PT.

AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S
1. LOADING PERALATAN KE UNIT/KENDARAAN
1 Loading Counter Pengangkatan tidak R S counter weight jatuh menimpa Melakukan pengangkatan 1 5
weight ke unit ke sesuai (UC) pekerja counter weight dengan cara
truk/LV yang benar pastikan saat
mengangkat harus dalam
kondisi stabil

2. PRECLEANING INSPECCTION
1 Membersihkan oli, Paparan Debu (UC) R S Terpapar debu berlebih dari proses Mematuhi peraturan di 2 2
minyak dan pembersihan drill pipe wellsite, aware dengan potensi
membersihkan ulir bahaya yang ada, selalu
koneksi pergunakan APD sesuai
ketentuan.

Peralatan rusak (UC) R S Sambungan arus pendek Penyediaan switch power 2 2

pack untuk disconnect power
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

Kondisi lingkungan kerja
yang berbahaya (UC)
L S
R S Terpapar kebisingan yang Mematuhi peraturan di 2 2
berlebihan wellsite, aware dengan potensi
bahaya yang ada, selalu
pergunakan APD sesuai
ketentuan.

Kondisi lingkungan kerja R S Tersayat batu gerinda Mematuhi peraturan di 2 2

yang berbahaya, (UC) wellsite, aware dengan potensi
bahaya yang ada, selalu
pergunakan APD sesuai
ketentuan.

3. VISUAL & DIMENTION INSPECTION BEFORE LOAD TEST

1 Memeriksa visual & Posisi / Penempatan R S Terjepit hook Mematuhi prosedur inspection 2 2
dimensi Tidak Sesuai (UB) crane (perhatikan saat OHC
dioperasikan)
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S

4. NON DESTRUCTIVE TEST BEFORE LOAD TEST

1 MPI/PTI Test Peralatan rusak (UC) R S Hubungan arus pendek listrik Melakukan pengecekan 2 2
sebelum peralatan digunakan

Kompetensi Karyawan R S Peralatan rusak dan kecelakaan Melakukan sertifikasi kepada 2 2

Kurang (UB) kerja crew yang akan melakukan
MPI/PTI Test
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S
Terpapar bahan kimia R S Gangguan pernafasan akibat aware dengan potensi bahaya 2 2
berlebih (UC) menhirup paparan bahan kimia yang ada, selalu pergunakan
APD sesuai ketentuan.
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S

5. PERSIAPAN LOAD TEST

1 Set up tool Pengangkatan tidak R S peregangan berlebih akibat cara Melakukan pengangkatan tool 2 1
sesuai (UC) pengangkatan yang salah dengan cara yang benar

Kompetensi Karyawan R S Kerusakan alat, kecelakaan kerja Dilakukan training terkait 2 1

Kurang (UB) dengan prosedur load test

Pengangkata R S garpu forkklift bisa patah kapasitas forklift harus 2 2

n tidak disesuaikan dengan
sesuai (UB) couterweight yang diangkat
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S
forklift bisa terbalik kapasitas forklift harus 2 2
disesuaikan dengan
couterweight yang diangkat

2 Power up Tool Berada pada posisi R S terjepit load cell Perhatikan posisi tangan pada 2 2
yang salah dalam saat pemasangan load cell
melakukan pekerjaan
(UB)

6. PROSES LOAD TEST

2 Proses Load Test Posisi couter weight
tidak seimbang (UC)
R S Pekerja tertimpa counter weight - Memastikan couter weight 2 2
saat diangkat dalam keadaan
stabil
- Memasang police line
disekitar tempat load test
untuk memastikan crew di
belakang garis police line
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S

7. VISUAL & DIMENTION AFTER LOAD TEST

1 Memeriksa visual & Posisi / Penempatan R S Terjepit hook Mematuhi peraturan di 2 2

dimensi Tidak Sesuai (UB) wellsite, aware dengan potensi
bahaya yang ada, selalu
pergunakan APD sesuai
ketentuan.

8. NON DESTRUCTIVE TEST AFTER LOAD TEST

1 MPI/PTI Test Peralatan rusak R S Sambungan arus pendek Melakukan pengecekan 2 2

sebelum peralatan digunakan
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S
Kompetensi Karyawan R S Peralatan rusak dan kecelakaan
Kurang (UB) kerja

Terpapar bahan kimia R S Gangguan pernafasan akibat aware dengan potensi 2 2

berlebih menghirup paparan bahan kimia bahaya yang ada, selalu
pergunakan APD sesuai
ketentuan.
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S

9. MARKING

Memberikan tanda Kurang Konsentrasi / R S Terpukul palu Aware dengan potensi bahaya 2 2
pada benda kerja Perhatian Terganggu yang ada, selalu pergunakan
yang sudah APD sesuai ketentuan.
diinspeksi

Jatuh dari ketinggian R S Kematian -Menggunakan permit 2 2

sebelum bekerja diketinggian
- Selalu menggunakan full
body hardness saat bekerja
diketinggian
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S
1 Pengecekan dan Limbah (sampah R S Limbah bukan B3 (plastik, botol Mengumpulkan sampah dan 2 2
pembersihan domestik, majun, kaos minum, sisa makanan), limbah B3 membawa sampah yang
sampah apabila tangan) (majun, kaos tangan bekas) dihasilkan pada saat job
pada saat job kembali ke workshop untuk
dihasilkan sampah dikelola lebih lanjut

11. LOADING PERALATAN KE UNIT/KENDARAAN

1 Loading Counter Pengangkatan tidak R S counter weight jatuh menimpa Melakukan pengangkatan 1 5
weight ke unit ke sesuai pekerja counter weight dengan cara
truk/LV yang benar pastikan saat
mengangkat harus dalam
kondisi stabil

Is the scenario enough to cover the significant risk? £ YES £ NO If No, Contingency Plan is require
Ext/Int

Responsibility of
Planned Date Recipient / Receiver Related Documented Information
Communication
 PT. AKURA BINA CITRA HAZARD IDENTIFICATION, RISK ASSESSMENT, AND RISK

Department Personnel participated &

Field Department Prep
consulted: Assessors name
Area Workshop/Site Name Designation 1) Asep Sudrajat Name:

2) Elvandi Signature:
Activity Inspection Crane Willy
3) Date:

Initial Risk

Likelihood
Type*)

Severity
No R/O Current Control / Existing
Activity Description Hazard/Aspect Consequence (Risk/ Impact) Situation

L S

Is the action taken (still) effective to control th Last Review By : Date: Sign
£ YES £ NO. Refer to Risk Assessment No. :
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Severity
Verifcation
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No

5/VH Y Training External SOP-HSE-20 2-May-18 2-May-18 V 2-May-18 2 2 4/L Yes

terkait
penggunaan PAA
-

4/L N - - QA-GEN-01 - - V 2 2 4/L Yes

SOP-HSE-01
SOP-HSE-13

4/L N - - QA-GEN-01 - - V 2 2 4/L Yes

 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Severity
Verifcation
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No
4/L N - - QA-GEN-01 - - V 2 2 4/L Yes
SOP-HSE-01
SOP-HSE-13

4/L N - - QA-GEN-01 - - V 2 2 4/L Yes

SOP-HSE-01
SOP-HSE-13

4/L N SOP-HSE-01 - - V 2 2 4/L Yes

SOP-HSE-13
- -
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Verifcation

Severity
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No

4/L N - - SOP-HSE-01 - - V 2 2 4/L Yes

SOP-HSE-13
ABC-MT-
0204 ABC-MT-
0205

4/L` N SOP-HSE-01 - - V 2 2 4/L Yes

SOP-HSE-13
ABC-MT-
- - 0204 ABC-MT-
0205
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Severity
Verifcation
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No
4/L N - - SOP-HSE-01 - - V 2 2 4/L Yes
SOP-HSE-13
ABC-MT-
0204 ABC-MT-
0205
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Verifcation

Severity
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No

2/L N SOP-HSE-20 V 2 1 2/L Yes

- -

2/L N FS-LT-01 V 2 1 2/L Yes

- -

2/L N FS-LT-02 V 2 2 2/L Yes

 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Verifcation

Severity
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No
2/L N FS-LT-02 V 2 2 2/L Yes

4/L N SOP-HSE-20 2 2 4/L Yes

- -

4/L N SOP-HSE-20 V 2 2 4/L Yes

- -
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Severity
Verifcation
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No

4/L SOP-HSE-01 V 2 2 4/L Yes

SOP-HSE-13
- -

4/L SOP-HSE-01 V 2 2 4/L Yes

SOP-HSE-13
ABC-MT-
- - 0204 ABC-MT-
0205 ABC-PT-
0301
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Verifcation

Severity
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No
ABC-MT-0204 V Yes
ABC-MT-0205
ABC-PT-0301
- -

4/L SOP-HSE-01 V 2 2 4/L Yes

SOP-HSE-13
ABC-MT-
- - 0204 ABC-MT-
0205ABC-PT-
0301
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Severity
Verifcation
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No

4/L SOP-HSE-01 V 2 2 4/L Yes

SOP-HSE-13
QA-MARK-
- - 05

4/L SOP-HSE-01 V 2 2 4/L Yes

SOP-HSE-13
QA-
- - MARK-05
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Severity
Verifcation
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No
4/L SOP-HSE-14 V 2 2 4/L Yes

- -

5/VH Y Training External SOP-HSE-20 2-May-18 2-May-18 V 2-May-18 2 2 4/L Yes

terkait
penggunaan PAA
-

y Plan is required CONTINGENCY PLAN FOR RISK NO :

Likelihood
Residual

Severity
Verifcation
Closed Out
Status Related
Optional Action to Responsibility / Risk Risk Next

Open
Documented Planned Date Target Date Closing Date Acceptable Review
Mitigate Risk Authority Rating Date
Information
L S Yes No
 Doc No. Form ABC/HSE/01
AND RISK CONTROL
Ref Code / Rev 00

Prepared by: Reviewed by: Approved by:

Name: Elvandi Name: Asep Sudrajat Name: Andi Setyo Budianto

Signature: Signature: Signature:

Date: 21/03/2018 Date: 21/03/2018 Date: 21/03/2018

Initial Risk Status Residual Risk

Action to Take Residual

Likelihood
Related

Severity
Verifcation
Closed Out
Significant Opportunity / Responsibility / Risk Next
Risk Hazard ? (Y/N) Mitigation to reduce Documented Planned Date Target Date Closing Date Risk Review

Open
Authority Acceptable Date
Rating Information Rating
Risk
L S Yes No

Sign
NOTE *) B = Business C = Cost D = Delivery E = Environment H = Health Q = Quality S = Safety Page 3 of 3