28 August - 1 September 2023

Task Level Risk Assessment - TLRA WORKSHEET
HBS-P-11-HSM-22-06
HAZSCAN (Fire System Installation)

Periode : 28 August - 1 September 2023
Management of Change – (Unplanned Event, new activities, or job steps, change in conditions, new hazards/& or controls)
RESPONSIBLE
CONTROLS
TASK STEPS PERSON
HAZARD For each hazard, list the control measures
List the steps required to perform the task in the (List who is
List the potential hazards that could cause harm. required to eliminate or minimise the risk
sequence they are carried out. responsible to
What can harm me, others, or the environment? What must be in place to prevent or minimise
What am I going to do? implement the
harm?
control)
Permit, toolbox meeting, protect of the edge of SM, SPV and
1. Preparation tools and Material Slip Trip Fall, Sharp Object, Ergonomic Risk,
sharp, PPE HSE
Slip Trip Fall, Sharp Object, Ergonomic Risk, Permit, protect of the edge of sharp, PPE, SM, SPV and
2. Moving / transport material and tools
Flying Object maintain 5S HSE
Permit, protect of the edge of sharp, PPE, SM, SPV and

3. Installing metal conduit, Cable pipe, Work at height, falling object, dust, sharp object,
maintain 5S, full body harness, hand tools HSE
devices ergonomic risk, flying object, electric shock
guarding, training arc flash
Permit, maintain 5S, protect of the edge of sharp, SM, SPV and
4. Installing of wiring Sharp object, ergonomic risk, flying object, dust
set clearance area around work area HSE
SM, SPV and

5. System integration Electric Shock Permit, training arc flash, maintain 5S
HSE
SM, SPV and
6. Housekeeping Bad houskeeping Maintain 5S
HSE
Where a change is made, all personnel to re-sign on the daily sign on page.
Page | 1
TLRA #
HBS-P-11-HSM-22-06
HAZSCAN (VESDA System Installation)

Periode : 28 August - 1 September 2023
Management of Change – (Unplanned Event, new activities, or job steps, change in conditions, new hazards/& or controls)
RESPONSIBLE
CONTROLS
TASK STEPS PERSON
HAZARD For each hazard, list the control measures
List the steps required to perform the task in the (List who is
List the potential hazards that could cause harm. required to eliminate or minimise the risk
sequence they are carried out. responsible to
What can harm me, others, or the environment? What must be in place to prevent or minimise
What am I going to do? implement the
harm?
control)
Permit, toolbox meeting, protect of the edge of SM, SPV and
1. Preparation tools and Material Slip Trip Fall, Sharp Object, Ergonomic Risk,
sharp, PPE HSE
Slip Trip Fall, Sharp Object, Ergonomic Risk, Permit, protect of the edge of sharp, PPE, SM, SPV and
2. Moving / transport material and tools
Flying Object maintain 5S HSE
Permit, protect of the edge of sharp, PPE, SM, SPV and

3. Installing metal conduit, Cable pipe, Work at height, falling object, dust, sharp object,
maintain 5S, full body harness, hand tools HSE
devices ergonomic risk, flying object, electric shock
guarding, training arc flash
Permit, maintain 5S, protect of the edge of sharp, SM, SPV and
4. Installing of wiring Sharp object, ergonomic risk, flying object, dust
set clearance area around work area HSE
Pinch, Hit, scratch, ergonomic risk (low back Permit, PPE, good handling material, FBH, SM, SPV and
5. Installing Support Hanger Pipe
pain), drop object, falling, dust exposure maintains 5S HSE
6. Installing Branch Pipe and Join Vesda Pinch, Hit, scratch, ergonomic risk (low back Permit, PPE, good handling material, FBH, SM, SPV and
Pipe pain), drop object, falling, dust exposure maintains 5S HSE
7. Procedure Test & Commisioning
pain), drop object, falling, dust exposure maintains 5S HSE
8. Installing Vesda Panel
pain), drop object maintains 5S HSE
SM, SPV and

9. System integration Electric Shock Permit, training arc flash, maintain 5S
HSE
SM, SPV and

10. Housekeeping Bad houskeeping Maintain 5S
HSE
Page | 2
TLRA #
HBS-P-11-HSM-22-06
CONSULTATION AND INITIAL SIGN OFF:

I have conducted a HAZSCAN and believe that all HSE hazards have been identified, and the controls listed have reduced the risk to as low as reasonably practicable and will
enable us to effectively manage the hazards of this task. This TLRA has been communicated to me, I understand it, and I agree to work to its intent to the best of my ability.
TLRA attendance record

Name Company Position Signature Date Name of PIC
Agus (SPV of Swahusada) & Mugi
1. Sariaman Honeywell Site Manager 28 August 2023
(SPV of Cakrawana)
2. Naufal Swahusada Safety Personal 28 August 2023
(SPV of Cakrawana)
3. Sodik Swahusada Worker 28 August 2023
(SPV of Cakrawana)
4. Maulana Swahusada Worker 28 August 2023
(SPV of Cakrawana)
5. Misno Swahusada Worker 28 August 2023
(SPV of Cakrawana)
6. Marno Swahusada Worker 28 August 2023
(SPV of Cakrawana)
7. Fauzi Swahusada Worker 28 August 2023
(SPV of Cakrawana)
8. Andri Swahusada Worker 28 August 2023
(SPV of Cakrawana)
9. Heri Swahusada Worker 28 August 2023
(SPV of Cakrawana)
10. Ghalih Honeywell QC 28 August 2023
(SPV of Cakrawana)
11. Tanto Cakrawana Safety Personal 28 August 2023
(SPV of Cakrawana)
12. Marsel Cakrawana Worker 28 August 2023
(SPV of Cakrawana)
13. Bagoes Cakrawana Worker 28 August 2023
(SPV of Cakrawana)
Page | 3
TLRA #
HBS-P-11-HSM-22-06
CONSULTATION AND DAILY SIGN OFF:

I have conducted a HAZSCAN and believe that all HSE hazards have been identified and the controls listed have reduced the risk to as low as reasonably practicable and will
enable us to effectively manage the hazards of this task. This TLRA has been communicated to me, I understand it, and I agree to work to its intent to the best of my ability.
TLRA Reinduction Record
Name Work location Date Sign Work location Date Sign Work location Date Sign Work location Date Sign Work location Date Sign
28 August 29 August 30 August 31 August 1 Septem
1. Sariaman Site Office 2023
Site Office 2023
Site Office 2023
Site Office 2023
Site Office 2023
2. Naufal All Area 2023
All Area 2023
All Area 2023
All Area 2023
All Area 2023
3. Sodik Colo 1 2023
Colo 1 2023
Colo 1 2023
Colo 1 2023
Colo 1 2023
Colo 1 28 August Colo 1 29 August Colo 1 30 August Colo 1 31 August Colo 1 1 Septem
4. Maulana
2023 2023 2023 2023 2023
5. Misno
2023 2023 2023 2023 2023
6. Marno
2023 2023 2023 2023 2023
7. Fauzi Admin 2023
Admin 2023
Admin 2023
Admin 2023
Admin 2023
Admin 28 August Admin 29 August Admin 30 August Admin 31 August Admin 1 Septem
8. Andri
2023 2023 2023 2023 2023
Admin 28 August Admin 29 August Admin 30 August Admin 31 August Admin 1 Septem
9. Heri 2023 2023 2023 2023 2023
10. Ghalih All Area 2023
All Area 2023
All Area 2023
All Area 2023
All Area 2023
11. Tanto All Area 2023
All Area 2023
All Area 2023
All Area 2023
All Area 2023
Colo 2, 28 August Colo 2, 29 August Colo 2, 30 August Colo 2, 31 August Colo 2, 1 Septem
12. Marsel 2023 2023 2023 2023 2023
Mechplant 2 Mechplant 2 Mechplant 2 Mechplant 2 Mechplant 2
Colo 2, 28 August Colo 2, 29 August Colo 2, 30 August Colo 2, 31 August Colo 2, 1 Septem
13. Bagoes 2023 2023 2023 2023 2023
Mechplant 2 Mechplant 2 Mechplant 2 Mechplant 2 Mechplant 2
Page | 4
TLRA #

28 August - 1 September 2023

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28 August - 1 September 2023

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Task Level Risk Assessment - TLRA WORKSHEET

HAZSCAN (Fire System Installation)

Permit, protect of the edge of sharp, PPE, SM, SPV and

SM, SPV and

HAZSCAN (VESDA System Installation)

Permit, protect of the edge of sharp, PPE, SM, SPV and

SM, SPV and

SM, SPV and

CONSULTATION AND INITIAL SIGN OFF:

TLRA attendance record

CONSULTATION AND DAILY SIGN OFF:

TLRA Reinduction Record

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