Facility/ Lokasi : Assessed by (dipersiapakan Oleh) :
Job/ Pekerjaan/ Aktifitas : Tanggal/Bulan : Job Dilakukan oleh (jabatan) : Revisi No : Group Leader untuk Preventive action : : JSA Number : Disetujui oleh Ka Departemen / Section : SHE Coordinator :
Urutan Potensi Akibat yang Tindakan
Lokasi/ K3 Tingkat Resiko Rekomendasi kegiatan pada Bahaya ditimbulkanya. Pengendalian Kemungkinan Akibat Peraturan No. Kegiatan/ L A / Dampak pengendalian pekerjaan (Hazard/ ( Consequence yang telah (K) (A) terkait Bahan S H (K)x(A) tambahan (Proses) Aspek) /Dampak) dilakukan
Likelihood/ Kemungkinan terjadi Severity/ Kemungkinan besarnya dampak B. Dampak bagi Aset/ Perlengkapan/Lingkungan Tabel Nilai Resiko 1. Rare = practically impossible A. Dampak bagi Personal 1. Insignificant = loss < 5,000,000. 2. Unlikely = may occur at some time 1. Insignificant = no treatment required, level 2. Minor = 5,000,001 < loss < 50,000,000. Likeli- Severity of Risk 3. Possible = could occur or “I have heard of it short time injury 3. Moderate = 50,000,001< loss < 500,000,000 hood 1 2 3 4 5 happening” 2. Minor = first aid 4. Major = 500,000,0001 < loss < 4. Likely = known to occur or “it has happened” 3. Moderate = MTI or LTI by doctor 1,000,000,000. 1 L L L M H 5. Almost Certain = occur in most circumstances certificate 5. Catastrophic = loss > Rp 2 L L M H H or repeating occurrence 4. Major = permanent disability or single fatality 1,000,000,000. 3 L M H H E 5. Catastrophic = multiple fatalities 4 M H H E E 5 H H E E E Prosedur-QSHE-001/S1 Rev 0 Eliminasi, subtitusi, engineering desain, dengan cara administrasi atau memberlakukan prosedur operasional (Work Instruction) serta fasilitas Alat pelindung diri
Likelihood/ Kemungkinan terjadi Severity/ Kemungkinan besarnya dampak B. Dampak bagi Aset/ Perlengkapan/Lingkungan Tabel Nilai Resiko 6. Rare = practically impossible A. Dampak bagi Personal 6. Insignificant = loss < 5,000,000. 7. Unlikely = may occur at some time 6. Insignificant = no treatment required, level 7. Minor = 5,000,001 < loss < 50,000,000. Likeli- Severity of Risk 8. Possible = could occur or “I have heard of it short time injury 8. Moderate = 50,000,001< loss < 500,000,000 hood 1 2 3 4 5 happening” 7. Minor = first aid 9. Major = 500,000,0001 < loss < 9. Likely = known to occur or “it has happened” 8. Moderate = MTI or LTI by doctor 1,000,000,000. 1 L L L M H 10. Almost Certain = occur in most certificate 10. Catastrophic = loss > Rp 2 L L M H H circumstances or repeating occurrence 9. Major = permanent disability or single fatality 1,000,000,000. 3 L M H H E 10. Catastrophic = multiple fatalities 4 M H H E E 5 H H E E E Prosedur-QSHE-001/S1 Rev 0
