(SHE/dept/year/month/number)

REGISTRY NO : (SHE/PS/2020/06/017)

PERMIT TO WORK Applicant Manager Safety Project Owner Project Leader

PT. Hyundai Motor Manufacturing Indonesia

A. GENERAL INFORMATION
Main Contractor
Company Name
Name

Project Owner
(Name & Phone Number) Date
(HMMI) (☎)
(DD/MM/YYYY 00:00 - DD/MM/YYYY 00:00) (Sign) (Sign) Construction Shop Area HOD Construction

Person in Duration (Days)

(Name & Phone Number)
Charge(☎) Type of Permit
New Extend (Name) (Name) (Name) (Name)

B. DESCRIPTION OF WORK
Shop Location
Project Name
Specific Area

Hot Work Electrical Work Civil Work Machine Installation Chemical Handling
Type of Work
Work at Height Confined Space Excavation Work Lifting Work

High Risk Medium Risk Low Risk

Work Classification
*Please see attachment to determine
Rank A Rank B Rank C
the rank *If Rank "A", please fulfill "General A Rank Safety Control"

Safety Supervisor ( ) Engineer ( ) General Worker ( )

Total Worker
Specification of Worker
Involve
Supervisor ( ) ( )
Specialist ( )*
*Please specify and attach certified license for specialist worker (ex. Rigger, Welder, Heavy Equipment Driver, Eletrical expert, etc.)
C. WORKING TOOLS
List of Working Tools :

Forklift
Ladders Bending Machine Wire Rope Scissor Lift

Air Compressor Chain Sling Self-Propelled Lift Backhoe

Scaffolding

Hand Drill Chain Block Exhaust / Blower

Welding Machine Truck Mounted Lift

Circular Saw Electrical Cable Crane Gas Detector

High Speed
Cutter

Drill Machine Electrical Panel Portable Generator

Oxy Cutter Excavator

D. DOCUMENT LIST
I. MANDATORY DOCUMENT (S) : II. OPTIONAL DOCUMENT(S) : <based on classification of work, and requirement from owner>

• One Time Submission

Equipment Inspection Checklist Temporary Facility
Pre-Qualification Work Agreement Organization Structure
Certification of Equipment (SIA) Design / Drawing
Emergency Response Plan
Master Schedule Work Procedures (SOP)
License of Specialist Worker (SIO)
• Periodical Submission
Worker List Working Tool List PPE Specification List

Material Safety Data Sheet

General A Rank Safety Control

Good (√), Poor (X) (work after improvement)

PPE (safety helmet, safety shoes, Full body harness) Install pipe blanking or blinding, clean container, ventilation
Common Prepare equipment for communication, extinguishment,
Wear safety supervisor tag rescue, explosion proof)
Safety Confined Space
Measures Safety training Respiratory equipment (for work / for rescue)
Check & record concentration of oxygen and gas (before
Post plans for safe work entry)

Remove combustible materials & hazardous materials Assign personnel to control vehicles when occupying a road

Install fire blanket Check safety devices for transport apparatus

Hot Work Locate fire fighting equipment (3 fire extinguishers, fire Heavy Material
hydrant) Check signs for mutual communication of workers

Assign a fire watcher for hot work Install signage to prohibit access during using equipment

Check the securing condition of ladder / scaffolding Check whether active electric line or non-active electric line

Working at Install lifeline to secure safety belt Shut off electricity and attach tag
Prohibit to move MEWP (Mobile Elevating Work Electricity
Height PPE for insulation (e.g. insulation gloves)
Platform) when workers are on the platform

Baricade around the working area Prohibit active electric line work
PT. Hyundai Motor Manufacturing Indonesia Risk Level
1. High Risk (Rank A)

Hot work in paint booth or paint mixing room Painting works at places where ventilation facilities are not applied

Hot work at 4 meters or more heights (e.g. truss structure) Painting works at heights (3meters or more)
Hot work within 10 meters from entrance or openings of paint booth
Painting works within 5 meters from hot work places
and paint mixing room
Painting
Hot work for facilities and pipes that are connected to paint booth and
Painting works in confined spaces or oil tanks
paint mixing room
Painting works in underground PIT which is 2 meters or more
Hot work for sandwich pannel or roof of urethane foam heights (including anti-rust work in case that organic solvent is
included)
Cleaning or reparing works for facilities/pipes for 1st grade
Hot work in laboratory handling hazardous materials
Hot Work petroleum prodcuts (gasoline, solvent, thinner)
Hazard-
Hot work for dismantling or maintaining dust collector, air Hot works for dismantling or mantaining facilities/pipes for 2nd
ous
supply/exhaust ducts grade petroleum products (diesel, kerosene)
Material
Hot work for dismantling or maintaining pipes for flammable materials Painting works or flammable handling works in confined spaces
(paint, thinner, solvent, LNG, etc.) (underground PIT, inside of tank)
Works for installing/dismantling scaffolidng 3 floors or more /
Hot work in confined spaces (underground pit, inside of tank, etc.)
Works on scaffolding 3 floors or more

Hot work to install, dismantle or repair cooling tower Works on cranes in plants (e.g. girder, crab, passage ways, etc.)

Hot work near hazardous materials handling location and oil tank, Working Electrical work, hot work, painting, cleaning works on 6 meters or
inside/above anti-rust booth at Height more building truss, ceiling of structures, etc.
Works at 6 meters or more heights using constrution equipment
Live-wire works (200V or more)
(e.g. cherry pickers, table lifts, etc.)
Works adjacent to 3.3 kv or more high-voltage live part (minimum Works for installation or maintenance of roofs (e.g.slate roof,
Electri- safe distance: 20㎝) sunlight roof, tent roof)
city Works adjacent to 22.9kv or more high-voltage live part (minimum Works adjacent to high-voltage lines within radius of construction
safe distance: 30cm) Contruc- equipment
tion Equip-
Works adjacent to 154kv or more high-viltage live part (minimum
ment Heavy lifting works using hydro crane (100 tons or more)
safe distance:140㎝)
Loading/unloading works for equipments, machines, toxic storage
Hot works for flammable gas facilities
containers
Gas
Dismantling facilities operating toxic and flammable gases, cutting Transpor-
Transport flammable materials containers below 21 degree celsius
pipes including toxic and flammable gases tation
Transport large structure exceeding widths and heights of
20kg or more heavy material manual handling (6 meters or more)
vehicle's cargo box
100㎏ or more heavy material lifing using chain block (6 meters ore Use metal processing oils for engine, transmission in tanks Works
Heavy more)
inside of tanks
Material
Works in confined spaces where immediate evacuation is not
10tons or more heavy lifting using cranes available in emergency situations such as fire, explosion,
suffocation incidents
Works in confined spaces are 1 time or more and
Excavate the place where hazardous material stora tanks are buried
fire/explosion/suffocation hazards are exist
Excava-
tion 2 meters or more excavation work adjacent to buildings (within 2 Confined Works for pipes/tanks including/remaining Inert gas (e.g. nitrogen,
meters) Space carbon dioxide, argon) or gases cause a lack of oxygen

Confined spaces that intensive management is required such as

hazardous material storage facilities, high pressure gas tanks,
Cleaning works using thinner, solvents in painting booth
organic compound handling locations, sewage treatment facility
utilizing microorganism)
Cleaning
Hot works in confined spaces in accordance with legal
Cleaning works for tanks in a state of remaining thinner
requirements
Works causing asbestos dusts by dismantling facilities or
Cleaning works causing impact, friction in mixing room Asbestos
materials including asbestos
2. Medium Risk (Rank B)
Hot works implemented at the locations where the distance is 10 Works causing asbestos dusts while installing structures, equipment or
Hot Work
meters or more from paint booth, mixing room dismantling partial asbestos materials
Asbestos
Hot works at PIT(less than 2 meters) / within 6 meters from Works have high possibilities to cause asbestos dusts by dismantling
combusitble materials asbestos
Works dismantling or maintaining facilities that used to
Hot works near oven, heat treatment, coveyors of outfitting lines Gas be utilized as gas storages (only in case that gases are
not detected)
Hot works near roll test room, combustible material storage, PIT, Heavy material(20kg or less) manual lifting(6 meters or
offices Heavy less heights)
Material Lifting heavy materials(100kg or less) using by chain
Hot works in confined spaces, substations, computer rooms, etc.
block (6 meters or less)
Excava-
Hot works within 10 meters from urethane foam roof Excavation works (2 meters or less depths from ground)
tion
Hot works within 5 meters from sandwich type panel that polystyrene
Cleaning Cleaning works in paint booth
is exposed.
PT. Hyundai Motor Manufacturing Indonesia
Risk Level
2. Medium Risk (Rank B)

Cleaning works at the inside of oven, change filters of the

Hot works on top side of buildings, structures or equipments
upside of paint booth
Works adjacent to hazard live part(less than 600V) Others Equipment commissioning, etc.
Electri-
city Electric work and maintenance work for high voltage facilities (dead- Transport wood that exceed widths or heights of a cargo
line work) box, and it is possible to cause traffic interruption
Transpor-
tation Loading/unloading equipments, machines have high
Painting works at PIT (less than 2 mete heights, including anti-rust
possibilities to impact on envionment, fire or any incident
work by organic solvent)
related to HSE due to indirect causes during transportation

Loading/unloading containers for 2nd grade petroleums

Transpor- products (In case that quantity of containers storing or
Painting works at locations where ventilation facilities are installed
tation using 2nd grade petroleums products are morethan
getting permits)
Painting
Works in PIT, culvert, manhole, containers that are not
Painting works at locations where the distance is 5 meters or more Confined used for long period / at the place where calbes or gas
from hot work areas. Space pipes are buried / at the location where waste water,
industrial water are exist or being used

Works in boiler, tank, reactor, basement where are

Painintg works on the top of working platforms or structures (less confiened for long period / at places being painted
than 3 meter heights) (including drying oil) / at locations waste water, inert
gas, chemicals are possibly exist
Hazar-
Cutting(cold work only) pipes including hazarous materials (4th grade Works in septic tanks, settling tanks, sumps where easily decompos
dous ed
or less petroleums product: cutting oil, hydraulic fluid, etc) materials are exist such as waste water
Material
Works for pipes, dust collector where hazarous gases
Works at less than 2 meter heights using ladders are exist (except for gases causing a lack of oxygen
such as inert gases)
Working Confined Works at locations where concentration of O2 is less than
at Height Works on top of structures or equipments (2 meters or more) Space 18%, O2 is 23.5% or more / CO2 is 1.5% or more / H2S is
10ppm or more
Works at 6 meters or less heights on sound working platforms Works in other confined spaces described in legal
(except for hot works) requirements

Works using a pile driver equipment Except for confiend spaces described in legal requirement,
Construc-
1. Hot works at the place where ventilation is not enough
tion
(in case only that there is no risk of suffocation)
Equip-
2. Locations where there are high possibilities to casue
ment Lifting heavy materials suing hydro-crane (100 tons or less)
hazardous gases during painting or other works.

3. Low Risk (Rank C)

Heavy Manual handling materials that weights are 20kg or less at 2
Hot works at places where combustible materials are not exist
Material meters or less heights
Hot Work
Hot works at places 10 meters or more away from combustible Excava-
Excavation (less than 50cm of depth)
material storages or handling areas. tion
Dead-line work less than 220V (in case of less than 2 meters of
Cleaning Simple cleaning work
heights)
Electri-
city Confined Hot works at places where ventilation is not enough except for
New electric cable pulling work (less than 2 meters of heights)
Space confined spaces are not described in legal requirements

Paintings at opened areas where there is no hot work (in case that Loading/unloading dismantled steel structures, equiment (only low
working platforms are not used) risk & hazard works are not applied to Lv.B)
Transpor-
Painting Loading/unloading/transportaion works for containers storing or
tation
Painting work using water paint using hazardous materials (3rd or more grade of petroleums
product
Hazar-
Other works are not described in this standard and there is no risk
dous Install new pipes for hazardous materials at places less than 2 meters
& hazard to cause any incident
Material
Others
Working Works at less than 2 meters of heights on working platforms (except
at for hot work) Simple equipment commissioning
Height Other working at heights not applied to Lv.A or Lv.B