CONFINED SPACE ENTRY PERMIT

Izijn Kerja Area Terbatas

KALSEL-1 Project
Permit Registry No. HSE- WPCS-

THIS PERMIT IS AUTOMATICALLY SUSPENDED UPON ACTUATION OF THE GENERAL ALARM ISSUED DATE
AND MUST BE RETURNED TO THE PTW OFFICE FOR RE-ISSUE BEFORE RESTARTING WORK

1. SPECIFICATION OF WORK

Work Location : Company : PTW Receiver

Work Description : INITIAL ENTRY NORMAL ENTRY Name :

Position :

Sign :
Equipment & Tools to be used :

Validation :
Requested by : NAME POSITION SIGN

2. SAFETY CHECK

YES NO NA* YES NO NA*

A. Equipment Preparation 7 Have minutes of prescribed been reviewed
Apakah waktu di dalam area telah dipertimbangkan
1 Has been thoroughly drained
Telah dikeringkan
Are adequate gas analysis
8 Apakah analisis gas memadai
2 Telahbeen
Has isolated by :
terisolasi dari : 9 apakah rambu /telah
Are cordoning warning sign put up
terpasang
- Blinds
- Disconnecting C. Adjacent work site precautions
3 Has been water flushed
Telah dibilas dengan air 1 Is hazards from adjacent work taken into
Apakah bahaya dekat area kerja telah
Has been steamed
4 Telah consideration
diuapkan dipertimbangkan
5 Has been purged with inert gas
Telah dibersihakan dengan gas inert 2 Are close by sewage drains etc., sealed
Apakah saluran air limbah, dll telah disegel
6 Has been ventilated
Telah diberikan ventilasi udara
B. Site preparations/ precautions D. Prime mover and other isolations
1 Will lighting be used during entry
Penerangan digunakan ketika masuk 1 Has been mechanically isolated
Apakah penggerak mekanis telah diisolasi
Is the site cleared of combustible/toxic Has been isolated from other power sources
2 2
Apakah area telah aman dari material mudah Apakah telah terisolasi dari sumber tegangan
materials 3 Electrically isolated and tagged
terbakar/mledak Elektrikal diisolasi dan ditandai (tagged)
3 Is adequate fire-fighting equipment
Apakah peralatan pemadam api telah
Has power source been disconnected
4 Apakah sumper tegangan telah diisolasi
located to the work site Isolation slip No.
disiapkan di lokasi kerja
4 Are entry and escape adequate (ladder etc.)
Apakah jalur masuk dan keluar memadai 5 Has been isolated from radio active source
Apakah telah diisolasi dari sumber radioaktif
Have
5 Apakah monitoring personnel been
personel monitoring telah dilengkap
adequately equipped and informed
peralatan memadai dan diinformasikan
6 Are life-line, safety harness and breathing
Apakah life-line, safety harness and breathing
equipment readily available
equipment telah tersedia NA * - Not Applicable

3. HAZARDS IDENTIFIED
Extreme weather Flammable materials Explosives Noise High Voltage
Cuaca ekstrim Material mdh terbakar Ledakan Kebisingan Tegangan tinggi
Confined space Electrical Spark Danger of falling Tripping/Slipping Hazard Low Voltage
Ruang Terbatas Percikan listrik Bahaya tertimpa Bahaya tersandung/tergelincir Tegangan rendah

Awkward Access/Egress Welding sparks Vehichle Traffic Hot materials Manual handling
Jalur/jalan keluar Percikan las Lalu lintas kendaraan Material panas Manual handling
Toxic gases/fumes Eqpmt causing sparks Lifting operation Working at Height Severe/Adverse Weather
Gas beracun/asap Peralatan penyebab percikan Operasi pengangkatan Bekerja di ketinggian Cuaca buruk
Limited/poor lighting Moving machinery Pintch points Live Equipment Sharp edges
Penerangan kurang Mesin bergerak Titik terjepit Peralatan penunjang hidup Sisi tajam
Radioactive Source Vibration Excavation Collapse Pressurized Hose Failure Unguarded Opening
Sumber Radioaktif Getaran Runtuh galian Kegagalan selang bertekanan Area terbuka tdk terlindungi
Lines/hoses under pressure Hazardous Substances Underground Utility Overhead Power Line Dropped Object
Jalur/selang bertekanan Zat berbahaya Utilitas bawah tanah Jalur listrik atas Benda jatuh

Others :

4. PRECAUTION TO BE TAKEN
Thoroughly ventilated Fire hose run out and pressurised Provided with suitable access and egress
Ventilasi baik Selang fire disediakan dan bertekanan Menyediakan akses dan jalan keluar
Gas test required Fire resistance blanket/habitat erected Area free of flammable/combustible materials
Pengecekan gas Fire blanket dipasang Area bebas dari material mudah terbakar
Maintain radio contact Depressurised Earthed for static
Menjaga kontak radio Memperhatikan tekanan Memasang electrical earthed/grounding
Water flushed Secure loose objects Drained free of liquids
Air pembilas Mengamankan benda longgar Bebas dari air tergenang
Firewatcher present Containers for welding rods to be provided System Electrically Isolated
Firewatcher tersedia Wadah untuk welding rods tersedia Kelistrikan terisolasi
Firewatch extinguisher Work area kept wet System Mechanically Isolated
Alat pemadam api Area kerja kering Sistem mekanis terisolasi
 Erect signs and barriers Keep work site free of trip hazards Adhere to lifting plan/method statement
Rambu dan pembatas Area kerja bebas bahaya tersandung/terpeleset Mematuhi rencana/metode pengangkatan
JSA Comply with MSDS Equipment to be isolated when left unattended
JSA Mematuhi MSDS Peralatan terisolasi ketika ditinggalkan
Control the working hours Measure the temperature Water station
Kontrol jam kerja Memastikan suhu Air minum

Others :

5. PERSONAL(PERSONNEL) PROTECTIVE EQUIPMENT & SAFETY EQUIPMENT REQUIRED

Eye protection Face shield Full chemical suit Fire Blanket Safety harness Eye Wash Station
Pelindung wajah Pelindung wajah Pakaian pelindung bhn kimia Fire Blanket Safety harness Pembilas mata
Hearing protection Dust mask Paper Coveralls Inertial reels Work lifevest Radio
Pelindung pendengaran Masker debu Pakaian pelindung Inertial reels Rompi pelampung Radio
Head protection Foot protection Fire Extinguisher Life Line Escape (BA) Set Rubber Boots
Pelindung kepala Pelindung kaki Pemadam api Life Line SCBA Bot karet
Rigger Gloves Personnel Gas Detector Industrial Gloves Welding shield Tripod OSR Equipment
Sarung tangan rigger Pendeteksi gas Sarung tangan industri Pelindung wajah Tripod Peralatan OSR
Cold Weather Clothing Ice and Snow Traction Fire Retardant Clothing Emergency Shower Fresh air mask Full/hair face gas mask
Pakaian pelindung dingin Ice and Snow Traction Pakaian Tahan Api Shower darurat Masker udara bersih Masker gas

Gas Detection : O2 CH4 H2S CO Other :

Others :

6. GAS ANALYSES OR INITIAL GAS TEST(Authorized Gas Tester)

8 hourly 4 hourly Continuous Others : Authorized Gas Tester

Date Name
Time Initials
Combustible (%) Date
Toxic/H2S Time
Oxygen (%)
Signature
Signature
※ To be performed at least every 8hrs ※ Usable O2 CH4 H2S
※ Initialled by Authorized Gas Tester as being within acceptable gas test limits. other sheet CO Other
※ Comments/Remarks :

7. APPROVAL & ISSUE

Step1. Reviewed by ( Contractor Engineer ) Reviewed by ( Contractor HSE Engineer )

Name : Name :
Date : Sign : Date : Sign :

Step2. Reviewed & Approved by (Construction Autorized Reprentative) (Manager)

Date : Time : Name : Signed :
Comments :

Step3. Reviewed & Approved by (HSE Autorized Reprentative) (Manager)

Date : Time : Name : Signed :
Comments :

Step4. Received by (Subcontractor Task Supervisor / Side Manager)

I have read and understand the above conditions and precautions and declare that I accept responsibility for carrying out work specified on this Permit, that no attempt will be made by myself or by the persons
under my control to carry out any other work, and that I will notify the Contractor engineer(HGU) upon completion/suspension of this work.

Saya telah membaca dan memahami kondisi diatas dan tindakan pencegahan dan menyatakan bahwa saya menerima tanggung jawab untuk melaksanakan pekerjaan tertentu pada izin kerja ini, bahwa tidak ada upaya akan
dilakukan sendiri atau dengan orang-orang dibawah kendali saya melaksanakan pekerjaan lain, dan bahwa saya akan memberitahukan kontraktor engineer (HGU) setelah selesai/penangguhan dari pekerjaan ini.

Date : Time : Name : Signed :

8. RE-VALIDATION ( Compulsory RE-VALIDATION of the work permit each shift - to Continue work )

Subcontractor HGU HGU - HSE Subcontractor HGU HGU - HSE

Date Validity Time (Task Supervisor)
Date Validity Time (Task Supervisor)
Site in-charge (Coordinator) Site in-charge (Coordinator)

Signature Signature Signature Signature Signature Signature

Signature Signature Signature Signature Signature Signature
Signature Signature Signature Signature Signature Signature
Signature Signature Signature Signature Signature Signature
Signature Signature Signature Signature Signature Signature
Signature Signature Signature Signature Signature Signature

9. PERMIT CLOSE-OUT ( CLOSURE )

Closed by(Subcontractor) Accepted by (HGU CM) Registered by (Permit Coordinator/HGU HSE)

Date Time Date Time Date Time
Signed Signed Signed

Cross-Referenced Documents : YES NO

※ NOTE
Attached File : YES NO