AI/SHES/FORM/001/00

HAZARD IDENTIFICATION AND RISK ASSESSMENT (HIRA)

AND IDENTIFICATION OF ENVIRONMENTAL ASPECTS IMPACT

Project : BHCCPP1 AMNT JEL Combined Cycle Power Plant No. HIRADC : AMNT/001/HIRADC/VI/2022
Work process : Preparation Work Revision : 00
Phase : GIS Building Issued date

Initial Risk Assessment Residual Risk Assessment

Residual Risk Value

Accepted (Yes/No)
Type of Additional risk
Operational Potential Hazards

Initial Risk Value

Activity Risk Control: Control of hazards that have been possessed control
Conditions Issue Internal/ (hazardous actions and Safety and Health Risks / Environmental References /
No Activities (Routine/ (Elimination, Subtitute, Engineering, Administration, Personal (filled in when Remark
(Normal/ External conditions) / Environmental Impacts Regulations
non- Protective Equipment) residual risk is not

Likelihood

Likelihood
Abnormal) Aspects
Routine) acceptable)

Severity

Severity
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Heavy Equipment Mobilization
a. UU No 1 th
1970 tentang K3
OHS: Broken bones 3 5 15 Elimination : 1 3 3 Y b. PerMenaker RI
No 8 Tahun 2020
Tentang
Keselamatan &
OHS: Death Subtitution : Kesehatan Kerja
Pesawat Angkat
& Pesawat
Angkut
c. Permenaker no
Unloading the heavy
1 R N Internal Heavy equipment slips off Environment: Exposure to soil Engineering : Area demarcation - 8 tahun 2010 ttg
equipment from the trailer
Alat Pelindung
Diri

Administration: Every heavy equipment operator must have a

Property : Broken heavy equipments
SIO

Public Safety : PPE : Using Mandatory PPE, Mask

 a. UU No 1 th
1970 tentang K3
OHS: 3 5 15 Elimination : 1 3 3 Y b. Undang-
undang No. 14
Tahun 1992
tentang Lalu
OHS: Death Subtitution : Lintas dan
Angkutan Jalan
c. Permenaker no
8 tahun 2010 ttg
Mobilization of heavy Heavy equipment slips off Alat Pelindung
2 R N External Environment: exposure to soil or road Engineering : Fastening heavy equipments with the trailer -
equipment and trailer crash Diri

Property : Broken heavy equipments & Administration: Every heavy equipment operator must have a
trailer SIO, P2H of the Trailer, SIMPER for driver

Public Safety : Crash with public vehicle PPE : Using Mandatory PPE, Mask

a. UU No 1 th
1970 tentang K3
OHS: Broken bones 3 5 15 Elimination : 1 3 3 Y b. PerMenaker RI
No 8 Tahun 2020
Tentang
Keselamatan &
Kesehatan Kerja
OHS: Heavy Injury Subtitution : Pesawat Angkat
& Pesawat
Angkut
c. Permenaker no
8 tahun 2010 ttg
Unloading of heavy Alat Pelindung
3 R N Internal Heavy equipment slips off Environment: Engineering : Area demarcation -
equipment Diri

Administration: Every heavy equipment operator must have a

Property : Broken heavy equipments
SIO

Public Safety : PPE : Using Mandatory PPE, Mask, Lifebuoy

a. UU No 1 th
1970 tentang K3
OHS: 3 5 15 Elimination : 1 3 3 Y b. PerMenaker RI
No 8 Tahun 2020
Tentang
Keselamatan &
OHS: Subtitution : Kesehatan Kerja
Pesawat Angkat
& Pesawat
Landslides and erosion, Angkut
Equipment Parking in resulting in the derailment of c. Permenaker no
4 R N Internal Environment : Engineering : Area demarcation -
workshop or working area heavy equipment and 8 tahun 2010 ttg
vehicles Alat Pelindung
Diri
Administration: Every heavy equipment operator must have a
Property : Broken heavy equipments
SIO, P2H of the Trailer

Public Safety : PPE : Using Mandatory PPE, Mask, Lifebuoy

Materials Mobilization
a. UU No 1 th
OHS: Hit by materials or heavy 1970 tentang K3
3 5 15 Elimination : 1 3 3 Y b. PerMenaker RI
equipments
No 8 Tahun 2020
Tentang
Keselamatan &
Kesehatan Kerja
OHS: Subtitution : Pesawat Angkat
& Pesawat
Angkut
c. Permenaker no
8 tahun 2010 ttg
5 Loading materials R N Internal Heavy equipment slips off Environment: Engineering : Area demarcation, tagline - Alat Pelindung
Diri
 Keselamatan &
Kesehatan Kerja
Pesawat Angkat
& Pesawat
Angkut
c. Permenaker no
8 tahun 2010 ttg
5 Loading materials R N Internal Heavy equipment slips off - Alat Pelindung
Diri

Administration: Every heavy equipment operator must have a

Property : Materials drop
SIO

Public Safety : PPE : Using Mandatory PPE, Mask

a. UU No 1 th
1970 tentang K3
b. Undang-
OHS: 3 5 15 Elimination : 1 3 3 Y
undang No. 14
Tahun 1992
tentang Lalu
Lintas dan
Angkutan Jalan
c. Permenaker no
OHS: Death Subtitution : 8 tahun 2010 ttg
Alat Pelindung
Diri

Heavy equipment slips off

6 Mobilization of materials R N External Environment: exposure to soil or road Engineering : Fastening heavy equipments with the trailer -
and trailer crash

Administration: Every heavy equipment operator must have a

Property : Broken materials & trailer
SIO, P2H of the Trailer, SIMPER for driver

Public Safety : Crash with public vehicle PPE : Safety Car Belts

Construction of Office & Facilities

a. UU No 1 th
OHS: Bruised 4 3 12 Elimination : 1 3 3 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched (external injuries) Subtitution : Alat Pelindung
Diri
Site Office Fence
7 R N Internal Injured by work tools Environment : Engineering : -
Installation

Property : Administration : PTW, JSA, TBM , Avoid pinch points

Public Safety : PPE : Using Mandatory PPE, Gloves

a. UU No 1 th
1970 tentang K3
OHS: Death 3 5 15 Elimination : 1 3 3 Y
b. Undang-
undang No. 14
Tahun 1992
tentang Lalu
OHS: Wounded Subtitution : Lintas dan
Angkutan Jalan
c. Permenaker no
8 tahun 2010 ttg
R N Internal Excavator slips off Environment: Exposure to soil Engineering : Traffic Management - Alat Pelindung
Diri

Property : Broken heavy equipments Administration : SIO for Operator, SILO for Heavy Equipments

Cleaning of the project area

8
from reeds/grass
Public Safety : crash vith paper truck PPE : Using Mandatory PPE, gloves

a. UU No 1 th
OHS: swollen wound 3 5 15 Elimination : 1 3 3 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Subtitution : Alat Pelindung
Diri
Bitten by other insects /
R N Internal -
animals
 Cleaning of the project area
8
from reeds/grass

a. UU No 1 th
1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
Bitten by other insects /
R N Internal Environment : Engineering: -
animals

Property : Administration : PTW , JSA, TBM

Public Safety : PPE: Using Mandatory PPE

a. UU No 1 th
OHS: Ergonomic disturbance 4 3 12 Elimination : 1 3 3 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched (external injuries) Subtitution : Alat Pelindung
Diri
Injured by work tools &
9 Manual lifting of materials NR N Internal Environment : Engineering : -
Ergonomics

Property : Administration : PTW, JSA, TBM , Avoid pinch points

Public Safety : PPE : Using Mandatory PPE, Gloves

a. UU No 1 th
OHS: 4 3 12 Elimination : 1 3 3 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched (external injuries) Subtitution : Alat Pelindung
Diri
10 Bolting and nailing R N Internal Injured by work tools Environment : Engineering : -

Property : Administration : PTW, JSA, TBM , Avoid pinch points

Public Safety : PPE : Using Mandatory PPE, Gloves

a. UU No 1 th
1970 tentang K3
OHS: Death 4 5 20 Elimination : 1 3 3 Y b. Permenaker
No 12 Tahun
2015 tentang
Keselamatan &
OHS: Electrocuted Subtitution : Kesehatan Kerja
Listrik di Tempat
Kerja
c. Permenaker no
8 tahun 2010 ttg
11 Electrical installation NR N Internal Electrocuted Environment : Engineering : LOTO - Alat Pelindung
Diri

Property : Administration : PTW, JSA, TBM

Public Safety : PPE : Using Mandatory PPE, Electrical Gloves

a. UU No 1 th
OHS: Slip 4 5 20 Elimination : 1 3 3 Y 1970 tentang K3
b. Permenaker no
37 Th 2016
OHS: Subtitution : Tentang K3
Bejana Tekan &
Tangki Timbun
Environment: Contamination of the Engineering: Making fuel warehouses, Making secondary c. Permenaker no
Internal Fuel spill
Environment with toxic chemicals Contaiment 8 tahun 2010 ttg
Alat Pelindung
Diri
Property : Administration : PTW, JSA, Provision of fire extinguisher

Public Safety : PPE: Using Mandatory PPE

a. UU No 1 th
12 Fuel Storage NR N 1970 tentang K3
OHS: Fatality 4 5 20 Elimination : 1 3 3 Y
b. Permenaker no
37 Th 2016
Tentang K3
OHS: Subtitution : Bejana Tekan &
Tangki Timbun
c. Permenaker no
Spills have the potential for 8 tahun 2010 ttg
Internal Alat Pelindung
fire
Diri
 a. UU No 1 th
12 Fuel Storage NR N 1970 tentang K3
b. Permenaker no
37 Th 2016
Tentang K3
Bejana Tekan &
Tangki Timbun
c. Permenaker no
Spills have the potential for Engineering: Prepare a secondary containment to prevent 8 tahun 2010 ttg
Internal Environment : Alat Pelindung
fire leakage or fuel spills.
Diri

Property : Property Damage Administration : PTW, JSA, Provision of fire extinguisher

Public Safety: Disrupting other work

PPE: Using Mandatory PPE
activities

Preparation Works
a. UU No 1 th
OHS: Tetanus infection 4 4 16 Elimination : 1 2 2 Y
1970 tentang K3
b. Permenaker no
OHS: Subtitution : 8 tahun 2010 ttg
Alat Pelindung
R N Internal Foot pierced by nails Environment : Engineering : - Diri

Property : Administration : PTW, JSA, 5R

Public Safety : PPE: Using Mandatory PPE

13 Survey a. UU No 1 th
OHS: Infection wound 4 4 16 Elimination : 1 3 3 Y 1970 tentang K3
b. Permenaker no
OHS: Subtitution : 8 tahun 2010 ttg
Alat Pelindung
Stepping on sharp objects / Diri
R N Internal Environment : Engineering :
thorns

Property : Administration : PTW, JSA, TBM, Pemebersihan area proyek

Public Safety : PPE: Using Mandatory PPE

Diterbitkan oleh Diperiksa oleh Disetujui oleh

POM SHE PM

Penjelasan kolom Matrix risiko

1 Aktivitas : Kegiatan, Produk dan Jasa yang akan diidentifikasi dan dievaluasi aspek dan dampak OHSL nya
2 Jenis aktivitas : Rutin (aktivitas yang rutin dilakukan, misalnya : pengecoran)
Non rutin (aktivitas yang tidak rutin, misalnya : lifting )
3 Kondisi operasional : Normal (aktivitas dilakukan pada kondisi normal)
Abnormal (aktivitas dilakukan pada kondisi abnormal, misalkan : pemadaman api saat kebakaran)
4 Issue : External (issue external yang mempengaruhi kondisi bahaya/dampak Environment, misalnya : perubahan kebijakan pemerintah)
Internal (issue internal yang mempengaruhi kondisi bahaya/dampak Environment, misalnya : perubahan kebijakan perusahaan)
5 Aspek / bahaya : Aspek Environment / bahaya yang muncul dari aktivitas yang ada
6 Dampak SHE : Dampak yang ditimbulkan dari bahaya yang ada terhadap manusia, Environment, Property dan umum
7 Kemungkingan : Kemungkinan terjadinya kecelakaan dari aktivitas yang ada
8 Keparahan : Konsekuensi terjadinya kecelakaan dari aktivitas yang ada
9 Nilai risiko : Perkalian dari kemungkingan dan konsekuensi
10 Kontrol risiko : Kontrol yang telah dilakukan dari aktovotas dan bahaya yang ada
11 Risiko sisa : Penilaian risiko setelah dilakukan kontrol
12 Status diterima : Risiko sudah dapat diterima atu tidak sesuai matriks yang ada
13
14
15
 AI/SHES/FORM/001/00

HAZARD IDENTIFICATION AND RISK ASSESSMENT (HIRA)

AND IDENTIFICATION OF ENVIRONMENTAL ASPECTS IMPACT

Project : BHCCPP1 AMNT JEL Combined Cycle Power Plant No. HIRADC : AMNT/001/HIRADC/VI/2022
Work process : Civil Works Revision : 00
Phase : GIS Building Issued date : 19 September 2022

Initial Risk Assessment Residual Risk Assessment

Residual Risk Value

Accepted (Yes/No)
Type of Additional risk
Operational Potential Hazards

Initial Risk Value

Activity Risk Control: Control of hazards that have been possessed control
Conditions Issue Internal/ (hazardous actions and Safety and Health Risks / Environmental References /
No Activities (Routine/ (Elimination, Subtitute, Engineering, Administration, Personal (filled in when Remark

LiQHSlihood
(Normal/ External conditions) / Environmental Impacts Regulations
non- Protective Equipment) residual risk is not

Likelihood
Abnormal) Aspects
Routine) acceptable)

Severity

Severity
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
a. UU No 1 th
1970 tentang K3
OHS: Minor Injury 3 4 12 Eliminasi :- 2 2 4 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
OHS : Medical Treatment Injury Substitusi :- c. Kepmenaker
ESDM No 1827
K/30/MEM/2018
tentang Pedoman
Pelaksanaan
- Malfunction of heavy Engineering : Land Protection using SSP etc or 1:2
1 Excavation (Cut & Fill) R N Internal Environment : Oil spill to soil Kaidah Teknik
equipment Excavation Area, Pre use inspection
Pertambangan
yang Baik
Administration : Making work permits and JSA, making soil
Property : Broken Heavy Equipment excavation work methods, installing signs in the excavated
area

Public Safety : PPE : Mandatory use of PPE (Helmets, Vests, Safety shoes)
 a. UU No 1 th
1970 tentang K3
OHS : Fatality 4 5 20 Eliminasi : - 2 3 6 b. PerMenaker RI
No 8 Tahun 2020
Tentang
Keselamatan &
Kesehatan Kerja
Pesawat Angkat
OHS: Fracture Substitusi : -
& Pesawat
Angkut
c. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Workers hit by heavy Engineering : Install emergency stop button for heavy
R N Internal Environment : Diri
equipment equipment, pre use inspection
d. Kepmenaker
ESDM No 1827
K/30/MEM/2018
Administration : Making work permits and JSA, making soil tentang Pedoman
excavation work methods, Operators having SIO, Heavy Pelaksanaan
Property : Broken Heavy Equipment
equipment having SIA, making traffic management Kaidah Teknik
procedures, providing traffic man, making OHS signs Pertambangan
yang Baik

Public Safety : PPE : Mandatory use of PPE (Helmets, Vests, Safety shoes)

a. UU No 1 th
1970 tentang K3
OHS : Fatality 4 5 20 Eliminasi : - 2 3 6 b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
c. Kepmenaker
ESDM No 1827
OHS : Fracture Substitusi : -
K/30/MEM/2018
tentang Pedoman
Pelaksanaan
Kaidah Teknik
Workers buried in excavated Pertambangan
R N Internal soil due to dredging not Environment : Engineering : yang Baik
according to procedures

Administration : Making work permits and JSA, making soil

excavation work methods, Operators having SIO, Heavy
Property :
equipment having SIA, making traffic management
procedures, providing traffic man, making QHS signs

Public Safety : PPE : Mandatory use of PPE (Helmets, Vests, Safety shoes)

a. UU No 1 th
1970 tentang K3
OHS: Fatality 4 5 20 Elimination : 2 3 6 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri

OHS: Medical treatment injury Subtitution :

Sand load into Drum Truck

2 R N Internal Crash with other vehicle Environment: Paparan kebisingan Engineering : Traffic management,vehicle speed limit -
send to LD 10

Administration: Alternate personnel every five minutes, Install

Property : signs to watch out for noise work, noise measurements once
a day

Public Safety : PPE : Using Mandatory PPE, Mask, ear Plug

Lean Concrete
 a. UU No 1 th
1970 tentang K3
OHS: Minor Injury 4 3 12 Elimination : 1 3 3 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
c. Permenaker
No 8 tahun 2020
OHS: Falling Materials Subtitution :
tentang K3
Pesawat Angkat
& Angkut

3 Plastic Sheet laying NR N Internal Injured by work tools Environment: Engineering : Area demarcation, Pre-Use Check Equipment -

Administration: Making JSA & PTW, ensure that workers work

Property :
according the procedure

Public Safety : PPE : Using Mandatory PPE, Mask and gloves

a. UU No 1 th
1970 tentang K3
OHS: Minor injury 2 3 6 Eliminasi :- 1 4 4 Y b. Undang-
undang No. 14
Tahun 1992
tentang Lalu
Lintas dan
Angkutan Jalan
OHS : First aid injury Substitusi :-
c. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
Pinched when assemblythe
4 Formwork R N Internal Environment : Engineering :
formwork

Administration : Making work permits and JSA, making

Property : Broken Materials formwork assembly procedures, installing signs in the work
area,

PPE : Mandatory use of PPE (Helmets, Vests, Safety shoes)

Public Safety :
and gloves

a. UU No 1 th
1970 tentang K3
OHS: 2 4 8 Eliminasi :- 2 2 4 Y b. Undang-
undang No. 14
Tahun 1992
tentang Lalu
Lintas dan
Angkutan Jalan
OHS : Substitusi :-
c. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
d. Kepmenaker
Concrete pouring spill and
5 Concrete work Rutin N Internal Environment : Concrete spill Engineering : Making path cover for concrete flow - ESDM No 1827
polute the environment
K/30/MEM/2018
tentang Pedoman
Pelaksanaan
Administration : Making work permits and JSA, concrete work Kaidah Teknik
Property : procedure, installing signs in the working area, Operators Pertambangan
having SIO, Work method fot pouring concrete yang Baik

Public Safety : PPE : Mandatory use of PPE (Helmets, Vests, Safety shoes)

a. UU No 1 th
1970 tentang K3
OHS : Medical Treatment Injury 4 4 16 Eliminasi : - 2 3 6 Y b. Undang-
undang No. 14
Tahun 1992
tentang Lalu
Lintas dan
Angkutan Jalan
c. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
d. Permenaker
- Vechile overturned due to
Rutin N Internal - No 8 tahun 2020
difficult access paths
tentang K3
 a. UU No 1 th
1970 tentang K3
b. Undang-
undang No. 14
Tahun 1992
tentang Lalu
Lintas dan
Angkutan Jalan
OHS: Fracture Substitusi : -
c. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
d. Permenaker
- Vechile overturned due to Engineering : Make a proper access for concrete truck,no
Rutin N Internal Environment : - No 8 tahun 2020
difficult access paths elevation differential,traffic management
tentang K3
Pesawat Angkat
Administration : Making work permits and JSA, making soil & Angkut
excavation work methods, Operators having SIO, Heavy
Property : Broken Materials equipment having SIA, making traffic management
procedures, providing traffic man, making QHS signs, riger
certificate

Public Safety : PPE : Mandatory use of PPE (Helmets, Vests, Safety shoes)

a. UU No 1 th
1970 tentang K3
OHS : Fatality 4 5 20 Eliminasi : - 2 2 4 Y b. Undang-
undang No. 14
Tahun 1992
tentang Lalu
Lintas dan
Angkutan Jalan
OHS : Fracture Substitusi : -
c. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
d. Permenaker
Concrete truck crash with Engineering : Make a proper access for concrete truck,no
Rutin N Internal Environment : - No 8 tahun 2020
other vehicle elevation differential,traffic management applicable
tentang K3
Pesawat Angkat
Administration : Making work permits and JSA, making soil & Angkut
excavation work methods, Operators having SIO, Heavy
Property : equipment having SIA, making traffic management
procedures, providing traffic man, making QHS signs, riger
certificate

Public Safety : PPE : Mandatory use of PPE (Helmets, Vests, Safety shoes

Rebar Work
a. UU No 1 th
1970 tentang K3
OHS: Pinched 4 3 12 Elimination : 1 3 3 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri

OHS: Scratched Subtitution :

Rebar Cutting and bending

6 R N Internal '- workers' limbs pinched and Environment: Engineering : Installing adequate lighting at night -
work at Yard
crushed

Administration: Conducting training to workers regarding the

Property : procedures for installing formwork, making JSA & PTW,
Scaffolding must be installed by Scaffolder

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
1970 tentang K3
OHS: Fatality 5 4 20 Elimination : 2 3 6 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri

- Truck crash with other

Transportation of Rebar
7 R N Internal vechile when moving to -
from bending yard
laydown
 a. UU No 1 th
1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri

OHS: Fracture Subtitution :

- Truck crash with other

Transportation of Rebar Environment: Oil spill to environment Engineering : Escorting vehicle,traffic management,making
7 R N Internal vechile when moving to -
from bending yard from truck cover for truck material
laydown

Administration:Workers briefing about iron work, JSA, PTW,

Property : Vehicle damage
traffic signage and speed limit

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
1970 tentang K3
OHS: Fatality 5 4 20 Elimination : 3 3 9 Y b. Undang-
undang No. 14
Tahun 1992
tentang Lalu
OHS: Medical treatment injury Subtitution : Lintas dan
Angkutan Jalan
c. Permenaker no
8 tahun 2010 ttg
Engineering : Area demarcation, Pre-Use Check Alat Pelindung
Environment: CO gas poluted
R N Internal Fire hazard when fabrication Equipment,fire fighting equipment,use fire blanket - Diri
d. Kepmenaker
ESDM No 1827
K/30/MEM/2018
Administration: Making JSA & PTW, ensure that the tentang Pedoman
Property : Major property damage
fabrication procedure is safe Pelaksanaan
Kaidah Teknik
Pertambangan
yang Baik
PPE : Using Mandatory PPE, Mask and gloves,fire
Public Safety :
extinguisher
Rebar Fabrication and
8 a. UU No 1 th
Installation work
1970 tentang K3
OHS: Pinched 4 3 12 Elimination : 2 3 6 Y b. PerMenaker RI
No 8 Tahun 2020
Tentang
Keselamatan &
Kesehatan Kerja
OHS: bumped Subtitution : Pesawat Angkat
& Pesawat
Angkut
c. Permenaker no
Hand pinched and worker 8 tahun 2010 ttg
R N Internal Environment: Engineering : - Alat Pelindung
injured
Diri

Administration: Conducting training to workers regarding the

Property : procedures for installing & dismantling formwork, making JSA
& PTW, TOFS and SMTM

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

Formwork
a. UU No 1 th
1970 tentang K3
OHS: Major Injury 4 4 16 Elimination : 2 2 4 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
c. Permenaker
OHS: Pinched Subtitution : No. 186 Tahun
1999 ttg
Penanggulangan
Kebakaran

Injuries during assembling Engineering : Installing Fire Blanket for Hot Work
10 Fabrication of formwork R N Internal Environment: -
process and fire hazard Area,Provide Fire Extinguisher
during fabrication
 c. Permenaker
No. 186 Tahun
1999 ttg
Penanggulangan
Kebakaran

Injuries during assembling

10 Fabrication of formwork R N Internal -
process and fire hazard
during fabrication

Administration: Conducting training to workers regarding the

Property : Damage $5000-10000 procedures for assembly & fabrication, making JSA & PTW,
Fabrication must be worked by certified skills

PPE : Using Mandatory PPE, Mask, Safety

Public Safety :
Gloves,Apron,Safety Glass

a. UU No 1 th
1970 tentang K3
OHS: Fatality 5 4 20 Elimination : 2 3 6 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri

OHS: Fracture Subtitution :

- Truck crash with other

Formwork mobilization from Environment: Oil spill to environment Engineering : Escorting vehicle,traffic management,making
11 R N Internal vechile when moving to -
yard from truck cover for truck material
laydown

Administration:Workers briefing about iron work, JSA, PTW,

Property : Vehicle damage
traffic signage and speed limit

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
1970 tentang K3
OHS: Pinched 4 3 12 Elimination : 1 3 3 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
OHS: Scratched Subtitution : c. Permenaker
n0. 9 tahun 2016
tentang
Pekerjaan di
Environment: Engineering : Area demarcation Ketinggian
12 Installation of formwork R N Internal Injuries during the formwork -
installation process

Administration: Conducting training to workers regarding the

Property : procedures for installing formwork, making JSA & PTW,
Scaffolding must be installed by Scaffolder

Public Safety : PPE : Using Mandatory PPE, Mask and gloves

a. UU No 1 th
1970 tentang K3
OHS: Pinched 4 3 12 Elimination : 1 3 3 Y b. PerMenaker RI
No 8 Tahun 2020
Tentang
Keselamatan &
Kesehatan Kerja
OHS: bumped Subtitution : Pesawat Angkat
& Pesawat
Angkut
c. Permenaker no
8 tahun 2010 ttg
13 Environment: Engineering : - Alat Pelindung
Diri

Administration: Conducting training to workers regarding the

Property : procedures for installing & dismantling formwork, making JSA
& PTW, TOFS and SMTM

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

Concreting (Cast in
Situ/Pre Cast Foundation)
 a. UU No 1 th
1970 tentang K3
OHS: Heat stress 4 3 12 Elimination : 1 3 3 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
OHS: Scratched Subtitution : c. Permenaker
n0. 9 tahun 2016
tentang
Pekerjaan di
Ketinggian
14 Prepouring Inspection R N Internal Slip and heat stress Environment: Engineering : -

Administration: Conducting training to workers regarding the

Property :
procedures for inspection

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
1970 tentang K3
QHS : Abnormal body position 2 3 6 Eliminasi : - 1 3 3 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
QHS : First aid injury Substitusi : - c. Permenaker
n0. 9 tahun 2016
tentang
Pekerjaan di
Ketinggian
Ergonomics Hazard Environment : Engineering : Use lifting aids

Administration : Making work permits and JSAs, training for

Property :
ergonomics procedure,

Public Safety : PPE : Mandatory use of PPE ( Helmet , Vest , Safety shoes )

a. UU No 1 th
1970 tentang K3
OHS: Heat stress 4 3 12 Elimination : 1 3 3 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
OHS: Scratched Subtitution : c. Permenaker
n0. 9 tahun 2016
tentang
Pekerjaan di
Ketinggian
15 Concrete Pouring work R N Internal Slip and heat stress Environment: Engineering : -

Administration: Conducting training to workers regarding the

Property :
procedures for inspection

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
1970 tentang K3
QHS : Abnormal body position 2 3 6 Eliminasi : - 1 3 3 Y b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
c. Permenaker
n0. 9 tahun 2016
QHS : First aid injury Substitusi : -
tentang
Pekerjaan di
Ketinggian

Ergonomics Hazard Environment : Engineering : Use lifting aids

 c. Permenaker
n0. 9 tahun 2016
tentang
Pekerjaan di
Ketinggian

Ergonomics Hazard

Administration : Making work permits and JSAs, training for

Property :
ergonomics procedure,

Public Safety : PPE : Mandatory use of PPE ( Helmet , Vest , Safety shoes )

a. UU No 1 th
OHS: Pinched 4 3 12 Elimination : 1 3 3 Y 1970 tentang K3
b. Undang-
undang No. 14
OHS: Subtitution : Tahun 1992
tentang Lalu
Environment: Concrete material spills in Lintas dan
Engineering : Area demarcation Angkutan Jalan
the work area
Hand Pinched when pouring c. Permenaker no
16 - 8 tahun 2010 ttg
concrete
Alat Pelindung
Administration: Making JSA & PTW, ensure that the Diri
Property :
remaining concrate is cleaned

Public Safety : PPE : Using Mandatory PPE, Mask and gloves

a. UU No 1 th
QHS : Major Injury 4 4 16 Eliminasi : - 2 3 6 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
QHS : Fracture Substitusi : - Diri
c. Permenaker
no. 9 tahun 2016
Truck mixer manuver injured tentang
Environment : Engineering : Install barricades on work areas
workers Pekerjaan di
Ketinggian
Administration : Making work permits and JSAs, safety sign
Property :
and safe procedure briefing

Public Safety : PPE : Mandatory use of PPE ( Helmet , Vest , Safety shoes ) ;

a. UU No 1 th
1970 tentang K3
OHS: Pinched 4 3 12 Elimination : 1 3 3 Y
b. Permenaker
no. 9 tahun 2016
tentang
Pekerjaan di
OHS: bumped Subtitution : Ketinggian
c. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Environment: Engineering : Installing adequate lighting at night Diri
17 -

Administration: Conducting training to workers regarding the

Property : procedures for installing & dismantling formwork, making JSA
& PTW, TOFS and SMTM

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

Waterproofing &
Backfilling
a. UU No 1 th
OHS: Medical treatment injury 4 3 12 Elimination : 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched Subtitution : Alat Pelindung
Diri
c. Kepmenaker
Environment: Engineering : ESDM No 1827
K/30/MEM/2018
tentang Pedoman
Waterproofing work with Pelaksanaan
18 R N Internal Injuries during the geotextile - Kaidah Teknik
geotextile or plastic sheet
instalation Pertambangan
yang Baik
 a. UU No 1 th
1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
c. Kepmenaker
ESDM No 1827
K/30/MEM/2018
tentang Pedoman
Waterproofing work with Administration: Conducting training to workers regarding the Pelaksanaan
18 R N Internal Injuries during the geotextile Property : - Kaidah Teknik
geotextile or plastic sheet procedures for installing geotex, making JSA & PTW
instalation Pertambangan
yang Baik

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
OHS: Pinched 4 3 12 Elimination : 2 2 4 Y
1970 tentang K3
b. Permenaker no
OHS: Scratched Subtitution : 8 tahun 2010 ttg
Alat Pelindung
Environment: Engineering : Installing adequate lighting at night Diri
Injuries during the reinforcing
19 Deshuttering R N Internal - c. Permenaker
process
Administration: Conducting training to workers regarding the n0. 9 tahun 2016
Property : tentang
procedures for installing formwork, making JSA & PTW
Pekerjaan di
Ketinggian
Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
QHS : Major Injury 4 4 16 Eliminasi : - 2 3 6 Y 1970 tentang K3
b. Permenaker no
QHS : Fracture Substitusi : - 8 tahun 2010 ttg
Alat Pelindung
Diri
Workers fall while uninstall Environment : Engineering : Install barricades on work areas at heights
c. Permenaker
(working at height)
Administration : Making work permits and JSAs, training on n0. 9 tahun 2016
Property : work procedures at heights, job briefings about the dangers of tentang
working at heights Pekerjaan di
Ketinggian
PPE : Mandatory use of PPE ( Helmet , Vest , Safety
Public Safety :
shoes ) ; Special PPE (Full Body Harnes double land yard)
a. UU No 1 th
OHS: Heat stress 4 3 12 Elimination : 1 3 3 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched Subtitution : Alat Pelindung
Diri
c. Permenaker
Environment: Engineering : n0. 9 tahun 2016
Concrete surface tentang
20 R N Internal Slip and heat stress - Pekerjaan di
preparation work
Ketinggian
Administration: Conducting training to workers regarding the
Property :
procedures for inspection

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
QHS : Abnormal body position 2 3 6 Eliminasi : - 1 3 3 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : First aid injury Substitusi : - Alat Pelindung
Diri
c. Permenaker
NR N Internal Ergonomics Hazard Environment : Engineering : Use lifting aids n0. 9 tahun 2016
tentang
Pekerjaan di
Administration : Making work permits and JSAs, training for Ketinggian
Property :
ergonomics procedure,

Public Safety : PPE : Mandatory use of PPE ( Helmet , Vest , Safety shoes )

a. UU No 1 th
OHS: Pinched 4 3 12 Elimination : 1 3 3 Y 1970 tentang
keselamatan dan
kesehatan kerja
OHS: bumped Subtitution : b. Permenaker
no. 9 tahun 2016
tentang
Environment: Engineering : Installing adequate lighting at night Pekerjaan di
Ketinggian
21 Final inspection R N Internal Injury during QC insoection - c. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
 a. UU No 1 th
1970 tentang
keselamatan dan
kesehatan kerja
b. Permenaker
no. 9 tahun 2016
tentang
Pekerjaan di
Ketinggian
21 Final inspection R N Internal Injury during QC insoection - c. Permenaker no
8 tahun 2010 ttg
Administration: Conducting training to workers regarding the Alat Pelindung
Property : procedures for installing & dismantling formwork, making JSA Diri
& PTW, TOFS and SMTM

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
OHS: Medical treatment injury 4 4 16 Elimination : 2 3 6 Y 1970 tentang
keselamatan dan
kesehatan kerja
b. Kepmenaker
OHS: Fracture Subtitution : ESDM No 1827
K/30/MEM/2018
Heavy equipment manuver Engineering : Installing adequate lighting at night, traffic tentang Pedoman
21 Backfill & Compaction R N Internal -
injured workers in work area Environment: management,demarcation area Pelaksanaan
Kaidah Teknik
Administration: Conducting training to workers regarding the Pertambangan
Property : procedures for backfilling and compaction, making JSA & yang Baik
PTW, TOFS and SMTM and safety sign at work area c. Permenaker no
8 tahun 2010 ttg
Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves Alat Pelindung
Diri
Wall Construction
a. UU No 1 th
OHS: Pinched 4 3 12 Elimination : 1 3 3 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched Subtitution : Alat Pelindung
Diri
c. Permenaker
18 Block Wall Laying R N Internal Injuries during the laying of Environment: Engineering : - n0. 9 tahun 2016
block wall tentang
Pekerjaan di
Administration: Conducting training to workers regarding the Ketinggian
Property :
procedures for installing block wall layer, making JSA & PTW

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
QHS : Major Injury 4 4 16 Eliminasi : - 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : Fracture Substitusi : - Alat Pelindung
Diri
c. Permenaker
Workers fall while installing Engineering : Install barricades on work areas at heights, n0. 9 tahun 2016
Environment :
(working at height) clear platform tentang
Administration : Making work permits and JSAs, training on Pekerjaan di
Property : work procedures at heights, job briefings about the dangers of Ketinggian
working at heights d. Kepmenaker
ESDM No 1827
PPE : Mandatory use of PPE ( Helmet , Vest , Safety K/30/MEM/2018
Public Safety :
shoes ) ; Special PPE (Full Body Harnes double land yard) tentang Pedoman
Pelaksanaan
a. UU No 1 th
OHS: Pinched 4 3 12 Elimination : 2 3 6 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched Subtitution : Alat Pelindung
Diri
c. Kepmenaker
Injuries during the cementing ESDM No 1827
19 Cementing R N Internal Environment: Engineering : Installing adequate lighting at night -
process K/30/MEM/2018
Administration: Conducting training to workers regarding the tentang Pedoman
Property : procedures for cementing process, making JSA & PTW,safety Pelaksanaan
signage Kaidah Teknik
Pertambangan
Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves yang Baik

a. UU No 1 th
QHS : Abnormal body position 2 3 6 Eliminasi : - 1 2 2 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : First aid injury Substitusi : - Alat Pelindung
Diri
c. Kepmenaker
Ergonomics Hazard Environment : Engineering : Use lifting aids ESDM No 1827
K/30/MEM/2018
tentang Pedoman
Administration : Making work permits and JSAs, training for Pelaksanaan
Property :
ergonomics procedure, Kaidah Teknik
Pertambangan
yang Baik
 b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
c. Kepmenaker
Ergonomics Hazard ESDM No 1827
K/30/MEM/2018
tentang Pedoman
Pelaksanaan
Kaidah Teknik
Pertambangan
Public Safety : PPE : Mandatory use of PPE ( Helmet , Vest , Safety shoes ) yang Baik

a. UU No 1 th
QHS : Abnormal body position 2 3 6 Eliminasi : - 1 2 2 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : First aid injury Substitusi : - Alat Pelindung
Diri
c. Kepmenaker
20 Plastering R N Internal Ergonomics Hazard Environment : Engineering : Use lifting aids ESDM No 1827
K/30/MEM/2018
tentang Pedoman
Administration : Making work permits and JSAs, training for Pelaksanaan
Property :
ergonomics procedure, Kaidah Teknik
Pertambangan
Public Safety : PPE : Mandatory use of PPE ( Helmet , Vest , Safety shoes ) yang Baik

Wall Cladding & Roofing Work

a. UU No 1 th
OHS: Pinched 4 3 12 Elimination : 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched Subtitution : Alat Pelindung
Diri
c. Permenaker
Wall Cladding frame Injuries during the frame n0. 9 tahun 2016
18 R N Internal Environment: Engineering : -
installation installation installation tentang
process Pekerjaan di
Administration: Conducting training to workers regarding the Ketinggian
Property :
procedures for installing frame, making JSA & PTW

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
QHS : Major Injury 4 4 16 Eliminasi : - 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : Fracture Substitusi : - Alat Pelindung
Diri
c. Permenaker
Workers fall while installing Engineering : Install barricades on work areas at heights, n0. 9 tahun 2016
Environment :
(working at height) clear platform tentang
Administration : Making work permits and JSAs, training on Pekerjaan di
Property : work procedures at heights, job briefings about the dangers of Ketinggian
working at heights d. Kepmenaker
ESDM No 1827
PPE : Mandatory use of PPE ( Helmet , Vest , Safety K/30/MEM/2018
Public Safety :
shoes ) ; Special PPE (Full Body Harnes double land yard) tentang Pedoman
Pelaksanaan
a. UU No 1 th
OHS: Pinched 4 3 12 Elimination : 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched Subtitution : Alat Pelindung
Diri
c. Permenaker
Wall Cladding Sheet Injuries during the frame n0. 9 tahun 2016
19 R N Internal Environment: Engineering : -
Installation installation installation tentang
process Pekerjaan di
Administration: Conducting training to workers regarding the Ketinggian
Property :
procedures for installing frame, making JSA & PTW

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
QHS : Major Injury 4 4 16 Eliminasi : - 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : Fracture Substitusi : - Alat Pelindung
Diri
c. Permenaker
Workers fall while installing Engineering : Install barricades on work areas at heights, n0. 9 tahun 2016
Environment :
(working at height) clear platform tentang
Administration : Making work permits and JSAs, training on Pekerjaan di
Property : work procedures at heights, job briefings about the dangers of Ketinggian
working at heights d. Kepmenaker
ESDM No 1827
PPE : Mandatory use of PPE ( Helmet , Vest , Safety K/30/MEM/2018
Public Safety :
shoes ) ; Special PPE (Full Body Harnes double land yard) tentang Pedoman
Pelaksanaan
a. UU No 1 th
OHS: Pinched 4 3 12 Elimination : 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
Alat Pelindung
Diri
c. Permenaker
Injuries during the frame n0. 9 tahun 2016
20 Roof frame installation R N Internal -
installation installation tentang
process Pekerjaan di
Ketinggian
 a. UU No 1 th
1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
OHS: Scratched Subtitution : Alat Pelindung
Diri
c. Permenaker
Injuries during the frame n0. 9 tahun 2016
20 Roof frame installation R N Internal Environment: Engineering : -
installation installation tentang
process Pekerjaan di
Administration: Conducting training to workers regarding the Ketinggian
Property :
procedures for installing frame, making JSA & PTW

Public Safety : PPE : Using Mandatory PPE, Mask, Safety Gloves

a. UU No 1 th
QHS : Major Injury 4 4 16 Eliminasi : - 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : Fracture Substitusi : - Alat Pelindung
Diri
c. Permenaker
Workers fall while installing Engineering : Install barricades on work areas at heights, n0. 9 tahun 2016
Environment :
(working at height) clear platform tentang
Administration : Making work permits and JSAs, training on Pekerjaan di
Property : work procedures at heights, job briefings about the dangers of Ketinggian
working at heights d. Kepmenaker
ESDM No 1827
PPE : Mandatory use of PPE ( Helmet , Vest , Safety K/30/MEM/2018
Public Safety :
shoes ) ; Special PPE (Full Body Harnes double land yard) tentang Pedoman
Pelaksanaan
a. UU No 1 th
QHS : Major Injury 4 4 16 Eliminasi : - 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : Fracture Substitusi : - Alat Pelindung
Diri
c. Permenaker
Workers fall while installing Engineering : Install barricades on work areas at heights, n0. 9 tahun 2016
21 Roof Insulation Installation R N Internal Environment :
(working at height) clear platform tentang
Administration : Making work permits and JSAs, training on Pekerjaan di
Property : work procedures at heights, job briefings about the dangers of Ketinggian
working at heights d. Kepmenaker
ESDM No 1827
PPE : Mandatory use of PPE ( Helmet , Vest , Safety K/30/MEM/2018
Public Safety :
shoes ) ; Special PPE (Full Body Harnes double land yard) tentang Pedoman
Pelaksanaan
a. UU No 1 th
QHS : Major Injury 4 4 16 Eliminasi : - 2 2 4 Y 1970 tentang K3
b. Permenaker no
8 tahun 2010 ttg
QHS : Fracture Substitusi : - Alat Pelindung
Diri
c. Permenaker
Workers fall while installing Engineering : Install barricades on work areas at heights, n0. 9 tahun 2016
21 Roof Sheet Installation R N Internal Environment :
(working at height) clear platform tentang
Administration : Making work permits and JSAs, training on Pekerjaan di
Property : work procedures at heights, job briefings about the dangers of Ketinggian
working at heights d. Kepmenaker
ESDM No 1827
PPE : Mandatory use of PPE ( Helmet , Vest , Safety K/30/MEM/2018
Public Safety :
shoes ) ; Special PPE (Full Body Harnes double land yard) tentang Pedoman
Pelaksanaan
 Diterbitkan oleh Diperiksa oleh Disetujui oleh
POM SHE PM

Penjelasan kolom Matrix risiko

1 Aktivitas : QHSgiatan, Produk dan Jasa yang akan diidentifikasi dan dievaluasi aspek dan dampak OHSL nya
2 Jenis aktivitas : Rutin (aktivitas yang rutin dilakukan, misalnya : pengecoran)
Non rutin (aktivitas yang tidak rutin, misalnya : lifting )
3 Kondisi operasional : Normal (aktivitas dilakukan pada kondisi normal)
Abnormal (aktivitas dilakukan pada kondisi abnormal, misalkan : pemadaman api saat QHSbakaran)
4 Issue : External (issue external yang mempengaruhi kondisi bahaya/dampak Environment, misalnya : perubahan QHSbijakan pemerintah)
Internal (issue internal yang mempengaruhi kondisi bahaya/dampak Environment, misalnya : perubahan QHSbijakan perusahaan)
5 Aspek / bahaya : Aspek Environment / bahaya yang muncul dari aktivitas yang ada
6 Dampak SHE : Dampak yang ditimbulkan dari bahaya yang ada terhadap manusia, Environment, Property dan umum
7 QHSmungkingan : QHSmungkinan terjadinya QHScelakaan dari aktivitas yang ada
8 QHSparahan : Konsekuensi terjadinya QHScelakaan dari aktivitas yang ada
9 Nilai risiko : Perkalian dari QHSmungkingan dan konsekuensi
10 Kontrol risiko : Kontrol yang telah dilakukan dari aktovotas dan bahaya yang ada
11 Risiko sisa : Penilaian risiko setelah dilakukan kontrol
12 Status diterima : Risiko sudah dapat diterima atu tidak sesuai matriks yang ada
13
14
15
 - Sangat jarang terjadi
LOW LOW LOW LOW LOW 1 - Data kecelakaan : 1 kali terjadi insiden dalam 1 tahun atau lebih
- Insiden diasumsikan dapat terulang kembali dalam > 1 tahun

- Jarang terjadi
LOW LOW LOW MEDIUM MEDIUM 2 - Data kecelakaan : 2 - 3 kali terjadi insiden dalam 1 tahun

PROBABILITY
- Insiden diasumsikan dapat terulang kembali dalam ≤ 1 tahun

- Kadang kadang
LOW LOW MEDIUM MEDIUM HIGH 3 - Data kecelakaan : 4 - 6 kali terjadi insiden dalam 1 tahun
- Insiden diasumsikan dapat terulang kembali dalam ≤ 6 bulan

- Sering terjadi
LOW MEDIUM MEDIUM HIGH HIGH 4 - Data kecelakaan : 7 - 8 kali terjadi insiden dalam 1 tahun
- Insiden diasumsikan dapat terulang kembali dalam ≤ 3 bulan

- Sangat sering terjadi

LOW MEDIUM HIGH HIGH HIGH 5 - Data kecelakaan : > 9 kali terjadi insiden dalam 1 tahun
- Insiden diasumsikan dapat terulang kembali dalam ≤ 1 bulan

1 2 3 4 5

PPD / PTD / LTI (dengan cacat permanen)

MTC
P3K / First Aid
(Luka /cedera cukup ditangani dengan P3K)
(luka daoat ditangani dan sembuh dengan
perawatan medis ≤ 2x24 Jam)
RWC / LWC / LTI (tanpa cacat permanen)
(cedera yang mengakibatkan cacat
(Cedera yang mengakibatkan dislokasi atau
permanen/ parsial, amputasi, atau
Fatality dan multiple fatality K3 / OHS
perawatan medis > 2x 24 jam
disabilitas)

Terjadi kerusakan lingkungan yang
masih dapat ditangani dalam skala
proyek
Terjadi kerusakan lingkungan yang
Terjadi kerusakan lingkungan yang
masih dapat ditangani dalam skala
masih dapat ditangani dalam skala
perusahaan namun Insiden lingkungan
perusahaan
terekspose oleh media lokal
Menyebabkan kerusakan
lingkungan/pencemaran yang
Insiden lingkungan terekspose oleh Lingkungan
mengakibatkandihentikan/ditutupnya
media nasional
perusahaan dan mendapat sanksi dari
pemerintah

Kerugian < $500 Kerugian $500 < $1000 Kerugian $1000 < $5000 Kerugian $5000 < $10000 Kerugian > $10000 Properti

PPD / PTD / LTI (dengan cacat permanen)

MTC
P3K / First Aid
(Luka /cedera cukup ditangani dengan P3K)
(luka daoat ditangani dan sembuh dengan
perawatan medis ≤ 2x24 Jam)
RWC / LWC / LTI (tanpa cacat permanen)
(cedera yang mengakibatkan cacat
(Cedera yang mengakibatkan dislokasi atau
permanen/ parsial, amputasi, atau
Fatality dan multiple fatality Keselamatan umum
perawatan medis > 2x 24 jam
disabilitas)

SEVERITY
RISK RATING RISK GRADE - Risiko dapat diterima apabila penilaiannya menunjukkan LOW
1-7 Low - Risiko dengan nilai MEDIUM dan HIGH wajib diberikan kontrol tambahan
8 - 15 Medium
16 - 25 High
Project / Workshop :
Equipment Name :
Date :
Employee Reviewed
1.
2.
3.
4.
5.
Review the energy control procedure and employee responsibilities with the involved emp
and complete the following
1. LOTO procedure being followed and used correctly
2. Involved employees understand their responsibilities under the procedure
3. Copy of LOTO procedure on location
4. Long term LOTO process (more than 3 month)
5. Adequate employee knowledge about isolation
Person conducting the inspection & review
Name Sign Title
with the involved employees

view
Title