JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

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

JSA Title : TEMPORARY FACILITY INSTALATION

ATTENDANCE LIST – JSA PREPARATION

NO NAME POSITION COMPANY SIGNATURE
CONSTRUCTION
1 ENDANG MAULANA JAYA PT. DAEAH E&C
MANAGER
2 ACHMAD ARIFUDIN SUPPORT ENGINEER PT. DAEAH E&C
3 NURIMAN PIPING ENGINEER PT. DAEAH E&C
4 YOGA S HSE COORDINATOR PT. DAEAH E&C
5 CECEP N PIPING SUPERVISOR PT. DAEAH E&C
6 PANUJI PIPING SUPERVISOR PT. DAEAH E&C
7 SUHARI PIPE SUPPORT SPV PT. DAEAH E&C
8 RIZA ADIYANTO OPERATOR CRANE PT. DAEAH E&C
9 AGUNG LAKSANA ISMAIL W P OHC OPERATOR PT. DAEAH E&C
10 ADE NOPINA OHC OPERATOR PT. DAEAH E&C
11 HERU RIGGER PT. DAEAH E&C
12 PRIYO RIGGER PT. DAEAH E&C
13 SETIYAWAN HELPER PT. DAEAH E&C
14 RASIMAN PIPING FOREMAN PT. DAEAH E&C
15 TRI HARIYANTO PIPING FOREMAN PT. DAEAH E&C
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Project : RDMP Balikpapan JO Prepared By Reviewed By Approved By

Company : PT. Daeah E&C Indonesia SPV Chief/HSE Manager CM
Scope of Work/Pkg : RFCC Piping Shop Fabrication Name
JSA No. : RDMP / JSA / ............. / ............... Signature
Position : Construction Manager
Job Activity : Temporary Facility Instalation
Area : 75 H Kariangau
Date : 17 April 2021 Date

Status Status
No Permit Registry No No Permit Registry No
Open 🗸 Close 🗸 Open 🗸 Close 🗸

Sequence of Basic Consequence / Risk PIC

Hazard Risk Recommendation action Result Risk*)
NO Job Steps severity Assessment* Penanggung
Bahaya Resiko Tindakan Pengendalian
Tahapan pekerjaan Akibat PR SV RR PR SV RR Jawab
1 Pekerjaan persiapan • Komunikasi • Miskomunikasi • Proses PTW • Kordinasi dan
Preparation Work Comunication Miscomunication terhambat komunikas yang baik
• Proses • Prosedur dan • Melanggar aturan PTW process antara pekerja
Pembuatan Peraturan Violation of inhibited The good coordination
PTW Procedure and Rules • Mendapatkan and comunication
(Permit To Regulation violation between workers
Work) Get the penalty • Pembuatan PTW
PTW dilakukan oleh 2 3 6 Cecep (SPV)
3 2 6 & Yoga (HSE)
Processing penanggung jawab
yang telah memahami
proses pembuatan
PTW
Making PTW is carried
out by a person in
charge who has
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

understood the process

of making PTW
• Persiapkan semua
persyaratan PTW
Prepare all PTW
requirements
• Ikuti aturan dan
prosedur yang berlaku
di dalam project
Follow the rules and
procedures that apply
in the project
2 Mobilisasi Unit • Kendaraan • Kendaraan tidak • Kendaraan tidak • Seluruh komponen
Material Vehicle layak pakai diperbolehkan kendaraan berfungsi
Mobilization • Pergerakan Vehicle not beroperasi karena dengan baik seperti
Material Unit Kendaraan suitable atidak lolos alarm mundur, lampu,
Vehicle • Kecalakaan inspeksi kaca spion, rem dan
Movement Lalulintas Vehicles are not penglihatan pengemudi
• Material yang Trafic accident allowed to operate tidak terhalang
diangkut • Material because they do All components of the
Transported roboh/terjatuh not pass vehicle are functioning
material material collapses / inspections properly such as a
falls • Kerugian financial reverse alarm, lights,
Financial loss rearview mirror, brake
• Cedera personil and driver's vision are
4 4 16 2 3 6 Cecep (SPV)
Personnel injuries not blocked
• Memastikan kendaraan & Yoga (HSE)
• Kerusakan pada
kendaraan yang digunakan telah di
pengangkut inspeksi oleh JO
Damage to the Inspector dan memiliki
transport vehicle safety tag yang masih
• Material rusak berlaku
karena terjatuh Ensure the vehicle used
Material damaged has been inspected by
due to a fall the JO Inspector and
• Pekerjaan has a valid safety tag
terhambat • Memastikan pengemudi
adalah orang yang
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Work delay berpengalan dan

memiliki SIM yang
masih berlaku
Make sure the driver is
an experienced person
and has a valid SIM
• Lakukan induksi
keselamatan dan
pengenalan jalur yang
akan dilewati
Safety Induction and
identify the path to be
passed
• Ikuti aturan kecepatan
dan jalur yang telah
ditentukan di area
project
Follow the speed and
path rules that have
been determined in the
project area
• Menyediakan flagman
untuk mengawal
pergerakan kendaraan
jika diperlukan
Provide a flagman to
escort the movement of
the vehicle if needed
• Side section atau
proteksi harus terpasang
untuk menghindari
material terjatuh dari
bak kendaraan
Side sections or
protection must be
installed to avoid
material falling from the
body of the vehicle
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Mengikat material
dengan kuat sebelum
mobilisasi material
Binds material firmly
before material
mobilization

3 Mengakses atau • Pergerakan di • Tersandung atau • Cedera pada • Gunakan tangga yang
menjangkau trailer atas bak trailer terpeleset personil sesuai untuk akses naik
untuk proses rigging Movement above Tripping or Personal injuries dan turun dari bak trailer
Access or reach the trailer slipping • Patah tulang Use the appropriate
trailers for the • Pergerakan • Jatuh dari atas bak Fracture stairs for access up and
rigging process material saat trailer • Terkilir down the trailer
penurunan Fall from the top of Sprained • Segera menghindar dan
Material the trailer • Luka terbuka pada turun dari trailer saat
movement when • Alat kerja atau anggota badan pengangkatan di mulai
unloading maeterial terjatuh Open wound on Immediately dodge and
• Bagian material A working tool or limb dismount from the
yang keras dan material has been • Kematian trailer when lifting
tajam dropped Fatality starts
Hard and sharp • Terbentur atau • Gunakan full body
material parts terhantam material harness jika bekerja
4 5 20
Crash or get hit by >1,8 m 2 3 6 Cecep (SPV)
material Use Full body harness if & Yoga (HSE)
• Tertimpa material working >1,8 mtr
Overwritten • Gunakan tagline untuk
material mengontrol beban
• Tersayat material Use tag line to controll
yang tajam the load
Sharp cutting • Tidak berada di bawah
material material yang sedang di
bongkar
Not under the material
being unloading
• Side section atau
proteksi harus di pasang
untuk menghindari
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

material jatuh dari

trailer
Side sections or
protection must be
installed to avoid
material falling from the
trailer
• Beri pelindung atau
softener pada sisi
material yang tajam
Give a protective or
softener on the sharp
side of the material
• Pasang rambu-rambu
keselamatan dan
barikade di sekitar area
kerja
Install the safety sign
and baricade around
work area
• Gunakan sarung tangan,
helem keselamatan,
sepatu keselamatan dan
baju kerja
Use safety glove, saefty
helmet, safety shoes and
coverall

4 Proses pengangkatan • Pergerakan alat • Alat berat • Pekerjaan bongkar • Lakukan TBM sebelum
material berat terperosok muat terhambat memulai pekerjaan
menggunakan alat The heavy Heavy equipment Loading and Do TBM before start
berat (Crane & equipment has fallen unloading work is work 2 3 6
forklift) movement • Kecelakaan lalu hampered • Mmastikan semua Cecep (SPV)
Material lifting 4 4 16
• Bahan Bakar lintas • Kerugian finansial personil telah & Yoga (HSE)
process using heavy Minyak mudah Traffic accident Financial loss memahami isi JSA &
equipment (crane & terbakar • Kebakaran & • Material jatuh WMS
forklift) Flamable ledakan karena sling putus Ensure that all
material Fire and explosion personnel understand
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Memposisik • Peralatan angkat • Pencemaran tanah Material fell due to the contents of JSA &
an alat berat angkut yang tidak Oil spills sling breaking WMS
Positioning memadai • Alat angkat angkut • Kejatuhan material • Operator alat berat
the heavy Inadequate tidak dapat Fallout of material adalah orang yang
equipment lifting equipment digunakan di • Kerusakan pada berpengalaman dan
• Pengisian • Alat bantu angkat dalam project alat angkat angkut memiliki SIO resmi
BBM yang tidak sesuai karena tidak lolos The heavy yang berlaku
Refueling Inadequate inspeksi equipment broken Heavy equipment
• Memposisik lifting gears Lifting equipment • Cedera pada operators are
an base plate • Proses bongkar cannot be used in personil experienced people who
untuk muat material the project Personal injuries have a valid SIO
tumpuan yang tidak aman because it does not • Material rusak • Memastikan alat berat
outrigger Unsafe the pass inspection The material is telah diinspeksi oleh
Positioning loading • Alat bantu angkat broken pihak JO Inspektor dan
the base unloading rusak atau putus • Luka terbuka memiliki taging yang
plate for process The lifting gears is akibat terjepit masih berlaku
outrigger • Kelebihan beban broken material Ensure that the heavy
support Overload • Miskomunikasi Open wound do to equipment has been
• Memposisik • Kondisi tanah antara signalman pinched material inspected by JO
an barang di yang tidak stabil dan operator alat • Patah tulang inspector and have a
tempat yang Unstable soill berat Fracture valid tagging
telah di condition Miscommunicatio • Cacat permanen • Memastikan alat berat
tentukan • Titik jepit n between Permanent yang digunakan
Positioning material signalman and disability memiliki sertifikat
the goods in Pinch point of the operator • Kematian migas resmi (SILO)
a designated material • Material jatuh Fatality yang masih berlaku
place Material has fallen Ensure that the heavy
• Proses • Tertimpa atau eqipment have a valid
bongkar terhantam material official oil and gas
muat yang di angkat certificate
material Crashed or hit by • Sediakan flagman untuk
Loading the material being memandu pergerakan
unloading removed alat berat
process • Alat angkat angkut Provide the flagman to
tumbang guide movement of the
The heavy heavy equipment
equipment • Mengamankan area
collapse manufer alat berat dari
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Terjepit di antara orang yang tidak

titik jepit material berkepentingan
Pinched between Securing heavy
the material pinch equipment maneuvers
points from unauthorized
persons
• Jarak pekerja dari alat
berat yang beroperasi
adalah 5m
The distance of workers
from operating heavy
equipment is 5 m
• Memastikan mesin alat
berat dalam kondisi
mati saat melakukan
pengisian bahan bakar
Make sure the machine
is turned off when
refueling
• Gunakan pompa
portable saat melakukan
pengisian bahan bakar
Use the portable pump
when refueling
• Gunakan drip pan untuk
menampung ceceran
minyak
Use the drip pan to hold
of oil spills
• Jauhkan dari sumber api
Keep distance from
sourch of fire
• Sediakan alat pemadam
api di sekitar area
pengisian bahan bakar
Provide the fire
exthinguiser around
refueling area
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Memastikan semua
lifting gears telah
diinspeksi oleh pihak JO
Inspektor dan memiliki
safety tag yang masih
berlaku
Make sure the all lifting
gears has been
inspected by JO
Inspector and have a
valid tagging
• Gunakan lifting gears
sesuai dengan kapasitas
material yang akan
diangkat
Use lifting gears
according to the
capacity of the material
to be lifted
• Memastikan lifting
gears yang akan di
gunakan dalam kondisi
baik
Make sure the lifting
gears will used in good
condition
• Semua proses rigging
dilakukan oleh rigger
yang berpengalaman
dan memiliki sertifikat
resmi yang masih
berlaku
All rigging processes
are carried out by
experienced riggers
who have valid official
certificates
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Memastikan material
yang diangkat tidak
melebihi kemampuan
angkat alat berat
Ensure that the material
being lifted does not
exceed the lifting
capability of the heavy
equipment
• Hanya signalman yang
akan memberikan signal
pada operator
Only the signalman will
give the signal to the
operator
• Pandangan operator
tidak terhalang
The operator's view is
not obstructed
• Gunakan radio untuk
memberi signal jika
diperlukan
Use the radio to give a
signal if needed
• Tidak bercanda selama
proses pengangkatan
No kidding during the
appointment process
• Buatkan rigging plan
jika pengangkatan >50
ton, tandem lift, >80%
dari kapasitas angkat
dan di kondisi yang
tidak normal
Make a rigging plan if
lifting> 50 tons, tandem
lift,> 80% of lifting
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

capacity and in
abnormal conditions
• Selalu gunakan base
plat untuk tumpuan
outrigger
Always use base plate
for outrigger support
• Memastikan outrigger
dalam kondisi fully
extended saat
melakukan
pengangkatan
Make sure the outrigger
in fully extended
condition during lifting
activity
• Pasang rambu-rambu
keselamatan dan
barikade di sekitar area
pengangkatan
Install the safety sign
and baricade around
lifting area
• Hindari titik jepit
material
Avoid the pinch point of
material
• Komunikasi dan
koordinasi yang baik
anatara pekerja
The good comuniction
and coordination
between workers
• Gunakan sarung tangan,
helem keselamatan,
kacamata, coverall dan
sepatu safety
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Use safety glove,

safety helmet, safety
glasses, coverall and
safety shoes

5 Melepas lifting gears • Bagian atau sisi • Tersayat bagian • Luka terbuka • Semua proses pelepasan
Take off the lifting material keras material yang akibat tersayat lifting gears dilakukan
gears dan tajam tajam bagian material oleh rigger yang
Parts or sides of exposed to the yang keras dan berpengalaman dan
material are hard sharp and hard tajam memiliki sertifikat
and sharp sides of the Open wounds resmi yang masih
• Titik jepit material caused by cutting berlaku
material • Terjepit diantara hard and sharp All lifting gears removal
Material pinch ttik jepit material material parts processes are carried
points Pinched between • Luka terbuka out by experienced
• Berat beban pinch point akibat terjepit riggers who have valid
lifting gears • Tertimpa alat kerja diantara titik jepit official certificates
The lifting gears Struck down the Open wounds do to • Beri pelindung atau
load work tools pinched between of softener pada sisi
5 3 15 Cecep (SPV)
• Pergerakan atau • Terkena pinch point material yang tajam 2 3 6
• Cedera pada Give a protective or & Yoga (HSE)
ayunan lifting pergerakan atau
gears ayunan lifting personil softener on the sharp
movement or swing gears Personal injuries side of the material
lifting gears Exposed to the • Tangan terkilir • Hindari titik jepit
movement or swing Sprained hand material
of lifting gears • Patah tulang Avoid the pinch point of
Fracture material
• Komunikasi dan
kordinasi baik antara
pekerja
The good comunication
and coordination
between workers
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Tidak berada dibawah

lifting gears yang
sedang di lepas
Not under the lifting
gears that are being
removed
• Jaga jarak aman dengan
ayunan lifting gears
Keep safe distance from
swing of lifting gears
• Pasang rambu-rambu
keselamatan dan
barikade di sekitar area
kerja
Instal the safety sign
and baricade around
work area
• Gunakan sarung tangan,
helem keselamatan,
kacamata, coverall dan
sepatu safety
Use safety glove, safety
helmet, safety glasses,
coverall and safety
shoes
6 Membuat Pondasi • Lubang terbuka • Terperosok • Luka memar • Pasang rambu-rambu
Making Foundation Open Hole kedalam lubang atau terkilir keselamatan dan hard
• Penggalian • Debu galian akibat barikade di sekitar
pondasi Dusty Fell into the open terperosok ke lubang galian
Excavation • Bagian material hole dalam lubang Instal the safety sign
Foundation yang keras dan • Menghirup debu galian and hard baricade 2 3 6
Cecep (SPV)
• Pemasangan tajam Inhaling dust Bruises or 4 4 16 around open hole area
& Yoga (HSE)
besi pondasi Hard and sharp • Terpapar debu sprains from • Gunakan blower untuk
Iron material Dust expotion falling into a mengarahkan debu
foundation • Bahaya arus • Tersayat bagian dug Use the blower to direct
instalation listrik material yang • Gangguan the dust
• Pengecoran Danger voltage tajam saluran
Concreting electric pernapasan
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Penggrindaa • Putaran batu cut a sharp piece akibat • Sediakan air bersih
n pondasi gerinda of material menghirup debu untuk membasuh mata
Grinding concrete Grinding disk • Tersengat aliran Respiratory di sekitar area kerja
cement rotary listrik disorder Provide clean water to
Electrical shock causing inhaling wash the eyes around
• Terkena putaran dusty the work area
batu gerinda • Iritasi pada mata • Sediakan air minum
Hit the grinding karena terpapar yang di lengkapi dengan
disk roraty debu pompa galon dan tidak
Irritating to eyes terpapar sinar matahari
from exposure langsung
to dust Provide drinking water
• Luka bakar equipped with a gallon
akibat tersengat pump and not exposed
aliran listriki to direct sunlight
Burns caused by • Pastikan semua alat
electric shock yang digunakan telah di
• Kematian inspeksi oleh pihak JO
Fatality Inspektor dan memiliki
• Luka terbuka taging resmi yang masih
akibat terkena berlaku
putaran batu Make sure all tools used
gerinda have been inspected by
Open wound the JO Inspector and
caused by grinding have valid official
stone rotation taging
• Pastikan semua panel
listrik dilengkapi
dengan ELCB dan
sistem grounding yang
baik
Ensure that all
electrical panels are
equipped with an ELCB
and a proper grounding
system
• Semua kabel power
tidak ada yang
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

terkelupas dan dalam

posisi digantung
menggunakan hanger
kabel yang dilengkapi
dengan isolator
All power cables are not
exposed and are in a
hanging position using
a cable hanger
equipped with an
insulator
• Gunakan batu gerinda
sesuai dengan fungsinya
Use the grinding stone
according to its function
• Tidak menggunakan
batu gerinda yang rusak
atau basah
Do not use grinding
stones that are damaged
or wet
• Pastikan kapasitas RPM
batu gerinda lebih besar
dari mesin gerinda
Make sure the RPM
capacity of the grinding
stone is greater than the
grinding machine
• Tidak melepas
pelindung pada mesin
gerinda
Do not remove the
guard on the grinding
machine
• Tidak memodifikasi
mesin gerinda
Does not modify the
grinding machine
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Gunakan helm
keselamatan, sepatu
keselamatan, kaca mata,
pelindung wajah,
masker dan coverall
Use safety helmet, safety
shoes, safety google,
facecield, dust mask and
coverall.
7 Pemasangan • Pergerakan alat • Alat berat • Pekerjaan • Lakukan TBM sebelum
kelengkapan kantor berat terperosok terhambat memulai pekerjaan
Instal office Heavy equipment Heavy equipment Activity is Do TBM before start
equipment movement has fallen hampered work
• Penempatan • Pengangkatan • Kecelakaan lalu • Kerugian finansial • Mmastikan semua
kontainer kontainer yang lintas Financial loss personil telah
Container kurang aman Trafic accident • Kerusakan pada memahami isi JSA &
placement Unsafe container • Miskomunikasi alat angkat angkut WMS
• Pemasangan lifting antara signalman The heavy Ensure that all
atap dan • Pergerakan di dan operator alat equipment broken personnel understand
tembok ketinggian berat • Cedera pada the contents of JSA &
Roof and wall Movement at Miscommunicatio personil WMS
installation height n between Personal injuries • Operator alat berat
• Pergerakan signalman and • Material rusak adalah orang yang
peralatan dan operator The material is 4 4 16 berpengalaman dan 2 3 6 Cecep (SPV)
material di • Tertimpa atau broken memiliki SIO resmi & Yoga (HSE)
ketinggian terhantam material • Luka terbuka yang berlaku
Tools and yang di angkat akibat terjepit Heavy equipment
material Crashed or hit by material operators are
movement at the material being Open wound do to experienced people who
height removed pinched material have a valid SIO
• Titik jepit • Alat angkat angkut • Patah tulang • Memastikan alat berat
material tumbang Fracture telah diinspeksi oleh
Pinch point The heavy • Cacat permanen pihak JO Inspektor dan
• Bagian material equipment collapse Permanent memiliki taging yang
yang keras dan • Terjatuh dari disability masih berlaku
tajam ketinggian • Kematian Ensure that the heavy
Hard and sharp Fall from height Fatality equipment has been
of material part • Material jatuh inspected by JO
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Material has fallen inspector and have a

• Tertimpa material valid tagging
atau alat kerja • Memastikan alat berat
yang jatuh dari yang digunakan
ketinggian memiliki sertifikat
Hit by material or migas resmi (SILO)
work tools that yang masih berlaku
have fallen from a Ensure that the heavy
height eqipment have a valid
official oil and gas
certificate
• Sediakan flagman untuk
memandu pergerakan
alat berat
Provide the flagman to
guide movement of the
heavy equipment
• Mengamankan area
manufer alat berat dari
orang yang tidak
berkepentingan
Securing heavy
equipment maneuvers
from unauthorized
persons
• Jarak pekerja dari alat
berat yang beroperasi
adalah 5m
The distance of workers
from operating heavy
equipment is 5 m
• Memastikan semua
lifting gears telah
diinspeksi oleh pihak JO
Inspektor dan memiliki
safety tag yang masih
berlaku
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Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Make sure the all lifting

gears has been
inspected by JO
Inspector and have a
valid tagging
• Gunakan lifting gears
sesuai dengan kapasitas
material yang akan
diangkat
Use lifting gears
according to the
capacity of the material
to be lifted
• Memastikan lifting
gears yang akan di
gunakan dalam kondisi
baik
Make sure the lifting
gears will used in good
condition
• Semua proses rigging
dilakukan oleh rigger
yang berpengalaman
dan memiliki sertifikat
resmi yang masih
berlaku
All rigging processes
are carried out by
experienced riggers
who have valid official
certificates
• Memastikan material
yang diangkat tidak
melebihi kemampuan
angkat alat berat
Ensure that the material
being lifted does not
exceed the lifting
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

capability of the heavy

equipment
• Hanya signalman yang
akan memberikan signal
pada operator
Only the signalman will
give the signal to the
operator
• Pandangan operator
tidak terhalang
The operator's view is
not obstructed
• Gunakan radio untuk
memberi signal jika
diperlukan
Use the radio to give a
signal if needed
• Tidak bercanda selama
proses pengangkatan
No kidding during the
appointment process
• Buatkan rigging plan
jika pengangkatan >50
ton, tandem lift, >80%
dari kapasitas angkat
dan di kondisi yang
tidak normal
Make a rigging plan if
lifting> 50 tons, tandem
lift,> 80% of lifting
capacity and in
abnormal conditions
• Selalu gunakan base
plat untuk tumpuan
outrigger
Always use base plate
for outrigger support
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Memastikan outrigger
dalam kondisi fully
extended saat
melakukan
pengangkatan
Make sure the outrigger
in fully extended
condition during lifting
activity
• Pasang rambu-rambu
keselamatan dan
barikade di sekitar area
pengangkatan
Install the safety sign
and baricade around
lifting area
• Hindari titik jepit
material
Avoid the pinch point of
material
• Komunikasi dan
koordinasi yang baik
anatara pekerja
The good comuniction
and coordination
between workers
• Gunakan full body
harness jika bekerja
>1,8 m
Use Full body harness if
working >1,8 mtr
• Pasang rambu-rambu
keselamatan dan
barikade di sekitar area
kerja
Install the safety sign
and baricade around
working area
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Gunakan sarung tangan,

helem keselamatan,
kacamata, coverall dan
sepatu safety
Use safety glove, safety
helmet, safety glasses,
coverall and safety
shoes
8 Pemasangan toilet • Lubang terbuka • Terperosok • Luka memar atau • Pasang rambu-rambu
portable dan bio Open hole kedalam lubang terkilir akibat keselamatan dan hard
septictank • Pergerakan alat galian terperosok ke barikade di sekitar
Installation of berat Fell into the open dalam lubang lubang galian
portable toilets and Heavy equipment hole galian Instal the safety sign
bio septic tanks movement • Alat berat Bruises or sprains and hard baricade
• Penggalian • Pengangkatan terperosok from falling into a around open hole area
Excavation yang kurang Heavy equipment dug • Sediakan flagman untuk
• Penempatan aman has fallen • Pekerjaan memandu pergerakan
toilet Unsafe lifting • Kecelakaan lalu terhambat alat berat
portable dan activity lintas Activity is Provide the flagman to
bio septic • Bagian material Trafic accident hampered guide movement of the
tank yang keras dan • Miskomunikasi • Kerugian finansial heavy equipment
Placement tajam antara signalman Financial loss • Mengamankan area
of portable Hard and sharp dan operator alat • Kerusakan pada manufer alat berat dari 2 3 6 Cecep (SPV)
toilets and 4 4 16 & Yoga (HSE)
material berat alat angkat angkut orang yang tidak
bio septic • Bahaya arus Miscommunicatio The heavy berkepentingan
tanks listrik n between equipment broken Securing heavy
• Penyetelan Danger voltage signalman and • Cedera pada equipment maneuvers
pipa PVC electric operator personil from unauthorized
jalur air • Putaran batu • Tertimpa atau Personal injuries persons
Water line gerinda terhantam material • Material rusak • Jarak pekerja dari alat
PVC pipe Grinding disk yang di angkat The material is berat yang beroperasi
fitup rotary Crashed or hit by broken adalah 5m
the material being • Luka terbuka • The distance of workers
removed akibat terjepit from operating heavy
• Alat angkat angkut material equipment is 5 m
tumbang Open wound do to • Memastikan semua
The heavy pinched material lifting gears telah
equipment collapse • Patah tulang diinspeksi oleh pihak JO
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Tersayat bagian Fracture Inspektor dan memiliki

material yang • Cacat permanen safety tag yang masih
tajam Permanent berlaku
cut a sharp piece disability Make sure the all lifting
of material • Kematian gears has been
• Tersengat aliran Fatality inspected by JO
listrik Inspector and have a
Electrical shock valid tagging
• Terkena putaran • Gunakan lifting gears
batu gerinda sesuai dengan kapasitas
Hit the grinding material yang akan
disk roraty diangkat
Use lifting gears
according to the
capacity of the material
to be lifted
• Memastikan lifting
gears yang akan di
gunakan dalam kondisi
baik
Make sure the lifting
gears will used in good
condition
• Semua proses rigging
dilakukan oleh rigger
yang berpengalaman
dan memiliki sertifikat
resmi yang masih
berlaku
All rigging processes
are carried out by
experienced riggers
who have valid official
certificates
• Memastikan material
yang diangkat tidak
melebihi kemampuan
angkat alat berat
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Ensure that the material

being lifted does not
exceed the lifting
capability of the heavy
equipment
• Hanya signalman yang
akan memberikan signal
pada operator
Only the signalman will
give the signal to the
operator
• Pandangan operator
tidak terhalang
The operator's view is
not obstructed
• Gunakan radio untuk
memberi signal jika
diperlukan
Use the radio to give a
signal if needed
• Tidak bercanda selama
proses pengangkatan
No kidding during the
appointment process
• Buatkan rigging plan
jika pengangkatan >50
ton, tandem lift, >80%
dari kapasitas angkat
dan di kondisi yang
tidak normal
Make a rigging plan if
lifting> 50 tons, tandem
lift,> 80% of lifting
capacity and in
abnormal conditions
• Selalu gunakan base
plat untuk tumpuan
outrigger
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

Doc. No. 26071-JO-HSE-014

ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Always use base plate

for outrigger support
• Memastikan outrigger
dalam kondisi fully
extended saat
melakukan
pengangkatan
Make sure the outrigger
in fully extended
condition during lifting
activity
• Pasang rambu-rambu
keselamatan dan
barikade di sekitar area
pengangkatan
Install the safety sign
and baricade around
lifting area
• Berikan pelindung pada
sisi material yang tajam
atau keras
Provide protection
against sharp or hard
sides of material
• Pastikan semua alat
yang digunakan telah di
inspeksi oleh pihak JO
Inspektor dan memiliki
taging resmi yang masih
berlaku
Make sure all tools used
have been inspected by
the JO Inspector and
have valid official
taging
• Pastikan semua panel
listrik dilengkapi
dengan ELCB dan
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

sistem grounding yang

baik
Ensure that all
electrical panels are
equipped with an ELCB
and a proper grounding
system
• Semua kabel power
tidak ada yang
terkelupas dan dalam
posisi digantung
menggunakan hanger
kabel yang dilengkapi
dengan isolator
All power cables are
not exposed and are in
a hanging position
using a cable hanger
equipped with an
insulator
• Gunakan batu gerinda
sesuai dengan fungsinya
Use the grinding stone
according to its function
• Tidak menggunakan
batu gerinda yang rusak
atau basah
Do not use grinding
stones that are damaged
or wet
• Pastikan kapasitas RPM
batu gerinda lebih besar
dari mesin gerinda
Make sure the RPM
capacity of the grinding
stone is greater than the
grinding machine
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Tidak melepas
pelindung pada mesin
gerinda
Do not remove the
guard on the grinding
machine
• Tidak memodifikasi
mesin gerinda
Does not modify the
grinding machine
• Gunakan helm
keselamatan, sepatu
keselamatan, kaca mata,
pelindung wajah,
masker dan coverall
Use safety helmet, safety
shoes, safety google,
facecield, dust mask and
coverall.
9 Pemasangan Fasilitas • Bagian sisi • Anggota tubuh • Luka terbuka • Beri pelindung atau
Listrik Sementara material keras tersayat bagian akibat tersayat softener pada sisi
Temporaray Facility dan tajam material yang bagian material material yang tajam
Electricity Hard and sharp tajam yang tajam Give a protective or
Instalation material The limb is cut by a Open wound softener on the sharp
• Bahaya arus sharp material causing cut of side of the material
listrik • Tersengat aliran sharp material • Hindari titik jepit
Danger voltage listrik • Luka bakar serius material
electric Electrical shock akibat tersengat Avoid the pinch point of
• Pergerakan di • Jatuh dari aliran listrik 4 4 16 material 2 3 6 Cecep (SPV)
ketinggian ketinggian Serious burns • Komunikasi dan & Yoga (HSE)
Movement at Fall from height resulting from kordinasi baik antara
height • Terpeleset electric shock pekerja
• Area kerja basah slip • Peralatan listrik The good comunication
dan licin • Salah dalam rusak karena salah and coordination
Wet and sllipery komunikasi dalam between workers
work area Miscomunication penyambungan • Pemasangan dan
• Komunikasi yang kabel penyambungan kabel
buruk
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

Bad Electrical hanya dilakukan oleh

communication equipment is teknisi elektrik yang ahli
damaged due to Installation and
incorrect cable connection of cables is
connections only performed by
• Kematian qualified electricians
Fatality • Gunakan FBH jika
bekerja >1,8 m
Use FBH if working
>1,8 m
• Semua panel listrik telah
terpasang ELCB dan
kabel pertanahan yang
baik
All the electrical panel
must be instal the ELCB
and grounding cable
• Gunakan APD dengan
baik dan benar sesuai
dengan fungsinya
Use PPE properly and
properly according to
its function
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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10 Pekerjaan di malam • Tingkat • Tersandung • Cidera pada • Pastikan penerangan

hari pencahayaan material personil pada malam hari
Working at night yang kurang Stumble by Personel injury mencukupi
Less lighting material • Luka terbuka Ensure adequate
level • Terjepit diantara Open wound lighting at night
• Cuaca buruk titik jepit materia • Luka berat • Pastikan jarak pandang
Bad weather sandwiched Major wound operator tidak terhalang
• Kondisi fisik between the clamp • Luka memar Ensure that operator
pekerja points of the karena terpeleset visibility is not
Physical material Bruises from obstructed
condition of • Terperosok slipping • Tempatkan penerangan
workers Is mired • Patah tulang di setiap titik aktifitas
• Kesalahan dalam • Area kerja Fracture bongkar muat
pengangkatan tergenang air • Alat kerja rusak Place lighting at each
Lifting failure The work area is Tools is broken point of loading and
flooded • Pekerja pingsan unloading activity
• Alat kerja terguyur karena kelelahan • Segera hentikan
hujan The worker aktifitas jika turun
The tools were collapsed from hujan, petir dan angin Cecep (SPV)
5 3 12 2 3 6
poured in by rain exhaustion kencang & Yoga (HSE)
• Kecepatan angin • Kematian Immediately stop
di atas 10m/s Fatality activities when it rains,
Wind speed is lightning and strong
more than 10m/s winds
• Pekerja • Pastikan pekerja dalam
mengalami kondisi sehat atau fit
kelelahan Make sure the workers
Workers are fit to work
exhausted • Lakukan manajemen
• Alat berat fatigue
tumbang Do the fatigue
Heavy equipment management
collapsed • Pekerja tidak bekerja
• Material runtuh secara terus menerus
Material crumbling Workers do not work
continuously
• Istirahat secara regular
Take regular breaks
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

• Sediakan air minum di

area kerja
Provide the wather
drinking station on the
work area
• Pastikan beban yang
diangkat adalah
dibawah 5ton
Make sure the load
lifted is below 5 tons
• Tinngi pengangkatan
<3mtr
Lifting height <3mtr
• Radius pengangkatan
tidak >20mtr
Lifting radius is not> 20
mtr
• Max 75% dari kapasitas
angkat crane
Max 75% of crane
lifting capacity
• Kecepatan angin
dibawah 10m/s
Wind speed below
10m/s
• Diawasi langsung oleh
SPV yang
bertanggungjawab
Supervised directly by
the responsible SPV
• Lakukan pengukuran
penerangan
Take lighting
measurements
• Gunakan kacamata
bening
Use clear safety glases
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
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12 Aktifitas • Area kerja • Tersandung • Cedera pada • Perhatikan sekitar saat

housekeeping berantakan Stumble personil melangkah
Housekeeping The work area is • Terpeleset Personil injuries Pay attention around
activity a mess Slip • Luka memar pada when stepping
• Alat kerja dan • Terperosok tubuh • Komuinikasi dan
material Is mired Bruises on the kordinasi yang baik
berantakan • Material atau alat body anatar pekerja
Working tools kerja hilang • Terkilir Good communication
and materials are Material or work Sprained and coordination
a mess tools are missing • Tulang retak atau between workers
• Paku dan benda • Menginjak paku patah • Menutup semua lubang
tajam atau menyentuh Broken bones or terbuka
Nails and sharp benda tajam fracture Close all open holes
objects Stepping on a nail • Kerugian materi • Simpan dan rapikan
or touching sharp karena material kembali alat dan
objects atau alat kerja material di dalam box
hilang alat dan material storage
Financial loss due Store and trim back Cecep (SPV)
to missing work 3 2 6 tools box and materials 2 2 6
& Yoga (HSE)
materials or tools in tool and material
• Luka terbuka storage boxes
akibat tersayat • Bengkokan atau cabut
benda tajam semua paku
Open wounds Bend or remove all nails
caused by sharp • Berikan proteksi atau
objects cover pada semua sisi
material yang tajam
Provide protection or
cover on all sides of the
sharp material
• Gunakan sarung tangan,
helem keselamatan,
kacamata, masker,
coverall dan sepatu
safety
Use safety glove, safety
helmet, safety glasses,
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
DEVELOPMENT MASTER PLAN (EPC FOR RDMP) RU-V BALIKPAPAN PROJECT
Revision No. 001

mask, coverall and

safety shoes

Risk Rangking (RR) Recommendation Action

Probability (PR) Severity / consequence Tingkat Risiko Tindakan Pengendalian
x =
Kemungkinan Keparahan
Score Level Tingkat pengendalian Hierarchy of Control
Frequent =5 Catastrophic =5 19-25 Extreme high E= 1+2+3+4+5 1= Elemination
Probable =4 Major =4 13-18 High H= 3+4+5 2= Substitution
Occasional = 3 Moderate / Serious = 3 6-12 Medium M= 4+5 3= Engineering Control
Unlikely =2 Minor =2 1-5 Low L=5 4= Administration
Improbable = 1 Negligible =1 5= PPE

Note : * : Without Control / Tanpa control

*) : With Control / Dengan control
 JOB SAFETY ANALYSIS (JSA) AND RISK ASSESSMENT FORM

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ENGINEERING PROCUREMENT CONSTRUCTION FOR REFINERY Effective Date 13 January 2021
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JSA No. : RDMP / JSA /......................... / .....................

JSA Title : TEMPORARY FACILITY INSTALATION

ATTENDANCE LIST – PRE-JOB SAFETY MEETING (JSA SOCIALIZATION)

Signature
No Name Position Company
Date: Date: Date: Date: Date: Date: Date:

10

11

12