress on
operator, if
view is
obstructed use
radio for
communication
.
• Loads lifted • Material fell/slipped  Asset damage 
and hit workers. • • Body injury
Items that are
 • Fatality
lifted swing hit
workers or the
surrounding
column/equipmen
t material. • Lifting
gear breaks or
fails and hits
workers
  Swing boom  •Swing boom crane • Asset damage •  The lifting
hit Worker / Body injury •
Equipment/ Crane
radius is in
Fatality
accordance

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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with the lifting

plan. • Identify
the fall zone
area (the size
of the boom
length area). •
Ensure that
lifting activities
have been
coordinated
with the area
owner and the
work team
around the
lifting area. •
Ensure the
installation of
barricades and
warning signs. •
Clear
communication
by signalman
including

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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signaling by
hand when
work is in
progress on
operator, if
view is
obstructed use
radio for
communication
.
  • Traffic  • Traffic  • Asset damage •  •
disturbance/access/ Body injury •
conditions mobilization of other
Communicatio
Fatality
work teams. n with the area
owner or
Incharge
person
regarding the
activity. •
Coordination of
work locations
that use the
main access,
which has the

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
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potential to
disrupt access
and
mobilization of
other parties. •
Installing a
Flagman to
help with traffic
control.
4. Utility Activities  Lack off coordination • Overrides other  • Complete the
workers • Harm to interface form
other workers 2
and coordinate
with workers at
the work site •
Locating the
work area and
equipped with a
sign board. •
Coordinate
between
supervisors and
HSE before
carrying out

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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activities.
5 Work Activities  • Contact with • Electrocution •   • Monitor workers who
other activities • Exposed to have received training
that intersect Monitor SWP Perform
Danger of steam/hot water
with the Filtering/Brewing hot surface •
active coordination and
Filtering/Brewing communication both
AREA • Biological Hearing disorders internally and with utility
Area hazards • Exposed to area workers related to
(venomous materials/equipme changing conditions in
snakes/insects) nt • Inhalation of field conditions •
toxic gases • Fire • Monitor related work
Explosion steps and related
controls in the Utility
Area, both Manpower,
Work Tools, Materials
and Work Environment
• Conducting
Socialization to
Workers • Conducting
intense supervision and
daily coordination in
collaboration with HSE
regarding the HSE
Supervision Checklist •
Socializing, preparing
and reporting
emergency response
preparedness, in
accordance with
emergency mitigation •
Guide the evacuation of
workers if instructed to

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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the muster point •

Prepare, distribute,
supervise the use of
PPE that has been
determined according
to hazard control
6 Housekeeping/clean the  • Work area The presence of sharp • • Minor Injury • • Burns  • Perform
area working before or  • Remaining residual material • Deaf • • Bruises and •
after working fractures • • Poisoning • general
materials
 •B3 waste
• Fatality • • Activity is housekeeping
stopped • Scratches, optimally
stab wounds
according to
company
regulations •
Socialize
regarding
Housekeeping •
Ensure that the
General
housekeeping
Agenda is
always
maximized
from all
manpower •
Make sure there

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
Document No. Rev No. Contract No : Page
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are no materials
that have the
potential to
drop of objects
• Use
appropriate PPE
in accordance
with the hazard
control

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT (RA) FORM

Health Safety Security Environment
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