Document number 3952/4041

General Permit to Work Issue number 01

Date Jun 12, 2024

Permit Approver
Date Jun 12, 2024 Job Location Production FG
(or representative)
Uzil Pratama

Job Duration of Work From(date/time) 13.06.2024/08:00:00

INSTALL PIPA & PIPA SUPPORT
Description (up to 7 days max) 30.06.2024/23:59:40
To(date/time)

Trades Involved (tick) Electrician Plumber Fitter Painter Scaffolder Other :

Name of Contractor : PT FICO INDO REKAYASA

Name of Employee : SUDARTANTO

Permit Validation: Where the validity period of the permit is extended, the Permit Issuer must reinspect the surroundings and acknowledge that the controls are still adequate
by providing the data at the start of the shift and signature.
Date:
Signature:

Freq. of Supervision Constant 10 min 30 min Hourly 2-Hourly Start & Finish Other:
Additional Permit Required(tick)

Hot Work Work at Heights Confined Space Entry Designated High Risk Activities
Attachments (tick)
Additional Permits Chemical MSDSs Engineering Drawings, etc Other
Safety Isolation(s) required (tick) Isolation(s) Locations

Water Electricity Smoke Alarm Gas

Compressed Air Mechanical Flame Detectors Ingredient

Steam Gravity Sprinkler system Others

Comments
Quality Precautions and Identified Food Safety Hazards

Screening required
Dust Interim Cleaning Selalu lakukan housekeeping sebelum dan sesudah pekerjaan

Taint Move Product Final Cleaning gunakan APD hygiene such as cover shoes wearpack jaslab

Foreign Matter Process Intervention Other Hair net dan masker

Environment Risk Comments

Generating Waste Pests Potential for spill gunakan selalu apd hygiene
Bringing Generating Emissions Potential to contaminate
Contaminants on site (solid / liquid / gas / noise) Storm Water

Microbiological
Interaction with Site Aspects Flora/Fauna Interaction
Contamination
PPE Comments

Safety Glasses Face Shields Hearing Protection Arm Guards gunakan APD sesuai pekerjaan yang di lakukan
Harness / Fall
Safety Footwear Dust Mask Safety Helmet
Protection cek kondisi APD sebelum TBM
Gloves Welding Mask Safety Goggles Other

Notifications of External Agencies

Fire Services Gas provider EPA Effluent Discharge Electricity Provider Health

Other

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Page 1 of 3
 Document number 3952/4041

General Permit to Work Issue number 01

Date Jun 12, 2024

Graphical Risk Matrix

Risk matrix Reportable Minor Serious Major Catastrophic Risk Rating(Number)

Color Code RRN
Almost Certain M11 H16 E20 E23 E25
L Low(1-5)
Likely M7 H12 H17 E21 E24
M Moderate(6-11)
Possible L4 M8 H15 E18 E22

Unlikely L2 L5 M9 H13 E19 H High(12-17)

Rare L1 L3 M6 M10 H14 E Extreme(18&Above)

Action shall be based on the risk rating number

* Fire Service Impairment requires Notification to Risk Engineering

Sequence of job / Basic Task Steps
Against each task list the risks that could cause
List the task required to perform the activity in the
sequence they are carried out
1. Persiapan Sebelum bekerja dan langsir
2. Install Scaffolding
Potential Risks Identified*
Risk
injury or contamination when the task is
Rating**
performed
Terdapat serbuk coklat di area kerja,
terpeleset, tersandung, terbentur,
ergonomis, tangan tergores, dehidrasi,
terjatuh
Terjatuh dari ketinggian, paparan debu
coklat, scaffolding roboh, kejatuhan
benda atau barang, scaffolding sesuai
standar
Risk Controls
Inherent list the controls required to eliminate or minimize the risk Residual
of injury or Contamination from identified risk, including Risk
PPE. Alternatively list the specialized permit, (if Rating**
applicable) required particular task.
Eng : Memproteksi material/ permukaan yang
tajam membersihkan area kerja, menggunakan
H17
alat bantu angkat seperti troli atau hand pallet.
Adm : semua pekerja telah di induction, permit
- Komunikasi dengan supervisor terkait metode
kerja, adanya pengawasan dari EHS, tidak
M8
mengangkat beban lebih dari 25 kg, melakukan
cleaning area secara berkala, barikade area kerja
TBM sebelum bekerja, peralatan di inspeksi
sebelum bekerja.
APD : helm, Rompi, Baju kerja, masker, sarung
tangan sesuai dengan jenis pekerjaan, sepatu
Eng : Terdapat lifeline sebagai pengait hook FBH,
memproteksi material/permukaan yang tajam
H17 M8
dengan kain, mencantolkan body harness pada
angkur yang tersedia, mengikat kunci atau
Memastikan scaffolding proper dan sudah dicek
oleh pihak olam, pemasangan tag scaffolding
APD : Tambahan body harness

3. Pemasangan Clamp Beam & Chain block
4. Pemasangan support pipa
Kejatuhan benda, calmp beam tidak kuat
menahan beban, rantai chainblock putus,
H15
chainblock aus atau tidak lyak di
gunakan, terjepot
- Kebakaran, timbul asap pada tumpukan
bubuk coklat, percikan bunga api, sinar
E18
las pada saat proses welding, gram dari
percikan gerinda, benda berputar
Eng : pemakaian chainblock dengan kapasitas 1
ton atau lebih pada saat melakukan erection,
M8
melakukan pengecekan bema yang akan
menahan beban, mengecek rantai visual
Eng : lakukan pembersihan area kerja dari bubuk
coklat atau bahan yang mudah terbakar,
M8
menggunakan fireblanket untuk mencegah bunga
api tidak terkontrol, siapkan air dan semprotan air,
ADM : terdapat firewatch di area kerja, melakukan
firrewatch selama 30 menit setelah melakukan
pekerjaan, mengisolasi area kerja dengan
membersihkan area bila terdapat minyak dan
APD : Faceshield, Kap las, Sarung tangan las

5. Pemasangan Pipa Fatigue, shackle putus atau patah Eng : pemakaian chainblock dengan kapasitas 1
ton atau lebih pada saat melakukan erection,
E18 M8
melakukan pengecekan bema yang akan
menahan beban, mengecek rantai visual

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 Document number 3952/4041

General Permit to Work Issue number 01

Date Jun 12, 2024

Members of WORK GROUP sign below (Use 'Additional Permit to work Sign - On / Sign - Off Sheet " if extra space is required

Date SIGN-ON SIGN-OFF

Name Signature Time Signature Time

Name Signature Time Signature Time

Name Signature Time Signature Time

Name Signature Time Signature Time

Name Signature Time Signature Time

PERMIT CREATOR (SIGN-ON) PERMIT ACCEPTOR (SIGN-ON)

The work has been discussed with the person in charge and all quality, I understand the hazards involved and the precautions to be taken. I will
safety and environmental precautions considered. All controls will be in ensure that hazards and work precautions are explained to all other
place prior to commencement.. persons who will be working on this job.

Name Ayu S Name

SIGNATURE : DATE : SIGNATURE : DATE :

PERMIT CREATOR (SIGN-OFF) PERMIT ACCEPTOR (SIGN-OFF)

The work covered by this permit is completed. All locks, tags, isolations, etc , Work covered by this Permit has been completed. All persons, materials
have been removed the work area plant has been cleaned and sanitized and and equipment have been removed from the area
is now fit to return to service

Name Ayu S Name

SIGNATURE : DATE : SIGNATURE : DATE :

Save & Submit

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Page 3 of 3
 Permit Number: 3952/4041

Hot Work Permit

Actual Permit Date: 06/12/2024

PERMIT INFORMATION & CONDITIONS

This Permit is to be issued in accordance with Hot Work Permit Standard and General Permit to Work Standard. A Hot Work Permit is required,
in addition to a General Permit to Work, when Hot Work, i.e. any work with the potential to create an ignition source e.g. oxy cutting, welding,
grinding, soldering, is undertaken outside the trades' workshops.
Permit Conditions
1. Only an "authorised" Permit Issuer can issue the Permit (refer to Register of Permit Issuers for the relevant site).
2. Permit Issuer must complete the Permit and risk assessment in consultation with the person(s) performing the work, prior to commencing any
work.
3. Permit Issuer must be satisfied that work is performed according to the Permit (e.g. appropriate level of supervision) and the area made safe
on completion.
4. Fire Watch must monitor the area and, on completion of hot work, do a final inspection, sign the Permit and return it to a Permit Issuer for
closure.
5. A Permit Issuer to sign closure section of the Permit at completion of work and return Permit to Maintenance Planning Department, or site
equivalent, to be filed for 1 year.

Note: The fire watch period shall be for a minimum of 30 minutes following the completion of the task. After this minimum period of watch,
monitoring, either through visual inspection every fifteen (15) minutes or direct surveillance using CCTV or smoke detectors shall continue for a
further 90 minutes (or longer where there is the potential for combustion processes to take some time before becoming obvious).

Project Number:

Contract Company (if applicable):

Work at Heights Yes No

Confined Space Entry Yes No
Designated High risk Activities Yes No
Other Permits Required
Other permits may be required, depending on the location and nature of work.

INDIVIDUAL(S) INVOLVED WORD DETAILS

Permit Approver Location of Work
Name Uzil Pratama Signature
Production FG
Secondary Approver
Name Devy Susanti Pakpahan Signature
Description of work to be performed (brief)
Job Supervisor
Install Pipe Support
Name Sudartanto Signature
Fire Watch Equipment to be used
Name Dani Dwi A Signature
Mesin gerinda, mesin las, chainblock, cl
Area Manager (Representative)
Name Signature
General Permit to Work completed and attached Risk
assessment completed and controls identified (refer overleaf)
Person(s) undertaking work (Permit Acceptor)
Controls discussed with each person undertaking the work
I acknowledge that I have been consulted on the work to be performed and agree Isolation required
to comply with the controls stated on the permit.
Water Stream Gas Electricity
Comp air Mechanical Gravity Ingredient
Name Signature Smoke & Flame detectors Sprinkler System
Others
Name Signature
Frequency of supervision
Name Signature Constant 10 min 30 min Hourly 2-Hourly
Start & Finish Other
 Permit Number: 3952/4041

Hot Work Permit

Actual Permit Date: 06/12/2024

PERMIT VALIDITY
This Permit is valid: To on the
Where the validity period of the permit is extended, the Permit Issuer must reinspect the surroundings and acknowledge that the controls are still adequate by
providing the date at the start of the shift and signature.
Date:
Signature

FIRE WATCH AT COMPLETION OF WORK (30 MINUTES MIN)

Person completing the fire watch Actual Fire Watch Start

Name Signature Actual Fire Watch End

PERMIT CLOSURE
Has the work been completed? Yes No NOTE: The validity period of a permit may be extended for work continuing into a
new shift or into the next day provided that the job and surroundings are re-inspected
Has the work area been made safe? Yes No at the start of each shift to ensure that no new risks have arisen and that the risk
controls are still adequate.
Have fire detection systems been Yes No N/A
reinstated ? Permit Issuer closing this permit
If NO, detail the issues outstanding and the action to be taken.
Name
1. Signature Time of Closure:

2.

EMERGENCY CONTROLS
In the event of an emergency, define action required and/or who should be contacted (include contact telephone numbers):

Is there a Risk?
RISK IDENTIFICATION CONTROLS IMPLEMENTED
Yes No N/A Yes
Ignition of nearby combustibles
Reallocation of Hot Work
Fire to Occur Complete some/all of the work in a designated safe area
During the hot work ■ Yes No N/A Protection of Combustibles
■ Yes No N/A · Removal of Combustibles within 10 m
following completion of the hot work
■ Yes No N/A · Remove/bleed combustible linings, residues or gases from containers,
from ignition of nearby combustibles
etc. being worked on

· Sweep floors clean

· Protect all floor and wall openings, open pipes, duct work, electrical
cables, etc. with fire resistant tarpaulins or metal shields

· Suspend fire resistant tarpaulins beneath work

· Confirm walls and ceilings do not have combustible coverings or

insulation

Fixed Detection System

· Automatic fire sprinkler protection is in service

· Relevant persons have been notified of any isolated systems, eg.

Trades, Checklodge)
 Permit Number: 3952/4041

Hot Work Permit

Actual Permit Date: 06/12/2024

Fire Watch
The fire Watch person has
· Suitable extinguishers
· Chared hose
· Fire Blanket
Explosive Atmosphere Ventilation
· Atmosphere being flammable or Yes ■ No N/A · Ventilate area, e.g. fans, open doors, work in open area
explosive (e.g. due to dust, vapours,
excess oxygen) · Wipe down, vacuum, sweep work area to ensure dust levels are
negligible

· Flash back arrestors on both oxygen and acetylene gas lines

· Cylinders maintained in upright position and secured from falling

· Coatings on metal surfaces stripped away to a minimum of 150 mm

from Hot Work
During the Hot Work Equipment, Work Environment and PPE
Injury from faulty equipment ■ Yes No N/A · Hot Work equipment is in a satisfactory condition
Fall, trip or slip during the work ■ Yes No N/A
· Electrical equipment tagged and within test date
Worker(s) injured from exposure to
· Work area cleared of obstructions and trip risks
Inhalation of harmful dusts, vapours or gases Yes ■ No N/A
Foreign object in eye ■ Yes No N/A · Floor dry and free of oils
Excessive noise levels ■ Yes No N/A · Screens in place
Handling sharp objects ■ Yes No N/A · Respiratory Protection
Lifting heavy weights · Eye Protection
■ Yes No N/A
High temperatures · Hearing Protection
■ Yes No N/A
High UV exposure · Gloves
Yes No N/A
Injury to other people walking past · Leather apron
Yes ■ No N/A
Injury to other people below the work · Warning Notices displayed
■ Yes No N/A
· Barricades installed or work area taped off
· Area beneath work cordoned off
· Other (state)

Save & Submit

 Document No 3952/4041
Working at Height Permit
Permit Date Jun 12, 2024

PERMIT INFORMATION and CONDITIONS

This Permit is to be issued in accordance with Work at Heights Standard and General Permit to Work Standard. A Work at Heights Permit is required, in addition
to a General Permit to Work, whenever there is a potential for a person to fall more than 2 metre.
Exceptions include:
� A task that is undertaken on a structure (including stairs, fixed ladders, ramps and balconies) that comply with applicable Building Regulations.
� Access to roof areas where the worker will remain on fixed walkways at all times.
� Where a risk assessment has previously been completed and a Safe Work Procedure (SWP) or Standard Operating Procedure(SOP) written.
Permit Conditions
1. Only an "authorised" Permit Issuer can issue the Permit (refer to Register of Permit Issuers for the relevant site).
2. Permit Issuer must complete the permit and risk assessment in consultation with the person(s) performing the work, prior to commencing any work.
3. Permit Issuer must be satisfied that work is performed according to the Permit (e.g. appropriate level of supervision) and the area made safe on completion.
4. A Permit Issuer to sign closure section of the Permit at completion of work and return Permit to Maintenance Planning Department, or site equivalent, to be filed for 1 year

Project Number
Contract Company( If applicable)
Other Permits Required
Other permits may be required, depending on the location and nature of work.

• Hot Work Yes No

• Confined Space Entry Yes No

• Designated High Risk Activities Yes No

INDIVIDUAL(S) INVOLVED WORK DETAILS

Permit Approver Location of Work

Production FG
Name Uzil Pratama Signature
Description of work to be performed (brief)
Job Supervisor

Name Signature
Equipment to be used
Stand by/Spotter (if requried)

Name Signature
General Permit to Work completed and attached
Area Manager(Representative) Risk assessment completed and controls identified (refer overleaf)
Controls discussed with each person undertaking the work
Name Signature
Person(s) undertaking work (Permit Acceptor) Isolation required

I acknowledge that I have been consulted on the work to be performed and agree to Water Stream Gas Electricity
comply with the controls stated on the permit.
Comp air Mechanical Gravity Ingredient
Smoke & Flame detectors Sprinkler System
Name Signature Others

Frequency of supervision
Name Signature
Constant 10 min 30 min Hourly 2-Hourly
Start & Finish Other
Name Signature
PERMIT VALIDITY

This Permit is
AM /PM TO AM / PM: on the
valid:

Where the validity period of the permit is extended, the Permit Issuer must reinspect the surroundings and acknowledge that the controls are still adequate by providing the date at the
start of the shift and signature. to to AM / PM

Date:
Signature:

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 Document No 3952/4041
Working at Height Permit
Permit Date Jun 12, 2024

PERMIT CLOSURE
� Has the work area been completed? Yes No NOTE: The validity period of a permit may be extended for work continuing into a new
shift or into the next day provided that the job and surroundings are re-inspected at the
� Has the work area been made safe? Yes No start of each shift to ensure that no new risks have arisen and that the risk controls are still
adequate.
If NO, detail the issues outstanding and the action to be taken:

Pemit Issuer Closing this Permit

1.
Name

2.
Signature Time of Closure:

EMERGENCY CONTROL
In the event of an emergency, define action required and/or who should be contacted (include contact telephone numbers):
NOTE:
What is the method of communication? What will be the retrieval method?
Have you practiced a dry run?
IS THERE A RISK?
RISK IDENTIFICATION CONTROLS IMPLEMENTED
Yes No N/A YES
Falls from Heights Relocation of work to ground level
• From an ungarded edge • Complete some/all of the work at ground level
• Through a fragile structure or penetrations
• Through the ceiling structure Passive fall prevention device
• Down a sloping surface • Scaffolding
• Off a ladder • Elevated work platforms, e.g. scissor lift, knuckle boom
• While working above handrails • Temporary guard/hand rails
• Caused by overloading capacity of surface • Equipment is right for the task
• From high winds • Equipment inspected and in good/safe working condition
• Due to a wet or slippery surface • Operator has appropriate licence or training
• From an electrical shock • Operator is familiar with controls and load limitations
• Due to damaged equipment, eg.laneyard, harness static lines • Overhead obstructions removed, isolated or administratively
• Resulting in pendulum effect controlled, e.g. spotter
• From being accidentally knocked or pushed • Harness (fitted correctly), & anchorage point in good condition

Work positioning system

Note: Fall risk controls to be implement in accordance with the
Note: Only workers trained in the safe use of work positioning equipment are
following hierarchy:
to use the equipment
• Industrial rope access system
i) The work should be done at ground level
ii) The work should be done from a passive fall prevention device (eg • Travel restraint system
scaffolding, elevated work platform, temporary hand rails, step • Anchorage points are in good condition & appropriate for task
platform)
iii) The work should be done using a work positioning system (eg Fall injury prevention systems
travel restraint, rope access system) Note: Only workers trained in the safe use of harnesses are to wear the
iv) The work should be done using fall injury prevention systems (eg equipment
fall arrest, safety net) • Safety harness with fall arrest equipment (as per AS1891)
v) The work should be done using a fixed or portable ladder (as per • Anchorage points are in good condition & appropriate for task
code of practice)
Ladders
• Appropriate for the task to be undertaken
• Is in sound condition
• Appropriate for the duration of the task
• Is set up in the correct manner, secured

Ladder - Do nots
X Do not climb/work in a manner that involves facing away from the ladder
X Do not stand on a rung closer than 900mm from the top of a single or
extension ladder
X Do not carry out work that involves restricted vision or hot work, e.g.
welding
X Do not use any equipment or tool that is designed to be operated with
two hands

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 Document No 3952/4041
Working at Height Permit
Permit Date Jun 12, 2024
IS THERE A RISK?

RISK IDENTIFICATION CONTROLS IMPLEMENTED

Yes No N/A
YES
Other Risks Work Environment and PPE

• Dropping equipment, materials, tools onto people below • Signage displayed highlighting presence of overhead work
• Dropping equipment, materials, tools onto food processes below • Witches hats/barricades installed below work area
• Tripping from uneven surface or ground level obstructions • Tools and materials secured during the work
• Strains from handling heavy or awkward loads • Area tidied
• Foreign object in eye • Eye Protection
• Excessive noise levels • Hearing Protection
• Handling sharp objects • Gloves
• Lifting heavy weights • Non-slip boots
• High temperatures
• Safety helmets/headwear (with chin strap)
• High UV exposure
• Sunscreen
• Other (define below)
Other Comments:
1) Use of knuckle booms/cherry pickers with a telescopic device over 11m requires a national certificate of competency (licence).
2) Construction of scaffolding over 4m requires a national certificate of competency (licence).

Save & Submit

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