RISK ASSESSMENT FORM

Company / Department : PT Arina Veritas Nusantara Approved by : Romansyah

RA Leader : Mahmud Efendi (HSE Supervisor) Designation : Project Manager
Process/ Location : Installation of Drain Line Below Helipad Signature :
RA Member 1 : Noldy Pijoh (HSE Officer)
RA Member 2 : Taufik Roman (Engineering
Original Assessment Date : 22/03/2019 Date : 25/03/2019
Manager)
Last Review Date : NA RA Member 3 : Ahmad Do Hamid (Supervisor)
Next Review Date : 22/03/2020 Doc No. : AVN-MAR-PIP-RA-003

1. Hazard Identification 2. Risk Evaluation 3. Risk Control

1a 1b 1c 1d 2a 2b 2c 2d 3a 3b
Action

Degree Of Risk
Officer,

Probability
Possible Accident / Designation,

Severity
No Work Scope / Work Ill Health & Due date
Hazard Persons-at-Risk / Implemented Risk Control Additional Risk Control
. Activity/ Sub Activity
EHS impact

1. Scaffold erection - Falling from - Fatal injury - Erection only done by trained - Check thoroughly the scaffold
heights scaffold before assign to workers Piping
Supervisor and
- Use of fall protection devices 5 2 10
Scaffolding
(harness, etc.) Supervisor

2 Collection and - Hand Injury - Hand hit by falling - Wearing hand glove and beware - Pre – job briefing in morning
mobilization of materials - Fall objects of material of pinch point Piping
from workshop include Supervisor and
- Ensure no over loading and 2 4 8
tools Lifting
appropriate lifting gears Supervisor

3 Lifting of spools using yard - Caught in - Hand injury - Wear hand gloves - Competent & trained person
cranes between - Secure properly bundle of pipes to do rigging
- Beware of pinch point - Check & inspect of belts Lifting
2 4 8
- Use proper lifting gears condition (keep clear of lifting Supervisor
area)

1
 RISK ASSESSMENT FORM
Company / Department : PT Arina Veritas Nusantara Approved by : Romansyah
RA Leader : Mahmud Efendi (HSE Supervisor) Designation : Project Manager
Process/ Location : Installation of Drain Line Below Helipad Signature :
RA Member 1 : Noldy Pijoh (HSE Officer)
RA Member 2 : Taufik Roman (Engineering
Original Assessment Date : 22/03/2019 Date : 25/03/2019
Manager)
Last Review Date : NA RA Member 3 : Ahmad Do Hamid (Supervisor)
Next Review Date : 22/03/2020 Doc No. : AVN-MAR-PIP-RA-003

1. Hazard Identification 2. Risk Evaluation 3. Risk Control

1a 1b 1c 1d 2a 2b 2c 2d 3a 3b
Action

Degree Of Risk
Officer,

Probability
Possible Accident / Designation,

Severity
No Work Scope / Work Ill Health & Due date
Hazard Persons-at-Risk / Implemented Risk Control Additional Risk Control
. Activity/ Sub Activity
EHS impact

4 Transfer the tools and - Falling - Injury from falling - Selection of appropriate belts & - Barricade the area & display
spools to install location chain blocks no entry sign
by chain block - Proper secure points of chain
Piping
block 4 3 12
Supervisor
- Ensure to wear body harness and
hang on secure place

5 Installation of pipes and - Caught in - Finger injury - Beware of pinch point -

pipe supports follow by between - Wear of gloves
welding - Proper tools box to be used Piping
3 2 6
- Provide fire cloth supervisor
- Ensure fire watch man

6 Removal of tools and - Falling object - Injury caused by - Immediately remove excess -
leftover materials and from height falling object materials and tools Piping
housekeeping 2 2 4
- Proper housekeeping Supervisor

2
 RISK ASSESSMENT FORM
Company / Department : PT Arina Veritas Nusantara Approved by : Romansyah
RA Leader : Mahmud Efendi (HSE Supervisor) Designation : Project Manager
Process/ Location : Installation of Drain Line Below Helipad Signature :
RA Member 1 : Noldy Pijoh (HSE Officer)
RA Member 2 : Taufik Roman (Engineering
Original Assessment Date : 22/03/2019 Date : 25/03/2019
Manager)
Last Review Date : NA RA Member 3 : Ahmad Do Hamid (Supervisor)
Next Review Date : 22/03/2020 Doc No. : AVN-MAR-PIP-RA-003

1. Hazard Identification 2. Risk Evaluation 3. Risk Control

1a 1b 1c 1d 2a 2b 2c 2d 3a 3b
Action

Degree Of Risk
Officer,

Probability
Possible Accident / Designation,

Severity
No Work Scope / Work Ill Health & Due date
Hazard Persons-at-Risk / Implemented Risk Control Additional Risk Control
. Activity/ Sub Activity
EHS impact

RISK MATRIX

Probability (P) Severity (S) S S1 S2 S3 S4 S5 Risk level Risk Acceptability Recommended Action
1 =Rare 1 =Negligible 1. No additional risk control measures may be needed.
P Low Risk 2. Frequent review and monitoring of hazards are required to
2 =Unlikely 2 =Minor P5 Acceptable
(1 - 3) ensure that the risk level assigned is accurate and does not
5 10 15 20 25
increase over time.
3 = Possible 3 =Moderate 1. A careful evaluation of the hazards should be carried out to
P4
4 =Likely 4 =Major 4 8 12 16 20 ensure that the risk level is reduced to as low as reasonably
Medium practicable (ALARP) within a defined time period.
5 =Almost Certain 5 =Catastrophic P3 Risk Tolerable 2. Interim risk control measures, such as administrative controls or
3 6 9 12 15
(4 – 12) PPE, may be implemented while longer term measures are being
P2 established.
2 4 6 8 10 3. Management attention is required.
1. High Risk level must be reduced to at least Medium Risk before
P1 1 2 3 4 5 work commences.
2. There should not be any interim risk control measures. Risk
High Risk
Not control measures should not be overly dependent on PPE or
(15 – 25)
acceptable appliances.
3. If practicable, the hazard should be eliminated before work
commences.
4. Management review is required before work commences.