Step 4 PTW Coordinator

RADIOGRAPHY Permit No:

WORK PERMIT Date:

Signature:

Step 1 By Permit Holder / Diisi oleh permit holder Site Description /deskripsi

M/S No.: CONTRACTOR NAME/ Nama Kontraktor:

WORK LOCATION/ Lokasi Kerja: TYPE OF WORK/ Jenis Pekerjaan :

DESCRIPTION OF THE WORK TO BE PERFORMED/ Jelaskan Pekerjaan Yang Dilakukan:

TYPE OF EQUIPMENT TO BE USED (attach if necessary)/ Peralatan Yang Digunakan (lampirkan jika dibutuhkan):

PLANNED STARTING DATE/ Rencana Tanggal Mulai: PLANNED COMPLETION DATE: /Rencana Tanggal Selesai:

OTHER RELATED PERMIT NO/Terkait Dengan No Permit Lainnya:

SUPERVISOR IN-CHARGE/ Supervisor Yang Bertanggung Jawab: DATE/ Tanggal:

CONTACT NUMBER/ Nomor kontak : SIGNATURE/ Tandatangan:

The permit (with Method Statement and Risk Assessment) is must be posted at the work site at all times.
Izin Kerja ( dengan metoda kerja dan penilaian resiko) harus berada ditempat kerja
This permit is not valid unless all appropriate fields are completed/ Permit ini tidak berlaku kecuali bidang
yang sesuai sudah dilengkapi

Radiation Source Information

Radiation Type / Sumber Radiasi :

..........................................................................................................................................................

Serial Number / No Seri :

..........................................................................................................................................................

Safe Radius Distance :………………………………meters Source Strength :………………………………curies

Safe Working Distance Calculation shall be attached.

Required Self Protective Equipment (Hardhat, Safety Glass, Traffic Vest, Long Sleeves and Safety Shoes are mandatory required)

Face shield/ Pelindung muka Fall protection (life line, safety harness) Pelindung jatuh

Hearing protection/ Pelindung telinga Special gloves/ Sarung tangan khusus

Particulate respirators Alat bantu pernafasan khusus Dust Mask Masker debu

Gas/Vapor respirators Alat bantu pernafasan gas/uap Floatation apparel Pelampung

Welding air purifying respirators Respirator penyaring udara las Apron / Apron

Arc flashes protective equipment Alat pelindung dari sinar arc Special cloth Pakainan khusus

Required Protective Equipment

Radio(s) Radio Fire Blanket / Pemadam api

Portable survey meters Meter survei portabel Fire extinguisher / APAR

Tripod / Penanda OSR equipment Penyerap tumpahan oli

SCBA Eyes Washer Pembersih mata

Gas detector / Pengukur Gas Mechanical ventilation Ventilasi mekanik

PTW form rev#4

 Step 4 PTW Coordinator

RADIOGRAPHY Permit No:

WORK PERMIT Date:

Signature:

PRECAUTIONS CHECKLIST
Competent Supervisor and HSE Officer are appointed.
Diawasi oleh pengawas dan ahli K3 yang berkompeten.
Is watchman is appointed for entry register log.(confined-space)
Apakah ada pengawas keluar masuk area pengetesan ?
Working areas shall be properly barricaded with specific tape as
per the requirements so that unauthorized entry shall be
restricted.Area pengujian harus diberi tanda pembatas area
terbatas.
Safe access/egresses available.
Tersedia jalur keluar masuk yang aman.
Housekeeping properly maintained.
Kerapihan dan kebersihan area kerja selalu terjaga.
All Radiographers need to wear film badge and dosimeter.
Semua Radiografer perlu memakai lencana film dan dosimeter
Mandatory and specific PPEs are available and properly worn.
Alat pelindung diri yang diwajibkan sudah dipakai dengan benar.
Are other operations are proceeding at safe distance.
Apakah pekerjaan dilakukan di dalam jarak yang aman ?
Collimators to be used where appropriate to minimize radiation
scatter. Kolimator dibutuhkan untuk mengurangi penyebaran radiasi.
Coordination meeting is conducted with nearby contractor.
Pekerjaan sudah dikordinasikan dengan kontraktor terkait.
Qualified and registered radiographer?
Radiographer yang memenuhi syarat dan terdaftar ?
Lighting to be arranged prior to work
Tersedia penerangan yang aman selama pekerjaan.

I fully understand the nature of the work and safety conditions that must be met. I have inspected the safety condition relating to the work to be
performed.
Sub-Contractor’s Radiographer: : Date:
Contact Number : Sign

Step 2 By Contractor Area Engineer / Supervisor & EHS Manager Oleh kontraktor supervisor area/ Engineer & EHS Manager

Reviewed By/ Direview oleh Name/ Nama Signature/ Tandatangan Date/ Tanggal

SCT Area Engineer / Supervisor

SCT EHS Manager (Deputy)

Step 3 Review and Approve / Memeriksa dan menyetujui

Approved By/ Disetujui oleh Name/ Nama Signature/ Tandatangan Date/ Tanggal

SCT Site Manager / Construction Manager

Step 5 Re-evaluated at worksite / Dievaluasi di area kerja

Evaluated by Name/ Nama Signature/ Tandatangan Date/ Tanggal

Sub-con. Site Manager or Delegate

SCT Const. Person in charge at Area

SCT EHS Person in charge at Area

Step 6 Permit Close/ Penutupan Permit

The Permit is to be signed off 30 minutes prior to the end of the shift at the last valid day of this permit and reported to SC&T permit coordinator.
Permit akan ditandatangani 30 menit sebelum berakhirnya shift dan diakhir masa berlaku permit serta laporkan ke Permit Kordinator SC&T.
Job Complete/Pekerjaan selesai Job Incomplete/ Pekerjaan belum selesai
I have checked the workplace and declaring that I withdraw all my workforces from the area and it is safe.
Saya telah memeriksa area kerja dan menyatakan bahwa saya telah menarik semua pekerja saya dari dari lokasi kerja dan aman
Permit holder Name and Signature/ Date/
Pemegang Permit dan tandatangan: Tanggal:

SAFETY FIRST!
*POV or Commissioning area will require additional PTW from Commissioning Dept.

PTW form rev#4

 Step 4 PTW Coordinator

RADIOGRAPHY Permit No:

WORK PERMIT Date:

Signature:

PTW form rev#4