& JSA AND RISK ASSESSMENT FORM QC-HSE Doc. No. 201488—PIPE—JSA—003_[Rev. No.0 HSE Date 20 November S016 Page | of 2 i PT. ADHIKARYA (PERSERO), Tok. Prepared By _| Reviewed By “Appipved By — Owner 7 ‘AMMONIA UREA PROJECT (APPLICATOR E PK PKG Person In Charge Inturtg Pr i NAME, dv-dpwem by | Novien- 5 cuufamy | Widede Position / Tittle of Job | = —— ee seoarune | AR (Ta == Date 2 Novencor SOF DATE [toneveripor Ses) Never 200 fT |e V0. wonce of Basie men ss San eae, a Consequence | __ Risk Assessment Recommended Action Risk Assessment ae Pato | aia PR | sv | RR crooner [pr [sve Dropped abject |= Human 2" Personalinjury, | 3 | 3 | 9 | Ensure thatno body 1 73 [3 ‘consequences | hit by material passing/working under the object, blocks; lever or equipment except if consider necessary by blocks; shackles; Rigging Supv. and the number of personnel shall be as minimum as posible and ling gears use Property; = Control and make sure that sling(s), chain block, lever block and shackle(s) are installed property and certified before liting the module; = Controlcheck and make sure that Pull; etc) 7 Fees ‘SWLof sings, chain block, lever = wateriat ——} (Materia nla Ocoee consequences | damage) the writen procedure; - ControVcheck and make sure that part line quantity of iting, ‘equipmentis capable for iting object, - Prolif the object wth gradual increase; - Wearing proper PPE (Personal Protective Equipment) ~ Only experienced & qualified / trained personnel are handling lining devices.JSA AND RISK ASSESSMENT FORM. OCHRE Do No OAS PIPE=JSA~0B [Rev No SE Dae Faseda oP Ser er rere : F cae a = gages | mares nm eet ‘nie on ee | SER RTE eT ‘mt | scone | SRST EeteTommrereSe | | om | coma [enrnoee - SE ata lyme nin es oe ee ieee eee so ra oe Tos oar — | aie ee ee : : | Beer ‘Siete been tte eon mT «| = ns Zoeaeeecnass aa eee eee remem er es oe a 7 , Tote wT erapen gma! Wa erase Tip : eos | trond aioe | tet ser marten OO Bonn a ng arn ec