Document Name: Document Type: HSE Form
Document No.: EGSI-HSE-FR-001
PERMIT TO WORK FORM / Revision: 7
Date: 21-Nov-2018
FORMULIR IJIN KERJA
Approved by: PEB
1. Task Description (to be completed by Performing Authority) /
Deskripsi Tugas (diisi oleh Performing Authority)
1.1 Permit to Work Number / Nomor Ijin Kerja: 1.2 Job Number / Nomor Pekerjaan:
Date / Tanggal:
1.3 Type of Permit : Cold Work Permit Hot Work Permit (Please refer to page 2 to for appropriate criteria)
Tipe Ijin Ijin Kerja Dingin Ijin Kerja Panas (Lihat halaman 2 untuk detil kriteria)
1.4 Location of Work / Lokasi Kerja:
1.5 Description of Work / Deskripsi Kerja:
1.6 Hazard Identification and Controls *) Please add an additional paper if required
Identifikasi Bahaya dan Kontrol *) Gunakan kertas tambahan jika diperlukan
Hazards / Bahaya Controls / Kontrol Hazards / Bahaya Controls / Kontrol
Liquid / Gas under pressure ................. 01. Toolbox meeting Equipment generating sparks ................. 07. Task assignment
Toxic material ................. 02. PPE Crane operation ................. 08. Gas detector
Corrosive materials ................. Safety helmet Safety shoes Pressure testing ................. 08. Good housekeeping
Flammable materials ................. Respiratory mask Safety glass Adjacent operations ................. 09. Fire extinguisher
Hot materials ................. Coverall Hand gloves Wind, weather, sea state ................. 10. Handheld radio
O2 deficiency ................. Life jacket Danger of falling ................. 11. Emergency Response Plan (ERP)
H2S area ................. Fall arrestors Safety lines Access/egress ................. 12. Stop work if unsafe
Naked flames or arcs ................. ..... Confined space .................
Flying particles or sparks ................. 03. First aid kit Explosives .................
Electricity ................. 04. Job Safety Analysis Substances harmful to health .................
Radioactivity ................. 05. Competent personnel Isolation of safety systems .................
Moving machinery ................. 06. Restricted/Barricade area .................
1.7 Other Safety Controls required for the Work / Kontrol Keselamatan Lainnya yang Diperlukan:
............................................................................................................................................................... ...................
*)
1.8 Person(s) performing the work / Personil yang melaksanakan pekerjaan:
The personnel shall sign before commencing work for the first time to show that they understand the task and its associated existing hazard
and preventive and control measures taken / Personil akan menandatangani sebelum memulai pekerjaan pertama kali untuk menunjukkan
mereka
memahami tugas dan bahaya yang ada dan tindakan pencegahan yang diambil.
Date & Time / Name / Function / Sign / Date & Time / Name / Function / Sign /
Tanggal & Jam Nama Fungsi Ttd. Tanggal & Jam Nama Fungsi Ttd.
Operator
Rigger
Rigger
*)
1.9 Person(s) to be notified/affected by the work / Personil yang diberitahu/terpengaruh oleh pekerjaan:
Date & Time / Name / Function / Sign / Date & Time / Name / Function / Sign /
Tanggal & Jam Nama Fungsi Ttd. Tanggal & Jam Nama Fungsi Ttd.
*) Please add an additional paper if required / Gunakan kertas tambahan jika diperlukan
1.10 I, as the Performing Authority declare that only the work stated above will be carried out, and all necessary precautions are taken to ensure
that the safety of the personnel involved in the work and other people.
I ensure that the person(s) performing the work understand(s) his work and the procedure pertaining to it.
Saya, sebagai Performing Authority menyatakan bahwa hanya pekerjaan yang disebutkan diatas yang akan dilaksanakan, dan
semua pencegahan yang diperlukan telah diambil untuk memastikan keselamatan personil yang terlibat dan orang lain.
Saya memastikan bahwa personil yang melaksanakan pekerjaan memahami pekerjaannya dan prosedur yang berhubungan.
Name: …..................................................................... Signature: ......................... Date: ….............................. Time: ...................
Nama Tanda tangan Tanggal Jam
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Document Name: Document Type: HSE Form
Document No.: EGSI-HSE-FR-001
PERMIT TO WORK FORM / Revision: 7
Date: 21-Nov-2018
FORMULIR IJIN KERJA
Approved by: PEB
2. Authorization (to be completed by Area Authority) / Otoritas (diisi oleh Area Authority)
(Department Managers/Project Manager/Vessel’s Master or his designate)
I give the authorization to commence the work as specified above. This permit valid:
Saya memberikan otoritas untuk memulai pekerjaan di atas. Ijin ini berlaku:
From Date / Dari Tanggal : ............................. Time / Jam ......................
Until Date / Sampai Tanggal : ............................. Time / Jam .......................
*) Every PTW shall be revalidated every 12 hours and maximum 7 (seven) times revalidation. If the work is still not completed yet, new PTW shall be issued.
Name: …..................................................................... Signature: ......................... Date: ….............................. Time: ...................
Nama Tanda tangan Tanggal Jam
3. Revalidation / Revalidasi
Performing Authority Area Authority
Date Time Name Sign Date Time Name Sign
4. Closing / Penutupan
4a. I, Performing Authority, declare that the work stated above has been properly performed, and all personnel, equipment affected by the
work have been withdrawn and the area has been restored to a safe and operational condition. The area has been de-isolation clearance.
Saya, Performing Authority menyatakan pekerjaan diatas telah dilakukan dengan baik, dan semua personil, alat yang dipengaruhi pekerjaan
telah ditarik dan area telah dikembalikan ke kondisi aman dan siap operasi. Area juga telah dibuka isolasinya.
The work is INCOMPLETE & the worksite has been left clean & tidy / Pekerjaan TIDAK SELESAI dan lokasi kerja telah rapi
The work is COMPLETE & the worksite has been left clean & tidy / Pekerjaan SELESAI dan lokasi kerja telah rapi
Name: …..................................................................... Signature: ......................... Date: ….............................. Time: ...................
Nama Tanda tangan Tanggal Jam
4b. I, Area Authority, have inspected the work area and declare that the work stated above has been properly performed, that all personnel,
equipment affected by the work have been withdrawn and the area has been restored to a safe and operation condition. The area has been de
- isolation clearance.
Saya, Area Authority telah menginspeksi area kerja dan menyatakan pekerjaan diatas telah dilakukan dengan baik, dan semua personil,
alat
yang dipengaruhi pekerjaan telah ditarik dan area telah dikembalikan ke kondisi aman dan siap operasi. Area juga telah dibuka
isolasinya.
The work is INCOMPLETE & the worksite has been left clean & tidy / Pekerjaan TIDAK SELESAI dan lokasi kerja telah rapi
The work is COMPLETE & the worksite has been left clean & tidy / Pekerjaan SELESAI dan lokasi kerja telah rapi
Name: …..................................................................... Signature: ......................... Date: ….............................. Time: ...................
Criteria for Cold Work Permit and Hot Work Permit / Kriteria Ijin kerja Dingin dan Panas
Cold Work Permit / Ijin Kerja Dingin Hot Work Permit / Ijin Kerja Panas
Entering confined space / Masuk ruang tertutup Any work that could generate ignition/spark sources inside hazardous area
Working over water / Bekerja di atas air / Pekerjaan yang dapat menimbulkan percikan di daerah berbahaya
Working at height of 2 (two) meters or higher above the ground/deck / Any work that has potentially explosive environment / Pekerjaan
Bekerja diketinggian di atas 2 meter yang berpotensi terjadi ledakan
Pressurized Operation / Operasi bertekanan Any electrical work / Pekerjaan kelistrikan
Crane Operation / Operasi Crane Welding, flame cutting / Pengelasan, pemotongan dengan penyinaran
Deviation from Procedure / Berbeda dengan prosedur
Work with an area isolation requirement / Bekerja pada area yang
memerlukan isolasi
Work that link to other associated work permits or simultaneous
operations / Bekerja yang berhubungan dengan operasi lainnya
Diving operation / Operasi penyelaman
Work with hazardous substances / Bekerja dengan zat berbahaya
Working on critical safety systems / Bekerja pada sistim kritikal
Excavations / Ekskavasi
All copies of this Permit To Work (PTW) and its supplementary documents shall be achieved.
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