HEALTH, SAFETY, SECURITY, AND ENVIRONMENT (HSSE)

DEPARTMENT PT. TIMAS SUPLINDO

PERMIT TO WORK AUDIT/REVIEW

Section 1 - Registration
PTW No. :
Work Description :

Section 2 - Administratives Check Yes No N/A Remark

Is the PTW requester/Work Team Leader signed the PTW
Is the Permit Approver signed the PTW
Are all personnel/members signed the PTW
Is Area Authority signed the PTW
Is the same Work Team Leader signed in the revalidation form
Do the Toolbox/Tailgate Meeting has been conducted and all personnel signed
Toolbox/Tailgate Meeting Form
Do the SOP and JHA has been discussed during Toolbox/Tailgate meeting
Do the Pre-Job Meeting has been conducted
Do the JSA has been discussed during Pre-Job meeting and all personnel signed Pre-
Job Meeting Form
Is the SOP has in Place
Is the work being performed same as the Work Description in PTW
Do all personnel being performed the job understood the SOP/JHA/JSA
Do all personnel metioned in the PTW present in the worksite
Are the the following requirement (SOP/JHA/JSA) met:
Energi isolation (LO/TO)
Safety equipment (i.e. Gas detector, Fire Extinguisher, Eyewash, First Aid Kit, SCBA,
Stretcher, etc)
Are the MSDS for chemical in place

Section 3 - Worksite Check Yes No Remark

Are all personnels being performed the job in a safe manner
Is the following worksite housekeeping satisfactory
Fall, slip, & trip hazards
Tools & equipments placement/layout
Clean, free from spill, and all waste segragate
Oil catcher or secondary containment
Are portable tools in good order
Are the correct PPE being used
Is any conflict the job being performed with other activities
Are the inspections tag for scaffold and ladders in place
Are the rigging gears being used in good condition and color coded

If the questions in this section are answered " NO ", job have to " STOP " because indicates a potential problem

Section 4 - Comments

Section 5 - Completion
I am fully responsible of this PTW audit and its results

Authorized Signature: Name Date:

: