JOB SAFETY ANALISYS FORM
PROJECT : Pembangunan Jalan tol JTTS – BA -S DATE : 16 April 2024 JSA NO.: 001
TASK / Job : Penimbunan tanah dengan menggunakan Dozer + Compactor JSA Team
LOCATION Banda Aceh NAME POSITION SIGNATURE
NO. OF PERSONS INCLUDED IN TASK 6 org Ari Suhendra Team JSA Leader
TASK DESCRIPTION / Job step:
Agung Supervisor
1. Survey utk menentukan volume timbunan
2. Galian tanah utk timbunan
Afsal Foreman
3. Menggeser tanah timbunan dengan dozer
4. Pemadatan Mega Engineer - QC
5. QC test
6. Pekerjaan selesai – Parkir alat
Nur kholis HSE / Team K3
REFERENCE: JSA Team Leader confirm that the risk for task 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 task can be proceed
1. Dena lokasi
2. SOP NAME SIGNATURE
3. Method Statement DESIGNATION
4. Mengisi form
5. Certificates Date:
6. MCU certificate
7. PTW / Izin kerja I am satisfied that the controls measures identified when put into place will reduce the risk to tolerable level. The
task/action change is permitted to proceed. CONFIRMED & APPROVED BY PROJECT MANAGER
NAME SIGNATURE
DESIGNATION
Date:
JSA WORK SHEET
TASK DESCRIPTION
Hazard Identification Risk Evaluation Risk Control
Hazard Effect: Initial Actions
Hazard Description TYPE Control measures: Residual Responsible
No. Task Activity : SD Manusia, Aset, Risk/ Resiko Closed
Potensi Bahaya Cidera, Loss, pencemaran E, S, RE, DC, APD Risk Person
Lingk Awal (Y/N)
S P R S P R
1 Survey utk
menentukan
volume
timbunan
2 Galian tanah utk
timbunan
3 Menggeser Terlindas/tertabrak alat Manusia Cidera - Gunakan APD yg dilengkapi No
tanah timbunan dozer reflector
- Dozer dilengkapi lampu Yes
dengan dozer
E 2 H4 penerangan C 1 L6 Supv
Yes
- Terdapat petugas pengawas
lalulintas
-Operator legal
Dozer terbalik Alat Loss - Operator Supv Yes
berpengalaman
E 3 H5 - Surat izin operasi D 1 M2 No
- Pemeliharaan rutin
Yes
jalan yg akan di lalui
Tertimbun tanah timbunan Manusia Cidera - Memasang rambu2 Supv Yes
peringatan No
H5 - Gunakan APD yg L5
E 3 B 1
dilengkapi reflector
No
- Terdapat petugas
pengawas lalulintas
4 Pemadatan
5 QC test
2
JSA WORK SHEET
TASK DESCRIPTION
Hazard Identification Risk Evaluation Risk Control
Hazard Effect: Initial Actions
Hazard Description TYPE Control measures: Residual Responsible
No. Task Activity : SD Manusia, Aset, Risk/ Resiko Closed
Potensi Bahaya Cidera, Loss, pencemaran E, S, RE, DC, APD Risk Person
Lingk Awal (Y/N)
S P R S P R
6 Pekerjaan
selesai – Parkir
alat
10
11
3
S = SEVERITY = TINGKAT KEPARAHAN
P = PROBABILITY = TINGKAT KEMUNGKINAN
R = RISK = RESIKO
