JSA FIREE PROOFING - Install Cap

JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM
Doc. No. 26071-100-VSC-FP1-00005

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 05 Jan 2022
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT Revision No. 00A
JSA No. : RDMP / JSA /......................... /.....................

JSA Title : FIREPROOFING, MIXING AND SPRAYING
ATTENDANCE LIST – JSA PREPARATION

NO NAME POSITION COMPANY SIGNATURE
1 SEO BO SANG CONSTRUCTION MANAGER PT KOIN KONSTRUKSI
2 SHANDY KRISNA DIBRATA CONSTRUCTION SUPERVISOR PT KOIN KONSTRUKSI
3 KIM SERYANG MANAGER FIREPROOFING PT KOIN KONSTRUKSI
4 PASDI SUYITNO FOREMAN FIREPROOFING PT KOIN KONSTRUKSI
5 KATHON HUGO HSE COORDINATOR PT KOIN KONSTRUKSI
6
7
8
9
10
Doc. No. 26071-100-VSC-FP1-00005

Project : RDMP JO Balikpapan Prepared By Reviewed By Approved By

Company : PT KOIN Engineer Chief HSE manager CM JO
Scope of Work/Pkg : RDMP JO Balikpapan Name
JSA No. : RDMP / JSA / ............. /...............
Position : Engineer Signature
Job Activity : Fire Proofing, Mixing and
Spraying
Area : Date
Date : Prepared By Reviewed By Approved By
Status Status
No Permit Registry No No Permit Registry No
Open ➹ Close ➹ Open ➹ Close ➹
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Doc. No. 26071-100-VSC-FP1-00005

Sequence of Risk PIC

Result Risk*)
NO Basic Job Hazard Risk Consequence / Assessment* Recommendation Penanggung
Steps Tahapan Bahay Resiko severity PR SV R action PR SV RR Jawab
pekerjaan a Akibat R Tindakan Pengendalian
1. Preparation Work supporting The Work takes Work delays occur 3 3 9 Make sure all the 2 1 2 HSE & SPV
Document. documents have not place without being because of required work support
Persiapan semua received approval completed with inadequate documents have been
dokumen penunjang from the client (JO). work supporting preparation of work prepared and approved
pekerjaan (MS, Dokumen penunjang documents. supporting by the JO before the
JSA, PTW, Lifting pekerjaan belum Pekerjaan documents. work starts.
Plan). mendapatkan berlangsung tanpa Terjadi Pastikan semua
persetujuan oleh dilengkapi oleh keterlambatan dokumen penunjang
pihak client (JO). dokumen pekerjaan pekerjaan yang telah
penunjang diakibatkan kurang disyaratkan sudah
pekerjaan. nya persiapan dipersiapkan dan
terhadap dokumen- disetujui oleh JO
dokumen sebelum pekerjaan di
penunjang mulai.
pekerjaan.
2. Preparation Work. Preparation of The tools and The tools and 2 2 4 Checking all tools and 2 1 2 SPV&HSE
Persiapan tools and materials used materials used in materials to be used to
Pekerjaan. materials. have not been damaged / not ensure that the tools and
Persiapan Alat inspected to check workable for use. materials to be used are
dan material. their condition and Alat dan material in good condition and fit
quality. yang di gunakan for use, passed JO’s
Alat dan material dalam kondisi inspection.
yang di gunakan rusak/tidak layak Memeriksa semua alat
belum di inspeksi pakai. dan material yang akan
untuk mengecek digunakan untuk
keadaan dan memastikan alat dan
mutunya. material yang akan
digunakan dalam
keadaan
baik dan layak pakai,
lulus pemeriksaan JO.
3. Checking Hazardous gas Poisoning and an Fatality damage and 3 4 12 Always do gas detector 3 3 9 HSE
hazardous gas and flammable explosion in fatality injury checking before working,
(LEL, H2S, O2) gas, poison gas workers Kerusakan material 5 minutes - 10 minutes
Page | 3
Doc. No. 26071-100-VSC-FP1-00005

Pemeriksaan gas Gas berbahaya Keracunan dan dan kematian before start working.
berbahaya dan gas beracun ledakan pada selalu lakukan
(LEL, H2S, 02) pekerjaa pengecekan gas detector
10-5 menit sebelum
memulai pekerjaan.
Gas testing must be

performed by AGT with
BNSP Certificate.
Gas test harus di lakukan
oleh AGT dan dilengkapi
sertifikat dari BNSP.
Make sure H2S and LEL

under NAB are
determined.
Pastikan H2S dan LEL
dibawah ambang batas
yang ditentukan
If necessary carry out a

continuous check
Jika diperlukan
pengecekan
berkelanjutan
SWA if there is a
condition of dangerous
gas that exceeds the
level of NAB.
Stop Work Authority jika
terjadi kondisi gas
berbahaya melebihi NAB.
Cover all energy release

with a fire blanket/ cover
100% activities hot work.
Tutup semua sumber
Page | 4
Doc. No. 26071-100-VSC-FP1-00005

pelepasan energy
dengan fire blanket/ tutup
100% aktivitas kerja
panas.
4. Install plastic Gravity People Injury. Fatality injury 4 4 16 Using full PPE 2 2 4 SPV & HSE
protection. Falling material. Seseorang cedera. Kecelakaan serius. (musk, coverall and
Pasang pelindung benda jatuh. body harness) As a
plastik. prevention of falling
The worker fall workers.
without using a Gunakan APD
body harness. lengkap (masker,
Pekerja jatuh baju pelindung dan
tanpa alat pelindung diri)
menggunakan sebagai
pelindung diri. pencegahan
terjatuhnya pekerja.
Ensure the life line is

provide properly.
Pastikan lifeline
tersedia dan
terpasang
Ensure the work

location is not
SIMOP with another
subcont.
Pastikan lokasi kerja
tidak Simpo dengan
subkon lain.
Pastikan area bersih
dari aktifitas lain
pada saat
pemasangan
pelindung plastik.
5. Grinding Motion Sparks and thin People injury, fatality 3 2 6 Using PPE (safety 2 2 4 SPV & HSE
Sparks can hit pieces of material injury. glasses, face shield
Page | 5
Doc. No. 26071-100-VSC-FP1-00005

workers. can get into the Seseorang cedera, and other PPE).
Percikan bisa eyes and skin of kecelakaan serius. Gunakan APD
melukai pekerja. workers. (kacamata
Percikan api dan pelindung, pelindung
potongan tipis wajah dan APD
material bisa lainya).
mengenai mata
dan kulit para Direct the spark to a
pekerja. safe place.
Arahkan percikan ke
tempat yang aman.
Cover the spark area

with a fire blanket.
Tutupi area percikan
api dengan fire
blanket.
6. Stud weld and Exposure Fire and explosion. Damage material dan 3 3 9 Check the gas 3 2 6 SPV&HSE
insttall pin Possibility of fatality injury. detector with a
adhesion. flammable and Kebakaran dan Kerusakan material Qualified gas
explosive gas. ledakan. dan kecelakaan fatal. detector 10 minutes
Kemungkinan before working.
ada gas mudah Pastikan lakukan
terbakar dan pengecekan gas
meledak. detector oleh QGT
10 menit sebelum
melakukan
pekerjaan.
Ensure the work

area is free of
flammable gases
and LEL.
Pastikan area kerja
bebas dari gas
mudah terbakar dan
LEL.
Page | 6
Doc. No. 26071-100-VSC-FP1-00005

Make welding (stud

weld) and grinding
habitat using fire
blanket properly.
Pekerjaan welding
(stud weld) dan
grinding selalu
gunakan cover fire
balnket.
Use fire blanket.

Gunakan fire
blanket.
7. Installation cap Exposed dust Minor injury Skin irritation 2 3 6 Using PPE 2 2 4 SPV & HSE
Pemasangan Terpapar debu Cedera ringan Iritasi kulit (Respirator/Air fed
cap mask, safety glasses,
Exposed vapor Respiratory disorders gloves
from epoxy glue Gangguan and other PPE).
Terpapar uap pernafasan Gunakan APD
dari lem epoxy (masker, kacamata
pelindung, sarung
tangan dan APD
lainya).
Use proper hand glove

(Rubber)
Gunakan sarng tangan
proper (karet).
Ensure worker using

mask (N95)
Pastikan pekerja
menggunakan masker
(N95).
8. Repaint structures Exposed to Minor injury Respiratory 2 3 6 Using PPE 2 3 6 SPV&HSE
Page | 7
Doc. No. 26071-100-VSC-FP1-00005

steel vapors of the Cedera ringan. disorders. (Respirator/Air fed

Pengecatan ulang paint used. Gangguan mask, safety glasses,
pada struktur baja Terpapar uap cat pernafasan. gloves
yang digunakan. and other PPE).
Skin irritation. Gunakan APD
Iritasi kulit. (masker, kacamata
pelindung, sarung
Eye irritation. tangan dan APD
Iritasi mata lainya).
Use the google nd

chemichal PPE
Gunakan kaca mata
dan chemichal PPE
Don’t breathe paint

vapor.
Jangan menghirup
uap cat.
Do the painting be
carefully.
Lakukan pengecatan
dengan hati-hati.
9. Install wire mesh. Motion Fatality Injury Hand injury 2 2 4 Use gloves when 2 2 4 SPV&HSE
Pemasangan sharp surface Luka Serius. Cedera pada working.
kawat wire mesh. Permukaan tangan. Gunakan sarung
tajam. tangan saat aktifitas
pekerjaan.
Pinched Fatality Injury. Ensure to properly

Terjepit. Cedera Serius. Fatality injury, fixed the wire mesh
material damage. before fire proofing.
Kecelakaan fatal, Pastikan wire mesh
kerusakan material. diperbaiki dengan
benar sebelum
dilakukan fire proofing.
Page | 8
Doc. No. 26071-100-VSC-FP1-00005

Cough because Health Injury. Ensure chemical mixing

of stripping and Masalah performs as
crushing work kesehatan. recommended.
Batuk karena Pastikan pencampuran
pengerjaan bahan kimia bekerja
pengupasan dan seperti yang
penghancuran. direkomendasikan..
Stored energy Exposure Injury, Make sure workers

Energi material damage. understand the dangers
tersimpan. Cedera karena of exposure to chemical
paparan, dust and always use PPE
kerusakan (masks, long coveralls
material. and hazmat, protective
glasses, etc).
Fatality Injury Pastikan pekerja
Irritation Luka Serius. memahami bahaya
iritasi. paparan chemichal debu
dan selalu mengunakan
APD (masker, baju
Fire coverall panjang dan
Api. HAZMAT, kacamata
pelindung, dll).
Ensure their energy is

isolated and used and
make a LOTO plan in the
work area.
Pastikan energy sudah
diisolasi dan gunakan
LOTO dan membuat
LOTO plan di area kerja.
Ensure the pressure line,

connection complete with
safety line/whip check
safety sling.
Page | 9
Doc. No. 26071-100-VSC-FP1-00005

Pastikan teggangan tali

terkoneksi baik dengan
safety line/whip check
safety sling.
10. Fill Water For Supply Carrying profil Profill tank fall from Property demage 3 3 9 Ensure profil tank tied 2 2 4 HSE & SPV
fire Proffing work. tank using Pick up Pick Up when moving Kerusakan property correctly
Pengambilan Air Membawa profil Profll tank jatuh dari Pastikan profill tank
untuk Pekerjaan fire tank pick up saat bergerak Vehicle can’t move.. terikat dengan benar
proofing. menggunakan Kendaraan tidak
Pick up Vehicle stuck dapat bergerak. Make sure area clean
Kendaraan and ground cindition are
Fill water using tersangkut tight
pick up Pastikan area dalam
pengisian air keadaan bersih dan
menggunakan kondisi tanah
pick up padat/keras
Muddy and
slippery work
area.
Area kerja
berlumpur dan
licin.
11. Turn on the mixer. Electrical 2 3 6 Use electrical 2 2 4 SPV &

Menghidupkan Turning on the It can shock Fatality injury gloves. WORKER
mixer. power button with workers when Cidera serius. Gunakan sarung
wet hands can turning on the tangan electrikal.
result in an electric mixer if in wet
shock. hands. Ensure it installed
Menghidupkan Pekerja bisa electrical safety in
tombol power tersentum saat the work
dalam keadaan menghidupkan environment
tangan basah mixer jika dalam pastikan pengaman
dapat keadaan tangan listrik terpasang di
mengakibatkan basah. lingkungan kerja.
Page | 10
Doc. No. 26071-100-VSC-FP1-00005

tersetrum.
Ensure your hands
are not wet.
Pastikan tangan
tidak dalam keadaan
basah.
Always inspect the

electric equipment.
Selalu periksa
peralatan listrik.
Install grounding
temporary.
Pemasangan
grounding
sementara.
Ensure Connector
waterproof.
Pastikan konektor
tahan air.
12. Mixing Using a cement Irritated eyes, skin Minor - moderate injury 2 3 6 Do a pre-job meeting / 2 3 6 SP &
mix. and respiratory Cidera ringan – TBM before work and WORKER
Menggunakan tract because of sedang. follow the statement/
campuran exposure to procedure method.
semen. chemical cement. Melakukan Pre Job
Mata, kulit dan meeting /TBM
saluran sebelum bekerja
pernapasan dan ikuti metode
teriritasi karena statement /
paparan bahan prosedur.
kimia semen.
Focus, be careful
at work.
Cough because Health Injury. From acute to Fokus, hati-hati
3 4 12 3 3 9
of stripping and Masalah chronic saat bekerja.
crushing work kesehatan. Akut hingga kronis.
Page | 11
Doc. No. 26071-100-VSC-FP1-00005

Batuk karena MSDS

pengerjaan socialization use
pengupasan dan proper and
penghancuran. appropriate PPE
(use mask & PVC
gloves).
Sosialisasi MSDS
menggunakan
APD yang baik
Hand can hit by dan benar 2 2 4
rotator fan into 3 4 12 (menggunakan
mixer. Hand can injury Fatality Injury masker & sarung
tangan bisa Tangan bisa cidera serius. tangan PVC).
terkena dari kipas terluka.
rotator pemutar Ensure hands are
dari mixer. away from the
mixer when mixing
cement.
Pastikan tangan
jauh dari mixer
saat
mencampurkan
semen.
Page | 12
Doc. No. 26071-100-VSC-FP1-00005

11. Spraying Using cement Irritated eyes, skin Minor - moderate injury 2 3 6 Do a pre-job meeting / 2 2 4 SPV &
mixing. and respiratory Cidera ringan – TBM before work and WORKER
Menggunakan tract because of sedang. follow the statement/
campuran exposure to procedure method.
semen. chemical cement. Melakukan Pre Job
Mata, kulit dan meeting /TBM
saluran sebelum bekerja
pernapasan dan ikuti metode
teriritasi karena statement /
paparan bahan prosedur.
kimia semen
Focus, be careful
at work.
Fokus, hati-hati
. saat bekerja.
Should be using
mask N95
Harus menggunakan
masker N95
Cough because Health Injury. Acute and kronis 3 4 12 MSDS socialization use 3 3 9 SPV &
of stripping and Masalah kesehatan. Akut dan kronis. proper and appropriate WORKER
crushing work PPE (use mask & PVC
Batuk karena gloves).
pengerjaan Sosialisasi MSDS
pengupasan dan menggunakan
penghancuran APD yang baik
dan benar
(menggunakan
masker & sarung
tangan PVC).
Page | 13
Doc. No. 26071-100-VSC-FP1-00005

SOP must be
ready on location.
Sop harus
tersedia dilokasi
pekerjaan.
Should be using
mask N95
Harus
menggunakan
masker N95
Page | 14
Doc. No. 26071-100-VSC-FP1-00005

13. Plastering finishing Cement Skin irritation Peeling hands 2 2 4 Using PPE (mask, 2 2 4 SPV &
Iritasi kulit. tangan terkelupas. safety glasses, gloves WORKER
and other PPE).
Health Injury. Gunakan APD
Masalah kesehatan. (masker, kacamata
pelindun
g, sarung tangan dan
APD lainya).
Should be using
additional mask N95
Wajib menggunakan
tambahan masker N95
Page | 15
Doc. No. 26071-100-VSC-FP1-00005

Covid – 19 Virus Spread Virus Infection Medical Treatment 4 4 12 Always wear a medic 3 3 9 ALL CREW
Covid-19 Sebaran Virus Terinferksi Virus Perawatan Medis mask properly with 3 ply.
Selalu gunakan masker
Illness Fatality medis dengan 3 lapis.
Penyakit Fatal
Routine hand washing and
hand sanitizer in every
activity.
Rutin cuci tangan dan
handsanitizer pada setiap
aktivitas.
Follow government and JO

/ Pertamina regulation
about covid-19 spread.
Ikuti aturan
pemerintah, JO /
Pertamina mengenai
penyebaran covid-19.
Page | 16
Doc. No. 26071-100-VSC-FP1-00005

Housekeeping Slip/Trip/Fall Unsafe area Minor - moderate 2 3 6 Ensure the surface 2 2 4 SPV & Crew
Personal injury conditions injury. conditions are clean
because of do (slippery) Cidera ringan – and safe and use the
house keeping Kondisi area tidak sedang. 5S guidelines in
unsafe. aman (licin). doing house keeping
Terpeleset/ Pastikan kondisi
Tersandung/ permukaan bersih
Terjatuh/Kecelak dan aman serta
aan pada gunakan pedoman
seseorang yang 5S dalam
melakukan melakukan house
pembersihan keeping
dengan tidak
aman. Ensure it placed
correctly for
equipment
Pastikan peralatan
Chemical hazard Irritation ditempakan dengan
Bahaya bahan Iritasi. benar.
kimia.
Always communicate to
SPV, HSE, and the entire
team if you see a
dangerous condition.
Selalu komunikasikan
kepada SPV, HSE, dan
seluruh team jika melihat
kondisi bahaya.
Page | 17
Doc. No. 26071-100-VSC-FP1-00005

Risk Rangking Recommendation Action

Probability (PR) x Severity / = (RR) Tindakan Pengendalian
Kemungkinan consequence Tingkat Risiko
Keparahan Score Level Tingkat pengendalian Hierarchy of Control
Frequent =5 Catastrophic =5 19-25 Extreme E= 1+2+3+4+5 1= Elimination
high
Probable =4 Major =4 13-18 High H= 3+4+5 2= Substitution
Occasional = 3 Moderate / Serious = 6-12 Medium M= 4+5 3= Engineering Control
3
Unlikely =2 Minor =2 1-5 Low L=5 4= Administration
Note: *): Without Control / Tanpa control
*): With Control / Dengan control
Page | 18
Page | 19

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JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-100-VSC-FP1-00005

JSA No. : RDMP / JSA /......................... /.....................

ATTENDANCE LIST – JSA PREPARATION

Doc. No. 26071-100-VSC-FP1-00005

Project : RDMP JO Balikpapan Prepared By Reviewed By Approved By

Doc. No. 26071-100-VSC-FP1-00005

Sequence of Risk PIC

Doc. No. 26071-100-VSC-FP1-00005

Gas testing must be

Make sure H2S and LEL

If necessary carry out a

Cover all energy release

Doc. No. 26071-100-VSC-FP1-00005

Ensure the life line is

Ensure the work

Doc. No. 26071-100-VSC-FP1-00005

Cover the spark area

Ensure the work

Doc. No. 26071-100-VSC-FP1-00005

Make welding (stud

Use fire blanket.

Use proper hand glove

Ensure worker using

8. Repaint structures Exposed to Minor injury Respiratory 2 3 6 Using PPE 2 3 6 SPV&HSE

Doc. No. 26071-100-VSC-FP1-00005

steel vapors of the Cedera ringan. disorders. (Respirator/Air fed

Use the google nd

Don’t breathe paint

Pinched Fatality Injury. Ensure to properly

Doc. No. 26071-100-VSC-FP1-00005

Cough because Health Injury. Ensure chemical mixing

Stored energy Exposure Injury, Make sure workers

Ensure their energy is

Ensure the pressure line,

Doc. No. 26071-100-VSC-FP1-00005

Pastikan teggangan tali

11. Turn on the mixer. Electrical 2 3 6 Use electrical 2 2 4 SPV &

Doc. No. 26071-100-VSC-FP1-00005

Always inspect the

Doc. No. 26071-100-VSC-FP1-00005

Batuk karena MSDS

Doc. No. 26071-100-VSC-FP1-00005

Doc. No. 26071-100-VSC-FP1-00005

Doc. No. 26071-100-VSC-FP1-00005

Doc. No. 26071-100-VSC-FP1-00005

Follow government and JO

Doc. No. 26071-100-VSC-FP1-00005

Doc. No. 26071-100-VSC-FP1-00005

Risk Rangking Recommendation Action

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