FM-SHE-05

Rev : 02
Section / Dept :
Area Project / Plant :
Penanggung Jawab / PIC :
Tanggal review / Review date :

No Proses / Aktifitas / Pekerjaan

Process / Activities / Task
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 FM-SHE-05
Rev : 02
Section / Dept :
Area Project / Plant :
Penanggung Jawab / PIC :
Tanggal review / Review date :

Penilaian Risiko & Dampak Risiko & Dampak Sisa Pengendalian Tambahan Penanggung Jawab
Risk & Impact Assessment Residual Risk & Impact Additional Control Responsibility
Tipe
Risiko Tingkat Risiko & Peraturan Perundangan
Proses / Aktifitas / Pekerjaan Kondisi Bahaya / Aspek Lingkungan Risiko / Dampak Lingkungan Pengendalian Saat Ini (jika ada) Administrasi Tanggal Penyelesaian
No Type of Dampak Terkait
Process / Activities / Task (R,NR,N,AN,E) Hazard / Environmental Aspects Risk / Environmental Impact Existing Control (if any) Administration Due Date
Risk Risk & Impact Level Eliminasi Substitusi Pengendalian Rekayasa APD / Alat Emergency Unit Kerja Personil Legal Requirement
(S,H,E) L S RN L S RN
Elimination Substitution Engineering Non Training PPE / Spill Kit Department Person In Charge
Training
(Rambu/SOP/Lainnya)

Dibuat oleh, Diperiksa oleh,

Create by, Check by,

(Name) (Name)
(Job title) (Job title)
 FM-SHE-05
Rev : 02
Jenis Bahaya & Aspek Penjelasan Bahaya & Aspek
No Hazard & Aspect Type Description of Hazard & Aspek

1 Api Penanganan produk mudah terbakar, sumber api

Fire Flammable product handling, sources of ignition

2 Ledakan Tekanan tinggi, suhu, campuran eksplosive, eksotermik, reaksi, dll

Explosions High pressure, temperature, explosive mixtures, exothermic, reactions, etc
Peralatan terkait Tidak ada pengaman, memasuki, pemeliharaan, alat berat dan kegagalan
3
Equipment related Not safe guarded, entering, maintenance, heavy equipment and failures

4 Ergonomi Kenyamanan, jangkauan, akses, kuda-kuda, ruang, pengangkatan manual, dll

Ergonomics Comfort, reach, access, stance, space, manual handling, etc

5 Kimia Asap beracun atau produk, asam/basa, iritasi, karsinogenik, dll

Chemical Toxic fumes or products, acid/basic, irritant, carcinogenic, etc

Pencahayaan, suhu, ventilasi, debu, getaran, bahaya tersandung, rel tangan, platform, tangga, penggalian, pemuatan, Height, confined spaces, noise,
Fisika etc.
6 Physical Lighting, temperature, ventilation, dust, vibration, tripping hazards, hand rails, platforms, ladders, excavations, loading, tinggi, ruang terbatas,
kebisingan, dll

7 Biologi Mikroorganisme, bakteri, virus, dermatitis, dll.

Biological Microorganisms, bacteria, viruses, dermatitis, etc.
Listrik Isolasi listrik/switching, tegangan tinggi, Instrumen yang bekerja pada peralatan hidup, perangkat safety, flash listrik (shock), dll.
8 Electrical Electrical isolating/switching, high voltage, Instruments working on live equipment, safety devices, electrical flash (shock), etc.

9 Radiasi X-rays (radiasi), sumber radio aktif, uji kebocoran penyimpanan, pengelasan, dll.
Radiation X-rays (radiation), radio active sources, storage leak test, welding, etc.

10 Lingkungan
Environment
Emisi, air, udara, pencemar tanah, tumpahan, penggunaan sumber daya seperti : kertas, bahan kimia, tumbuhan, hewan dll.
Emission, water, air, ground pollution, spill, use of resources ex : paper, chemical material, flora, fauna, etc.

11 Jalan dan dinding tinggi Lereng, tanggul, kondisi jalan, dll.

Road and high wall Slope, berm, road condition, etc.
Kelelahan Gangguan tidur, nutricition, alkohol, obat-obatan, shift kerja, jam kerja per hari.
12 Fatigue Sleep disorder, nutricition, alcohol, drugs, working roster, working hour per day.

13 Lainnya
Other
Bahaya lain yang terkait dengan aktivitas yang tidak ada dalam daftar
There other hazards related with the activity are not in the list

Jenis Risiko & Dampak Penjelasan Risiko & Dampak

No Risk & Impact Type Description of Risk & Impact

1 Lingkungan Kerusakan ekologi, penipisan lapisan ozon, kontaminasi tanah, polusi air, polusi udara
Environment Ecological damage, depletion of ozone layer, soil contamination, water pollution, air pollution

2 Kematian Cepat, sewaktu-waktu/pada akhirnya akan meninggal

Fatality Instant, eventual
Cacat permanen Amputasi, dll
3 Permanent disability Amputation, etc

4 Cacat sementara Terbakar, patah tulang, dll

Temporary disability Burning, fracture, etc
Kelainan otot dan tulang Ketegangan otot yang ditimbulkan dari bahaya ergonomi
5 Musculoskeletal disorders and Muscle tension arising from ergonomics hazard
bone abnormalities

Kehilangan pendengaran
akibat bising Pengaruh paparan kebisingan
6 Noise induced hearing loss Noise exposure effect
(NIHL)

7 kehilangan penglihatan Permanen, sementara

Blind Permanent, temporaty

8 Kesehatan kerja Kelainan ginjal, kelainan sistem pembuluh darah, jantung, sistem penafasan, kulit, hematologi, saraf, hati, sisitem pencernaan, genetik, dll
Occupational health Kidney disorders, blood vessel disorders, cardio, respiratory system, skin, hematology, nerves, liver, digestive system, genetics, etc

9 Psikososial Kekerasan, pelecahan seksual, tekanan mental

Psychosocial Violence, sexual harassment, mental stress

10 Kerusakan harta benda Kerusakan ringan, sedang ,berat

Property damage Minor, moderate, major damage
 FM-SHE-05

Rev : 02

MATRIKS PENILAIAN RISIKO & DAMPAK LINGKUNGAN Keparahan Kerusakan benda Pengaruh ke orang Pengaruh ke hiegine Dampak lingkungan
RISK & ENVIRONMENTAL IMPACT ASSESSMENT MATRIX Severity (S) Damage cost Effect on personal Hygine effect Environmental Impact

5-Sangat besar Meninggal lebih dari 1 orang Meninggal lebih dari 1 orang Nasional atau global : tetap atau dampak jangka panjang
25 20 15 10 5 Catastrophic > Rp 100 Juta / Million
More than one fatality More than one fatality National or global : permanent or long term impact

4-Besar Satu orang meninggal dunia Satu orang meninggal dunia atau sakit permanen Regional : menengah atau dampak jangka panjang
20 16 12 8 4 Major Rp 51- 100 Jt / Million
One fatality One fatality or Permanent incapacity (Occupational disability) Regional : medium or long term impact

3-Sedang Efek PAK lebih dari 5 hari Regional : dampak jangka pendek
15 12 9 6 3 Moderate Rp 21 - 50 Jt / Million Lost time injury
Reversible incapacity health effects (long & short absentees) more than 5 days Regional : short term impact

2-Rendah Medical treatment or restricted Pengaruh PAK sedang, recovery kurang dari 5 hari Area internal CG : dampak ke beberapa area
10 8 6 4 2 Minor Rp 6 - 20 Jt / Million
workday case Medium health effects, recovery in a few days Less than 5 days Internal CG Area : secondary area impact

1-Sangat rendah Pengaruh Pak rendah, recovery beberapa jam Tidak ada dampak atau dampak hanya di dalam / internal
5 4 3 2 1 Insignificant Rp 0 - 5 Jt / Million First aid or no injury
Low health effects recover within hours None or inside impact

Kemungkinan untuk
keselamatan kerja dan
5-Terjadi 4-Mungkin terjadi 3-Sedang
Almost certain Likely Moderate lingkungan
Likelihood for safety and
environmental (L)
2-Jarang 1-Sangat jarang
Unlikely Rare
5-Sekali setiap bulan Kemungkinan untuk
4-Sekali dalam 3-Sekali dalam
atau permanen
Once per month or setahun sepuluh tahun higiene
permanent Once per year Once in ten years Likelihood for Hygiene (L)

Tingkat
Nilai Risiko Tindakan Perbaikan
Risiko
Risk Number Corrective Action
Risk Level

Extreme > 16 HIGH RISK – Action Required

Risiko Sedang TOLERABLE RISK – Apply ALARP (As Low As Reasonably

6-16
(Moderate) Possible) Principles

Risiko Rendah <6 LOW RISK – No Action Required

(low)