JSA Form

Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
Date : 1 March 2017 JSA No. : JSA/001 Name Sign

Job Title : Erection of Pole with Crane Person In charge :

Location. : Depot Area Originator Team : [Link] Y

2. Muchlis
Standard Requirement : 3.
Standard PPE: Safety Helmet Safety shoes Special PPE : 4.
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
Safety glasses Ear protection
Reviewed by :
Special attention :
Approved by :
Jika kondisi / cuaca buruk STOP semua kegiatan dan Evaluasi ( if the condition or weather getting worst, please stop all activity and conduct evaluation)
No Work Steps Hazards Identified Hazards Effect Risk Factor * Safety Measures & Residual Risk
. Prevention Factor *)
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
Tindakan untuk mencegah
Langkah kerja secara Bagaimana bisa terjadi mencederai
Type dari cedera atau kerugian L C RF agar tidak terjadi cedera atau L C RF
berurutan orang atau kerugian
kerugian

1 Konfirmasi status
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
pembentukan dan

mencegah tenggelam,

miring formasi bila

diperlukan. Memperpanjang
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
outrigger truk Crane

sepanjang jalan dan

mengatur crane ke posisi

2 Memasang kawat sling ke Tangan terjepit atau terjerat saat Cidera, Cacat 3 3 9 Menggunakan alat Pelindung 3 1 3
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
tiang di tempat sekitar 1 m memasang sling ke tiang Diri : Handglove

dari puncak tiang

3 Ketika siap, naik ke puncak

tiang dengan wending

 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
winch sedikit dan Tangan / kaki / terpukul oleh palu /

mengkonfirmasi jika alat bantu pada saat erection Cidera, Cacat Menggunakan alat Pelindung

lampiran kawat sling dan Diri : Handglove, Safety Shoes

4 posisinya sudah benar

 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.

Wind winch atas jauh dan Tertimpa oleh material tiang yang Cidera, Cacat, Kematian Safety talk, Induction,

mengarahkan akar tiang ke jatuh pada saat erection / Penggunaan tali pengendali

lubang di fondasi mencegah pengangkatan saat melakukan pengangkatan,

 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
bergoyang atasnya dengan pengawasan selama pekerjaan,

5 menggunakan puling rope Safety line,APD

Operasikan winch perlahan

Cran roboh pada saat erection Cidera, Cacat, KematianCidera,
dan tempat akar tiang ke
dalam lubang dengan benar
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
karena kecerobohan operator / Cacat, Kematian, Kerusakan aset

6 operator tidak ahli

Pegang tiang dan pondasi

dengan wedges dan Periksa Material Tiang menabrak barang / Cidera, Cacat, KematianCidera,
erection gauge dan
menggunakan plum-bob
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name

dan mengkonfirmasi Div.

alat lain pada saat erection / Cacat, Kematian, Kerusakan aset
keselarasan dan posisi
secara vertikal tiang dan pengangkatan karena kecerobohan
memperbaiki tiang ke
dalam posisinya operator / operator tidak ahli

7
Spirit Level / Waterpass
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
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PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name

akan diperlukan untuk tiang Div.

pengaturan vertikal.

8
Pada bagian balok V-Truss,
tiang jarak ke tiang harus
akurat untuk mencocokkan
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name

panjang V-Truss balok yang Div.

akan diinstal
9 Tempatkan pole ke dalam
lubang pondasi

Tangan terjepit atau terjerat saat Cidera,Cacat,

 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
memasang pole ke dalam lubang

pondasi
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.

Safety Measures & Residual Risk

Work Steps Hazards Identified Hazards Effect Risk Factor *
No Prevention Factor *)
.
Langkah kerja secara Bagaimana bisa terjadi mencedrai Type dari cedera atau kerugian L C RF Tindakan untuk mencegah L C RF
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
agar tidak terjadi cedera atau
berurutan orang atau kerugian
kerugian
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
 JSA Form
Security Level 2

ENGINEERING GUIDE FOR XXXXXX XXXX G-TEGX-XXXX-XXX

XXXXXXXXX XXXXXXXX XXXXXXXXX
HISTORY
XXXXXX XXXXXXXX XXXXXXXXXX
PAGE　1　OF

･ISSUE DATE

REV. ･ISSUE GRADE DESCRIPTION

･AUTHORIZATION

0 [Link],'YY (1) Background and Reasons for Establishment

(a)
Newly Established (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name
Div.
1 [Link]'YY (1) Background and Reasons for Revision
(a)
Partly Revised (b)
(c)
XXXXXXXXXXX (2) Department and Author xxxxxxxxx xxxxxxxx Dept. Name

Note : * : Without Control *): With Control Div.

L = likelihood C = Consequences RF = Risk Factor
Risk Factor (RF) Determined Control
Likeliho Severity / consequence Tingkat Risiko Penetapan Pengendalian
X =
od (L) Keparahan (C
Score Level Tingkat pengendalian Hierarchy of Control
Frequent =5 Catastrophic = 5 14-25 High (H) E= 1+2+3+4+5 1= Eleminasi
Probable = 4 Major = 4 11-13 Medium (Med) H= 3+4+5 2= Substitusi
Occasional = 3 Moderate/serious =3 7-10 Moderate (Mod) M= 4+5 3= Engineering technik
Unlikely = 2 Minor = 2 4= Administrasi
1-6 Low (L) L=5
Improbable = 1 Negligible = 1 5= APD