PMO

JOB SAFETY ANALYSIS (JSA) FORM

PROJECT PD#3 PROJECT DATE : 13 Maret 2025 JSA NO.:09/HSPD/PMO/JPN/25 REV. 00
JSA TEAM
CONTRACTOR PT. Jaya Pondasi Nusantara
(First Named – JSA Team Leader)
Dismantling HSPD (Hydraulic
JOB TITLE
Static Pile Drive)
NAME POSITION SIGNATURE

LOCATION PD#3 Upgrade Putra Sinuhaji Site Manager

ITEM Fahmi Candra HSE
JOB DESCRIPTION: Imannuel Sitepu Supervisor PT JPN
- Persiapan Kerja
- Set up Crane Imam Ghazali Civil PMO
- Dismantle & Loading Aksesoris HSPD (Hydraulic Static
Indra Sitorus / Andri S HSE PMO
Pile Drive)
- Shifting and positioning body HSPD at Lowbed Edbert Gozali PD Operation
- Demobilisasi HSPD (Hydraulic Static Pile Drive)
- House keeping Arry Susanto PD Project Leader
- Emergency Response Team Della OHS LPnC

REFERENCE AND OTHER RELEVANT

INFORMATION: NAME Putra Sinuhaji
e.g. ERP required, Competency requirements, Tools &
equipment, PTW, Drawings, Lifting Plan, Procedures, POSITION Site Manager
P&IDs, Certificates, PPE required, etc.
- PPE - Equipment SIGNATURE Date:
1. Safety Helmet 1. Crane Service 90 T
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
2. Safety Glasses 2. Trailer proceed. CONFIRMED & APPROVED BY PROJECT/SITE MANAGER/HSE MANAGER
3. Safety Shoes 3. Lifting Gear
4. Uniform 4. HSPD NAME Ajis Ismail
5. Full Body Harness POSITION Manager HSE PMO
6. Hand Glove
SIGNATURE Date:
# STOP Work if Found Un-Safe #
1. Persiapan Kerja Tidak kompeten  MTI 1. Spv harus memastikan kru yang terlibat memiliki pengetahuan, - HSE PT JPN
JSA WORK SHEET dan keterlibatan  LTI kompetensi dan diberikan otoritas untuk melaksanakan aktivitas (Fahmi)
pekerja yang tidak diarea PD#3. - SPV PT JPN
JOB TITLE memiliki otoritas 2. Spv harus melakukan pendampingan dan memberikan arahan dan (Imannuel)
instruksi sesuai dengan aktivitas di area PD#3. - HSE PMO
Hazard Identification Risk Evaluation Risk Control (Andri
3. Pastikan sebelum pekerjaan di mulai PERMIT dan JSA sudah
Seqience of Job Hazard Description Hazard Effect S)/(KevinF)
Done by Check
No. tersedia dan sudah di approved olehmeasures
Control User, HSE PMO, LPnC dan
(Urutan Pekerjaan (Penjelasan Bahaya) (Dampak Bahaya) - Civil PMO
(Dilakukan Oleh) ()
team Proses.
(Imam)
4. Pastikan untuk pekerjaan critical lifting sudah tersedia Lifting Plan. - OHS LPnC
5. Pastikan melakukan Tool Box Meeting sebelum memulai (Della)
pekerjaan. - Team Proses
6. Pastikan Heavy Equipment sudah diperiksa dan diinspeksi dalam (Edbert)
keadaan bagus/lulus inspeksi.
7. Pastikan operator atau rigger bersertifikat dan kompeten yang
diizinkan untuk mengoperasikan Heavy Equipment.
8. Pastikan akses Heavy Equipment tersedia.
9. Pastikan hanya pekerja yang berkepentingan (ditunjuk) yang
diizinkan berada di area kerja. Jika dibutuhkan, maka akan ada
seorang flagman/signalman untuk mengamankan area kerja dan
memberikan sinyal kepada operator HE.
10. Pastikan semua kru mendapatkan informasi yang tepat dari Spv
lapangan.
11. Flagman harus melakukan survey terkait jalur laulan dan kondisi
tanah cukup kuat untuk dilalui oleh HE.
12. Pastikan signboard/ Traffic corn terpasang untuk memberikan
peringatan bahaya kepada pekerja.
13. Pekerja harus selalu menggunakan APD mandatory (Safety
Helmet, Safety Shoes, Safety Glass, uniform, sarung tangan sesuai
jenis pekerjaan.
Pekerja tidak fit MTI Pastikan pekerja dalam keadaan sehat, fokus pada saat bekerja dan - HSE PT JPN
melakukan komunikasi yang baik dan tepat. (Fahmi)
- SPV PT JPN
(Imannuel)
Cuaca Buruk MTI Stop pekerjaan saat kondisi cuaca hujan, petir, angin kencang dan - HSE PT JPN
gempa bumi. (Fahmi)
- SPV PT JPN
(Imannuel)
2. Set Up Crane Crane  Property 1. HSE personil harus memastikan bahwa JSA dan Permit sudah - HSE PT JPN
Tumbang/Terbalik Damage tersedia saat set up crane akan dilakukan. (Fahmi)
 Fatality 2. Operator mobile crane harus berpengalaman dan bersertifikasi - SPV PT JPN
memiliki SIO yang valid. (Imannuel)
3. Rigger harus berpengalaman dan memiliki lisensi. - Rigger PT
4. Mobile crane harus yang layak dioperasikan dan sudah lulus JPN (Indra)
- Opr Crane PT
inspeksi.
JPN (Pattar)
5. Spv memastikan area laluan & tempat destinasi akhir dari crane
memiliki luas yang cukup dan permukaan tanah yang solid.
6. Rigger memastikan Out rigger terbuka full dan menggunakan base
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) ()
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