Risk Assessment Work Sheet Subcont logo

Project Title: HEI BSA PROJECT

Risk Assessment No. Page Permit No.

Job Title
of Revision Date No.

Work Location Subcontractor Discipline

Prepared by (RA Team) Name Position Date Signature

Subcontractor Discipline Manager / Engineer
Subcontractor HSE Engineer / Supervisor
Subcontractor Discipline Supervisor

Checked by (Preliminary Review) Name Position Date Signature

Discipline Manager / Engineer
Discipline Supervisor / Engineer
HSE Manager / Engineer
HSE Supervisor / Engineer
 Risk Assessment Work Sheet Subcont logo
Job Title:
Training / competency HSE equipment / facilities
Equipment & Tools to be used Materials to be used Inspection required
required required
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
5 5 5 5 5
6 6 6 6 6
7 7 7 7 7
8 8 8 8 8
9 9 9 9 9
10 10 10 10 10

Number of personnel Worker Discipline Supervisor Safety Supervisor

required Other Discipline Foreman Safety Officer / Inspector

Risk Assessment Matrix (RAM) and Hierarchy of Control

PROBABILITY [1 - 3] Can proceed with the task
HSE Risk Assessment of Incident Rare (1) Possible (2) Likely (3) Of ten (4) Frequent (5)
Encountered
in industry
Has occurred
in HEC
Has occurred
in HEC
Occurs Occurs
sev eral times sev eral times
[4 - 10] Can proceed with the task. Consider more controls.
SEVERITY People Assets Environment Reputation
but not in project within project within a y ear in a y ear at this
HEC projects last 5 y ears last 3 y ears HEC projects project [12 - 25] Stop work. Change work method or put more controls
Slight injury Slight ef f ect Slight ef f ect
or health (less than 500 (less than 50
1-Insignificant
ef f ects USD liter oil/
Slight impact 1 2 3 4 5
(FAC) Damage) Chemical)
Minor ef f ect Minor ef f ect
Minor injury or
(500 ~ 10,000 (less than 100
2-Minor health ef f ects
USD liter oil/
Minor impact 2 4 6 8 10
(MTC)
Damage) Chemical)

Major injury or Local damage Localized

health ef f ects (10,000 ~ ef f ect (100 ~ Considerable
3-Moderate (RWC; LTI <7 100,000 USD 200 liters of impact 3 6 9 12 15
day s) Damage) oil/Chemical)

Single f atality Major damage Major ef f ect

or permanent (100,000 ~ (200 ~ 1000 National
4 -Major disability or 500,000 USD liters of impact 4 8 12 16 20
LTI > 7 day s Damage) oil/Chemical)

Extensiv e Massiv e
damage ef f ect (more
Multiple International
5-Catastrophic
f atalities
(more than than 1000
impact 5 10 15 20 25
500,000 USD liters oil/
Damage) Chemical)
 Risk Assessment Work Sheet Subcont logo
Job Title:

Initial Risk Action Residual Risk

No. Description of Work Step Potential Hazards & Consequences Control and / or Recovery Measures Responsible
S P R Person S P R
1.1.1 Measure 1.1.1 Person 1
1.1 Hazard 1.1 1 3 Low 1.1.2 Measure 1.1.2 Person 2 1 2 Low
1.1.3 Measure 1.1.3 Person 1
1.2.1 Measure 1.2.1 Person 2
1 Step 1 1.2 Hazard 1.2 2 3 Med 1.2.2 Measure 1.2.2 Person 1 2 1 Low
1.2.3 Measure 1.2.3 Person 3
1.3.1 Measure 1.3.1 Person 2
1.3 Hazard 1.3 3 4 High 1.3.2 Measure 1.3.2 Person 1 3 2 Med
1.3.3 Measure 1.3.3 Person 4
2.1.1 Measure 2.1.1 Person 1
2.1 Hazard 2.1 2.1.2 Measure 2.1.2 Person 2
2.1.3 Measure 2.1.3 Person 1
2.2.1 Measure 2.2.1 Person 2
2 Step 2 2.2 Hazard 2.2 2.2.2 Measure 2.2.2 Person 1
2.2.3 Measure 2.2.3 Person 3
3.3.1 Measure 2.3.1 Person 2
2.3 Hazard 2.3 3.3.2 Measure 2.3.2 Person 1
3.3.3 Measure 2.3.3 Person 4
3.1.1 Measure 3.1.1 Person 1
3.1 Hazard 3.1 3.1.2 Measure 3.1.2 Person 2
3.1.3 Measure 3.1.3 Person 1
3.2.1 Measure 3.2.1 Person 2
3 Step 3 3.2 Hazard 3.2 3.2.2 Measure 3.2.2 Person 1
3.2.3 Measure 3.2.3 Person 3
3.3.1 Measure 3.3.1 Person 2
3.3 Hazard 3.3 3.3.2 Measure 3.3.2 Person 1
3.3.3 Measure 3.3.3 Person 4
 Risk Assessment Work Sheet
Subcont logo
Project Title: HEI BSA PROJECT

Job Title Page Permit No.

of Revision Date No.
Work Location Subcontractor Discipline
INDUKSI / PENANDATANGANAN (INDUCTION / SIGNATURE) :
Saya mengkonfirmasi bahwa RA telah dijelaskan dan isinya benar-benar dapat dipahami dan diterima
(I confirmed that the JSEA has been explained and totally understandable and acceptable)
Saya benar-benar memahami kontrol-kontrol dalam RA ini harus diterapkan sebagaimana yang didokumentasikan; apabila tidak, pekerjaan dihentikan segera
(I totally understood these controls in JSEA should be implemented as documented; otherwise, the work will be stopped
immediately)

No Name Position Company Signature Date

Name Position Date Signature

Subcontractor Discipline Manager / Engineer
Subcontractor HSE Engineer / Supervisor
Subcontractor Discipline Supervisor
 TBM Attendance Sheet
Subcont logo
Project Title: HEI BSA PROJECT

Group Date

Location
Work Description
Supervisor (Sign)

No Name Signature No Name Signature

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