Daihatsu Sales Operation - Prosedur LK3

IJIN BEKERJA DI ATAS KETINGGIAN

WORK AT HEIGHT PERMIT

A. Isi sebelum memulai pekerjaan / To be completed prior to work Form : F 05/EHS-DSO/P 001
Lokasi kerja ketinggian: ………………………………….………………………………………………………
Location of work at height
Departemen/Seksi:.………….......................................................................................................................................
Dept./Section
Uraian Pekerjaan:…………………………………………………………………………………………………...
Description of Work …………………….....................................................................................................................
Tanggal dikeluarkan:……...……….....................................
Issue Date
Berlaku dari tanggal :......................................jam............. hingga tanggal:......................................jam.............
Valid from :...........hrs, on……./......./................…..to:................ .... hrs, on……./......./................
Ijin bekerja ketinggian yang dilakukan:……………………………………………………………………….
Type of work at height to be performed
Potensi Bahaya :...............................................................................................................................................
Potential Hazard :...............................................................................................................................................
Tindakan pencegahan
Safety Precaution Ya Tidak TS* Keterangan
Yes No NA** Description
Ada tanda peringatan/penghalang ...............................................
Warning signs/barricade placed
Semua sumber energi/listrik terkait telah di-lock out ...............................................
All energy sources locked out
Ada prosedur keadaan darurat (mis. jatuh) .............................................
Rescue plan in place in the event of a fall
Peralatan listrik sudah dipastikan berfungsi normal ...............................................
Electrical equipment apropriate
Pencahayaan cukup memadai ...............................................
Illumination adequate
Tersedia Alat Pelindung Diri (APD) ...............................................
Personal Protective Equipment (PPE) provided
Alat angkat (lift) dan APD telah diinspeksi ...............................................
Lifting equipment and PPE inspected
Tindakan pencegahan tambahan ……………………………………………………….
Additional safety precaution ……………………………………………………….
Alat Pelindung yang Diperlukan (Y/T/TS)
Protection Equipment Required (Y/N/NA)
1. Tali keselamatan .......... 5. Lokasi dibawah pekerjaan bebas ..........
Safety harness Underneath are is cleared
2. Perancah sesuai .......... 6. Tanda penghalang keamanan ..........
Scaffolding Safety barries signs
3. Angker diperiksa .......... 7. Penjaga lokasi ..........
Anchored examined Site watcher
4.
Tali telah diperiksa .......... 8. Lain – lain ..........
Rope examined Others
PersetujuanApproval
Nama/Name Tanda tangan/Sign
1. Penanggung Jawab/PIC : ..…………………………………. ……………………………..
2. Kontraktor/Contractor : …………………………………… .. ……………….
3. Pengawas Area/Area Spv : ……………………………………. ……………………………..
4. Pengawas LK3/EHS Spv : ……………………………………. ………………………………
*)
TS: Tidak Sesuai
**)
NA: Not Applicable

COPY ASLI : ENVIRONMENT, HEALTH & SAFETY – DSO, 2014 Halaman 1 dari 2
 Daihatsu Sales Operation - Prosedur LK3

B. Isi setelah pekerjaan selesai / To be completed after work is completed

Aktual penyelesaian pekerjaan
Actual work completion
Tanggal/Date : .................................
Jam/Time : .................................
Keamanan Area setelah Penyelesaian Pekerjaan
Safety of working area after work completion
Ya Tidak TS Keterangan
Yes No NA Description
Semua peralatan dipindahkan ...............................................
All equipment removed
Area telah dibersihkan ...............................................
Area cleaned
Semua lock-out telah dihilangkan ...............................................
All lock out area removed
Semua alat kontrol area telah dihilangkan ...............................................
Site controls are removed
Jelaskan masalah yang timbul ketika pekerjaan berlangsung:
Describe any problems encountered
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Persetujuan
Approval
Nama/Name Tanda tangan/Sign

1. Penanggung Jawab/PIC : ..…………………………………. ……………………………..

2. Kontraktor/Contractor : …………………………………… .. ……………….
3. Pengawas Area/Area Spv : ……………………………………. ……………………………..
4. Pengawas LK3/EHS Spv : ……………………………………. ………………………………
*)
TS: Tidak Sesuai
**)
NA: Not Applicable

COPY ASLI : ENVIRONMENT, HEALTH & SAFETY – DSO, 2014 Halaman 2 dari 2