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
Job Purpose / Tujuan
C. Pekerjaan : Workers for Installation : : Persons
D. Scaffolding Material Inspection / Inspeksi Bahan Perancah 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 Poor PPE Minimum Item Yes No
Jenis Material
1 Frame or Pipe / Pipa atau Bingkai Full body Harness / Pelindung Bekerja di ketinggian
2 Bracing / Palang Penguat Safety Line / Tali Keselamatan
Safety Helmet complete with chin strip /
3 Scaffold Plank / Papan, Numinum Perancah 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 Toe Board / Landasan Respiratory Protection / Pelindungan Pernapasan
9 Other / Lain lain G. SCAFFOLDING REQUIREMENT / Persyaratan Perancah To
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 H. GAS TEST REQUIREMENT / Persyaratan Pengukuran Gas
To be checked by Area Supv, or Team Leader or Area Pse / Diperiksa Oleh Area Supv, To be checked by OHS Officer or Area PSE / Dicek oleh OHS Officer atau PSE Area
Team Leader or PSE
Gas Limit Result Checked By Sign Time
Workplace Hazards / Bahaya Tempat Kerja
1 Noise / Kebisingan 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. 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 Remarks
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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
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 Name & Signature Date / Time
Original - Scaffolder 1st Copy - LP&C 2nd Copy - Civil 3rd Copy - Area Authority
QMIS Document ID No. : MNT/CVL-0009-FM Issue Date : 17 November 2016 Revision : 1 Page 1 of 1
Supersedes: AGRC/LPC-051-FM
DAFTAR PERIKSA PERANCAH
SCAFFOLDING INSPECTION CHECKLIST
LOKASI PEMERIKSAAN / INSPECTION LOCATION
TANGGAL PEMERIKSAAN / INSPECTION DATE
TIDAK
NO BAGIAN PERANCAH YANG DIPERIKSA / Scaffold part of Inspection SESUAI
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
