Doc No : KSK-HSE-FM-22

Tgl Terbit : 24-Oct-17

WORK PERMIT FORM Revision : 0
Halaman : 1

Fasilitas (facility): No. Izin (Permit Number):

Kerja Panas (Hot Work) Kerja Dingin (Cold Work) Galian (Excavation) Ruang terbatas (Confined space) Radioaktif (Radioactive) Penyelaman (Diving)

1. Deskripsi/ Lokasi Pekerjaan (Description/ location of job) 2. Masa Berlaku Izin (Validity of Permit)
Dari (From) Pukul (hour): ke (to) Pukul (hours):
Jumlah Pekerja (number of men): Tanggal (Date):
Peminta izin (Permit Applicant):
Pemegang izin (Permit Holder): Pemberi izin (Authorized Person)
3. Isolasi (Isolation) Elektrik (Electrical) Mekanik (Mechanical) Tanda jika dilakukan dan jelaskan dibawah
Hidrolik (Hydraulic) Pneumatik (Pneumatic) (Mark if it has been done and explain below)
Waktu & tanggal isolasi (Time & Date Isolated): Diisolasi oleh (Isolated by):
Pengawas Utilities & Mekanik (Utilities & Mechanical Supervisor)

4. Bahaya (Hazards)
Tekanan gas/ cairan (Liquid/ gas pressure) Cuaca (Weather) Peralatan bergerak (Moving machinery) Keracunan (Toxins)
Ledakan (Explosion due to combustibles) Kebisingan (Noise) Bahaya jatuh (Danger of falling) Pengangkatan (Lifting Ops)
Kebakaran (Fire) Korosif (Corrosive) Kekurangan oksigen (Oxygen difficiency) Perancah (Scaffolding)
Listrik (Electricity) Radiasi (Radiation) Bahaya terjepit (Pinch points) Pekerjaan pihak ketiga (jelaskan dibawah)

Bahaya lain (Other hazards): (3rd party operation (explain below)

Persyaratan (Precaution):
Job Safety Analysis - JSA Pasokan udara (Airline/ cascade) Inert purging Pengawasan (Supervision) Alat bantu pernafasan individu (SCBA)

Rencana HSE (HSE Plan) Ventilasi (Ventilation) Stand-by-man Pembatas (barrier) Pengukuran Gas (Gas Monitoring)

Pemadam api (Fire Extinguishers) APD (PPE) Safety harmness Grounding Pembilasan dengan air (Water Flushing)

Kelengkapan & kesiapan peralatan kerja (Tools preparation):

Persyaratan lainnya (Other precautions):
5. Tes (Gas testing) Oksigen H2S Flammable Gas (Methane - CH4) Pengawasan (Supervision)
Jenis Gas Baku Mutu Pengukuran Awal Tanda tangan Pengukuran saat kerja berlangsung Tanda tangan
(Type of Gas) (Quality Standard) (Initial measurement) (Signature) (Measurement when work in progress) (Signature)
Oksigen Min. 19,5%
H2S Max 10 ppm
Flammable gas (Methane - CH4) LEL 5%
CO 25 ppm
Tanda tangan dilakukan oleh Petugas Uji Gas (Signed by Gas Tester)
6. Peminta Izin (Permit Applicant) 7. Pimpinan Peminta Izin - jika diperlukan
Saya telah memeriksa lokasi kerja dan telah memenuhi persyaratan yang (Authorization of Permit Applicant - if required)
diperlukan dan telah didiskusikan dengan seluruh pihak terkait
(I have checked the worksite and the required precautions have been
taken and discussed with all involved)

Nama & Tanda tangan (Name & Signature)

Peminta Izin (Permit Applicant)
8. Penerbitan & Persetujuan (Issue & Acceptance) 9. Pengalihan Pekerjaan (Job Hand Over)
Detail izin telah didiskusikan dengan Peminta Izin dan pihak terkait Pemegang izin berubah sejak pukul tanggal
(The details of the permit have been discussed with the (Permit Holder changed at) (hours) (date)
Permit Applicant and those involved) Pemegang izin baru dan pekerjanya telah diarahkan dengan baik dan menyeluruh

(The new permit holder and their employees have been directed properly and thoroughly)
Pemegang SIKA Lama (Outgoing Permit Holder)
Pemegang Izin (Permit Holder) Pemegang SIKA Baru (Incoming Permit Holder)
10. Pelepasan Isolasi Listrik (Electrical) Mekanik (Mechanical) 11. Penghentian izin Sementara (Suspension of Permit)
(De-isolations) Hidrolik (Hydraulic) Pneumatik (Pneumatic) Saya menyatakan bahwa pekerjaan dalam izin yang telah terbit ini untuk
sementara ditunda semua yang terlibat telah ditarik dari area kerja/
Isolasi yang terdapat pada izin telah diambil peralatan telah ditinggalkan dalam keadaan aman.
(The isolations applicable to the Permit have taken been removed)
Alasan penundaan (Reason of Suspension):
Isolator (Isolator):
Tanggal (Date): (All involved have withdrawn and the area/ equipment has been left
Pukul (Hours): in a clean safe state)
Pengawas Utilities & Mekanik (Utilities & Mechanical Supervisor):
Penghenti Pekerjaan (Authorized Person):
12. Pekerjaan telah Selesai (Work Completion) 13. Penutupan Izin (Permit Closure)
Pekerjaan tersebut di atas telah selesai. Tempat kerja telah ditinggalkan dalam Pekerjaan telah diinspeksi & telah selesai, isolasi telah dilepas
keadaan aman, bersih dan rapi. dan area kerja aman
(The above work has been completed. The worksite has been left safe, (The work has been inspected and is complete. The isolations have been
clean, and tidy) removed and area is safe)
Pemegang Izin (Permit Holder) Peminta Izin (Permit Applicant) Pemberi izin (Authorized Person)
Putih/ asli: Pemegang izin (White/ Original: Permit Holder) Merah: Peminta izin/ pengawas (Red: work crew supervisor) Biru: HSE (Blue: HSSE) Kuning: Pemberi izin (Arsip) (Yellow: Filling)
 JOB SAFETY ANALYSIS

DATE/ JSA No. (Tanggal/ JSA No.) DEPARTMENT (Bagian/ Fungsi):

JOB (Pekerjaan): SUPERVISOR (Pengawas):
LOCATION (Lokasi):

PROTECTIVE EQUIPMENT REQUIRED TO PERFORM THIS JOB (ALAT PELINDUNG YANG DIPERLUKAN UNTUK MELAKSANAKAN PEKERJAAN)
SAFETY HELMET EAR PLUG/ EAR MUFF RUBBER GLOVES FIRE EXTINGUISHER
SAFETY SHOES RUBBER BOOT FULL BODY HARNESS LOCK OUT/ TAG OUT
SAFETY GLASSES FACE SHIELD CHEMICAL COAT OIL SPILL/ KIT
COTTON GLOVES APRON RESPIRATOR/ SCBA WORK PERMIT REQUIRED
LEATHER GLOVES DUST/ GAS MASKER GOOGLES OTHER

SEQUENCE OF BASIC JOB STEPS POTENTIAL ACCIDENT OF HAZARDS RISK LEVEL RECOMMENDED SAFE JOB PROCEDURE RESPONSIBLE PERSONAL

(URUTAN LANGKAH DASAR PEKERJAAN) (POTENSI DAPAT TERJADI KECELAKAAN) (TINGKAT RISIKO) (REKOMENDASI PROSEDUR KERJA SECARA AMAN) (PENANGGUNG JAWAB)

PELAKSANA PEKERJAAN PENGAWAS PEKERJAAN SITE/ PEMILIK ASET