SAFE WORK PERMIT
Jenis Pekerjaan Cold Work Hot Work Masuk Ruang Terbatas Koordinasi dengan Kontraktor
Gangguan Tanah Kendaraan Masuk/Masuk Site
Tanggal:
Lokasi:
Deskripsi pekerjaan:
Kontraktor/Employer(s):
Jumlah Pekerja:
TINJAUAN DAFTAR PERIKSA BAHAYA IZIN KERJA AMAN
LIHAT HALAMAN BERIKUTNYA untuk daftar bahaya umum yang mungkin ingin Anda diskusikan sebagai bagian dari izin kerja.
Tentukan bahaya spesifik pekerjaan di bawah ini
Resiko BAHAYA IZIN KERJA PENGENDALIAN RISIKO/TINDAKAN PENCEGAHAN
(Risiko menilai setiap bahaya KESELAMATAN/RENCANA KERJA UNTUK MENGHADAPI SETIAP
dengan matriks) BAHAYA YANG TERIDENTIFIKASI (Referensi prosedur & standar
ditinjau)
PROSES MATRIKS PENILAIAN RISIKO (lihat Kriteria Matriks Nama Perusahaan untuk Deskripsi)
6 III II I I I I
KEMUNGKIN
5 III III II I I I
EMPAT PERTANYAAN RISIKO DASAR 4 IV III III II I I
Apa yang salah? Identifikasi Bahayanya. 3 IV IV III III II I
Seberapa buruk itu? Dampak / Konsekuensi / Keparahan 2 IV IV IV III III II
Apa Probabilitas/Kemungkinan hal itu terjadi? 1 IV IV IV IV III III
M
A
N
Apa yang dapat saya/kita lakukan? Kontrol risiko 1 2 3 4 5 6
KONSEKUENSI Meningkat
DAFTAR PERIKSA BAHAYA IZIN KERJA AMAN
CATATAN: PERIKSA BAHAYA DAN PERSYARATAN LAIN YANG DITINJAU SEBAGAI BAGIAN DARI RENCANA KERJA
INI
BAHAYA
Fire & Explosio Toxicity Mechanical Energy Effluents
Flammable Material H2S Kinetic Emissions
Explosive (perf. Guns.TNT etc) O2 Deficiency Equipment Dusts
Natural (e.g. forest fires) Carbon Monoxide Suspended / Potential Spills
Vapors/liquids Fumes / Vapors Trenching/Excavation Wastes
Flammable atmosphere Absorption Working at Heights Weather Conditions
Ignition Sources Chemical Slips /Trips Temperature
Welding Process People Visibility
Spark causing tools/motors Treating chemicals Physical Energy Site Conditions
Internal combustion engines Corrosives Noise/Light exposures Precipitation
Diesel Positive Air Shutoff Oxidizer/reactive Electrical Wind direction / speed
Pilot Lights Test Fluids Electromagnetic Biological
Static electricity Paints / Sealers etc. Pressurized Wildlife /animals
Identified/Controlled Asbestos Radiation (x-ray) Insects
MSDSs NORMS Bacteria/Molds/Viruses
Body fluids
KONTROL RESIKO
PROCEDURES Confined Space Entry Other Overhead Power Lines
Emergency Response Work / Rescue plan Gas Test Required Identified / Clearances
Emergency Phone List Trenching/Excavation Intermittent _______min. Hazards Related to Other Work
Site First Aid Plan Work/Rescue Plan Continuous Underway __ No __Yes, Specify_____
Alarms/Conditions Isolation Gas Detection Equipment Planned __No __ Yes, Specify_______
Egress/Muster Process/Pressure Bump Tested Other___________
Rescue Procedures & /Equip Bleeds & Drains Building Entry Miscellaneous
Plan Review & Exercise Flare System Purging/Venting/Flaring/Cleaning Lock out / Tag out
Critical Task Procedures Electrical Vessels Depressuring / Venting
Reviewed Cathodic protection Lines Grounding / Bonding
Copy Attached Mechanical Tanks/Incinerators/Flare Stacks Smoking Rules I Area
Working Alone Spacing / Clearances Other Ladders / Scaffolds
Company Name Fired Equipment Hazardous Areas Fall Protection
Contractor Site Hazards Identified Buddy System
Ground Disturbance Flares/Vents/Storage Vessels Barricaded / Signed Towing Procedures
GD Checklist Completed Safe Vehicle Operation Buried Facilities / Pipelines / Waste disposal
Vehicle back up beepers Conduits / Electrical Other —
TRAINING Competency for Task Fall Protection WORKPLACE
Safety Orientation Rigging and slinging High Angle Rescue Refusal of Unsafe Work
Health & Safety Rules First Aid / CPR Confined Space Entry & Rescue Workplace Violence
Reviewed
Orientation TDG Ground Disturbance NO FEAR Workplace
Contractor WHMIS Line Locating ALL incidents reported
Company Name H2S B0P / Well Control Hazard Identification Cards
Mobile Equipment, Basic Fire Training All Certifications On Site
Loaders,
Cranes, Forklifts. etc Gas Detection Equipment Other
Use
EQUIPMENT_REQUIRED Breathing Apparatus Communication Equipment Barricades
PPE Appropriate for Task SCABA (Intrinsically Safe) Miscellaneous
Monitors (LEL. H2S, 02, SABA / Air Trailer Intrinsically Safe Cords, Lights, Welding / Splash Shield
CO)
Other Respirator Flashlights, Equipment Ventilators / Air Moving Equip.
_______________
First Aid Kit / Equipment Safety / Fire Watch/Stand Fall Protection Equipment Air Hood
by
Eye / Skin Wash / Shower Personnel Assigned to Fall Arrest Devices Watertight Equipment
_______
Shower Truck Ignition Equip./ Flare Gun) Harness Spill / Pollution Control Equip.
Emergency Transport Firefly Signaling Device Equipment Spacing Tag Lines
Vehicle
Ambulance & EMT Fire Suppression Other Sewage Containment Equip.
Auto Resuscitator Portable Rescue Equipment Garbage/Recycle Bins
Auto Defibrillator Wheeled Ladders / Platforms / Scaffolds Supplemental Lighting
Fire Truck(s) Warning Signs Other
1. PERJANJIAN VALIDASI IZIN KERJA AMAN
PEMERIKSAAN SAFETY
DILAKUKAN OLEH:
Name Signature Contact Number Date/Time
Permit Date & Time Permit Valid Date & Time Permit Date & Time
Issued Until Extended
PERMIT ISSUER/Print Name Signature
I understand the work explained to me and the requirements and safety precautions to be followed. I
understand that work conditions change or hazards occur (ex: flammable/toxic material leaks, spills,
drastic operating change in adjacent equipment/process, etc.) I am to stop work and contact the permit
issuer immediately.
PERMIT RECEIVER / Print Name Company - Signature - Permit Returned . Signature
PERMIT RECEIVER I Print Name Company Signature Permit Returned - Signature
PERMIT RECEIVER / Print Name Company Signature Permit Returned - Signature
PERMIT RECEIVER I Print Name Company Signature Permit Returned - Signature
PERMIT RECEIVER / Print Name Company Signature Permit Returned - Signature
Permit Returned (Date & Time Permit Issuer (Signature)
Work Complete
ORIGINAL — ISSUER COPY — WORKSITE / WORK-
GROUP
