Continuation of Work permit n°

HOT WORK PERMIT Kelanjutan dari Ijin Kerja n°

No. : HWP XXXXXX
IJIN KERJA PANAS
Site: Installation: Equipment: Tag number: Attachements / Lampiran
Lapangan: Instalasi: Peralatan: Nomor identitas: (tick when requested)
(beri tanda pada bila diminta)
Company/Entity to execute work: Representative/Foreman: Manpower:
Perusahaan / Yang berwenang: Perwakilan / Mandor: Jumlah pekerja: ‰  Specific procedure
REQUEST (PERMINTAAN)

Tata cara khusus

‰  Drawings, sketches, …
Gambar, denah
Work permit requested for: day month year Expected duration: (days)
Ijin kerja diminta untuk: tgl bulan tahun Perkiraan durasi: (hari)
‰  Marine Operation Permit
Ijin Operasi Marin
Description of work: / Persiapan pekerjaan: ‰  Isolation Procedure
(electrical, process,
mechanical)
Tata cara Isolasi (listrik,
proses, mekanis)
‰  Risk Assessment Study
Studi penilaian resiko
‰ 
Requestor (name, entity):
Pemohon (nama, posisi): ‰ 
Tools/ Equipment:
Perlengkapan/ alat:

( checking before approval)

( permeriksaan sebelum pengesahan

HAZARDOUS CONDITIONS / KEADAAN YG MEMBAHAYAKAN

‰ Flame, spark (welding, cutting torch, ‰ Confined space ‰ Heavy lifting ‰ Live electricity
grit blasting, …) Ruang tertutup Pengangkatan benda berat Listrik
Api terbuka, percikan (pengelasan, alat ‰ Work on drains ‰ Adjacent / Overhead works ‰ Static electricity
potong gas, blasting, …) Kerja di pembuangan Ada pekerjaan di dekat / atas - nya Listrik statis
‰ Flammable material ‰ Excavation (underground installations) ‰ Work at height ‰ Radioactive source
Bahan mudah terbakar Penggalian (instalasi bawah tanah) Kerja di ketinggian Radiasi radio aktif
‰ Presence of gas (hazardous area, work ‰ Weather conditions (visibility, lightning, ‰ Work at night ‰ High temperature
in vessel or tank, …) wind, …) Kerja malam Temperatur tinggi
Gas (daerah berbahaya, bekerja didalam
bejana atau tangki, …)
Kondisi cuaca (penglihatan, petir, ‰ Work above water ‰ Road transportation
angin, …) Kerja di atas air Transportasi darat
‰ Liquid hydrocarbon (oil, ‰ Downgraded safety device ‰
condensate) ‰ Underwater operation Naval transportation
Penurunan alat pengaman Operasi didalam air Transportasi laut
Cairan hydrocarbon (minyak,
kondensat)
‰ Single valve isolation ‰ Underwater installation (pipe, …) ‰ Internal combustion engine
Isolasi kerangan tunggal Pemasagan didalam air (pipa, …) Mesin bensin
‰ Hazardous substances
‰ Moving parts / Uncontrolled start
Bahan berbahaya ‰ Use of non-intrinsicaly safe equipment Other hazards, comments, …
Peralatan bergerak / Permulaan yang in hazardous area
‰ Liquid / gas under pressure Bahaya-bahaya lain, komentar …
tidak terkontrol Pemakaian alat non- IS di daerah
Cairan / gas bertekanan
‰ Manual handling / Lifting berbahaya ‰ …………………..
Pengangkatan manual / alat angkat
Interference with other work permit number / bercampur dengan lain ijin kerja no: …..…………..……………………………………………………………………….……………………………….…………
Interference with other operations in progress / bercampur dengan lain pekrjaan yang sedang berlangsung: …………………………………………………………………………………….……………….
(tick when requested, ❍ check for implementation before validation)
PRECAUTIONS / PENCEGAHAN (beri tanda pada apa bila diperlukan, ❍ periksa untuk penerapannya sebelum mulal bekerja)
PREPARATION (PERSIAPAN)

‰  Process isolation ‰  Vent to safe place ‰  Chemical adapted PPE ‰  Fire-Fighting boat
Proses diisolasi Dialirkan ke tempat aman PPE bahan kimia Kapal pemadam kebakaran
‰  Equipment spaded/blinded ‰  Confined Space Entry Permit ‰  Dust / gas mask ‰  Oil Boom Deployment
Peralatan disekat/disumbat Ijin ruang tertutup Masker debu / Gas Perintang minyak digelar
‰  Electrical isolation ‰  Excavation Permit ‰  Safety harness / life line ‰  Stand-by Boat
Listrik diisolasi Ijin penggalian Harnes / tali pengaman Kapal di tempat
‰  Mechanical isolation ‰  Safety system override ‰  Goggles ‰  Rescue Equipment
Mekanis diisolasi Alat pengaman dimatikan Kacamata Peralatan penyelamatan
‰  Equipment depressurized ‰  Standby operator ‰  Ear Protection ‰  Communication means
Peralatan tanpa tekanan Operator di tempat Pelindung telinga Peralatan komunikasi
‰  Equipment drained ‰  Warning sign/barrier ‰  Life Jacket / Work Vest (Radio, Phone, MAC)
Peralatan dikuras Tanda perringatan /pagar larangan Baju pelampung / Pelampung kerja ‰  Spark / blasting protection
‰  Equipment fully gas free ‰  Additional safety lighting ‰  Scaffolding Proteksi percikan api / pasir
Peralatan bebas dari gas Tambahan lampu penerangan Perancah ‰  Anti spark tools
‰  Equipment ventilated ‰  Permanent gas monitoring ‰  Water screen / spray Alat anti percikan
Peralatan di-ventilasi Pengetesan gasterus menerus Tabir air / semprotan air ‰  Equipotential liaison
‰  Equipment fully inerted ‰  Breathing Apparatus / Air-lines ‰  Fire water hose Pentanahan / bonding
Peralatan di-inert Alat pernafasan bertekanan Selang pemadam kebakaran ‰  Safety devices on engines
‰  Equipment filled with water ‰  Gas check prior starting (LEL, 02, toxic) ‰  Dry powder / CO2 Extinguisher Alat pengaman di mesin
Peralatan diisi air Pengetesan gas sebelum mulai Alat pemadam api tepung / CO2 ‰  Pre-job meeting
Rapat sebelum kerja
Additional required precautions / Permitaan tambahan tindakan pengaman
‰  …………………………………………………………………………………………………………………………………………………………………………………………..
‰  …………………………………………………………………………………………………………………………………………………………………………………………..
‰  …………………………………………………………………………………………………………………………………………………………………………………………..

COMPLEMENTARY PERMITS / IJIN KERJA TAMBAHAN

Excavation Permit n0 / Ijin Penggalian no ……………………………………….…... Confined Space Entry Permit n0 / Ijin Masuk Ruang Tertutup no …………………………………..…………….
0 o
Electrical Isolation Permit n / Ijin Pengisolasian Listrik n ……………………..… Other / Lain-lain ………………………………………………………………………… ……………………………….

Appointed Performing Authority Representative (name, position) Appointed Operating Authority Representative (name, position)
Perwakilan Wewenang Pelaksana Yang ditunjuk (nama, posisi) Perwakilan Wewenang Operasi Yang ditunjuk (nama, posisi)

Reviewed by Performing Authority Reviewed with Safety & Environment Superintendent Approved by Operating Authority
Diperiksa oleh Wewenang Pelaksana Diperiksa oleh Supt. Keselamatan & Lingkungan Disetujui oleh Wewenang Operasi

Name / Nama: Name / Nama: Name / Nama:

Date / Tgl: Date / Tgl: Date / Tgl:
Signature / Tanda Tangan: Signature / Tanda Tangan: Signature / Tanda Tangan:

Distribution: WHITE: work location YELLOW: Operating Authority BLUE: Control Room PINK: Safety Authority GREEN: RSES Rev. 3 of 11-04-04
Distribusi: PUTIH: tempat kerja KUNNING: Wewenang Operasi BIRU: Control Room MERAH MUDA: Wewenang Safety HIJAU: RSES
 Work Permit validation requested day(s) shift(s)
Permintaan validasi ijin kerja hari pergantian giliran
APPROVAL

RSES comments and additional requests / Komentar dari RSES dan atau tambahan permintan
………………………………………………………………………………………………………………………………………………………………..… Work planned to start
……………………………………………………………………………………………………………………………………………………..…………… Pekerjaan akan dimulai ………………………..
………………………………………………………………………………………………………………………………………………………..…………
I the undersigned, give authorisation as Responsible for Safety and Environment on Site (RSES), for the execution Date, time
of the above described works , provided required precautions are implemented. Tgl, waktu
Saya yang bertandatangan dibawah ini sebagal penanggung jawab Keselamatan dan Lingkungan di Lapangan, mengijinkan untuk Name, Signature
memulai melaksanakan pekerjaan yang dijelaskan di atas, jika seluruh tindakan pencegahan yang ditentukan telah dipenuhi Nama, Tanda Tangan

GAS MEASUREMENTS / PENGUKURAN GAS (in case of periodic measurement is requested, gas measurements shall be reported on a separate table)
(dalam hal pengukuran secara periodik, hasil pengukuran gas harus dilaporkan di formulir terpisah)
Only formally nominated Authorised Gas Tester may perform gas measurements
Hanya Gas Tester yang telah disahkan dan ditentukan yang boleh melakukan pengukuran gas
Date Time Name Signature
Tanggal Waktu % LEL % O2 Other (toxic, …) Nama Tanda Tangan Gas detector n0
EXECUTION (PELAKSANAAN)

ON SITE VALIDATION / VALIDASI DILAPANGAN

The undersigned acknowledges that the required precautions have been
implemented, and that work may start. The shift supervisor / panel operator has
been informed.
Yang bertandatangan di bawah ini menyatakan bahwa tindakan pencegahan yang
diperlukan telah dipenuhi dan parkerjaan dapat mulai dilaksanakan.
Pemberitahuan telah diberikan kepada shift Supervisor / operator panel
I accept the requirements of this Work Permit and acknowledge that they will remain
implemented during the course of the works
Saya menerima persyaratan dari Ijin Kerja ini dan menyatakan bahwa persyaratan tersebut akan tetap
dilaksanakan selama pekerjaan berlangsung

OPERATING AUTHORITY or Rep. PERFORMING AUTHORITY or Rep. CONTRACTOR FOREMAN

Wewenang Operasi / yg ditunjuk Wewenang Pelaksana / yg ditunjuk Pengawas Kontraktor
Date Time Name Signature Name Signature Name Signature
Tanggal Waktu Nama Tanda Tangan Nama Tanda Tangan Nama Tanda Tangan

MOMENTARY INTERRUPTION / DIHENTIKAN SEMENTARA

INTERRUPTION

I declare that the works for which this Work Permit was issued and which were interrupted
I declare that the works for which this Work Permit was issued has been interrupted by
may start again after I have checked environmental conditions and implementation of
myself, and that I have informed the shift supervisor / panel operator of this interruption
Saya menyatakan bahwa pekerjaan yang tercantum pada ijin kerja ini telah saya hentikan untuk required precautions
Saya menyatakan bahwa pekerjaan yang tercantum pada ijin kerja yang telah diberhentikan untuk
sementara dan saya telah memberitahukan pemberhentian ini kepada Supervisor / Operator
sementara ini, bisa dimulai kembali setelah saya memeriksa kondisi sekitarnya dan telah
Panel.
melaksanakan pencegahan-pencegahan yang diminta
REASON / ALASAN OPERATING AUTHORITY / WEWENANG OPERASI
Date Time Name Signature Date Time Name Signature
Tanggal Waktu Nama Tanda Tangan Tanggal Waktu Nama Tanda Tangan

__ / __ / ___ __ : ___ __ / __ / ___ __ : ___

WORK PERMIT COMPLETION / SELESAI PEKERJAAN

COMPLETION (SELESAI)

We undersigned declare that the works for which this Work Permit has been issued is:
Kami yang bertanda tangan dibawah ini menyatakan bahwa pekerjaan yang tercantum pada Ijin Kerja ini adalah:
Completed and commissioned, that specific precautions (isolations, …) have been removed, Not completed and definitively interrupted
that the place is left in safe conditions, and that installation may return to routine service Tidak terselesaikan dan secara tegas dihentikan
Selesai dan diperiksa, bahwa tindakan pencegahan khusus (isolasi, ) telah diambil
kembali, bahwa lokasi kerja ditinggalkan dalam keadaan aman dan bahwa instalasi dapat Mandatory actions have to be undertaken before installation may return to service
kembali beroperasi secara normal Langkah-langkah yang harus diambil sebelum instalasi dapat kembali bekerja

Not completed and to be continued under Work Permit n0 …………………… …………………………………………………………………………….

Belum selesai dan dilanjutkan dengan Ijin Kerja n0 …………………………………………………………………………..

Date Time Name Signature

Tanggal Waktu Nama Tanda Tangan

PERFORMING AUTHORITY
WEWENANG PELAKSANA
___ / ___ / _____ ___ : ___ ___________________________________ ____________________________________
OPERATING AUTHORITY
WEWENANG OPERASI
___ / ___ / ____ ___ : ___ ___________________________________ ____________________________________
Filing after completion: WHITE: Performing Authority YELLOW: Operating Authority BLUE: Control Room PINK: Safety Authority GREEN: RSES Rev. 3 of 11-04-04
Diisi setelah selesai: PUTIH: Wewenang Pelaksana KUNNING: Wewenang Operasi BIRU: Control Room MERAH MUDA: Wewenang Safety HIJAU: RSES