JOB SAFETY ANALYSIS (JSA) FORM PMO

PROJECT SITE FABRICATION & ERECTED METALIC

DATE : 18 Mar 2021 JSA NO.: 28/JSA/PMB-22 REV. 0
STORAGE TANK-FL3B PROJECT
JSA TEAM
CONTRACTOR PRAKARSALANGGENG MAJU BERSAMA
(First Named – JSA Team Leader)
JOB TITLE Loading Unloading Material NAME POSITION SIGNATURE

LOCATION Area ETP Junaidi Ari PMB SPV Rigger

ITEM Karman PMB Coordinator

JOB DESCRIPTION :
Khairul Amri PMB HSE Officer
- LOADING UNLOADING MATERIAL
Rediel Sitohang PMB HSE Coordinator

Sutardi HSE PMO

Sumarno PMO

REFERENCE AND OTHER RELEVANT INFORMATION :. JSA Team Leader confirm that the risk for job 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 job can be proceed

- PPE Standar NAME Ganda Siregar

- Permit To Work POSITION Construction Manager
- Foco truck / Crane
- Lifting plan SIGNATURE Date:
- Lifting gear certificate
- Crew certificate I am satisfied that the controls measures identified when put into place will reduce the risk to tolerable level. The job/action
change is permitted to proceed. CONFIRMED & APPROVED BY PROJECT/SITE MANAGER/HSE MANAGER
STOP WORK IF FOUND UNSAFE NAME R. Damanik
POSITION Deputy HSE Manager

SIGNATURE Date:

1 Persiapan Pekerjaan Slip, strip & fall MTI  Pastikan semua orang hadir di tool box meeting Karman
JSA WORK SHEET
JOB TITLE
Hazard Identification Risk Evaluation Risk Control
Seqience of Job Hazard Description Hazard Effect Done by Check
No. Control measures
(Urutan Pekerjaan (Penjelasan Bahaya) (Dampak Bahaya) (Dilakukan Oleh) ()

 Ceck wire sling Manual handling  Pastikan lifting plan dan JSA dikomunikasikan dengan Khairul Amri
 Cek shackle crew
 Komunikasi  Pastikan semua orang yang berkompeten saja yang
 Cek tag line terlibat
 Cek unit alat angkat  Pastikan instruksi kerja ada, dan dipahami oleh semua
pekerja
 Pastikan semua rigging crew menggunakan APD yang
standard an lengkap
 Lakukan house keeping area pengngkatan
2 Persiapan akses foco truck Moving equipment MTI  Pastikan acces yang dilalui foco truck/ crane tanahnya Karman
atau crane Manual handling Properti demage stabil atau rata Khairul Amri
 Base plate  Pastikan road acces foco truck telah dibaricade
 Road access control  Pasang sign board peringatan dilarang melintas

3 Persiapan install wire sling,
webbing sling dan shackle
4 Pengangkatan material
dengan menggunakan foco
truck dan atau crane
KDP-HSE-F033
Manual handling MTI  Pastikan wire sling, shackle dan peralatan lifting gear Karman
Slip, strip & fall Property demage lainnya sudah diinspeksi oleh pihak yang berwenang Khairul Amri
dan memiliki sertifikat
 Pastikan semua rigging crew menggunakan APD yang
standard an lengkap
 Pastikan semua wire sling dan shackle yang dipasang
harus sesuai dengan beban yang akan diangkat
 Hindari dari titik jepit ketika melakukan pemasangan
wire sling dan shackle
Lifting operation Fatality  Pastikan rigger yang qualified mengikat beban Karman
Property demage  Pastikan SWL sling sesuai dengan kapasitas Khairul Amri
 Pastikan COG sudah tepat
 Pastikan pengangkatan harus bertahap tidak langsung
100% terhadap beban yang diangkat
 Pastikan komunikasi antara operator dan signalman
tidak ada hambatan
 Pastikan rigger dan signalman memakai memakai baju
reflektif agar mudah terlihat operator
 Jangan ada orang yang berada dibawah beban yang
Page 1 of 2
JSA WORK SHEET
JOB TITLE
Hazard Identification Risk Evaluation Risk Control
Seqience of Job Hazard Description Hazard Effect Done by Check
No. Control measures
(Urutan Pekerjaan (Penjelasan Bahaya) (Dampak Bahaya) (Dilakukan Oleh) ()

sedang diangkat, pasang barricade area lifting

5 Melepaskan wire sling atau
shacle
6 House keeping
7 Emergency response
 Pakai tagline pada untuk mengarahkan beban yang
diangkat
 Pakai PPE lengkap sewaktu bekerja
 Jangan posisikan jari atau tangan pada titik jepit
Manual handling MTI  Pastikan beban sudah diturunkan dengan aman Karman
 Pakai sarung tangan Khairul Amri
 Lantai kerja rata
Manual handling MTI  Menggunakan APD yang lengkap Karman
 Tempat sampah yang terjangkau dan memadai Khairul Amri
Slip, trip & fall LTI  Pastikan sudah dilakukan sosialisasi prosedur Karman
keselamatan kedaruratan diarea kerja Khairul Amri
 Jangan panic, segera menuju ke assembly point
 Laporkan ke ERT atau ke fire station, gunakan laporan
emergency extention 1113 atau 0761-491113

KDP-HSE-F033 Page 2 of 2
Hazard Check List

GENERAL CONFINED SPACE ENTRY PROCESS

No Hazard Description No Hazard Description No Hazard Description
1 Asphyxiation 1 Adequacy of lighting within the CS 1 Asbestos gaskets
2 Barriers/access restrictions 2 Adequacy of ventilation 2 Chemical hazards
3 Biological agents 3 Comm. Difficulties within the CS or with the standby man 3 Chemical reactions with cleaning materials
4 Chemical hazard 4 Competency of standby man 4 Chemical reactions with cleaning materials
5 Cold/Heat 5 Danger of falling into CS boots or sumps 5 Electrical risk of using portable tools
6 Collision (impact from moving object to fixed object) 6 Disposal of CS cleanings 6 Environmental impact of spills or emissions
7 Electricity 7 Falling from height Residual gases/ vapors 7 Flammable or toxic vapors arising from sludge in vessel
8 Falling from height 8 Frequency of gas testing 8 Hazardous substances trapped around bends, linings etc.
9 Falling object/Drop Object 9 Ingress of gases/vapors from other nearby activities/systems 9 Inert atmospheres
10 Open flame 10 Ionizing radiation; nucleonic instrumentation 10 Liquids remaining from flushing
11 Flammable gas 11 Location of rescue kits 11 Hazardous Chemical Scale
12 Flammable liquid 12 Hazardous Chemical scale 12 Pyrophoric scale
13 Fume/dust 13 Need for air movers during entry. 13 Residual heat
14 Grit blasting 14 Noise when using power tools 14 Residual pressure
15 Hand tools 15 Noise, general 15 Trapped pressure
16 Ignition 16 Oxygen deficiency
17 Impact (force full contact) 17 Oxygen enrichment
18 Inert gas 18 Slip hazards within the CS or at the point of entry
19 Ionizing Radiation 19 Sludge which may give rise to vapors/gases when disturbed
20 Lifting operations 20 Standby man communication with the ERP
21 Lighting 21 Temperature effects
22 Machinery 22 Use of mechanical tools/power tools/electrical equipment
23 Manual Handling 23 Visibility within the Confined Space
24 Mental Stress
25 Noise
26 Potential for ignition
27 Power tools
28 Pressure
29 Static Electricity
30 Slip, Trip and Fall
31 Working at height
32 Bad Weather