‭JOB‬‭SAFETY‬‭ANALYSIS‬

‭Nomor‬‭JSA/‬ ‭Baru/‬‭New‬ ‭:‬ ‭Ya/‬‭Yes‬ ‭☐‬ ‭Tidak/‬‭No‬ ‭☐‬

‭JSA‬‭Number‬
‭Nama‬‭Perusahaan/‬
‭Company‬‭Name‬
‭Deskripsi‬‭Pekerjaan/‬
‭Work‬‭Description‬
‭:‬ ‭ anggal/‬‭Date‬‭:‬
T
‭Perawatan/‬‭Maintenance‬‭:‬ ‭Ya/‬‭Yes‬ ‭☐‬ ‭Tidak/‬‭No‬ ‭☐‬ ‭Tanggal/‬‭Date‬‭:‬
‭:‬
‭Perbaikan/‬‭Repair‬ ‭:‬ ‭Ya/‬‭Yes‬ ‭☒‬ ‭Tidak/‬‭No‬ ‭☐‬ ‭Tanggal/‬‭Date‬ ‭:‬ ‭______________‬
‭:‬

‭Aktivitas‬‭berbahaya/‬‭Hazardous‬‭Activities‬‭:‬

‭☐‬‭Bekerja‬‭di‬‭ketinggian/‬ ‭☐‬‭Penggalian‬‭Tanah/‬ ‭☐‬‭Konstruksi/‬ ‭☐‬‭Umum/‬

‭Workig‬‭at‬‭Height‬ ‭Ground‬‭Disturbance‬ ‭Construction‬ ‭General‬
‭☐‬‭Bekerja‬‭dengan‬‭api/‬ ‭☐‬‭Ruang‬‭terbatas/‬
‭☐‬‭Isolasi‬‭Energi/‬
‭Hot‬‭Work‬ ‭Confined‬‭Space‬
‭Isolation‬‭Energy‬

‭ raian‬‭Pekerjaan/‬‭Work‬‭Illustration‬‭:‬
U
‭Pengecekan‬‭kabel‬‭wifi.‬
‭Pengecekan‬‭perangkat‬‭wifi‬
‭Melakukan‬‭pergantian‬‭kabel‬

‭JSA‬‭ini‬‭dibuat‬‭dan‬‭dievaluasi‬‭oleh/‬ ‭:‬‭Rendra‬‭Wijaya‬
‭This‬‭JSA‬‭is‬‭created‬‭and‬‭evaluated‬‭by‬
‭Supervisor‬‭or‬‭Leader‬ ‭:‬

‭No‬ ‭Nama‬‭Pekerja/‬‭Name‬‭of‬‭Worker‬ ‭Posisi‬‭Pekerjaan/‬‭Job‬‭Responsibility‬ ‭No‬ ‭Nama‬‭Pekerja/‬‭Name‬‭of‬‭Worker‬ ‭Posisi‬‭Pekerjaan/‬‭Job‬‭Responsibility‬

‭1‬ ‭8‬ ‭ ‬
‭2‬ ‭9‬ ‭ ‬
‭3‬ ‭10‬ ‭ ‬
‭4‬ ‭11‬ ‭ ‬

‭ ersetujuan/‬‭Approval‬
P ‭Tanda‬‭tangan/‬‭Sign‬‭:‬ ‭Tanggal/‬‭Date‬‭:‬
‭Departemen‬‭Terkait/‬‭:‬
‭Related‬‭Department‬ ‭Tanda‬‭tangan/‬‭Sign‬‭:‬ ‭Tanggal/‬‭Date‬‭:‬
‭HSSE‬ ‭:‬
 ‭JOB‬‭SAFETY‬‭ANALYSIS‬
‭Analisa‬‭bahaya‬‭yang‬‭mungkin‬‭terjadi/‬‭Hazard‬‭analysis‬

‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭ enda‬‭tajam‬‭/‬

B ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭ lam:‬‭Hujan‬‭/‬
A ‭☐‬‭Ya/‬‭Yes‬
‭ ekerja‬
B ‭ ogam‬
L
‭Suara‬‭bising‬ ‭kasar‬ ‭Tumpahan‬ ‭Panas‬‭Matahari‬
‭dengan‬‭panas‬ ‭Noise‬
‭berkarat‬ ‭Sharp‬‭materials‬ ‭Spill‬ ‭ ature:‬‭Rain‬‭or‬
N
‭Hot‬‭Work‬ ‭☐‬‭Tdk/‬‭No‬ ‭☒‬‭Tdk/‬‭No‬ ‭Corrosive‬ ‭☒‬‭Tdk/‬‭No‬ ‭☐‬‭Tdk/‬‭No‬ ‭☒‬‭Tdk/‬‭No‬ ‭Heat‬‭from‬‭sun‬ ‭☐‬‭Tdk/‬‭No‬

‭ enggalian‬
P ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭ erjepit‬‭/‬
T ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬
‭ ermukaaan‬
P ‭Tertusuk‬ ‭ anas‬‭yang‬
P ‭ atuh,‬‭terpeleset,‬ ☒
J ‭ ‬‭Ya/‬‭Yes‬
‭tanah‬ ‭terjebak‬ ‭Pierced‬
‭panas‬ ‭berlebihan‬ ‭tersandung‬
‭ isturbance‬
D ‭ inched‬‭or‬
P
‭Grounding‬ ‭☐‬‭Tdk/‬‭No‬ ‭Heat‬‭surface‬ ‭☒‬‭Tdk/‬‭No‬ ‭stuck‬ ‭☐‬‭Tdk/‬‭No‬ ‭☒‬‭Tdk/‬‭No‬ ‭Excessive‬‭heat‬ ‭☒‬‭Tdk/‬‭No‬ ‭Fall,‬‭slip,‬‭trip‬ ‭☐‬‭Tdk/‬‭No‬

J‭ atuh‬‭dari‬ ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭ erendam‬

T ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬
‭ketinggian‬ ‭Radiasi‬ ‭Kebakaran‬ ‭cairan‬ ‭Ledakan‬ ‭Debu‬
‭ alling‬‭from‬‭a‬
F ‭Radiation‬ ‭Fire‬ ‭ oaked‬‭with‬
S ‭Explosion‬ ‭Dust‬
‭height‬ ‭☐‬‭Tdk/‬‭No‬ ‭☒‬‭Tdk/‬‭No‬ ‭☐‬‭Tdk/‬‭No‬ ‭liquid/fuel‬ ‭☒‬‭Tdk/‬‭No‬ ‭☐‬‭Tdk/‬‭No‬ ‭☒‬‭Tdk/‬‭No‬
‭Limbah‬‭material‬‭pekerjaan‬
‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭ urang‬
K ‭☐‬‭Ya/‬‭Yes‬ ‭☒‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭Work‬‭material‬‭waste‬
‭Konstruksi‬ ‭Getaran‬ ‭Tegangan‬‭listrik‬ ‭Ergonomik‬
‭Construction‬ ‭Vibration‬
‭penerangan‬ ‭Electricity‬ ‭Ergonomic‬
‭Low‬‭light‬
‭☐‬‭Tdk/‬‭No‬ ‭☒‬‭Tdk/‬‭No‬ ‭☒‬‭Tdk/‬‭No‬ ‭☐‬‭Tdk/‬‭No‬ ‭☐‬‭Tdk/‬‭No‬ ‭☐‬‭Ya/‬‭Yes‬
‭ kses‬‭atau‬
A ‭ ekerja‬‭di‬
B ‭Cairan‬
‭ eralatan‬‭yang‬
P ‭ ap‬‭yang‬
U
‭jalan‬‭keluar‬ ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭ketinggian/tepi‬ ‭☒‬‭Ya/‬‭Yes‬ ‭ uangan‬
R ‭☐‬‭Ya/‬‭Yes‬
‭Liquid‬
‭☒‬‭Tdk/‬‭No‬
‭menimbulkan‬ ‭mudah‬
‭terbatas‬ ‭yang‬‭terbuka‬ ‭terkontaminasi‬
‭percikan‬‭api‬ ‭terbakar‬ ‭ ork‬‭at‬‭height‬
W ‭ ontaminated‬
C
‭ estricted‬
R
‭ quipment‬‭that‬
E ‭ lammable‬
F
‭access‬‭or‬ ‭or‬‭exposed‬ ‭atmosphere‬
‭egress‬ ‭☐‬‭Tdk/‬‭No‬ ‭causes‬‭sparks‬ ‭☒‬‭Tdk/‬‭No‬ ‭Vapour‬ ‭☐‬‭Tdk/‬‭No‬ ‭edge‬ ‭☐‬‭Tdk/‬‭No‬ ‭☒‬‭Tdk/‬‭No‬ ‭☒‬‭Ya/‬‭Yes‬
‭Padat‬
‭ truktur‬‭yang‬
S ‭Solid‬
‭☒‬‭Ya/‬‭Yes‬ ‭ ekurangan‬
K ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Ya/‬‭Yes‬ ‭☒‬‭Ya/‬‭Yes‬ ‭ ahaya‬‭diatas‬
B ‭☐‬‭Ya/‬‭Yes‬ ‭☐‬‭Tdk/‬‭No‬
‭ alu‬‭lintas‬
L ‭mudah‬‭runtuh‬
‭oksigen‬ ‭Sisa‬‭material‬ ‭kepala‬
‭kendaraan‬ ‭ tructure‬
s ‭Residues‬
‭ xygen‬
O ‭ anger‬‭above‬‭the‬
D
‭Vehicle‬‭Traffic‬ ‭☐‬‭Tdk/‬‭No‬ ‭deficiency‬ ‭☐‬‭Tdk/‬‭No‬ ‭collapse‬ ‭☐‬‭Tdk/‬‭No‬ ‭☐‬‭Tdk/‬‭No‬ ‭head‬ ‭☐‬‭Tdk/‬‭No‬

‭Keterangan‬‭tambahan/‬‭Additional‬‭information‬‭:‬

‭ ‬
 ‭JOB‬‭SAFETY‬‭ANALYSIS‬

‭Urutan‬‭langkah‬‭kerja‬ ‭Bahaya‬‭potensial‬ ‭Pencegahan‬ ‭Keterangan‬

‭No‬ ‭Work‬‭steps‬ ‭Potential‬‭hazards‬ ‭Preventive‬‭action‬ ‭Remarks‬

‭1‬ ‭Perizinan‬‭pekerjaan/membuat‬‭izin‬‭kerja‬ ‭Breifing‬‭dan‬‭induction‬‭oleh‬‭site‬‭team‬

‭ p‬‭gunakan‬‭APD‬‭(Helm,‬‭Shoes‬‭&‬
b
‭Safety‬‭Vest)‬
‭2‬ ‭Persiapkan‬‭/‬‭penyiapkan‬‭alat‬‭&‬‭APD‬ ‭ .‬ T
1 ‭ idak‬‭mengerti‬‭resiko‬‭kerja.‬ ‭1.‬ ‭Potensi‬‭incident‬‭harus‬‭di‬‭jelaskan‬ ‭ ika‬‭penggunaan‬‭APD‬‭tidak‬
J
‭2.‬ ‭Pekerja‬‭kurang‬‭peduli‬ ‭oleh‬‭pelaksana‬‭dan‬‭membuat‬‭list‬ ‭lengkap,‬‭pekerjaan‬‭akan‬‭di‬
‭keselamatan‬‭pekerja‬ ‭pekerjaan‬‭yg‬‭dapat‬‭menimbulkan‬ ‭hentikan‬
‭bahaya‬‭dan‬‭pekerjaan‬‭tersebut‬
‭2.‬ ‭Lakukan‬‭Safety‬‭breefing‬‭sebelum‬
‭bekerjaan‬‭dan‬‭Taat‬‭Prokes‬
‭selama‬‭Pandemi‬
‭3.‬ ‭Gunakan‬‭APD‬‭sesuai‬‭kebutuhan‬
‭(helmet,‬‭Vest,‬‭Safety‬‭Shoes,‬
‭Masker‬‭&‬‭Gloves)‬
‭3‬ ‭Cek‬‭kendala‬‭kerusakan‬‭di‬‭kabel‬‭atau‬‭switch‬ ‭ .‬
1 ‭ erjatuh‬‭dari‬‭ketinggian‬
T ‭1.‬ ‭Inspeksi‬‭tangga‬‭oleh‬‭site‬‭team,‬ ‭1.‬ P‭ enggunaan‬‭tangga‬‭minimal‬‭2‬
‭2.‬ ‭Tertimpa‬‭tangga‬ ‭memastikan‬‭tangga‬‭ada‬‭yang‬ ‭orang,‬‭dan‬‭menerapka‬‭3‬‭titik‬
‭3.‬ ‭Tersengat‬‭listrik‬ ‭memegang.‬ ‭tumpu.‬
‭4.‬ ‭Titik‬‭jepit‬ ‭2.‬ ‭Menggunakan‬‭helm,‬‭barikade‬ ‭2.‬ ‭Apabila‬‭ada‬‭kabel‬‭yang‬‭putus‬
‭area‬‭pekerjaan‬ ‭akan‬‭di‬‭sambung‬‭atau‬‭di‬‭ganti‬
‭3.‬ ‭Isolasi‬‭energy‬
‭4.‬ ‭Hindari‬‭titik‬‭jepit‬
‭4‬ ‭Penarikan‬‭kabel‬‭ke‬‭perangkat‬ ‭ .‬
1 ‭ erjatuh‬‭dari‬‭ketinggia‬
T ‭1.‬ ‭Inspeksi‬‭tangga‬‭oleh‬‭site‬‭team,‬ ‭1.‬ P ‭ enggunaan‬‭tangga‬‭minimal‬‭2‬
‭2.‬ ‭Tertimpa‬‭tangga‬ ‭memastikan‬‭tangga‬‭ada‬‭yang‬ ‭orang,‬‭dan‬‭menerapkan‬‭3‬‭titik‬
‭3.‬ ‭Tersengat‬‭listrik‬ ‭memegang.‬ ‭tumpu‬
‭4.‬ ‭Titik‬‭jepit‬ ‭2.‬ ‭Menggunakan‬‭helm,‬‭barikade‬ ‭2.‬ ‭Lakukan‬‭isolasi‬‭energy‬‭dan‬
‭area‬‭pekerjaan‬ ‭LOTO‬
‭3.‬ ‭Isolasi‬‭energy‬
‭4.‬ ‭Hindari‬‭titik‬‭jepit‬
‭5‬ ‭Pengecekan‬‭hasil‬‭kerja‬ ‭ .‬ T
1 ‭ ersengat‬‭listrik‬ ‭ .‬ I‭solasi‬‭energy‬
1 ‭1.‬ ‭Pekerjaan‬‭minimal‬‭2‬‭orang.‬
‭2.‬ ‭Konsleting‬ ‭2.‬ ‭Menata‬‭ulang‬‭kabel‬
‭6‬ ‭Perapihan‬ ‭ .‬
1 ‭ itik‬‭jepit‬
T ‭1.‬ G ‭ unakan‬‭sarung‬‭tangan,‬‭hindari‬
‭2.‬ ‭Material‬‭Tajam‬ ‭titik‬‭jepit‬
‭3.‬ ‭Limbah‬‭pekerjaan‬ ‭2.‬ ‭Material‬‭sisa‬‭atau‬‭limbah‬‭yang‬‭di‬
‭hasilkan,‬‭di‬‭bersihkan‬‭oleh‬
‭kontraktor‬‭dan‬‭di‬‭bawa‬‭keluar‬‭site.‬
 ‭JOB‬‭SAFETY‬‭ANALYSIS‬
‭7‬ ‭Penyelesaian‬ ‭ ek‬‭area‬‭pekerjaan,‬‭dan‬‭close‬
C
‭PTW‬

‭Alat‬‭Pelindung‬‭Diri‬‭(APD)‬ ‭Perlengkapan,‬‭Peralatan‬‭kerja‬ ‭Informasi‬‭Tambahan‬

‭Personal‬‭Protective‬‭Equipment‬‭(PPE)‬ ‭Work‬‭equipment‬ ‭Additional‬‭informations‬
‭Pelindung‬‭dari‬‭ketinggian‬ ‭Pelindung‬‭tangan‬ ‭Pelindung‬‭kepala/wajah‬ ‭Alat‬‭pengelas‬ ‭Peralatan‬‭angkat‬ ‭Isolasi‬‭area‬
‭☐‬ ‭☐‬ ‭☐‬
‭Fall‬‭protector‬ ‭Hand‬‭protector‬ ‭Head/face‬‭protector‬ ‭Welding‬‭machine‬ ‭Lifting‬‭tools‬ ‭Isolation‬‭area‬
‭Peralatan‬‭tangan‬ ‭Peralatan‬‭angkut‬ ‭Barikade‬
‭Safety‬‭Body‬‭Harness‬ ‭☐‬ ‭Hand‬‭Gloves‬‭(Cotton)‬ ‭☒‬ ‭Safety‬‭Helmet‬ ‭☒‬ ‭☐‬ ‭☐‬ ‭☒‬
‭Hand‬‭tools‬ ‭Loading‬‭tools‬ ‭Baricade‬
‭ anyard‬‭with‬‭shock‬
L ‭Bendera‬
‭☐‬ ‭Gloves‬‭Nitrile‬ ‭☐‬ ‭Safety‬‭Glasses‬ ‭☐‬ ‭Shovel‬ ‭☐‬ ‭ eralatan‬‭khusus‬
P ‭☐‬
‭absorber‬ ‭Flag‬
‭untuk‬‭zone‬‭flammable‬ ‭☐‬
‭Prosedur‬‭/‬‭SOP‬
‭Life‬‭line‬ ‭☐‬ ‭Gloves‬‭Leather‬ ‭☐‬ ‭Goggles‬ ‭☐‬ ‭Grinder‬ ‭☐‬ ‭Non-sparking‬‭tools‬ ‭☒‬
‭Procedure‬
‭Pelindung‬‭pernafasan‬ ‭ loves‬‭Karet‬‭untuk‬
G ‭Lainnya‬‭(Jelaskan)‬ ‭☐‬ ‭Pengukuran‬
‭☐‬ ‭Face‬‭Shield‬ ‭☐‬ ‭Compactor‬ ‭☐‬ ‭☐‬
‭Respirator‬ ‭listrik/‬‭Electrical‬‭Gloves‬ ‭Measurement‬
‭Other‬
‭Lainnya‬‭(Jelaskan)‬ ‭☐‬ ‭Alat‬‭pengalian‬
‭Dust‬‭Mask‬ ‭☒‬ ‭Welding‬‭Helmet‬ ‭☐‬ ‭☐‬ ‭MSDS‬ ‭☐‬
‭Excavation‬‭tools‬
‭Other‬
‭Full‬‭Face‬‭Respirator‬ ‭☐‬ ‭Lainnya‬‭(Jelaskan)‬ ‭☐‬ ‭Crane‬ ‭☐‬ ‭Grounding‬ ‭☐‬

‭Pelindung‬‭pendengaran‬ ‭Pemadam‬‭Api‬ ‭Tanda‬‭bahaya‬

‭Breathing‬‭Apparatus‬ ‭☐‬ ‭Other‬ ‭☐‬ ‭☒‬
‭Ear‬‭protector‬ ‭Fire‬‭extinguisher‬ ‭Tag‬

‭Lainnya‬‭(Jelaskan)‬ ‭☐‬ ‭Informasi‬‭lainnya‬

‭Ear‬‭Plugs‬ ‭☐‬ ‭Fire‬‭Blanket‬ ‭☐‬ ‭☐‬
‭Additional‬‭information‬
‭Other‬
‭Petunjuk‬‭khusus‬
‭Ear‬‭Muffs‬ ‭☐‬ ‭Excavator‬ ‭☐‬ ‭☐‬
‭Special‬‭instructions‬
‭Pelindung‬‭kaki‬ ‭Pakaian‬‭khusus‬ ‭Peralatan‬‭listrik‬ ‭Izin‬‭Tempat‬‭Bekerja‬
‭☐‬ ‭☒‬
‭Foot‬‭protector‬ ‭Special‬‭clothes‬ ‭Electrical‬‭tools‬ ‭Work‬‭place‬‭clearance‬
‭Sepatu‬‭safety‬ ‭Sumber‬‭listrik‬ ‭Izin‬‭Isolasi‬‭Energi‬
‭☐‬ ‭☐‬ ‭☒‬
‭Safety‬‭shoe‬ ‭ eather‬‭/‬‭Disposable‬
L ‭Electrical‬‭sources‬ ‭Energy‬‭isolation‬‭permit‬
‭☐‬
‭Overalls‬ ‭Izin‬‭Kerja‬‭Panas‬
‭Boots‬ ‭☐‬ ‭Scissor‬‭lift‬ ‭☐‬ ‭☐‬
‭Hot‬‭work‬‭permit‬

‭Lainnya‬‭(Jelaskan)‬ ‭☐‬ ‭Tangga‬ ‭Izin‬‭Penggalian‬‭Tanah‬

‭Wet‬‭Weather‬‭Gear‬ ‭☐‬ ‭☒‬ ‭☐‬
‭Ladder‬ ‭Ground‬‭disturbance‬‭permit‬
‭Other‬
‭JOB‬‭SAFETY‬‭ANALYSIS‬
‭Lainnya‬‭(Jelaskan)‬ ‭☐‬ ‭Izin‬‭Memasuki‬‭Ruang‬‭Terbatas‬
‭Scaffolding‬ ‭☐‬ ‭☐‬
‭Confined‬‭space‬‭entry‬‭permit‬
‭Other‬
‭Izin‬‭Bekerja‬‭di‬‭Ketinggian‬
‭Manlift‬‭Truck‬ ‭☐‬ ‭☒‬
‭Working‬‭at‬‭height‬‭permit‬