RISK ASSESSMENT FORM

DATE: SYSTEM NO.:

INSTALLATION / SITE: JOB : Doc. NO.:
GRINDING (MENGGERINDA) REV : 0 STATUS.

HAZARD EFFECT X PROBABILITY = RISK MINIMIZE RISK BY

NOTES:
TASK
HAZARD HAZARD EFFECT 1. REDUCE PROBABILITY ACTION RESIDUA
DESCRIPTION
DESCRIPTION HE P R 2. REDUCE HAZARD EFFECT BY L
3. IDENTIFY MONITORING RISK

GRINDING  Tergores  Luka robek H M H  Mesin gerinda dan kabel harus Site Supv. L
(MENGGERINDA)  Tersetrum  Fatality selalu di check sebelum Site HSE
 Batu gerinda  Luka berat digunakan
terlepas  Jari terpotong  Mesin grinda harus
 Terkena putaran  Infeksi mata menggunakan cover
batu gerinda  Kebakaran  Menggunakan APD yang
 Mata terkena memadai (Faceshield, Sarung
gram tangan)
 Potensi  Harus disiapkan proteksi
menimbulkan seperti (Fireblanket, APAR)
kebakaran

RISK LEVEL ESTIMATE

HAZARD EFFECT PROBABILITY RISK

(HE) (P) (R)

H H H
H M H
HE : Hazard Effect
H L M P : Probability
M M M R : Risk
H : High
M L M M : Medium
L L L L : Low
OVERALL RISK LOW
HAZARD EFFECT X PROBABILITY = RISK
 RISK ASSESSMENT FORM

DATE: SYSTEM NO.:

INSTALLATION / SITE: JOB : Doc. NO.:
WELDING (PENGELASAN) REV : 0 STATUS.

HAZARD EFFECT X PROBABILITY = RISK MINIMIZE RISK BY

TASK NOTES:
HAZARD
DESCRIPTION HAZARD EFFECT 1. REDUCE PROBABILITY ACTION RESIDUAL
DESCRIPTION HE P R 2. REDUCE HAZARD EFFECT BY RISK
3. IDENTIFY MONITORING
WELDING  Tersetrum  Kematian H M H  Mesin dan kabel las harus selalu Site L
 Potensi  Kebakaran di check sebelum digunakan Supv.
(PENGELASAN)
Penyebab  Mata iritasi  Grounded gabel las harus selalu Site SHE
kebakaran (merah) bisa didekatkan dengan matrial yang
 Mata terkena menyebabkan dilas
paparan sinar kebutaan  APD Welding (Cover wleding,
las  Luka bakar Appron, sarung tangan welder)
 Terkena  Luka jangka  Harus disiapkan proteksi
percikan Api las panjang pada pengelasan (Fire blanket, Apar)
 Terhirup asap las paru-paru
(gosong)

RISK LEVEL ESTIMATE

HAZARD EFFECT PROBABILITY RISK

(HE) (P) (R)

H H H
H M H
HE : Hazard Effect
H L M P : Probability
M M M R : Risk
H : High
M L M M : Medium
L L L L : Low
OVERALL RISK LOW
HAZARD EFFECT X PROBABILITY = RISK
 RISK ASSESSMENT FORM

DATE: SYSTEM NO.:

INSTALLATION / SITE: JOB :
BEKERJA DI KETINGGIAN REV : 0 STATUS.

HAZARD EFFECT X PROBABILITY = RISK MINIMIZE RISK BY

TASK NOTES:
HAZARD
DESCRIPTION HAZARD EFFECT 1. REDUCE PROBABILITY ACTION RESIDUAL
DESCRIPTION HE P R 2. REDUCE HAZARD EFFECT BY RISK
3. IDENTIFY MONITORING
BEKERJA DI  Jatuh dari  Patah tulang H M H  Menggunakan full bodyhardnes Site Supv. L
KETINGGIAN ketinggian  Terkilir dan dicantolkan Site SHE
 Terpeleset saat  Meninggal  Tangga dipasang handrail
naik ke atas  Menjatuhi rekan  Pastikan tag hijau pada
 Peralatan jatuh kerja scaffolding
 Scaffolding dibawahnya  Lantai kerja harus kokoh
roboh  Harus ada surat ijin bekerja di
ketinggian
 Orang yang bekerja di
ketinggian harus sudah
berpengalaman
 Dilarang ada orang bekerja
dibawahnya

RISK LEVEL ESTIMATE

HAZARD EFFECT PROBABILITY RISK

(HE) (P) (R)

H H H
H M H
HE : Hazard Effect
H L M P : Probability
M M M R : Risk
H : High
M L M M : Medium
L L L L : Low
OVERALL RISK LOW
HAZARD EFFECT X PROBABILITY = RISK
 RISK ASSESSMENT FORM

DATE: SYSTEM NO.:

INSTALLATION / SITE: JOB :
LIFTING / PENGANGKATAN MATERIAL REV : 0 STATUS.

HAZARD EFFECT X PROBABILITY = RISK MINIMIZE RISK BY

TASK NOTES:
HAZARD
DESCRIPTION HAZARD EFFECT 1. REDUCE PROBABILITY ACTION RESIDUAL
DESCRIPTION HE P R 2. REDUCE HAZARD EFFECT BY RISK
3. IDENTIFY MONITORING
LIFTING /  Tangan terjepit  Luka memar, H H H  Selalu fokus dan gunakan Site Supv. L
 Sling putus lecet, berdarah sarung tangan Site HSE
PENGANGKATAN
MATERIAL  Material  Material rusak  Sling yang digunakan harus
terjatuh  Patah tulang dicheck dahulu dan
 Kejatuhan  Meninggal pastikan tidak melebihi
material kapasitas beban
 Crane collapse  Material yang diikat harus
benar-benar terikat
dengan baik
 Pastikan tidak ada orang
yang bekerja / melintasi
area lifting
 Gunakan barricade pada
saat lifting

RISK LEVEL ESTIMATE

HAZARD EFFECT PROBABILITY RISK

(HE) (P) (R)

H H H
H M H
HE : Hazard Effect
H L M P : Probability
M M M R : Risk
H : High
M L M M : Medium
L L L L : Low
OVERALL RISK LOW
HAZARD EFFECT X PROBABILITY = RISK
 RISK ASSESSMENT FORM

DATE: SYSTEM NO.:

INSTALLATION / SITE: JOB :
PEMASANGAN SCAFFOLDING (PIPA) REV : 0 STATUS.

HAZARD EFFECT X PROBABILITY = RISK MINIMIZE RISK BY

TASK NOTES:
HAZARD
DESCRIPTION HAZARD EFFECT 1. REDUCE PROBABILITY ACTION RESIDUAL
DESCRIPTION HE P R 2. REDUCE HAZARD EFFECT BY RISK
3. IDENTIFY MONITORING
PEMASANGAN  Jatuh dari  Patah tulang, H H H  Pastikan scaffolding yang Site Supv. L
SCAFFOLDING ketinggian bisa sampai diinstal, pembongkaran,
 Scaffolding meninggal pemindahan harus berada
runtuh  Luka memar, dibawah orang yang
 Overload Robek berdarah berkompeten
 Alat/benda  Material/peralat  Aman, kuat, kokoh dapat
jatuh kebawah an mesin rusak menyangga beban
akibat  Gunakan lantai kerja yang
scaffolding baik, tidak bergelombang
roboh  Surat ijin (PERMIT)
 Tag hijau menandakan
scaffolding aman digunakan
 Gunakan selalu Full Body
Harnes sebagai pengaman

RISK LEVEL ESTIMATE

HAZARD EFFECT PROBABILITY RISK

(HE) (P) (R)

H H H
H M H
HE : Hazard Effect
H L M P : Probability
M M M R : Risk
H : High
M L M M : Medium
L L L L : Low
OVERALL RISK LOW
HAZARD EFFECT X PROBABILITY = RISK
 RISK ASSESSMENT FORM

DATE: SYSTEM NO.:

INSTALLATION / SITE: JOB :
BEKERJA DI RUANG TERBATAS/ CONFINED SPACE REV : 0 STATUS.

HAZARD EFFECT X PROBABILITY = RISK MINIMIZE RISK BY

TASK NOTES:
HAZARD
DESCRIPTION HAZARD EFFECT 1. REDUCE PROBABILITY ACTION RESIDUAL
DESCRIPTION HE P R 2. REDUCE HAZARD EFFECT BY RISK
3. IDENTIFY MONITORING
BEKERJA DI  Kekurangan  Sesak nafas H H H  Periksa area kerja terlebih Site L
RUANG TERBATAS oksigen  Pingsan dahulu dan pastikan aman Supv.
/ CONFINED SPACE  Kelebihan  Lemas  Perijinan dari pihak Site HSE
Oksigen  Mual departemen yang terkait
 Bahan beracun  Koma  Periksa terlebih dahulu
(Gas, Uap,  Kematian kadar oksigen cukup dan
Fumes) tidak terdapat gas yang
 Bhan mudah berbahaya
terbakar dan  Gunakan Gas Tester dan
meledak bila perlu lakukan blowing
untuk memasukkan oksigen
 Pekerja tidak boleh
sendirian, minimal 2 orang

RISK LEVEL ESTIMATE

HAZARD EFFECT PROBABILITY RISK

(HE) (P) (R)

H H H
H M H
HE : Hazard Effect
H L M P : Probability
M M M R : Risk
H : High
M L M M : Medium
L L L L : Low
OVERALL RISK LOW
HAZARD EFFECT X PROBABILITY = RISK
 RISK ASSESSMENT FORM
DATE: SYSTEM NO.:
INSTALLATION / SITE: JOB :
PEKERJAAN ELEKTRIKAL REV : 0 STATUS.

HAZARD EFFECT X PROBABILITY = RISK MINIMIZE RISK BY

TASK
DESCRIPTION NOTES:
HAZARD
HAZARD EFFECT 1. REDUCE PROBABILITY ACTION RESIDUAL
DESCRIPTION HE P R 2. REDUCE HAZARD EFFECT BY RISK
3. IDENTIFY MONITORING
PEKERJAAN  Tersetrum  Luka bakar H H H  Pastikan isolasi listrik dalam Site L
ELEKTRIKAL  Kebakaran  Kejang otot keadaan yang baik, tidak Supv.
 Ledakan  Serangan terkelupas Site HSE
jantung  Tidak kelebihan beban
 Kehilangan pada saat instalasi listrik
kesadaran  Pastikan panel listrik dalam
sementara keadaan mati ketika ingin
 Kematian menyambung arus
 Pastikan orang yang
berkompeten dibidangnya
 Permit to work

RISK LEVEL ESTIMATE

HAZARD EFFECT PROBABILITY RISK

(HE) (P) (R)

H H H
H M H
HE : Hazard Effect
H L M P : Probability
M M M R : Risk
H : High
M L M M : Medium
L L L L : Low
OVERALL RISK LOW
HAZARD EFFECT X PROBABILITY = RISK