Job information

  Job activity description: Topography Survey Date: MM/DD/YY

Work-order number: Job Requestor: Juli H Work area:

Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1. Bekerja tanpa permit 1. Tidak boleh melakukan pekerjaan sebelum

1.Pembuatan ijin kerja permit di validasi.

2. Pemeriksaan Peralatan Topography 2. Peralatan tidak berfungsi dengan baik 2.1. Pastikan peralatan berfungsi dengan baik

2.2. Peralatan sudah dilakukan kalibrasi.

3. Topography Survey 3. material yang berserakan ( adanya tumpukan 3.1. Pada saat akan melakukan pekerjaan
material ) topography karyawan mengambil posisi yang aman

3.2. Housekeeping
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir - Stop pekerjaan

1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - Paramedic Standby + P3K Stand by
- Emergency Call 081196203811 Cargill Representative Quality Review
(Print Name)

2. Angin Kencang 2.1. Material berserakan - Bawa ke Klinik terdekat

2.2. Tertimpa Material - Safety Patrol Stand by
- Electrical Orientasi lapangan

Employees working in the area have

been notified of this work?
3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja )

4. SIMOPS 4. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan

Koordinasi dengan Kontraktor lain
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

 Job information
  Job activity description: Electrical Activity ( Maintanance, Equipment, Instalasi ) Date:
7/5/2023
Work-order number: Job Requestor: Juli H Work area: ALL Area OSBL
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. PERSIAPAN DOCUMENT (PERMIT TO WORK) 1. PEKERJAAN TIDAK MEMILIKI IJIN KERJA 1.1. LAKUKAN PEMBUATAN PERMIT DAN JSA SESUAI DENGAN
PEKERJAAN YANG AKAN DIKERJAKAN
1.2. LAKUKAN TOOLBOX MEETING SEBELUM PEKERJAAN
DIMULAI

1.3. PASTIKAN MENGGUNAKAN APD SESUAI DENGAN

PEKERJAANNYA
2.1. PASTIKAN PERALATAN DALAM KONDISI BAIK DAN LAYAK
2. PERSIAPAN PERALATAN (Amperemeter) 2.1. PERALATAN RUSAK
PAKAI
2.2. PASTIKAN PERALATAN YANG DIGUNAKAN TELAH DI
2.2. PERALATAN BELUM DILAKUKAN INSPEKSI
INSPEKSI DAN VALID

3.1. PEKERJA TIDAK MEMAHAMI METODE KERJA SERTA 3.1. LAKUKAN TOOLBOX MEETING / PJSM SEBELUM PEKERJAAN
3. PERSIAPAN PEKERJAAN
BAHAYANYA DIMULAI

3.1. PASTIKAN PEKERJA MENGERTI TUGAS SERTA BAHAYANYA

3.2. BEKERJA TIDAK SESUAI PROSEDUR KERJA AMAN

3.2. PASTIKAN PEKERJA MENGGUNAKAN APD SESUAI DENGAN

PEKERJAANNYA

4.1. SEBELUM BEKERJA PASTIKAN TIDAK ADA BAHAYA YANG

4. ELECTRICAL ACTIVITY ( MAINTANANCE, EQUIPMENT,
4.1. KABEL YANG TERKELUPAS DAPAT MENGAKIBATKAN TERSENGAT LISTRIK ATAU MATIKAN
INSTALASI LISTRIK.
SUMBER ARUS LISTRIK.

4.2. PASTIKAN PEKERJA MENGGUNAKAN APD SESUAI DENGAN

4.2. KONSLETING LISTRIK
PEKERJAANNYA
4.3. HOUSEKEEPING DAN PASTIKAN AREA KERJA TIDAK
4.3. MATERIAL YANG BERSERAKAN TERDAPAT TUMPUKAN MATERIAL YANG MENYEBABKAN
TERSANDUNG, TERJATUH, ATAUPUN TERPELESET.
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir - Stop pekerjaan

1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - Paramedic Standby + P3K Stand by
- Emergency Call 081198203811 Cargill Representative Quality Review
(Print Name)

2. Angin Kencang 2.1. Material berserakan - Bawa ke Klinik terdekat

2.2. Tertimpa Material - Safety Patrol Stand by

- Electrical Orientasi lapangan
3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja ) - Untuk Maintanance terkait listrik hanya
boleh dilakukan oleh TIM Electrical
4. SIMOPS 4. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan
Koordinasi dengan Kontraktor lain
Employees working in the area have
been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

5. House keeping 5. Sampah potongan kabel berserakan 5. Penarapan 5R sebelum dan sesudah melakukan
pekerjaan

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fabrication Piping Date: 1414-05-
7/5/2023 2023-05-
Work-order number: Job Requestor: Juli H Work area: Workshop
2023
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1. Pembuatan ijin kerja 1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit
di validasi.
2. Peralatan belum dilakukan function test 2. Inspeksi peralatan kerja

3.1. Fabrication 3.1. Material dan sampah yang berserakan 3.1.1. Pastikan area kerja di barricade, terpasang
sign board
3.1.2. Housekeeping dan pastikan area kerja dalam
kondisi rapih.

3.2. Fabrication material piping ( Hot Work) 3.2.Terkena percikan saat pemotongan, 3.2.1. Penggunaan APD sesuai dengan Pekerjaan
pengelasan, atau pengerindaan. yang dilakukan ( Face shield, afron, caplas ) .

3.2.2. Sedia APAR dan Stand by Firewacher.

 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
2.2. Tertimpa Material

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

4. Sumber Listrik ( Genset Trouble ) 4. Stop Pekerjaan - Maintanance ( LOTO ) hanya Employees working in the area have
dilaksanakan oleh Electrician been notified of this work?
5. Fire Wacher tidak stndby 5. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )

Yes No

( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

4. Pengangkatan material ( Manual Handling) 4. Low Back Pain ( Ergonomic) 4.1. Pastikan Pekerja menggunakan APD
4.2. Pastikan pekerja melakukan pengankatan
material sudah sesuai procedure ( Max beban
20kg )
4.3. Gunakan alat bantu untuk pengangkatan lebih
dari 25 kg.

5. House keeping 5. Tumpukan material ( Material yang berserakan ) 5. Penarapan 5R sebelum dan sesudah melakukan
pekerjaan

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Pengerjaan Pipe Trench (Install Rebar, Bekisting dan Concreate) Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Pipe Trench 06
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1.1. Tidak ada ijin kerja 1.1. Jika tidak ada ijin kerja maka pekerjaan di stop dan buat
1. Pembuatan ijin kerja ijin kerjanya serta validasi dengan Cargill
1.2. Miss Komunikasi 1.2. Koordinasikan planning pekerjaan antar Foreman, SPV,
Serta EHS
2. Persiapan peralatan (Penekuk Besi, Vibrator, Hand 2. Peralatan belum silakukan function test 2. Inspeksi peralatan area kerja ( pastikan area aman )
Mixer)
3. Penggalian menggunakan Excavator 3.1. Pekerja sekitar terkena swing dari excavator 3.1. Pastikan spotter standby lokasi untuk mengatur pengguna
akses lainnya supaya aman dan bebas dari swing exavator.
3.2. Longsor sisi vertikal galian 3.2. Sediakan shoring di sisi vertical galian.
3.3. Pekerja terjerumus ke dalam galian 3.3. Pasang hardbarricade di sekitar lubang galian.

4. Install Rebar dan Formwork 4. Sisi tajam material dan benda-benda yang ada di sekitar 4.1.1. Pemakaian APD sesuai pekerjaan ( Sarung Tangan Cut
area kerja Resist lvl 3 )
4.1.2. Pemasangan rebar cup
5. Pengecoran 5.1. Material semen yang masih basah 5.1.1. Penggunaan APD lengkap dan sesuai dengan pekerjaan

5.1.2. Procedure kerja sudah di bahas di TBM dan pastikan

semua pekerja bekerja sesuai dengan Procedure yang ada.
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
2.2. Tertimpa Material

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja )

- Klinik Terdekat
4. Tidak terdapat barricade di sekitar 4. Cidera - Fatality
galian
5. SIMOPS 5. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan Employees working in the area have
Koordinasi dengan Kontraktor lain been notified of this work?

6. Tidak ada Anchor Point dan Shoring jika galian - Buat Anchor Point dan shoring terlebih dahulu
>1.2 m

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Pengangkatan Material ( Manual Handling ) 6. Procedure pengangkatan yang salah ( Beban yang berlebih ) 6. Max beban untuk manual handling 25kg, apabila berat beban lebih
dari 25kg menggunakan alat bantu.

7. Housekeeping 7. Material atau sampah yang berserakan 7. Penerapan 5R baik sebelum maupun sesudah melakukan
pekerjaan.

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Piping Work ( Stringing, Fit up , Welding ) Date: MM/DD/YY

Work-order number: Job Requestor: N.Halim Work area: ALL Area OSBL
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Pembuatan ijin kerja 1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di validasi.
2. Persiapan tools dan equipment 2.1. Tools dan Equipment belum dilakukan function test 2.1.1. Inspeksi peralatan kerja dan di beri tagging layak pakai.
2.1.2. Daily Ceklist inspek tools dan equipment

3. Positioning alat berat ( Crane / TMC ) 3.1. Permukaan tanah area kerja 3.1. Supervisi / Koordinasi antara operator dan rigger

3.2. Line of fire ( Swing alat berat ) 3.2. Tidak ada aktivitas di sekitar area line of fire
3.3. Pemasangan barricade dan signboard
4. Rigging ( Pipe ke alat berat ) 4. Rigging yang salah 4.1. Personiel yang bertugas terutama rigger berkompeten dan
bersertifikat

5. Stringing Pipe 5.1. Overload 5.1. Sebelum melakukan pengangkatan harus melakukan Load
6. Work at Height 6.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) test
6.1. Penggunaan FBH dan double lanyard 100% tie off.
6.2. Scaffolding roboh 6.2. Di install dan di inspek oleh orang yang berkompeten,
7. Fit-up dan welding joint 7.1. Terjepit Pipe Spool weekly inspek.
7.1. Pekerja memperhatiakn titik jepit dan sebelum memulai
pekerjaan pastikan semua area aman dan sudah sesuai
procedure ( SPV, EHS, Pekerja )
7.2. Percikan api dan radiasi sinar las 7.2. Pemakaian APD lengkap. ( Cap las+kaca mata hitam,
afron, sarung tangan , long arm, fire blanked )

7.3. Hot work ( Kebakaran ) 7.3.1. Stand by Apar dan Fire Wacher
7.3.2. Aktivitas dilakukan jauh dari semua benda-benda yang
mudah terbakar ( menimbulkan api )
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
2.2. Tertimpa Material

3. Scaffolding Roboh ( tidak proper ) 3.1. Terjatuh dari ketinggian

3.2. Tertimpa scaffolding

4. Pekerja tidak memakai APD 4. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

Employees working in the area have

been notified of this work?
5. Penerangan (di bawah 200 lx ) 5. Cidera-Fatality - Stop pekerjaan. Pengecekan pencahayaan
6. Fire Wacher tidak stndby 6. Kebakaran - Fatality menggunakan
- Stand by Apar, LUX meter
Fire blanked, Fire Wacher
(di identifikasi dengan pemakaian arm band )

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: N.Halim Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
8. Grinding Activity 8.1. Terkena Gram dan kebisingan 8.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
8.1.2. Standy Eye wash di area kerja
8.2. Cuting disk pecah 8.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
8.2.2. Install Safety Guard
9. Hot work menggunakan pressure gas cylinder 9.1. Tabung argon ( tabung bertekanan ) tidak double 9.1. Penerapan procedure penyimpanan dan perawatan
penghalang material yang telah di tentukan ( disosialisasikan keseluruh
pekerja ).

9.2. Kebocoran pada selang/ tabung 9.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).

10. Housekeeping 10. Tumpukan material dan sampah 10. Penerapan 5R sebelum dan sesudah pekerjaany

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Pekerjaan Fabrication Rebar dan Formwork Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Workshop
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1. Bekerja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di validasi.
1. Pembuatan ijin kerja

2. Persiapan peralatan 2. Peralatan belum dilakukan function test 2.1. Pastikan peralatan telah diinspeksi

2.2. Pastikan peralatan dalam kondisi baik

3. Fabrikasi 3.1. Material tajam di sekitar area kerja 3.1. Pastikan area kerja aman

3.2. Material berserakan 3.2. Pastikan area kerja dalam kondisi rapih

3.3. Manual handling tidak benar 3.3. Pastikan Menggunakan APD

 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
2.2. Tertimpa Material

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja )

- Klinik Terdekat
4. Tidak terdapat barricade di sekitar 4. Cidera - Fatality
galian
Employees working in the area have
been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

4. Pemasangan rebar 4. Pekerja lupa atau tidak memakai APD ( Sarung Tangan ) 4. Pastikan pekerja pakai APD

5. Pengangkatan material ( Manual Handling) 5. Low Back Pain ( Ergonomic) 5.1. Pastikan Pekerja menggunakan APD
5.2. Maksimal manual handling 20 kg
5.3. Gunakan alat bantu untuk pengangkatan lebih dari 20 kg.

6. House keeping 6. Tumpukan material ( Material yang berserakan ) 6. House Keeping

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Pemasangan Rebar & Formwork Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Pump Shelter
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements

( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1. Bekerja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di validasi.
1. Pembuatan ijin kerja

2. Persiapan peralatan 2. Peralatan belum dilakukan function test 2.1. Pastikan peralatan telah diinspeksi

2.2. Pastikan peralatan dalam kondisi baik

3. Fabrikasi 3.1. Material tajam di sekitar area kerja 3.1. Pastikan area kerja aman

3.2. Material berserakan 3.2. Pastikan area kerja dalam kondisi rapih

3.3. Manual handling tidak benar 3.3. Pastikan Menggunakan APD

 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
2.2. Tertimpa Material

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja )

- Klinik Terdekat
4. Tidak terdapat barricade di sekitar 4. Cidera - Fatality
galian
Employees working in the area have
been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

4. Pemasangan rebar 4. Pekerja lupa atau tidak memakai APD ( Sarung Tangan ) 4. Pastikan pekerja pakai APD

5. Pengangkatan material ( Manual Handling) 5. Low Back Pain ( Ergonomic) 5.1. Pastikan Pekerja menggunakan APD
5.2. Maksimal manual handling 20 kg
5.3. Gunakan alat bantu untuk pengangkatan lebih dari 20 kg.

6. House keeping 6. Tumpukan material ( Material yang berserakan ) 6. House Keeping

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Pekerjaan Cooling Pond (Install Rebar, Formwork & Concreate) Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: WWTP
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements

( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1. Bekerja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di validasi.
1. Pembuatan ijin kerja

2. Persiapan peralatan(Exavator SH330) 2.1. Peralatan belum dilakukan Inspection 2.1. Pastikan peralatan telah diinspeksi oleh Sucufindo

2.2. Pastikan peralatan dalam kondisi baik

3. Penentuan titik koordinat oleh surveyor 3. Terjatuh, cidera, kerusakan alat survey 3. Pastikan pada saat menentukan titik koordinat
memperhatikan medan sekitar terdapat benda yang
menghalangi atau tidak.
4. Exavation/Galian ( Excavator) 4.1. Pekerja sekitar terkena swing dari excavator 4.1. Pastikan spotter standby lokasi untuk mengatur pengguna
akses lainnya supaya aman dan bebas dari swing exavator.
4.2. Longsor sisi vertikal galian 4.2. Sediakan shoring di sisi vertical galian.
4.3. Pekerja terjerumus ke dalam galian 4.3. Pasang hardbarricade di sekitar lubang galian.
5. Backfill menggunakan lime stone, dan pemadatan 5.1. Mobil truck terjerumus ke galian 5.1. sediakan Spotter untuk mengatur mobil yang membawa
menggunakan baby roller. lime stone
5.2. Blind Spot menyebabkan man power tertabrak mobil 5.2. Pastikan Flagman stand by di lokasi area kerja sebagai
pemberi aba aba
5.2. Cidera, mallfunction alat 5.2. Pekerjaan compact dilaksanakan oleh tenaga yang
6. Pemasangan rebar 6. Pekerja lupa atau tidak memakai APD ( Sarung Tangan ) kompeten
6. Pastikanbukan dilakukan
pekerja oleh helper.
pakai APD
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
2.2. Tertimpa Material

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja )

- Klinik Terdekat
4. Tidak terdapat barricade di sekitar 4. Cidera - Fatality
galian
5. Flagman tidak standby 5. Cidera-fatality - Pastikan Flagman standby di lokasi Employees working in the area have
area kerja ditandai dengan bendera been notified of this work?
semaphore

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

7. Pengecoran 7.1. Mata, Tubuh terkena percikan dari semen 7.1. Pastikan pekerja menggunakan APD pada saat pengecolan
7.2. Pekerja tertabrak mobil concreate 7.2. Pastikan spotter atau flagman standby di lokasi kerja.

8. House keeping 8. Tumpukan material ( Material yang berserakan ) 8. Pastikan 5R diterapkan pada saat sebelum dan sesudah beker

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Pengerjaan Pipe Sewer (Exavation) Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Pipe Trench 01 & PH 01
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1.1. Tidak ada ijin kerja 1.1. Jika tidak ada ijin kerja maka pekerjaan di stop dan buat
1. Pembuatan ijin kerja ijin kerjanya serta validasi dengan Cargill
1.2. Miss Komunikasi 1.2. Koordinasikan planning pekerjaan antar Foreman, SPV,
Serta EHS
2. Persiapan peralatan (Penekuk Besi, Vibrator, Hand 2. Peralatan belum silakukan function test 2. Inspeksi peralatan area kerja ( pastikan area aman )
Mixer)
3. Penggalian menggunakan Excavator 3.1. Pekerja sekitar terkena swing dari excavator 3.1. Pastikan spotter standby lokasi untuk mengatur pengguna
akses lainnya supaya aman dan bebas dari swing exavator.
3.2. Longsor sisi vertikal galian 3.2. Sediakan shoring di sisi vertical galian.
3.3. Pekerja terjerumus ke dalam galian 3.3. Pasang hardbarricade di sekitar lubang galian.

4. Install Rebar dan Formwork 4. Sisi tajam material dan benda-benda yang ada di sekitar 4.1.1. Pemakaian APD sesuai pekerjaan ( Sarung Tangan Cut
area kerja Resist lvl 3 )
4.1.2. Pemasangan rebar cup
5. Pengecoran 5.1. Material semen yang masih basah 5.1.1. Penggunaan APD lengkap dan sesuai dengan pekerjaan

5.1.2. Procedure kerja sudah di bahas di TBM dan pastikan

semua pekerja bekerja sesuai dengan Procedure yang ada.
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
2.2. Tertimpa Material

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja )

- Klinik Terdekat
4. Tidak terdapat barricade di sekitar 4. Cidera - Fatality
galian
5. SIMOPS 5. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan Employees working in the area have
Koordinasi dengan Kontraktor lain been notified of this work?

6. Tidak ada Anchor Point dan Shoring jika galian - Buat Anchor Point dan shoring terlebih dahulu
>1.2 m

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Pengangkatan Material ( Manual Handling ) 6. Procedure pengangkatan yang salah ( Beban yang berlebih ) 6. Max beban untuk manual handling 25kg, apabila berat beban lebih
dari 25kg menggunakan alat bantu.

7. Housekeeping 7. Material atau sampah yang berserakan 7. Penerapan 5R baik sebelum maupun sesudah melakukan
pekerjaan.

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Lifting Activity ( Crane ) Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: ALL Area OSBL
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Pembuatan ijin kerja 1. Bekerja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
2. Persiapan tools dan equipment (Webing Sling, 2.1. Tools dan Equipment belum dilakukan function test validasi.
2.1.1 Inspeksi peralatan kerja dan di beri tagging layak
Shacle, Tagline, Full Body Harness, HT) pakai.
2.1.2. Daily Ceklist inspek tools dan equipment

3. Persiapan area kerja 3.1. Penutupan akses jalan 3.1. Pemasangan sign board, barricade, stand by
flagman.
3.2. Simobs 3.2. Koordinasi antara SPV dan EHS setiap kontraktor
4. Positioning alat berat 4.1. Permukaan tanah area kerja ( Peninjauan ) 4.1. Supervisi / Koordinasi antara kontraktor ( Oriantasi
4.2. Line of fire ( Swing alat berat ) lapangan ). ada aktivitas di sekitar area line of fire
4.2.1. Tidak

4.2.2. Pemasangan barricade dan signboard

4. Lifting dan Rigging 4.1. Webbing dan Shackle tidak layak pakai 4.1. Daily checklist yang dilakukan dan diketahui rigger,
operator, spv, dan ehs.
4.2. Rigger dan operator yang tidak kompeten 4.1. Personiel yang bertugas terutama rigger berkompeten dan
bersertifikat
4.3. Sling terlepas 4.3. Procedure yang digunakan sudah di riview oleh cargill dan
dan di sosialisasikan di TBM
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
>13 knots ( WAH ) 2.2. Tertimpa Material
>17 knots ( Lifting )

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

4. Rigger tidak berlisensi 4. Fatality karena pengikatan tidak

sesuai prosedur
5. Simops 5. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan Employees working in the area have
Koordinasi dengan Kontraktor lain been notified of this work?
6. Alat Berat Trouble 6. Stop pekerjaan
7. Tag Line tidak Stand by 7. Kecelakaan Kerja
8. Line of Fire tidak jelas 8. Cidera-Fatality - Pasang Barricade sesuai dengan Line
of Fire
9. Outrigger Pad tidak Proper 9. Amblas, roboh crane - Sedikan Outrigger pad sesuai spesifikasi p = 1 Yes No
m, l = 20 cm, t = 10 Cm ( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

5. Reposisi alat berat dan moving material 5.1. Swing alat berat 5.1.1. Signboard dan Barricade di sekitar araea pengangkatan
5.1.2. Flag man stanby

5.2. Kondisi Cuaca dan penijauan area 5.2.1. Pemantauan cuaca dan pengecekan kecepatan angin
5.2.2. Supervisi dan Koordinasi antara kontraktor

6. Housekeeping 6. Material dan sampah berserakan 6. Penerapan 5R baik sebelum dan sesudah pekerjaan.

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Lifting Activity ( TMC ) Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: ALL Area OSBL
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Pembuatan ijin kerja 1. Bekerja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
2. Persiapan tools dan equipment (Webing Sling, 2.1. Tools dan Equipment belum dilakukan function test validasi.
2.1.1 Inspeksi peralatan kerja dan di beri tagging layak
Shacle, Tagline, Full Body Harness, HT) pakai.
2.1.2. Daily Ceklist inspek tools dan equipment

3. Persiapan area kerja 3.1. Penutupan akses jalan 3.1. Pemasangan sign board, barricade, stand by
flagman.
3.2. Simobs 3.2. Koordinasi antara SPV dan EHS setiap kontraktor
4. Positioning alat berat ( Crane / TMC ) 4.1. Permukaan tanah area kerja ( Peninjauan ) 4.1. Supervisi / Koordinasi antara kontraktor ( Oriantasi
lapangan ).
4.2. Line of fire ( Swing alat berat ) 4.2.1. Tidak ada aktivitas di sekitar area line of fire

4.2.2. Pemasangan barricade dan signboard

4. Lifting dan Rigging ( Pipe ke alat berat ) 4.1. Webbing dan Shackle tidak layak pakai 4.1. Daily checklist yang dilakukan dan diketahui rigger,
operator, spv, dan ehs.
4.2. Rigger dan operator yang tidak kompeten 4.1. Personiel yang bertugas terutama rigger berkompeten dan
bersertifikat
4.3. Sling terlepas 4.3. Procedure yang digunakan sudah di riview oleh cargill dan
dan di sosialisasikan di TBM
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
>13 knots ( WAH ) 2.2. Tertimpa Material
>12 knots ( Lifting )

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

4. Rigger tidak berlisensi 4. Fatality karena pengikatan tidak

sesuai prosedur
5. Simops 5. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan Employees working in the area have
6. Alat Berat Trouble 6. Stop pekerjaan Koordinasi dengan Kontraktor lain been notified of this work?

7. Tag Line tidak Stand by 7. Kecelakaan Kerja

8. Line of Fire tidak jelas 8. Cidera-Fatality - Pasang Barricade sesuai dengan Line
of Fire
9. Outrigger Pad tidak Proper 9. Amblas, roboh crane - Sedikan Outrigger pad sesuai spesifikasi p = 1 Yes No
m, l = 20 cm, t = 10 Cm ( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

5. Reposisi alat berat dan moving material 5.1. Swing alat berat 5.1.1. Signboard dan Barricade di sekitar araea pengangkatan
5.1.2. Flag man stanby

5.2. Kondisi Cuaca dan penijauan area 5.2.1. Pemantauan cuaca dan pengecekan kecepatan angin
5.2.2. Supervisi dan Koordinasi antara kontraktor

6. Housekeeping 6. Material dan sampah berserakan 6. Penerapan 5R baik sebelum dan sesudah pekerjaan.

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit up dan welding Pipe Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Seg G,H,F,Boiler

Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
w Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height
3.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 3.1. Penggunaan FBH dan double lanyard 100% tie off.

3.2. Di install dan di inspek oleh orang yang

3.2. Scaffolding roboh
berkompeten, weekly inspek.
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >13 Knot (WAH) 2.1. Material berserakan
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)
- Emergency Call ( 081198203811 )

3. Scaffolding Roboh ( tidak proper ) 3.1. Terjatuh dari ketinggian

3.2. Tertimpa scaffolding

4. Pekerja tidak memakai APD 4. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

5. Penerangan ( di bawah 200 lx ) 5. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

6. Fire Wacher tidak stndby 6. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader : Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata
hitam, afron, sarung tangan , long arm, fire blanked )

5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda
yang mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel

6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
8. Torsi/kencangkan baut ball valve to pipespool 8. Urutan pengencangan tidak sesuai sehingga menyebabkan 8. sesuaikan pengerjaan torsi dengan petunjuk yang ada
kerusakan atau ketidaksesuaian, dan tangan terluka karena sisi didalam methode, dan kenakan APD berupa sarung tangan cut
tajam Ressistan
9. Housekeeping 9. Tumpukan material dan sampah 9. Penerapan 5R sebelum dan sesudah berkerja
Employees working in the area have been notified of this work?
Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit up dan welding Pipe Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Seg EH,EG,ED,EE,EF,Load Truck, PH 01, PH 04

Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
w Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height
3.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 3.1. Penggunaan FBH dan double lanyard 100% tie off.

3.2. Di install dan di inspek oleh orang yang

3.2. Scaffolding roboh
berkompeten, weekly inspek.
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >13 Knot (WAH) 2.1. Material berserakan
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)
- Emergency Call ( 081198203811 )

3. Scaffolding Roboh ( tidak proper ) 3.1. Terjatuh dari ketinggian

3.2. Tertimpa scaffolding

4. Pekerja tidak memakai APD 4. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

5. Penerangan ( di bawah 200 lx ) 5. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

6. Fire Wacher tidak stndby 6. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader : Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata
hitam, afron, sarung tangan , long arm, fire blanked )

5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda
yang mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel

6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
8. Torsi/kencangkan baut ball valve to pipespool 8. Urutan pengencangan tidak sesuai sehingga menyebabkan 8. sesuaikan pengerjaan torsi dengan petunjuk yang ada
kerusakan atau ketidaksesuaian, dan tangan terluka karena sisi didalam methode, dan kenakan APD berupa sarung tangan cut
tajam Ressistan
9. Housekeeping 9. Tumpukan material dan sampah 9. Penerapan 5R sebelum dan sesudah berkerja
Employees working in the area have been notified of this work?
Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit up dan welding Pipe Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Seg EB,EA,PH 02, PH 03

Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
w Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height
3.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 3.1. Penggunaan FBH dan double lanyard 100% tie off.

3.2. Di install dan di inspek oleh orang yang

3.2. Scaffolding roboh
berkompeten, weekly inspek.
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >13 Knot (WAH) 2.1. Material berserakan
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)
- Emergency Call ( 081198203811 )

3. Scaffolding Roboh ( tidak proper ) 3.1. Terjatuh dari ketinggian

3.2. Tertimpa scaffolding

4. Pekerja tidak memakai APD 4. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

5. Penerangan ( di bawah 200 lx ) 5. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

6. Fire Wacher tidak stndby 6. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader : Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata
hitam, afron, sarung tangan , long arm, fire blanked )

5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda
yang mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel

6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
8. Torsi/kencangkan baut ball valve to pipespool 8. Urutan pengencangan tidak sesuai sehingga menyebabkan 8. sesuaikan pengerjaan torsi dengan petunjuk yang ada
kerusakan atau ketidaksesuaian, dan tangan terluka karena sisi didalam methode, dan kenakan APD berupa sarung tangan cut
tajam Ressistan
9. Housekeeping 9. Tumpukan material dan sampah 9. Penerapan 5R sebelum dan sesudah berkerja
Employees working in the area have been notified of this work?
Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit up dan welding Pipe Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Seg EC,C,B,D,PH05, Pump Shelter

Company:

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
w Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height
3.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 3.1. Penggunaan FBH dan double lanyard 100% tie off.

3.2. Di install dan di inspek oleh orang yang

3.2. Scaffolding roboh
berkompeten, weekly inspek.
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >13 Knot (WAH) 2.1. Material berserakan
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)
- Emergency Call ( 081198203811 )

3. Scaffolding Roboh ( tidak proper ) 3.1. Terjatuh dari ketinggian

3.2. Tertimpa scaffolding

4. Pekerja tidak memakai APD 4. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

5. Penerangan ( di bawah 200 lx ) 5. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

6. Fire Wacher tidak stndby 6. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader : Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata
hitam, afron, sarung tangan , long arm, fire blanked )

5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda
yang mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel

6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
8. Torsi/kencangkan baut ball valve to pipespool 8. Urutan pengencangan tidak sesuai sehingga menyebabkan 8. sesuaikan pengerjaan torsi dengan petunjuk yang ada
kerusakan atau ketidaksesuaian, dan tangan terluka karena sisi didalam methode, dan kenakan APD berupa sarung tangan cut
tajam Ressistan
9. Housekeeping 9. Tumpukan material dan sampah 9. Penerapan 5R sebelum dan sesudah berkerja
Employees working in the area have been notified of this work?
Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit up dan welding Pipe Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Pedestarian Sisi Julong

Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
w Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height
3.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 3.1. Penggunaan FBH dan double lanyard 100% tie off.

3.2. Di install dan di inspek oleh orang yang

3.2. Scaffolding roboh
berkompeten, weekly inspek.
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >13 Knot (WAH) 2.1. Material berserakan
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)
- Emergency Call ( 081198203811 )

3. Scaffolding Roboh ( tidak proper ) 3.1. Terjatuh dari ketinggian

3.2. Tertimpa scaffolding

4. Pekerja tidak memakai APD 4. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

5. Penerangan ( di bawah 200 lx ) 5. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

6. Fire Wacher tidak stndby 6. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader : Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata
hitam, afron, sarung tangan , long arm, fire blanked )

5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda
yang mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel

6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
8. Torsi/kencangkan baut ball valve to pipespool 8. Urutan pengencangan tidak sesuai sehingga menyebabkan 8. sesuaikan pengerjaan torsi dengan petunjuk yang ada
kerusakan atau ketidaksesuaian, dan tangan terluka karena sisi didalam methode, dan kenakan APD berupa sarung tangan cut
tajam Ressistan
9. Housekeeping 9. Tumpukan material dan sampah 9. Penerapan 5R sebelum dan sesudah berkerja
Employees working in the area have been notified of this work?
Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Install Support & Fit Up Welding Pipe Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Tank 404,405
Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) 1
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Stringging pipe menggunakan chain block atau 3.1. Terjepit Pipe Spool 3.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
3.2. Pipe Spool terjatuh
3.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >13 Knot (WAH) 2.1. Material berserakan
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)
- Emergency Call ( 081198203811 )

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

4. Penerangan ( di bawah 200 lx ) 4. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

5. Fire Wacher tidak stndby 5. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
4. Take weld and Full weld join pipe Spool 4.1. Percikan api dan radiasi sinar las 4.1. Pemakaian APD lengkap. ( Cap las+kaca mata
hitam, afron, sarung tangan , long arm, fire blanked )

4.2. Hot work ( Kebakaran ) 4.2.1. Stand by Apar dan Fire Wacher
4.2.2. Aktivitas dilakukan jauh dari semua benda-benda
yang mudah terbakar ( menimbulkan api )
4.3. Kabel berserakan menyebabkan tersandung pekerja
4.3. Pemasangan hanger kabel dan isolator kabel
5. Grinding Activity 5.1. Terkena Gram dan kebisingan 5.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
5.1.2. Standy Eye wash di area kerja
5.2. Cuting disk pecah 5.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
5.2.2. Memastikan EXP date Disk masih berlaku.
6. Hot work menggunakan pressure gas cylinder 6.1. Tabung argon Terjatuh 6.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
6.2. Kebocoran pada selang/ tabung 6.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
6.3. Manual Handling 6.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
7. Housekeeping 7. Tumpukan material dan sampah 7. Penerapan 5R sebelum dan sesudah berkerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit Up & Welding Pipe Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Rooftop Tank
Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height
3.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 3.1. Penggunaan FBH dan double lanyard 100% tie off.

3.2. Di install dan di inspek oleh orang yang

3.2. Scaffolding roboh
berkompeten, weekly inspek.
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board dan susunanya rapat terikat kuat.
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >13 Knot (WAH) 2.1. Material berserakan
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)
- Emergency Call ( 081198203811 )

3. Scaffolding Roboh ( tidak proper ) 3.1. Terjatuh dari ketinggian

3.2. Tertimpa scaffolding

4. Pekerja tidak memakai APD 4. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

5. Penerangan ( di bawah 200 lx ) 5. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

6. Fire Wacher tidak stndby 6. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader : Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata
hitam, afron, sarung tangan , long arm, fire blanked )

5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda
yang mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel

6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan

9. Housekeeping 9. Tumpukan material dan sampah 9. Penerapan 5R sebelum dan sesudah berkerja
Employees working in the area have been notified of this work?
Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit up dan welding Pipe Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Jetty
Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height 3.1. Jatuh dari HT ( Hook tidak dicantolkan ) dan 3.1. Penggunaan FBH dan double lanyard 100% tie off.
terbentur ke beton lantai
3.2. Di install dan di inspek oleh orang yang
3.2. Scaffolding roboh, dan terjatuh kelaut berkompeten, weekly inspek. Serta kenakan Work vest
dan sediakan pelampung, & standby Lifebouy
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >6 Knot (WAH) 2.1. Material berserakan - Emergency Call ( 081198203811 )
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)

3. Tsunami 3. Hanyut terbawa arus - BPBD (0721)2527412

4. Scaffolding Roboh ( tidak proper ) 4.1. Terjatuh dari ketinggian
4.2. Tertimpa scaffolding

5. Pekerja tidak memakai APD 5. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

6. Penerangan ( di bawah 200 lx ) 6. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

7. Fire Wacher tidak stndby 7. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata
hitam, afron, sarung tangan , long arm, fire blanked )
5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda
yang mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel

6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
8. Housekeeping 8. Tumpukan material dan sampah 8. Penerapan 5R sebelum dan sesudah berkerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit up dan welding Pipe Night Shift Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Jetty
Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height 3.1. Jatuh dari HT ( Hook tidak dicantolkan ) dan 3.1. Penggunaan FBH dan double lanyard 100% tie off.
terbentur ke beton lantai
3.2. Scaffolding roboh, dan terjatuh kelaut 3.2. Di install dan di inspek oleh orang yang
berkompeten, weekly inspek. Serta kenakan Work vest
dan sediakan pelampung, & standby Lifebouy
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other(Night Shift)
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >6 Knot (WAH) 2.1. Material berserakan - Emergency Call ( 081198203811 )
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)

3. Tsunami 3. Hanyut terbawa arus - BPBD (0721)2527412

4. Scaffolding Roboh ( tidak proper ) 4.1. Terjatuh dari ketinggian
4.2. Tertimpa scaffolding

5. Pekerja tidak memakai APD 5. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

6. Penerangan ( di bawah 200 lx ) 6. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

7. Fire Wacher tidak stndby 7. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
8. Fatigue/Kelelahan 8. Microsleep-Cedera Patah Tulang (terjatuh) - Fatigue Check Sebelum bekerja Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata hitam,
afron, sarung tangan , long arm, fire blanked )
5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher, Fire Blanket
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda yang
mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel
5.4. Fatigue 5.4. Fatigue Test,Paramedic Stand by, Observasi kerja oleh
SPV & EHS
5.5. Poor Visibility, Terjatuh 5.5. Penerangan Min 200 Lux, Tim Electrical Standby
5.6. Working over water 5.6. Awarrenes training sebelum bekerja, kenakan pelampung
6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
8. Housekeeping 8. Tumpukan material dan sampah 8. Penerapan 5R sebelum dan sesudah berkerja

Employees working in the area have been notified of this work?

Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Fit up dan welding Pipe Night Shift Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: OSBL AREA
Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekrja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2. Persiapan tools dan equipment ( Chain block, 2.1. Inspeksi peralatan kerja dan di beri tagging layak
2.1. Tools dan Equipment belum dilakukan function test
Lever Block, Webing sling 1 m x 1 ton, Inverter, pakai.
Tabung Argon, Full Body Harness, Grinding
2.1.2. Daily Ceklist inspek tools dan equipment
Machine)
3. Work at Height 3.1. Jatuh dari HT ( Hook tidak dicantolkan ) dan 3.1. Penggunaan FBH dan double lanyard 100% tie off.
terbentur ke beton lantai
3.2. Scaffolding roboh, dan terjatuh kelaut 3.2. Di install dan di inspek oleh orang yang
berkompeten, weekly inspek. Serta kenakan Work vest
dan sediakan pelampung, & standby Lifebouy
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Stringging pipe menggunakan chain block atau 4.1. Terjepit Pipe Spool 4.1. Pekerja memperhatiakn titik jepit dan sebelum
lever block memulai pekerjaan pastikan semua area aman dan
sudah sesuai procedure ( SPV, EHS, Pekerja )
4.2. Pipe Spool terjatuh 4.2. Pastikan pada saat fit up pipe spool hanging
menggunkan Cahin block yang dimana antar upper hook
dan bottom hook straight dan anchor chain block
pastikan menggunakan webing sling dan apabila
menggunakan temporary support scaffolding pastikan
kalkulasi perhitungan instalasinya sesuai dengan berat
beban yang akan di support
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other(Night Shift)
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >6 Knot (WAH) 2.1. Material berserakan - Emergency Call ( 081198203811 )
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)

3. Tsunami 3. Hanyut terbawa arus - BPBD (0721)2527412

4. Scaffolding Roboh ( tidak proper ) 4.1. Terjatuh dari ketinggian
4.2. Tertimpa scaffolding

5. Pekerja tidak memakai APD 5. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

6. Penerangan ( di bawah 200 lx ) 6. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

7. Fire Wacher tidak stndby 7. Kebakaran - Fatality - Stand by Apar, Fire blanked, Fire
Wacher (di identifikasi dengan
pemakaian arm band )
8. Fatigue/Kelelahan 8. Microsleep-Cedera Patah Tulang (terjatuh) - Fatigue Check Sebelum bekerja Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
5. Take weld and Full weld join pipe Spool 5.1. Percikan api dan radiasi sinar las 5.1. Pemakaian APD lengkap. ( Cap las+kaca mata hitam,
afron, sarung tangan , long arm, fire blanked )
5.2. Hot work ( Kebakaran ) 5.2.1. Stand by Apar dan Fire Wacher, Fire Blanket
5.2.2. Aktivitas dilakukan jauh dari semua benda-benda yang
mudah terbakar ( menimbulkan api )
5.3. Kabel berserakan menyebabkan tersandung pekerja 5.3. Pemasangan hanger kabel dan isolator kabel
5.4. Fatigue 5.4. Fatigue Test,Paramedic Stand by, Observasi kerja oleh
SPV & EHS
5.5. Poor Visibility, Terjatuh 5.5. Penerangan Min 200 Lux, Tim Electrical Standby
5.6. Working over water 5.6. Awarrenes training sebelum bekerja, kenakan pelampung
6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl 3 )
6.2.2. Memastikan EXP date Disk masih berlaku.
7. Hot work menggunakan pressure gas cylinder 7.1. Tabung argon Terjatuh 7.1. Penerapan procedure penyimpanan dalam rak argon diikat
dengan rantai dan pastikan swing gate terpasang, serta tidak
overload dalam rak argon
7.2. Kebocoran pada selang/ tabung 7.2. Daily pengecekan sebelum dan sesudah melakukan
pekerjaan ( Welder, Helper, EHS ).
7.3. Manual Handling 7.3. Pastikan pada saat pengangkatan di bantu dengan alat
bantu berupa Trolley tabung gas bertekanan
8. Housekeeping 8. Tumpukan material dan sampah 8. Penerapan 5R sebelum dan sesudah berkerja

Employees working in the area have been notified of this work?

Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Install dan Dismantling Scaffolding Untuk Platform Kerja Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: ALL AREA OSBL
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja
2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Transfer material baik manual maupun menggunakan 3.1. Prosedur pengangkatan yang tidak diikuti (Low Back Pain) 3.1. Pastikan pengangkatan manual dilaksanakan dengan
mobil beban kurang dari 25 kg
3.2. Akses yang tidak layak untuk dilewati menyebabkan 3.2. Assesment lokasi terlebih dahulu akses mana yang bisa
tersandungnya pekerja ketika transfer material, ataupun dilewati ketika mau dilaksankan pengangkatan manual maupun
selipnya mobil ketika transfer menggunakan mobil

3.3. Mobil melebihi batas kecepatan ( Kecelakaan) 3.3. Pastikan mobil beroperasi dengan kecepatan maks 10
km/jam, dan driver berlisensi (Simper), serta nyalakan rambu
rambu mobilnya
4. Peninjauan lokasi kerja 4. Lokasi yang kontur tanahnya tidak stabil/tidak padat 4. Assesment lokasi kerjanya apabila tidak padat lokasinya
agar ditambah tanah supaya lebih padat ataupun sediakan sole
plate
5. Install Scaffolding 5.1. Terjatuh dari ketinggian 5.1. Buat temporary tangga dengan pipa satu meter untuk
install Scaffolding dan pastikan FBH 100 % tie off Anchor
5.2. Drop Object Potential ( Cidera ) 5.2.1. Ikat peralatan seperti kunci ratchet dll ke tubuh
5.2.2. Barricade area sekitar area kerja dan pasang signboard
 Is there any LIFEsaver or SIF precursor involved? No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting - Inspector Scaffolding Orientasi lapangan
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 1.1. Kejatuhan Material - Emergency Call 081198203811
1.2. Terhempas dan Terjatuh - Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)

3. Scaffolder tidak bersertifikasi 1. Penginstallan scaffolding tidak sesuai - Safety Patrol Stand by
spesifikasi menyebabkan robohnya Platform - Electrical Orientasi lapangan

4. Pekerja tidak mengenakan APD 4. Cidera-Fatality

5. Tidak ada Barricade di area kerja 5. Cidera - Sediakan Barricade dan sign board
6. Simops 6. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan
Koordinasi dengan Kontraktor lain Employees working in the area have
been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Kusnadi Name: Ibnu Ipriyadi Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Work at Height 6. Terjatuh dari ketinggian 6. Pastikan FBH 100 % Tie off Anchor

7. Dismantling Scaffolding 7.1. Drop Object Potential 7.1.1. Ikat peralatan seperti kunci ratchet dll ke tubuh
7.1.2. Barricade area sekitar area kerja dan pasang signboard

8. Housekeeping 8. Sampah kawat dan material Scaffolding berantakan 8. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Date: MM/DD/YY
Install Scaffolding Untuk Temporary Stand & Lifting Point ( Manual Stringging by Chain Block)
5/14/2023
Work-order number: Job Requestor: Juli H Work area:
Company:

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja
2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Transfer material baik manual maupun menggunakan 3.1. Prosedur pengangkatan yang tidak diikuti (Low Back Pain) 3.1. Pastikan pengangkatan manual dilaksanakan dengan
mobil beban kurang dari 25 kg
3.2. Akses yang tidak layak untuk dilewati menyebabkan 3.2. Assesment lokasi terlebih dahulu akses mana yang bisa
tersandungnya pekerja ketika transfer material, ataupun dilewati ketika mau dilaksankan pengangkatan manual maupun
selipnya mobil ketika transfer menggunakan mobil

3.3. Mobil melebihi batas kecepatan ( Kecelakaan) 3.3. Pastikan mobil beroperasi dengan kecepatan maks 10
km/jam, dan driver berlisensi (Simper), serta nyalakan rambu
rambu mobilnya
4. Peninjauan lokasi kerja 4. Lokasi yang kontur tanahnya tidak stabil/tidak padat 4. Assesment lokasi kerjanya apabila tidak padat lokasinya
agar ditambah tanah supaya lebih padat ataupun sediakan sole
plate
5. Install Scaffolding 5.1. Terjatuh dari ketinggian 5.1. Buat temporary tangga dengan pipa satu meter untuk
install Scaffolding dan pastikan FBH 100 % tie off Anchor
5.2. Drop Object Potential ( Cidera ) 5.2.1. Ikat peralatan seperti kunci ratchet dll ke tubuh
5.2.2. Barricade area sekitar area kerja dan pasang signboard
 Is there any LIFEsaver or SIF precursor involved? No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting - Inspector Scaffolding Orientasi lapangan
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 1.1. Kejatuhan Material - Emergency Call 081198203811
1.2. Terhempas dan Terjatuh - Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)

3. Scaffolder tidak bersertifikasi 1. Penginstallan scaffolding tidak sesuai - Safety Patrol Stand by
spesifikasi menyebabkan robohnya Platform - Electrical Orientasi lapangan

4. Pekerja tidak mengenakan APD 4. Cidera-Fatality

5. Tidak ada Barricade di area kerja 5. Cidera - Sediakan Barricade dan sign board
6. Simops 6. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan
Koordinasi dengan Kontraktor lain Employees working in the area have
been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Kusnadi Name: Ibnu Ipriyadi Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Work at Height 6. Terjatuh dari ketinggian 6. Pastikan FBH 100 % Tie off Anchor

7. Dismantling Scaffolding 7.1. Drop Object Potential 7.1.1. Ikat peralatan seperti kunci ratchet dll ke tubuh
7.1.2. Barricade area sekitar area kerja dan pasang signboard

8. Housekeeping 8. Sampah kawat dan material Scaffolding berantakan 8. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Install dan Dismantling Scaffolding Untuk Platform Kerja Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: jetty
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja
2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Transfer material baik manual maupun menggunakan 3.1. Prosedur pengangkatan yang tidak diikuti (Low Back Pain) 3.1. Pastikan pengangkatan manual dilaksanakan dengan
mobil beban kurang dari 25 kg
3.2. Akses yang tidak layak untuk dilewati menyebabkan 3.2. Assesment lokasi terlebih dahulu akses mana yang bisa
tersandungnya pekerja ketika transfer material, ataupun dilewati ketika mau dilaksankan pengangkatan manual maupun
selipnya mobil ketika transfer menggunakan mobil

3.3. Mobil melebihi batas kecepatan ( Kecelakaan) 3.3. Pastikan mobil beroperasi dengan kecepatan maks 10
km/jam, dan driver berlisensi (Simper), serta nyalakan rambu
rambu mobilnya
4. Peninjauan lokasi kerja 4. Lokasi yang kontur tanahnya tidak stabil/tidak padat 4. Assesment lokasi kerjanya apabila tidak padat lokasinya
agar ditambah tanah supaya lebih padat ataupun sediakan sole
plate
5. Install Scaffolding 5.1. Terjatuh dari ketinggian 5.1. Buat temporary tangga dengan pipa satu meter untuk
install Scaffolding dan pastikan FBH 100 % tie off Anchor
5.2. Drop Object Potential ( Cidera ) 5.2.1. Ikat peralatan seperti kunci ratchet dll ke tubuh
5.2.2. Barricade area sekitar area kerja dan pasang signboard
 Is there any LIFEsaver or SIF precursor involved? No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting - Inspector Scaffolding Orientasi lapangan
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 1.1. Kejatuhan Material - Emergency Call 081198203811
1.2. Terhempas dan Terjatuh - Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)

3. Scaffolder tidak bersertifikasi 1. Penginstallan scaffolding tidak sesuai - Safety Patrol Stand by
spesifikasi menyebabkan robohnya Platform - Electrical Orientasi lapangan

4. Scaffolding Roboh ( Tingkat korosif yang tinggi 4. Terjatuh kelaut - kenakan Work Vest or Life Jacket
di laut ) - Life Buoy with Line Stand by

5. Pekerjaan install dan dsimantling scaffolding di 5. Cidera-Fatality

water intake tidak mengenakan FBH Employees working in the area have
been notified of this work?
6. Pekerja tidak mengenakan APD 6. Cidera-Fatality
7. Simops 7. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan
Koordinasi dengan Kontraktor lain
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Kusnadi Name: Ibnu Ipriyadi Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Work at Height 6.1. Terjatuh dari ketinggian 6.1. Pastikan FBH 100 % Tie off Anchor
6.2. Terjatuh kelaut 6.2. Kenakan Work Vest or Life Jacket

7. Dismantling Scaffolding 7.1 Drop Object Potential 7.1.1. Ikat peralatan seperti kunci ratchet dll ke tubuh
7.1.2. Barricade area sekitar area kerja dan pasang signboard

8. Housekeeping 8. Sampah kawat dan material Scaffolding berantakan 8. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Date: MM/DD/YY
Install Scaffolding Untuk Temporary Stand & Lifting Point ( Manual Stringging by Chain Block)
5/14/2023
Work-order number: Job Requestor: Juli H Work area: Jetty
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja
2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Transfer material baik manual maupun menggunakan 3.1. Prosedur pengangkatan yang tidak diikuti (Low Back Pain) 3.1. Pastikan pengangkatan manual dilaksanakan dengan
mobil beban kurang dari 25 kg
3.2. Akses yang tidak layak untuk dilewati menyebabkan 3.2. Assesment lokasi terlebih dahulu akses mana yang bisa
tersandungnya pekerja ketika transfer material, ataupun dilewati ketika mau dilaksankan pengangkatan manual maupun
selipnya mobil ketika transfer menggunakan mobil

3.3. Mobil melebihi batas kecepatan ( Kecelakaan) 3.3. Pastikan mobil beroperasi dengan kecepatan maks 10
km/jam, dan driver berlisensi (Simper), serta nyalakan rambu
rambu mobilnya
4. Peninjauan lokasi kerja 4. Lokasi yang kontur tanahnya tidak stabil/tidak padat 4. Assesment lokasi kerjanya apabila tidak padat lokasinya
agar ditambah tanah supaya lebih padat ataupun sediakan sole
plate
5. Install Scaffolding 5.1. Terjatuh dari ketinggian 5.1. Buat temporary tangga dengan pipa satu meter untuk
install Scaffolding dan pastikan FBH 100 % tie off Anchor
5.2. Drop Object Potential ( Cidera ) 5.2.1. Ikat peralatan seperti kunci ratchet dll ke tubuh
5.2.2. Barricade area sekitar area kerja dan pasang signboard
 Is there any LIFEsaver or SIF precursor involved? No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting - Inspector Scaffolding Orientasi lapangan
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 1.1. Kejatuhan Material - Emergency Call 081198203811
1.2. Terhempas dan Terjatuh - Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)

3. Scaffolder tidak bersertifikasi 1. Penginstallan scaffolding tidak sesuai - Safety Patrol Stand by
spesifikasi menyebabkan robohnya Platform - Electrical Orientasi lapangan

4. Scaffolding Roboh ( Tingkat korosif yang tinggi 4. Terjatuh kelaut - kenakan Work Vest or Life Jacket
di laut ) - Life Buoy with Line Stand by

5. Pekerjaan install dan dsimantling scaffolding di 5. Cidera-Fatality

water intake tidak mengenakan FBH Employees working in the area have
been notified of this work?
6. Pekerja tidak mengenakan APD 6. Cidera-Fatality
7. Simops 7. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan
Koordinasi dengan Kontraktor lain
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
3 Name: Supandi Name: Safety Officer

Name: Kusnadi Name: Ibnu Ipriyadi Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Work at Height 6.1. Terjatuh dari ketinggian 6.1. Pastikan FBH 100 % Tie off Anchor
6.2. Terjatuh kelaut 6.2. Kenakan Work Vest or Life Jacket

7. Dismantling Scaffolding 7.1 Drop Object Potential 7.1.1. Ikat peralatan seperti kunci ratchet dll ke tubuh
7.1.2. Barricade area sekitar area kerja dan pasang signboard

8. Housekeeping 8. Sampah kawat dan material Scaffolding berantakan 8. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Steel Structure (Tightening bolt & Touch Up) Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area: Seg EH,EA
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja

2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Memindahkan material steel structure (maks 125 kg) 3.1. low back pain 3.1. Pengangkatan beban diatas 25 kg harus dibantu dengan
dekat water intake platform dengan cara manual (hand alat bantu angkat.
palet 2 ton)
4. Work at Height 4.1. Terjatuh dari ketinggian, Drop Object Potential 4.1. Pastikan FBH 100 % Tie off Anchor
4.2. Ikat peralatan seperti kunci ratchet dll ke tubuh
4.3. Pastikan Toe Board terpasang pada instalasi platform
Scaffolding
5.pekerjaan welding structure 5.1 Terkena percikan saat pemotongan, pengelasan, 5.1. Barricade area sekitar area kerja dan pasang signboard
atau pengerindaan 5.2. penggunaan APD sesuai dengan pekerjaan yang di
lalukan( Welding Gloves, Apron, Welding cap)
5.3. sediakan APAR dan stand by fire wacher

6. Lifting material menggunakan chainblock dari workshop 6. Kejatuhan material 6.1. sediakan APAR dan stand by fire wacher
dan digeser kedalam area instalation, material dihanging
dan di assembling sesuai dengan gambar engineering 6.2. Pastikan tidak ada orang selain operator chainblock
berada di bawah area assembling
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)

( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Step 7: Quality Review
and its consequences? Emergency
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist) preparedne
job?) ss
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting - Inspector Scaffolding Orientasi lapangan
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 1.1. Kejatuhan Material - Emergency Call 081198203811 Cargill Representative Quality Review
1.2. Terhempas dan Terjatuh - Bawa ke Klinik terdekat (Print Name)

3. Scaffolding Roboh 3. Weekly inspect oleh Inspector Scaffolding - Safety Patrol Stand by
- Electrical Orientasi lapangan
4. Pekerja tidak mengenakan APD 4. Cidera-fatality
5. Simops 5. Perkelahian - Fatality - Orientasi
lapang
( SPV dan
EHS ) dan Employees working in the area have
Koordinasi been notified of this work?
dengan
Kontraktor
lain

Yes No
( ) ( )

Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Widiantoro Name: Hedi Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

7. Tightening bolt Bolt 7.1. Kebisingan NAB 85Db 7.1. Kenakan Ear plug
7.2. Tangan tergores atau keseleo dikarenakan penggunaan 7.2. Kenakan APD dan pastikan posisi pada saat tightening bolt
kunci torsi yang tidak pas menggunakan kunci torsi posisi diperhatikan agar tidak keseleo

7.3. Drop Object potential 7.3. Pastikan kunci torsi terikat dengan dengan lanyard ke
tubuh

8. Touch Up 8.1. Menghirup bahan kimia berbahaya 8.1. Kenakan Masker

8.2. Kulit Terpapar bahan kimia berbahaya 8.2. Kenakan Sarung tangan latex
8.3. Tumpahan bahan kimia berbahaya 8.3. Pastikan tersedia secondary containment
9. Housekeeping 9. Sampah dan material Scaffolding berantakan 9. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Employees working in the area have been notified of this work?

Cargill Representative Quality Review

(Name)
Step 7: Quality Review ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Steel Structure (Erection, Tightening Bolt) Date: MM/DD/YY
5/14/2023
Work-order number: Job Requestor: Juli H Work area: Seg EH
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja

2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Memindahkan material steel structure dekat Seg EH 3.1. low back pain 3.1. Pengangkatan beban diatas 25 kg harus dibantu dengan ala
platform dengan cara manual (hand palet 2 ton)

4. Work at Height 4.1. Terjatuh dari ketinggian 4.1. Pastikan FBH 100 % Tie off Anchor
4.2. Drop Object Potential 4.2. Ikat peralatan seperti kunci ratchet dll ke tubuh

4.3. Barricade area sekitar area kerja dan pasang signboard

4.3. Barricade area sekitar area kerja dan pasang signboard

4.4. Pastikan Toe Board terpasang pada instalasi platform
5. Lifting material menggunakan chainblock dari jetty dan 5. Kejatuhan material Scaffolding
5. Pastikan tidak ada orang selain operator chainblock berada
digeser kedalam area platform water intake, material di bawah area assembling
dihanging dan di assembling sesuai dengan gambar
engineering
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting - Inspector Scaffolding Orientasi lapangan
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 1.1. Kejatuhan Material - Emergency Call 081198203811
1.2. Terhempas dan Terjatuh - Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)

3. Scaffolding Roboh 3. Weekly inspect oleh Inspector Scaffolding - Safety Patrol Stand by
- Electrical Orientasi lapangan
4. Pekerja tidak mengenakan APD 4. Cidera-fatality
5. Simops 5. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan
Koordinasi dengan Kontraktor lain

Employees working in the area have

been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Widiantoro Name: Hedi Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Tightening bolt Bolt 6. Kebisingan NAB 85Db 6. Kenakan Ear plug

7. Housekeeping 7. Sampah dan material Scaffolding berantakan 7. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Install Steel Structure ( Welding H Beam) Date: MM/DD/YY
5/14/2023
Work-order number: Job Requestor: Juli H Work area:
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja

2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Marking position oleh Surveyor 3.1. Terjatuh kelaut 3.1. Perhatikan posisi pada saat marking, kenakan lifejacket/
workvest, dan pastikan disisi ujung jetty terdapat Guard Rail
4. Transfer Braching 4. Low Back Pain 4.2. Transfer material dibantu dengan Troli, pengangkatan
dibantu dengan 2 orang dan penarikan keatas menggunakan
katrol.

5. Fit Up & Welding H Beam 5.1. Terkena percikan api 5.1. Kenakan Hotwork PPE, Install Hotwork habitat
5.2. Terpapar radiasi las 5.2. Kenakan Caplas yang terconnect ke safety helmet
6. Grinding Activity 6.1. Terkena Gram dan kebisingan 6.1.1. Penggunaan APD lengkap ( Face Shield dan Ear Plug )
6.1.2. Standy Eye wash di area kerja
6.2. Cuting disk pecah 6.2.1. Pemakaian sarung tangan sesuai pekerjaan ( Sarung
Tangan Cut resist lvl
6.2.2. Memastikan EXP3 ) date Disk masih berlaku.
7. Housekeeping 7. Sampah dan material Scaffolding berantakan 7. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting
- Paramedic Standby
- Emergency Call 081198203811
- Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)

- Safety Patrol Stand by

- Electrical Orientasi lapangan

2. Pekerja tidak mengenakan APD 2. Cidera-fatality

3. Simops 3. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan
Koordinasi dengan Kontraktor lain Employees working in the area have
been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: N.Halim Name: Supandi Name: Safety Officer

Name: Widiantoro Name: Hedi Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Alignment Pump Date: MM/DD/YY

Work-order number: Job Requestor: N.Halim Work area: ALL Area OSBL
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja

2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Persiapan alat kerja ( Kunci-Kunci, Waterpass, Dial 3. Alat tidak dapat berfungsi dengan baik ( Kerusakan Pump ) 3. Pastikan semua tools sudah diinspek
Indicator)

4. Alignment Pump 4.1. Simops 4.1. Koordinasikan kepada SPV Kontraktor lain diarea kerja
tersebut
4.2. Mesin di dalam pompa rusak 4.2. Pekerjaan dilaksanakan dan diarahkan oleh orang yang
ahli dan berkompeten terhadap bidangnya

5. Leveling Pump/penambahan simplate 5.1. Terjepit 5.1. Kenakan sarung tangan dan pastikan tubuh bebas dari
himpitan
5.2. Tergores sisi tajam simplate 5.2. Kenakan Cut Ressist Gloves
5.3. Ergonomi ( Low Back Pain ) 5.3. Apabila terdapat pengangkatan manual laksanakan sesuai
prosedur, berat lebih dari 25 Kg pengangkatan dibantu dengan
alat bantu (Chain Block, dll)
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Bencana Alam 1.1. Gempa Bumi - Stop pekerjaan
1.2. Tsunami
- Paramedic Standby
- Emergency Call 081198203811
- Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)

- Safety Patrol Stand by

- Jangan bekerja sendirian
- Ikuti Evacuation Route

2. SIMOPS 2. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan

Koordinasi dengan Kontraktor lain
3. Pekerja tidak mengenakan APD 3. Cidera-fatality
Employees working in the area have
been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: N.Halim Name: Supandi Name: Safety Officer

Name: Ilham Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Housekeeping 6. Sampah dan material Scaffolding berantakan 6. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Pemasangan Pipa Support dan Stringging Pipe Vertical Menggunakan Man Backet Date: MM/DD/YY

Work-order number: Job Requestor: N.Halim Work area:

Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja

2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Persiapan alat kerja (Webing Sling, Shacle, Tagline, Full 3.1. Lifting gear tidak proper 3.1. Pastikan semua lifting gear sudah diinspeksi sebelum
Body Harness, HT) bekerja
3.2. Safety Device tidak berfungsi 3.2. Inspect alat berat sebelum bekerja dan pastikan safety
device berfungsi dengan baik
4. Positioning Crane 4.1. Permukaan tanah yang tidak padat menyebabkan 4.1. Assesment lokasi kerja terlebih dahulu dengan SPV,
robohnya crane Operator, Rigger serta EHS, sediakan plat dan balok untuk
setting outrigger
5. Rigging ( Man Backet ke Crane) 5. Prosedur Rigging yang salah ( Jatuhnya Man Backet ) 5. Rigging dilaksanakan oleh rigger yang bersertifikasi
6. Erection Man Backet 6.1. Overload 6.1. Max 2 orang beserta beban yang ada di dalam man Backet
200 Kg, serta laksankan Load Test sebelum dilaksankannya
Erection dengan kapasitas 150% dari beban yang dianjurkan
6.2. Angin kencang ( Robohnya Crane ketika Erection dengan 6.2. Perhatikan kondisi cuaca dengan kecepatan angin > 17
Full Boom ) Knot harus stop activity
6.3. Tertimpa Material 6.3. Tutup pintu Man Backet pada saat erection Man Backet
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 2.1. Cidera - Emergency Call 081198203811
> 12 Knot (Lifting) 2.2. Tertimpa Material - Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)
2.3. Jatuh dari ketinggian - Safety Patrol Stand by
3. Alat berat trouble 3.1. Wire Sling Terlepas - Electrical Orientasi lapangan
3.2. Crane Rusak - Maintenance and Repair

4. Rigger tidak berlisensi 4. Fatality karena pengikatan tidak sesuai pros

5. Simops 5. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan Koordinasi

6. Tag Line tidak Stand by 6. Kecelakaan Kerja Employees working in the area have
7. Line of Fire tidak jelas 7. Cidera-Fatality - Pasang Barricade sesuai dengan Line of Fire been notified of this work?

8. Pekerja tidak mengenakan APD 8. Cidera-fatality

9. Outrigger Pad tidak Proper 9. Amblas, roboh crane - Sedikan Outrigger pad sesuai spesifikasi p = 1
m, l = 20 cm, t = 10 Cm Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Widiantoro Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Pengelasan menggunakan Man Backet 6.1. Electrical Tools tidak proper dan belum diinspect 6.1. Inspect terlebih dahulu peralatan listrik dan di beri tagging
6.2. Tersetrum 6.2. Pastikan ada isolator pada kabel power dan hanging kabel
powernya
6.3. Terkena percikan api las dan mata terpapar radiasi sinar 6.3. Kenakan Welding Cap dengan kaca hitam, Apron, Long
las Arm, Welding Gloves, Cover denga Fire Blanket, dan Fire
Watcher stand by
6.4. Kebakaran 6.4. APAR stand by lokasi kerja
7. Stringging vertical pipe spool 7. Salah pengikatan menyebabkan pipe spool terjatuh (Fatality) 7. Pengikatan hanya boleh dilakukan oleh rigger yang
berkualifikasi
8.1. Kejatuhan material (Cidera-Fatality) 8.1. Pastikan area Line of Fire Clear dan dipasang baricade,
8. Pemasangan U bolt dan pasang tag line pada pipe spool
8.2. Terjatuh karena posisi pemasangan u bolt diluar Man Backe8.2. Pastikan manpower selalu bekerja di dalam man backet
dan kaitkan FBH di Anchor Point yang sudah disediakan

9. Housekeeping 9. Sampah dan material Scaffolding berantakan 9. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Pemasangan Grating dan Handrail Acess Stair Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli Hardi Work area: Seg D
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Persiapan ijin kerja /Permit to work 1. Bekerja tanpa ijin kerja/Permit to work 1. Stop pekerjaan dan buat Permit to work sesuai dengan
pekerjaannya dan validasi dengan Cargill
2. Persiapan Manpower 2.1. Manpower Unfit/Fatigue 2.1. Pastikan Manpower fit oleh paramedic sebelum bekerja
2.2. Manpower tidak memahami prosedur kerja aman 2.2. TBM sebelum bekerja dan sampaikan step by step
pekerjaan serta safe action dan safe conditionnya
3. Memindahkan material steel structure ke dekat titik lokasi 3.1. low back pain 3.1. Pengangkatan beban diatas 25 kg/Person harus
Pemasangan dilaksanakan dengan personel lebih sesuai dengan rasio
beban maks per person. Atau dibantu dengan alat bantu
angkat

4. Work at Height 4.1. Terjatuh dari ketinggian 4.1. Pastikan FBH 100 % Tie off Anchor
4.2. Drop Object Potential 4.2. Ikat peralatan seperti kunci ratchet dll ke tubuh
4.3. Barricade area sekitar area kerja dan pasang signboard
5. Pemasangan Grating dilaksanakan secara manual 5. low back pain 5. Pengangkatan beban diatas 25 kg/Person harus
dilaksanakan dengan personel lebih sesuai dengan rasio
beban maks per person. Atau dibantu dengan alat bantu
angkat
6. Pemasangan Handrail dilaksanakan manual 6. Terkena sisi tajam bagian dari acces stair (H beam, bolt, 6. pekerja pastikan sudah mengenakan sarung tangan cut
brace plate) ressist lv 3. Pengangkatan beban diatas 25 kg/Person harus
dilaksanakan dengan personel lebih sesuai dengan rasio
beban maks per person. Atau dibantu dengan alat bantu
angkat

7. Welding joint Hand Rail 7.1. Percikan api dan radiasi sinar las 7.1. Pemakaian APD lengkap. ( Cap las+kaca mata hitam,
afron, sarung tangan , long arm, fire blanked )
7.2. Hot work ( Kebakaran ) 7.2.1. Stand by Apar dan Fire Wacher, Fire Blanket
7.2.2. Aktivitas dilakukan jauh dari semua benda-benda yang
mudah terbakar ( menimbulkan api )
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting - Inspector Scaffolding Orientasi lapangan
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 2.1. Kejatuhan Material - Emergency Call 081198203811
2.2. Terhempas dan Terjatuh - Bawa ke Klinik terdekat Cargill Representative Quality Review
(Print Name)

3. Pekerja tidak mengenakan APD 3. Cidera-fatality

4. Simops 4. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan
Koordinasi dengan Kontraktor lain

Employees working in the area have

been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Widiantoro Name: Hedi Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

7.3. Kabel berserakan menyebabkan tersandung pekerja 7.3. Pemasangan hanger kabel dan isolator kabel
8. Tightening bolt Bolt 8.1. Kebisingan NAB 85Db 8.1. Pastikan pekerja sudah mengenakan Ear plug
8.2. Tangan tergores atau keseleo dikarenakan penggunaan 8.2. Kenakan APD dan pastikan posisi pada saat tightening bolt
kunci torsi yang tidak pas menggunakan kunci torsi posisi diperhatikan agar tidak keseleo

8.3. Drop Object potential 8.3. Pastikan kunci torsi terikat dengan dengan lanyard ke
tubuh

9. Housekeeping 9. Sampah dan material Scaffolding berantakan 9. Laksanakan 5R baik sebelum bekerja mauapun sesudah
bekerja

Employees working in the area have been notified of this work?

Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Radiography Test ( NDT ) Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli Hardi Work area:
Company: PT.Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1. Stop pekerjaan tidak ada permit 1. Pembuatan permit sesuai pekerjaan dan divalidasi serta
1. Persiapan izin kerja dipahami pekerja
2. persiapan pekerja ( manpower ) 2.1. pekerja kondisi sakit / unfit 2.1. Pastikan pekerja dalam keadaan sahat/fit
2.2. pekerja tidak memahami procedure 2.2. TBM sbelum melakukan pekerjaan
3. Persiapan alat kerja 3. Alat kerja tidak layak pakai / rusak 3. Inspek dan daily check tools kerja
4. Bekerja di malam hari 4.1. Cidera 4.1. Pastikan area aman ( orientasi lapangan )
4.2. Kurang penerangan 4.2. Penerangan yang cukup ( pengecekan menggunakan LUX
meter min. 200 lx )

5. Bekerja di ketinggian 5. Terjatuh dari ketinggian 5.1.1. Pastikan menggunakan FBH tie off 100%
5.1.2. Scaffolding di rangkai dan weekly inspek dengan orang
yang berkompeten.

6. Manual Handling 6.1. Ergonomi 6.1. Pastikan beban kurang 25kg

6.2. Tertimpa material 6.2. Metode pengangkatan yang benar dan apabilan beban
lebih dari 25kg gunakan alat bantu pengangkatan.
7.1. Pemasangan crank kabel 7.1. Terjepit 7.1. Pemakaian APD lengkap sesuai pekerjaan ( Hand Gloves )
7.2. Setting Film pada object joint welding 7.2. Material Film rusak 7.2. Pastikan pipa yang akan di pasangi film dalam kondisi kering
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)
1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan
1.2. Korsleting
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 2.1. Cidera - Emergency Call 081198203811 Cargill Representative Quality Review
(Print Name)

- Bawa ke Klinik terdekat

- Safety Patrol Stand by
- Electrical Orientasi lapangan
- Maintenance and Repair

3. Area NDT tidak steril dari para pekerja 3. Terpapar radiasi 4. Orientasi lapangan sebelum melakukan NDT

Employees working in the area have

been notified of this work?
4. Penerangan <200 lx 4. Cidera karena area gelap 5. Pengukuran penerangan menggunakan LUX
meter ( 200lx )

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
8. Radiography Activity 7.1. Terpapar radiasi 7.1.1. Pastikan area clear dari pekerja
7.1.2. Aktifkan survey meter
7.1. Pelepasan crank kabel dan film 7.1. Terjepit 7.1. Pemakaian APD lengkap sesuai pekerjaan ( Hand Gloves )

8. Housekeeping 8.1. Matrial tertinggal 8.1 Pastikan kembali alat yang di gunakan jangan sampai ada yang tertingg

8.2 Matikan lampu dan matikan genset sebelum pulang.

Step 7: Quality Review

Employees working in the area have been notified of this work?
Cargill Representative Quality Review
(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Assembling Jip Crane Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: N.Halim Work area: Hose Tower
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekerja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja
validasi.
2. Persiapan tools dan equipment (Webing Sling,Full 2.1. Tools dan Equipment belum dilakukan function test 2.1.1 Inspeksi peralatan kerja dan di beri tagging layak
Body Harness,Lever Block) pakai.
2.1.2. Daily Ceklist inspek tools dan equipment
3. Work at Height 3.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 3.1. Penggunaan FBH dan double lanyard 100% tie off.
3.2. Di install dan di inspek oleh orang yang
3.2. Scaffolding roboh
berkompeten, weekly inspek.
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Pekerjaan Instalasi Listrik Jip Crane 4. Tergores, tertusuk sisi tajam tembaga kabel, dan 4. Kenakan sarung tangan cut ressistant.
terjepit tang pemotong kabel
5. Pengisian Oli Hydraulik 5.1. Tumpahan Oli Hydraulik 5.1. Sediakan secondary containment
5.2. Tergelincir Oli 5.2. Kenakan safety boots dan sediakan secondary
containment

Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
 Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
>6 knots ( WAH ) 2.2. Tertimpa Material

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

4. Simops 4. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan Employees working in the area have
Koordinasi dengan Kontraktor lain been notified of this work?

5. Tidak ada secondary containment 5. Pencemaran lingkungan - Pastikan Secondary Containment

Tersedia

Yes No

Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

6. Pulling wire dan pemberian grease ke wire sling jip 6. Tangan terkena sisi tajam wire 6. Pastikan pekerja sudah menggunakan sarung
crane tangan cut resistant
7. Test Engine dan Test fungsi jip crane 7. Mesin rusak dan terkena swing boom jib crane 7. Pelaksanaan test fungsi dan test engine
dilaksanakan oleh teknisi ahli
8. Housekeeping 8. Lokasi area kerja kotor 8. Pastikan penerapan 5R dilaksanakan di area
kerja.

Employees working in the area have been notified of this work?

Step 7: Quality Review

Cargill Representative Quality Review

(Name)
( ) Yes ( ) No

Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Hydrostatic Test ( Flusing & Drying ) Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli Hardi Work area:
Company: PT. Gemilang Karya Mandiri

Error Traps: (Check all that apply)

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire r
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Pembuatan ijin kerja 1. Bekerja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di validasi.
2. Persiapan tools dan equipment (Pressure gate, Pressure 2.1. Tools dan Equipment belum dilakukan function test 2.1.1 Inspeksi peralatan kerja dan di beri tagging layak pakai.
Pump, Air Cmpressor, Hand Pump, Graphic indicator tools) 2.1.2. Daily Ceklist inspek tools dan equipment
3. Persiapan area kerja 3.1. Penutupan akses jalan 3.1. Pemasangan sign board, barricade, stand by flagman.
3.2. Simobs 3.2. Koordinasi antara SPV dan EHS setiap kontraktor
4. Pre Pressure Test 4.1.1. Equipment dan tools rusak 4.1.1.1. Lakukan pengecekan sebelum pemasangan
4.1.1.2. Maintanance ( jika ada kerusakan atau indindikasi kebocoran )
4.1.1.3. Loto ( Koordinasi antara SPV dan EHS )
4.1. Install suction, discharge water pump, dan pressure 4.1.2. Pemasangan tools dan equipment yang salah 4.1.2.1. Bekerja Sesuai Procedure kerja dan Procedure kerja sudah di
gauge pada piping line. sampaikan dalam TBM.

4.1.2.2. SPV ( foreman ) maupun EHS Stand by saat melakukan

pekerjaan
4.1.3. Tangan terjepit ( cidera ) 4.1.3.1. Hindari tangan dan jari dari titik titik yang potensial
menyebabkan terjepit.
4.1.3.2. Gunakan good gesture posture practice pada saat melakukan
connection suction dan discharge
4.1.3.3. Pastikan APD dan termasuk hand glove dipakai oleh pekerja.
Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
 Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik
- P3K

2. Angin Kencang 2.1. Material berserakan Cargill Representative Quality Review

(Print Name)
- Emergency Call ( 081198203811 )
2.2. Tertimpa Material

3. Pekerja tidak memakai APD 3. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

4. No PSV Install - Pastikan PSV sudah diinstal dan diuji cba

5. No Safety feature ( Whiplock) - Pastikan whip lock sudah di instal di Employees working in the area have
joint hose pipe been notified of this work?

5. Tidak ada barricade dan sign 5. Cidera-Fatality - Pasang Barricade dan sign
keselamatan
6. No SPV, EHS, Operator stand by di - pastikan SPV, EHS, Operator, dan Paramedic
lapangan stand by di lapangan
Yes No

Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Supandi Name: Safety Officer

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

4.2. Injek water ke piping line ( untuk flashing kotoran dan 4.2.1. Tools atau equipment yang digunakan rusak atau bocor 4.2.1.1. Pastikan tools atau equipment di operate oleh pekerja yang
hydrotest ) mengerti pengoperasiany dan selalu mengikuti pentunjuk
pengoperasian baik itu tools ataupun equipment.
4.2.1.2. Pastikan semua rangkaian, tools maupun equipement yang
digunakan sudah dalam kondisi aman dan sesuai dengan ketentuan /
petunjuk pengoperasian ( Orientasi lapangan ).
4.2.2. Sisa- sisa kotoran masih tersisa di dalam piping line 4.2.2. Tingkatkan volume / rate air yang masuk ke piping line agar
kotoran bisa tersapu keluar
4.2.3. Piping line bocor ketika di suplai water 4.2.3.1. Pastikan semua connection pada valve, vlange, gasket, baut
sudah di kencangkan.
4.2.3.2. Visual cek dan jika terdapat kebocoran segera perbaiki
5. Pressure Test ( 15 Bar, Water) 5.1. Tekanan pada piping line tidak kunjung naik ketika di injek air 5.1.1. Cek kebocoran pada piping line
dengan pressure pump, Pressure pump bekerja terlalu lama, motornya 5.1.2. Cek volume air di pipe line, pastikan air pada piping line sudah
panas atau rusak penuh atau cukup
5.1.3. Jika tekanan masih belum naik cek fungsi pressure gauge
5.2. Suction pressure pump pecah dan discharge bocor, dan pipa pecah 5.2.1. Pastikan suction yang digunakan pressure rate nya memenuhi
mengenai pekerja, baut atau extention pada piping line terpental tekanan yang direkomendasikan
mengenai pekerja
5.2.2. Injek pressure secara pelan dan berkala serta hold sesuai
dengan MS Pressure Test
5.2.3. Pastikan PSV dan Whiplock sudah diinstall
5.2.4. Laksanakan inspeksi untuk safety device nya
5.2.5. Pasang pelindung atau pagar pembatas antara injection dan
pond yang ditest dengan pekerja yang melakukan pengetesan
5.2.6. Pasang barricade dan sign keselamatan serta stand by
pengawas di area yang ramai pekerja
5.2.7. Pastikan pekerja mengenakan APD
6. Dewatering 6.1. Pekerja terkena semburan/Pressure air, pentalan baut, ketika 6.1.1. Pastikan posisi pekkerja tidak didepan/membelakangi vent atau
membuka vent,drain drain ketika akan membukanya
6.1.2. Buka vent/drain dengan pelan dan teratur, pastikan air keluar
dengan pelan dan teratur terus open hingga tekanan air rendah/kosong

6.2. Tangan atau jari terluka ketika membuka vent atau drain 6.2.1. Hindari tangan dan jari dari titik yang potensial menyebabkan
terjepit dan kenakan hand gloves

7.Housekeeping 7. Sampah dan material sisa berserakan 7. Laksanakan 5R sebelum dan sesudah bekerja
 Employees working in the area have been notified of this work?
Step 7: Quality Review

Cargill Representative Quality Review

(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Finishing Support (Painting) Date: MM/DD/YY

7/5/2023
Work-order number: Job Requestor: Juli Hardi Work area: ALL AREA OSBL
Company: PT. Gemilang Karya Mandiri
Error Traps: (Check all that apply)
( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1. Persiapan Dokumen 1. Bekerja tanpa permit 1.1 Pekerjaan tidak boleh dilakukan sebelum mendapat
persetujuan
dari Cargil Project Zulu
2. JSA tidak di mengerti oleh karyawan atau pekerja 1.2 Sebelum melakukan pekerjaan harus melakukan toolbox
meeting
untuk mensosialisasikan JSA dab aturan pekerjaan di
lingkungan Zulu Project
1.3 Pastikan semua pekerja mengerti tentang JSA dan apa
yang
disampaikan
2. Persiapan Peralatan 1. Sisi tajam alat kerja 2.1 Pastikan semua peralatan yang akan di pergunakan dalam
2. Kontur lantai yang licin atau tidak rata keadaan baik dan layak digunakan serta di sesuaikan dengan
yang akan dilakukan
2.2 Pastikan semua alat sudah di inspeksi dan disetujui oleh
Cargill Zulu pada saat akan digunakan berfungsi dengan baik
2.3 Lakukan persiapan alat dengan tidak terburu-buru
3. Work at Height 3.1. Terjatuh dari ketinggian 3.1. Pastikan FBH 100 % Tie off Anchor
3.2. Drop Object Potential 3.2. Ikat peralatan ke tubuh
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

Hujan dan Petir Tersambar petir Stop Pekerjaan

Terkilir, Terjatuh, terjepit, tertimpa P3K

Tertusuk, Tersayat, Terjatuh P3K, medical treatment Cargill Representative Quality Review
(Print Name)
Cairan B3 Iritasi pada kulit, mata terkena percikan P3K, medical treatment

Secondary Containment tidak stand by Pencemaran Lingkungan Pastikan secondary containment tersedia di area
pengecatan

Employees working in the area have

been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Name:

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
__/__/____ __/__/____ __/__/____ __/__/____
task been removed and accounted for as
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:
If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

4. Menuang cat kedalam wadah atau kaleng 4.1. Iritasi kulit saat terkena cat 4.1 Pastikan menggunakan APD mandatori, helm, sarung
4.2. Posisi ergonomi yang tidak bagus tangan
sepatu se-
4.3. Kontur lantai yang licin 4.2 Pastikan pekerja kompeten dan mengerti tentang pekerjaan
4.3 Pastikan saat penuangan di beri alas agar cat tidak
tercecer
4.4 Pastikan saat menuang cat kedalam wadah
tulang belakang aman dan senyaman mungkin
5. Pengecatan Pipa 5.1. Iritasi kulit saat terkena cat 5.1 Pastikan menggunakan APD lengkap, helm, sarung tangan,
5.2. Posisi ergonomi yang tidak bagus dan kacamata
5.3. Kontur tanah yang tidak proper 5.2 Pastikan saat pengecetan posisi tulang belakang aman dan
5.4. Material Cat tercecer senyaman mungkin
5.3 Pastikan saat pengecetan diberi alas triplek agar tidak ter-
cecer langsung ke tanah
5.4 Pastikan pekerja mengetahui metode kerja dan pekrja
kompeten dalam pekerjaan
6. Housekeeping 6. Barang-barang atau alat kerja yang berserakan 6. Pastikan setelah melakukan pekrjaan untuk melakukan
housekeeping agar tampak rapi dan bersih

Employees working in the area have been notified of this work?

Step 7: Quality Review

Cargill Representative Quality Review

(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 Job information
  Job activity description: Insulation Date: MM/DD/YY

7/5/2023
Work-order number: Job Requestor: Juli Hardi Work area: ALL AREA OSBL
Company: PT. Gemilang Karya Mandiri
Error Traps: (Check all that apply)
( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)

1. Persiapan Dokumen 1. Bekerja tanpa permit 1.1 Pekerjaan tidak boleh dilakukan sebelum mendapat
persetujuan
dari Cargil Project Zulu
2. JSA tidak di mengerti oleh karyawan atau pekerja 1.2 Sebelum melakukan pekerjaan harus melakukan toolbox
meeting
untuk mensosialisasikan JSA dab aturan pekerjaan di
lingkungan Zulu Project
1.3 Pastikan semua pekerja mengerti tentang JSA dan apa
yang
disampaikan
2. Persiapan Peralatan 1. Sisi tajam alat kerja 2.1 Pastikan semua peralatan yang akan di pergunakan dalam
2. Kontur lantai yang licin atau tidak rata keadaan baik dan layak digunakan serta di sesuaikan dengan
yang akan dilakukan
2.2 Pastikan semua alat sudah di inspeksi dan disetujui oleh
Cargill Zulu pada saat akan digunakan berfungsi dengan baik
2.3 Lakukan persiapan alat dengan tidak terburu-buru
3. Fabrication 3. Tergores dan terjepit sisi tajam alat serta material 3. Pastikan pada saat pekerjaan pekerja mengenakan Cut
Resist Gloves
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1. Hujan disertai petir 1.1. Tersambar Petir - Stop pekerjaan

1.2. Korsleting - Inspector Scaffolding Orientasi lapangan
- Paramedic Standby
2. Angin Kencang >13 Knot ( WAH ) 2.1. Kejatuhan Material - Emergency Call 081198203811 Cargill Representative Quality Review
2.2. Terhempas dan Terjatuh - Bawa ke Klinik terdekat (Print Name)

3. Pekerja tidak mengenakan APD 3. Cidera-Fatality

4. Tidak ada Barricade di area kerja 4. Cidera - Sediakan Barricade dan sign board
5. Simops 5. Perkelahian - Fatality - Orientasi lapang ( SPV dan EHS ) dan Employees working in the area have
Koordinasi dengan Kontraktor lain been notified of this work?

Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader: Juli Hardi Name: Name:

Name: Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
__/__/____ __/__/____ __/__/____ __/__/____
task been removed and accounted for as
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:
If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)

4. Work at Height 4.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 4.1. Penggunaan FBH dan double lanyard 100% tie off.
4.2. Di install dan di inspek oleh orang yang
4.2. Scaffolding roboh
berkompeten, weekly inspek.
4.3. Pastikan di setiap instalasi platform Scaffolding
4.3. Drop object potential
terdapat Toe Board

tulang belakang aman dan senyaman mungkin

5. Pengerjaan Isolasi pipa 5.1. Tergores sisi tajam 5.1. Pastikan menggunakan Cut Resist Gloves Lv 3
5.2. Kulit iritasi karena material Rockwool 5.2. Kenakan Seragam lengan panjang
5.3. Tertusuk Kawat Rockwool 5.3. Pastikan menggunakan Cut Resist Gloves Lv 3
5.4. Mata terkena serpihan material Rockwool 5.4. Pastikan pekerja mengenakan kacamata safety clear
5.5. Menghirup serpihan material Rockwool 5.5. Pastikan pekerja mengenakan Masker N95

6. Housekeeping 6. Barang-barang atau alat kerja yang berserakan 6. Pastikan setelah melakukan pekrjaan untuk melakukan
housekeeping agar tampak rapi dan bersih

Employees working in the area have been notified of this work?

Step 7: Quality Review

Cargill Representative Quality Review

(Name)
( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
 ,
  Job activity description: Leveling Pipe Spool Menggunakan ChainBlock or Lever Block Date: MM/DD/YY
7/5/2023
Work-order number: Job Requestor: Juli H Work area:
Company: PT.Gemilang Karya Mandiri

( ) Time Pressure, Stress, High Work load ( ) End of Shift or Work Cycle ( ) First time/Infrequent task ( ) Poor Verbal Communication
( ) Distractions ( ) First Day Back > 4 days ( ) Vague/poor work guidance ( ) Over-Confidence
( ) Simultaneous Tasks/Work in Vicinity ( ) Line of Fire
Social Distancing Considerations and Requirements
When work plan calls for individuals to be closer than 6ft (2m) from each other for longer than 15 min, the following requirements should be applied:
( ) Respiratory protection must be worn (facial covering) ( ) Must have a plan to minimize time within 6ft of each other
( ) Face and Eye protection shall be selected and available (glasses, goggles, face shield) ( ) Ensure that all participants are not symptomatic (no cough, fever, shortness of breath, or feeling ill)
( ) Hand and body protection must be selected and available (nitrile gloves, Tyvek suit, etc.) ( ) Post sanitation of equipment and tools as well as doffing plan created
During work, considerations must be taken to limit the potential spread of diseases. Hands should be washed pre & post task. It is also recommended whenever you leave the work zone
Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures
(**Identify critical steps with SIFp with an asterisk or (Ensure STRONG control measures are in place to
highlight** ) eliminate/mitigate SIFp risks)
1. Bekerja tanpa permit 1. Pekerjaan belum boleh dilakukan sebelum permit di
1. Pembuatan ijin kerja validasi.
2.1. Inspeksi peralatan kerja dan di beri tagging layak
2. Persiapan tools dan equipment ( Chain block, 2.1. Tools dan Equipment belum dilakukan function test
pakai.
Lever Block, Webing sling 1 m x 1 ton, Full Body
Harness) 2.1.2. Daily Ceklist inspek tools dan equipment
3. Work at Height
3.1. Jatuh dari ketinggian ( Hook tidak dicantolkan ) 3.1. Penggunaan FBH dan double lanyard 100% tie off.

3.2. Di install dan di inspek oleh orang yang

3.2. Scaffolding roboh
berkompeten, weekly inspek.
3.3. Pastikan di setiap instalasi platform Scaffolding
3.3. Drop object potential
terdapat Toe Board
4. Memasang Chain block ke Anchor Point 4.1. Kegagalan pemasangan Anchor dari tubular pipe, 4.1. Anchor point menggunakan tubular pipe diinstall
dan ikatan tidak menggunakan webbing sling, oleh tim secaffolding, dan ikatan pastikan menggunakan
menyebabkan jatuhnya chainblock dan bisa webbing sling
menyebabkan cideranya operator chain block.
4.2. Safety Latch chainblock tidak ada, menyebabkan 4.2. Inspect chainblock or lever block sebelum bekerja
jatuhnya material.
5. Pengikatan Pipe spool menggunakan webbing 5. Kegagalan pengikatan webbing menyebabkan 5. Perhatian cara pengikatan pipe spool dan hanya diikat
sling terjepitnya tangan menggunakan webbing sling.
 Is there any LIFEsaver or SIF precursor involved? ( ) No (Tier 1 - Move to step 8)  ( ) Yes (Tier 2 - Continue filling out the PJHA)
( ) Barge/Ship Operation
( ) Equipment Failure
( ) Machine/Conveyor Guarding
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mining Operation
Motor Vehicle Working at Lockout Tagout Mobile Ralicar Electrical Work Hazardous Bulk Material Confined Excavation and Hot Work Lifting and ( ) Animal/Biological
Traffic Safety Height Equipment Safety Materiais Handling/ Space Entry Trench Work Rigging
Storage ( ) Other
Is a PtW (Permit to Work) needed or any other additional check list? ( ) Yes ( ) No
If Yes, what are they?
Step 4: Define task specifics STOP criteria Step 5: What is the worst case scenario Step 6: Emergency preparedness Step 7: Quality Review
and its consequences?
(What are the conditions to cause ME to STOP that (More than one worst case scenario may exist)
job?)

1.1. Tersambar petir

- Stop Pekerjaan
1. Hujan 1.2. Cidera
1.3. Konsleting Listrik - P3K
2. Angin Kencang >13 Knot (WAH) 2.1. Material berserakan
2.2. Tertimpa Material Cargill Representative Quality Review
(Print Name)
- Emergency Call ( 081198203811 )

3. Scaffolding Roboh ( tidak proper ) 3.1. Terjatuh dari ketinggian

3.2. Tertimpa scaffolding

4. Pekerja tidak memakai APD 4. Cidera ( Kecelakaan kerja ) - Klinik Terdekat

- Stop pekerjaan. Pengecekan Employees working in the area have

5. Penerangan ( di bawah 200 lx ) 5. Cidera-Fatality
pencahayaan menggunakan LUX meter been notified of this work?

6. Chain block or lever block tidak ada saf 6. Terjatuhnya material - Stop pekerjaan, lengkapin safety latch
or diganti chainblock yang terdapat
safety latch
Yes No
( ) ( )
Step 8: Workers accepting PJHA, and will work according the identified herein:
Task Leader : Juli Hardi Name: Supandi Name: Safety Officer

Name: Sutrisno Name: Name:

 Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
Have tools and equipment used during the
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.:
Task Team Lead: Task Team Lead: Task Team Lead: Task Team Lead:

If additional steps. Hazards and controls are needed for the task, use the area below labeled Annex

Step 1: Describe the job steps Step 2: Identify the Hazards of the Job Step in the field Step 3: Control Measures

(Identify critical steps with SIFp with an asterisk or highlight ) (Ensure STRONG control measures are in place to
eliminate/mitigate SIFp risks)
6. Leveling Pipe spool 6. Terjepitnya tangan antar pipe spool yang sedang 6. Perhatikan posisi kerja dan pastikan pekerja
dilakukan leveling mengenakan sarung tangan cut ressistant.

7. Housekeeping 7. Tumpukan material dan sampah 7. Penerapan 5R sebelum dan sesudah berkerja

Employees working in the area have been notified of this work?

Step 7: Quality Review

Cargill Representative Quality Review

(Name) ( ) Yes ( ) No
Step 8: Workers accepting PJHA, and will work according the identified herein
Task Name: Name:
Leader:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Name: Name: Name:

Is a PtW needed or any other additional check list? ( ) Yes ( ) No

If Yes, what are they?

Teams quickly debrief the task they planned and consider anything that they missed, would change, or even assumed correctly after the task is complete:
( ) Yes ( ) No

Have tools and equipment used during the ( ) 2nd shift Revalidation ( ) 3rd shift Revalidation ( ) 4th shift Revalidation ( ) 5th shift Revalidation
task been removed and accounted for as __/__/____ __/__/____ __/__/____ __/__/____
well as the area being cleaned and debris Starts at: Starts at: Starts at: Starts at:
removed upon completion? Finishes at: Finishes at: Finishes at: Finishes at:
( ) Yes ( ) No Cargill Rep.: Cargill Rep.: Cargill Rep.: Cargill Rep.: