Permit Scafolding [PDF]

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SCAFFOLDING INSTALLATION & DISMANTLING WORK PERMIT IZIN KERJA PEMASANGAN & PEMBONGKARAN PERANCAH A.



Location / Lokasi Kerja



:



Time and Date



:



From



:



Hrs



B.



Work Order No



:



Valid



:



To



:



Hrs



C.



Job Purpose / Tujuan Pekerjaan



:



Workers for Installation :



D.



Scaffolding Material Inspection / Inspeksi Bahan Perancah



Persons



F. Personal Protective Equipment Requirement / Kebutuhan Alat Pelindung Diri



To be checked by Scaffolder or Scaffold Inspector / Diperiksa oleh Scaffolder atau



To be checked by scaffold Inspector, OHS Officer or Area PSE / Diperiksa Oleh Scaffold Inspector,



Scaffold Inspector



OHS Officer atau PSE



Scaffold Material /



No



:



Good



Jenis Material



Poor



PPE Minimum Item



Yes



1



Frame or Pipe / Pipa atau Bingkai



Full body Harness / Pelindung Bekerja di ketinggian



2



Bracing / Palang Penguat



Safety Line / Tali Keselamatan



3



Scaffold Plank / Papan, Numinum Perancah



Safety Helmet complete with chin strip / Helm lengkap dengan tali dagu



4



Ladder / Tangga



Safety Shoes / Sepatu Keselamatan



5



Jack Base / Sepatu Perancah



Safety Google / Kacamata



6



Scaffold Clamp or Wire / Alat pengikat Perancah



Hand Glove / Sarung Tangan



7



Wall Coupling / Angkur



Hearing Protection / Pelindung Telinga



8 9



Toe Board / Landasan



Respiratory Protection / Pelindungan Pernapasan



Other / Lain lain



G. SCAFFOLDING REQUIREMENT / Persyaratan Perancah be filled by Scaffolder / Diisi oleh Scaffolder I) Estimation Uses Scaffolding During /



a) _______________________________________ b) _______________________________________



Estimasi Pemakaian Scaffolding selama



c) _______________________________________



II) Height of Scaffold / Ketinggian Scaffolding



E. HAZARDS IDENTIFICATION / Identifikasi Bahaya To be checked by Area Supv, or Team Leader or Area Pse / Diperiksa Oleh Area Supv, Team Leader or PSE 6 Electrical / Listrik



2 Chemical / Bahan Kimia



7 Temperature / Suhu



3 Toxic / Beracun



8 Radiation / Radiasi



4 Height / Ketinggian



9 Biological / Biologi



5 Pressure / Tekanan



10 Mechanical /Mekanik



I.



To



: :



H. GAS TEST REQUIREMENT / Persyaratan Pengukuran Gas To be checked by OHS Officer or Area PSE / Dicek oleh OHS Officer atau PSE Area Gas



Workplace Hazards / Bahaya Tempat Kerja 1 Noise / Kebisingan



No



Limit



Result



Checked By



Sign



Time



Scaffolding Inspection and Installation Approval / Pengesahan Pemeriksaan dan Pemasangan Perancah



I Have checked dan verified the scaffolding material, hazards in location, and PPE required to perform the job and declare it is safe to start the scaffolding installation work with a must to follow the requirement checked or listed above and safe work procedure related /Saya telah memeriksa bahan perancah,bahaya lokasi kerja,dan APD yang dbutuhkan melakukan pekerjaan dan menyatakan keadaan aman untuk



memulai pekerjaan dengan catatan harus memenuhi ketentuan yang ditandai atau tertulis diatas dan prosedur kerja aman terkait. I)



Scaffolder



Name :



Signature :



Date :



II)



Scaffold Supervisor / Scaffold Inspector



Name :



Signature :



Date :



III)



Team Leader/ Area PSE/ OHS Officer



Name :



Signature :



Date :



J.



Weekly Scaffolding Inspection / Inspeksi Perancah Mingguan



NO



Weekly Inspection



Finding



Checked By



1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 If needed additional document please complete the attachment / Jika dibutuhkan informasi tambahan silahkan sertakan dokumen lain K.



Scaffolding Dismantling Approval / Pengesehan Pembongkaran Perancah



The work described that use scaffolding is completed and all scaffolding can be dismantled / Pekerjaan menggunakan perancah sudah selesai dan perancah dapat dibongkar



:



Workers for dismantle



persons



Scaffolder



Scaffolder Supervisor / Scaffolder Inspector



OHS Officer / Area PSE



Name & Signature



Name & Signature



Name & Signature



Remarks



L.



Closing Work Permit / Penutupan Izin Kerja To be Signed by Area Supervisor or Team Leader / Diperiksa Oleh Area Supv atau Team Leader I Declare the work and scaffolding dismantling have completed and area have cleaned Saya menyatakan pekerjaan dan pembongkaran perancah telah selesai dan area sudah dibersihkan Original - Scaffolder



QMIS Document ID No. : MNT/CVL-0009-FM Supersedes: AGRC/LPC-051-FM



1st Copy - LP&C Issue Date : 17 November 2016



Name & Signature 2nd Copy - Civil



Date / Time 3rd Copy - Area Authority



Revision : 1



Page 1 of 1



DAFTAR PERIKSA PERANCAH SCAFFOLDING INSPECTION CHECKLIST LOKASI PEMERIKSAAN / INSPECTION LOCATION TANGGAL PEMERIKSAAN / INSPECTION DATE



NO



BAGIAN PERANCAH YANG DIPERIKSA / Scaffold part of Inspection



SESUAI



TIDAK SESUAI



A.



Pemeriksaan Awal (Initial Inspection)



Conform



Not Conform



1.



Pemeriksaan Bahan Perancah (Sebelum bahan untuk perancah digunakan) Scaffol Material Checking (before scaffold material being used) - Kondisi pipa secara visual / Kesesuaian terhadap standar pipa / Jumlah / Panjang yang dibutuhkan Visual tube condition/appropriateness of tube standard/quantity/length required - Kondisi klem tetap dan klem putar / Fix Clamp & swivel clamp condition - Kondisi papan secara visual / ukuran PxLxT papan / Jumlah / Visual board condition/board dimension PxlxT/quantity - Kondisi landasan / postur landasan (rata/miring/gelombang/dsb) / Base condition/basement form (level/sloping/wave/etc) - Kondisi klem pengikat papan / Tie board condition - Kondisi tangga / Ladder condition



2.



Izin Kerja pemasangan perancah / Scaffolding Installation work permit



B.



Pemeriksaan setelah Perancah Terpasang (Inspection on Installed Scaffolding)



3.



Tanda / label perancah yang diperlukan tersedia / Sign/label of scaffold available - Tanda peringatan / pemberitahuan / tanda lain yang diperlukan / Warning sign/announcement/other sign required - Label merah (NO) / Label Hijau (YES) / Red Label (not safe to be used) / green label (safe to be used)



4.



Penahan Scaffolding / Scaffold stand - Penahan vertical/tegak, pengikatan klem baik, ujung pipa tidak membahayakan Vertical stand, good right, tube point is not dangerous - Penahan horizontal/datar, pengikatan klem baik, ujung pipa tidak membahayakan Ledger stand, good right, tube point is not dangerous - Penahan diagonal, pengikatan klem hidup baik / Bracing, swivel clamp good right: - Masing-masing penahan mempunyai jarak maksimum yang sama / Each stand must have appropriate maximum distance - Kelenturan perancah baik, tidak goyah / Scaffolding stability is good, fix condition



5.



- Papan scaffolding terikat kuat, jarak papan sesuai, setiap lantai menggunakan minimal dua lebar papan Scaffolding board is in good tight condition, distance of board is appropriate, every floor uses two board at least - Bracing penahan papan cukup, kelenturan baik, tidak goyah / Bracing enough, flexibiliy is good, fix condition - Ukuran (min.lebar 30 cm) dan mutu papan baik, tidak cacat, rata, tidak bermata, ketebalan sama (minimal tiga cm) Board dimension (min, width 30 cm) & good quality, no defect, level no hole, thickness similar (minimum 3 cm) - Sambungan papan saling mengikat dan berpenyangga, tidak mengakibatkan celaka Board jointis interconnected & with supporting, does not cause accidents - Pengikatan di ujung papan baik, terikat ke perancah, kawat pengikat semua tali ganda/ Tight board point is good, righten to scaffold, double tighten wire



6.



Pagar Pengaman / Toe boards - Tinggi Minimum toebard 10 cm / Toeboards shail be a minimum of 10 cm in height - Pengikatan klem pagar baik, tegang dan tidak goyah, tidak membahayakan pengguna Clamp right condition is good, tight and fix, does not cause condition - Ujung pipa pagar terlindung, tidak membahayakan / Pipe point is protected, does not cause accident



7.



Tangga / Ladder - Jarak anak tangga sesuai (maks. Jarak antara anak tangga = 40cm), terikat klem dengan baik Distance between ladder step is 40 cm, good right condition - Railing tangga baik, tidak menggangu kenyamanan pengguna / Handrails is good, does not cause user unpleasant



8.



Catatan / Note



9.



Disiapkan oleh / Prepared By



Diverifikasi Oleh / Verified by.



Scaffolder



Scaffold Supervisor / Scaffold Inspector



Nama / Name



Nama / Name



Tangal / Date



Tangal / Date