JOB SAFETY ANALISYS FORM

PROJECT : Pekerjaan Konstruksi Rumah type 45 DATE : 12 March 2024 JSA NO.: 001

TASK / Job : Pemasangan Atap JSA Team

LOCATION : Batam Ware house : Batam Centre NAME POSITION SIGNATURE

NO. OF PERSONS INCLUDED IN TASK 15 org Egi Team JSA Leader

TASK DESCRIPTION:
Kartika Supervisor
1. Persiapan Peralatan
2. Pemasangan kuda2 atau scaffolding/perancah/platform sementara
Tatang Foreman
3. Pemasangan Rangka atap
4. Trasfer material dari bawah keatas Gusti Engineer
5. Pemasangan atap
6. Pemasanagan secrup baja Sri Supplier
7. Pengecekan ulang / Finishing
8. Bersih bersih / Pemasangan kuda2 atau scaffolding/perancah/platform
sementara
9. Turun dari ketinggian
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. SOP
2. IK NAME SIGNATURE
3. Manual Book DESIGNATION
4. Method Statement
5. Mengisi form Date:
6. Certificate
7. MCU certificate 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
8. PTW
NAME SIGNATURE
DESIGNATION

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

1 Persiapan
Peralatan

2 Pemasangan
kuda2 atau
scaffolding/pera
ncah/platform
sementara

3 Pemasangan Jatuh dari ketinggian Manusia Kematian Menggunakan body harness

Rangka atap E 4 H6 Menggunakan sepatu anti slip A 1 L1 Supervisor
Memasang safety net
Salah hitungan Loss asset sedang Patikan pengawasan
engineering dilakukan sesuai dengan
M1 gambar design & perhitungan L1
C 2 A 1 Supervisor
Pekerja harus berpengalaman
dan kompetent terkait atap.
Tertimpah alat kerja Manusia, loss Kematian
aset
4 Trasfer material
dari bawah
keatas

5 Pemasangan
atap

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

6 Pemasanagan
secrup baja

7 Pengecekan
ulang / Finishing

8 Bersih bersih /
Pemasangan
kuda2 atau
scaffolding/pera
ncah/platform
sementara
Turun dari
ketinggian

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