Checklist For Site-Self Audit

CONFINED SPACE ENTRY

(Ref : HSE Standard Manual - Section C005 - ID-G-BU-00000-00000-00372 )
issued date: 28-Jul-05
revise date : 4-Aug-10
Date of Site-Self Audit :
Facility :
Conducted By :

No. Description Ref. Yes No N/A Other comment

Specific procedures must be developed for every confined space to be entered,

including :
- Responsibilities
- Training Requirements
- Hazards Commonly Encountered
- Pre-entry Procedures
- Rescue and Emergency Procedures
- Permitting Requirements
- Job Completion
1 4.1

Prosedur spesifik harus dibuat untuk setiap ruang terbatas yang akan dimasuki.
Informasi yang diperlukan, setidaknya:
- Tanggung jawab
- Pelatihan yang diperlukan
- Bahaya umum yang dijumpai
- Prosedur sebelum memasuki ruang terbatas
- Prosedur pertolongan dan situasi darurat
- Penyelesaian pekerjaan

Following site-specific procedures will minimize the risks of confined space entry. Any
deviation from these established procedures will be the responsibility of, and at the
discretion of, the designated Department/Area manager in charge.
2 4.2
SSP berikut akan mengurangi resiko memasuki ruang terbatas. Segala pengurangan
prosedur yang telah tersedia menjadi tanggung jawab dan kebijakan dari manajer
departement / area yang sedang bertugas.

All work conducted in or around a confined space must be under the direction of a
Supervisor who is completely familiar with the recommended procedures and
equipment, as well as aspects of safety relative to confined space entry
3 4.3
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3 4.3
Seluruh kegiatan yang dikerjakan di dalam ataupun sekitar ruang terbatas harus
berada dibawah pengawasan Supervisor yang menguasai prosedur dan peralatan,
serta aspek keselamatan memasuki ruang terbatas.

All workers involved in confined space entry have been trained to ensure that safe work
procedures are followed. This training must be conducted by a qualified person who is
thoroughly familiar with the hazards that may be encountered.
4 5.1
Seluruh pekerja yang memasuki ruang terbatas telah diberikan pelatihan guna
memastikan bahwa prosedur bekerja dengan aman dipatuhi. Pelatihan ini harus
dilakukan oleh personil yang kompeten dan mengenal secara detil bahaya yang
mungkin dapat muncul.

Training should be conducted annually, be as site-specific as possible, and must

include the following:
- Type of confined space to be entered
- Potential hazards which may be encountered
- Atmospheric testing requirements
- Use of personal protective equipment
- Regulations applicable to confined space entry
- Fire precautions and protection
- Emergency and exit procedures
5 5.2
Pelatihan haruslah dilakukan setiap tahun, sedetil mungkin dan harus setidaknya
mempertimbangkan aspek-aspek berikut:
- Jenis ruang terbatas yang akan dimasuki
- Kemungkinan bahaya yang akan muncul
- Pengujian kadar atmosfer
- Penggunaan alat pelindung diri
- Regulasi yang berkenaan dengan memasuki ruang terbatas
- Tindakan pencegahan dan perlindungan terhadap bahaya kebakaran
- Prosedur situasi darurat dan jalan keluar

A trained person is required when confined space is entered. In addition to the above
training, this person should be further trained to handle the:
• Use of communication equipment
• Use of atmospheric monitoring equipment
• Ventilation requirements
• Use of emergency equipment
• Rescue and emergency procedures.
6 6.1

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6 6.1
Hanya personil terlatih yang dapat memasuki ruang terbatas. Sebagai tambahan
materi pelatihan diatas, personil tersebut telah dilatih bagaimana menggunakan :
- Alat komunikasi
- Alat uji kadar atmosfer
- Keperluan ventilasi
- Perlengkapan darurat
- Prosedur penyelamatan dan situasi darurat

Only workers physically capable of working in a confined space, or performing a rescue

operation should be used.
7 6.2
Hanya personil dengan kondisi fisik yang baik yang dapat memasuki ruang terbatas,
atau melakukan kegiatan penyelamatan bila diperlukan.

A minimum of two members must be trained in cardio-Pulmonary resuscitation and

emergency first-aid. One of these members should be designated as a safety stand-by.
Training must be documented and maintained on file. Further information regarding
training can be provided by the safety Advisor.
8 7
Setidaknya dua anggota harus dilatih dalam resusitasi jantung paru dan bantuan
darurat pertama. Salah satu dari keduanya harus ditugaskan sebagai safety-standby.
Seluruh pelatihan yang telah dilakukan harus didokumentasikan. Safety Advisor akan
menginformasikan mengenai pelatihan yang perlu diambil.

Samples of sludge and other materials found adhering to walls should be removed and
tested to ensure they are safe (non-flammable and non-toxic), before hot work permits
are issued for work in a confined space
9 8.2
Sampel sludge dan material yang menempel di dinding harus dilepas dan diuji untuk
memastikan keamanannya (tidak mudah terbakar dan tidak beracun), sebelum izin
pekerjaaan hot work di ruang terbatas dikeluarkan.
Appropriate personal protective equipment must be worn for the particular job, i.e.,
clothing, gloves, boots, goggles, faceshields, respiratory equipment, safety harness
and life-lines
10 9.1
Alat pelindung diri yang tepat harus dipakai untuk pekerjaan tertentu, seperti bahan
pakaian, sarung tangan, sepatu boot, pelindung mata, pelindung wajah, alat
pernafasan, safety harness dan life-lines.

The supervisor in charge will be responsible for determining what personal protective
equipment is required. These requirements will be noted on the permit.
[See: Hydrogen Sulfide Safety ID-G-BU-00000-00000-00398]
[See: Respiratory Protection ID-G-BU-00000-00000-00476]
[See: Personal Protective Equipment ID-G-BU-00000-00000-00417]
11 9.2

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11 9.2
Supervisor yang sedang bertugas bertanggung jawab untuk menentukan alat
pelindung diri yang tepat. Spesifikasi tersebut harus dicatat didalam izin kerja.
[Lihat: Hydrogen Sulfide Safety ID-G-BU-00000-00000-00398]
[Lihat: Respiratory Protection ID-G-BU-00000-00000-00476]
[Lihat: Personal Protective Equipment ID-G-BU-00000-00000-00417]

Before a worker(s) enters a confined space, it must be isolated by blanking, blinding or

separating and plugging to prevent contaminants from entering. [See: Blinding and
Blanking ID-G-BU-00000-00000-00366]
12 10.1.1
Sebelum pekerja memasuki ruang terbatas, harus melakukan penyekatan dengan
blanking, blinding atau separating dan plugging untuk mencegah kontaminan
memasuki ruang terbatas. [lihat: Blinding and Blanking ID-G-BU-00000-00000-00366]

Water, steam or inert gas may be used to displace or purge hazardous products or
atmosphere from a confined space.
[See: Purging ID-G-BU-00000-00000-00429]
13 10.1.2
Air, uap air atau gas inert dapat digunakan untuk membersihkan atau mencuci dari
gas/barang berbahaya pada ruang terbatas.
[Lihat: Purging ID-G-BU-00000-00000-00429]

All power driven internal equipment and power sources must be locked in the off
position at the main fuse or breaker panel and tagged out. [See: Lock-Out/Tag-Out ID-
G-BU-00000-00000-00404]
14 10.1.3
Seluruh tenaga yang digerakkan oleh peralatan internal dan sumber tenaga harus
dikunci pada posisi off dibagian sekering utama atau breaker panel dan diberi tag out.
[Lihat: Lock-Out/Tag-Out ID-G-BU-00000-00000-00404]

Before entry, confined spaces must be opened and thoroughly ventilated

15 Sebelum memasuki ruang terbatas, area tersebut harus dibuka dan diberi ventilasi 10.1.4.1
udara yang cukup terlebih dahulu.
A positive method of mechanical ventilation is desirable so that a sufficient quantity of
fresh air may enter to remove contaminants from all pockets or corners.
16 Metode positif dari ventilasi mekanikal lebih diinginkan sehingga terdapat cukup udara
10.1.4.2
segar yang masuk untuk menggantikan udara yang terkontaminasi di sudut-sudut
ruangan.

518349178.xls Page 4
 After the contaminated space is cleaned and ventilated, the mechanical ventilation
equipment should be kept operating to provide secondary protection in case of the
accidental introduction of harmful substances, and to remove contamination or heat
that may be produced by the work (e.g., welding, cutting, painting, coating)
17 10.1.4.3
Setelah area yang terkontaminasi dibersihkan dan diberi ventilasi, peralatan ventilasi
mekanikal harus tetap beroperasi guna memberikan perlindungan sekunder bila
terdapat kecelakaan yang menyebabkan keluarnya substansi beracun dan sekaligus
mengeluarkan udara kotor dan panas yang dihasilkan dari suatu pekerjaan (seperti,
pengelasan, pemotongan, pengecatan dan pelapisan)

Before entering a confined space, the space should be emptied of all residual material
where practical
18 10.1.5.1
Sebelum memasuki ruang terbatas, area tersebut harus dikosongkan dari segala
material sisa sebelum pekerjaan dimulai bila memungkinkan.

Depending on the nature and the contents of the confined space, it could be drained,
or pumped out and cleaned by flushing, steaming, chemical neutralization, or purging.

19 Metode yang digunakan untuk mengosongkan ruang terbatas tergantung dari jenis dan 10.1.5.2
kandungan yang terdapat di ruang terbatas itu sendiri. Dapat dikeringkan ataupun di
pompa keluar dan dibersihkan dengan menyemprot, menggunakan uap air, netralisasi
dengan bahan kimia maupun dengan purging.

Sludge and spent cleaning fluids must be disposed of in a safe, approved manner
20 10.1.6
Sludge maupun sisa bahan pembersih harus dibuang dengan cara yang aman, dan di
setujui oleh personil terkait.
Confined space atmospheres must be tested before entry is allowed. [See:
Atmospheric Monitoring]
21 Kondisi udara didalam ruang terbatas harus diuji terlebih dahulu sebelum personil 10.1.7
diperbolehkan masuk.
(Lihat: Atmospheric Monitoring)
The percentage of oxygen for unprotected entry into confined space shall be no less
than 19.5% nor greater than 25%, at sea level
22 10.1.8.1
Bila memasuki ruang terbatas tanpa pelindung, persentasi oksigen harus tidak kurang
dari 19.5% namun tidak lebih dari 25% (pada kondisi di permukaan laut)

Entry into a confined space for any type of work shall be prohibited when testing
indicates the presence of flammable gas above a reading of 0% (LEL)
23 10.1.9.1
Larangan memasuki ruang terbatas untuk semua jenis pekerjaan diberlakukan ketika
tes menunjukkan adanya gas mudah terbakar di atas 0% (LEL)

518349178.xls Page 5
 In situations where the specific work activity (i.e. tank cleaning) will generate or
increase the level of flammables, a maximum of 10% (LEL) will be allowed, providing
no hot work is being performed. SCBA or SABA must be used while the task is being
performed and continuous atmospheric monitoring shall be conducted
24 10.1.9.2
Pada situasi di mana pekerjaan spesifik (seperti, pembersihan tangki) dapat
menghasilkan atau meningkatkan tingkat gas mudah terbakar yang terdeteksi, 10%
(LEL) maksimal diperbolehkan, selama pekerjaan tersebut bukan merupakan Hot
Work. SCBA atau SABA harus digunakan berikut dengan pemantauan kadar udara
secara terus menerus selama pekerjaaan berlangsung.

Where toxic contaminants may be present, measurements shall be taken prior to entry
10.1.10.
25 1
Tes perlu dilakukan sebelum masuk bilamana suatu area dicurigai terkontaminasi oleh
gas beracun.

The types of contaminants which may be present, and the need for monitoring, will
depend upon the service of the confined space. 10.1.10.
26 2
Jenis kontaminan yang mungkin ada dan apa saja yang diperlukan guna melakukan
pemantauan bergantung pada operasi tempat terbatas.

Employees shall not be allowed to enter confined spaces without the proper protective
equipment if the concentration of any toxic contaminant (gas, vapor, or particulate)
exceeds the Prudent Occupational Exposure Limits (OEL’s). If a contaminant is present
and no OEL’s exist, contact the Safety Supervisor. 10.1.10.
27 3
Karyawan tidak boleh memasuki ruang terbatas tanpa memakai alat pelindung yang
tepat bila terdapat kontaminan beracun (gas, uap atau partikel) melebihi batas yang
diizinkan. Hubungi Safety Supervisor jika batas kontaminan yang diizinkan tidak
tersedia.
Entry into a hazardous or potentially hazardous confined space will be by permit only
10.1.11.
28 Setiap personil yang akan memasuki ruang terbatas yang terdapat bahaya racun 1
ataupun berpotensi adanya bahaya harus mempunya surat izin.
This permit is an authorization specifying work location and type of work to be done. It
certifies that all potentially hazardous conditions have been evaluated by a qualified
person, and the necessary protective measures implemented or identified to ensure the
safety of all workers
10.1.11.
29 Surat izin tersebut memberikan otoritas dalam menentukan lokasi kerja dan jenis 2
pekerjaan yang akan dilakukan. Surat ini mengesahkan bahwa semua kondisi yang
berpotensi bahaya telah dievaluasi oleh orang yang kompeten dan langkah-langkah
perlindungan yang diperlukan telah dilakukan atau diidentifikasi untuk menjamin
keselamatan semua pekerja.

518349178.xls Page 6
 The permit is valid only for a specified period of time after which it must be re-issued
10.1.11.
30 3
Surat izin tersebut hanya berlaku pada kurun waktu tertentu. Setelah itu harus di buat
kembali.

518349178.xls Page 7
 The permit must be prepared and signed by the supervisor responsible for he safe
operation of the facility, or his designate 10.1.11.
31 4
Surat izin harus disiapkan dan disetujui oleh supervisor yang bertanggung jawab atas
keselamatan opearsi fasilitas atau delegasinya
A copy of this permit is to be conspicuously posted at the entrance to the confined
10.1.11.
32 space
5
Salinan izin ini harus jelas dipasang di jalur masuk ruang terbatas
A record must be kept of all permits issued 10.1.11.
33 6
Seluruh izin kerja yang diterbitkan harus selalu dicatat
All permits must be returned upon completion of work or when expired
10.1.11.
34 Seluruh izin kerja harus selalu dikembalikan bila pekerjaan telah selesai atau telah 7
kadaluarsa.
Permits must be retained on file for a minimum of one year 10.1.11.
35 8
Izin kerja harus disimpan didalam file dengan kurun waktu minimal 1 tahun.
If hot work is to take place in a confined space, a hot work permit must be issued. [See:
Safe Work Permits]
36 10.1.12
Bila mengerjakan pekerjaan Hot Work didalam ruang terbatas, izin kerja hot work harus
diterbitkan.
Where the potential exists for conditions to change, atmospheric monitoring and the re-
issue of permits is required before re-entry, after a lapse of time
37 Bila kondisi ruang terbatas berpotensi untuk berubah, maka pengawasan kualitas 10.1.13
udara dan mengurus ulang izin kerja diperlukan sebelum memasuki ruang terbatas
kembali setelah beberapa waktu.
Portable caution signs must be posted at the entry point(s) to a confined space
38 10.1.14
Tanda peringatan portable harus diletakkan di jalur masuk ruang terbatas.

Before anyone enters the confined space, a pre-entry safety meeting must cover at
least the following:
- What is a confined space?
- What are the hazards?
- What work will be performed?
- Emergency procedures
- Members of rescue team
- What safety equipment is required? (Familiarize all workers with the equipment.)
- Wearing of lifeline and breathing apparatus.
- Identifying special requirements and entering them on the appendix of procedure.
- Identify lighting requirements.

39 10.1.15

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39 10.1.15
Sebelum tiap orang memasuki ruang terbatas, pre-entry safety meeting perlu
membahas setidaknya:
- Apa yang dimaksud dengan ruang terbatas?
- Apa yang dimaksud dengan bahaya?
- Pekerjaan apa yang akan dikerjakan?
- Bagaimana dengan prosedur daruratnya.
- Siapa anggota tim penyelamat
- Peralatan apa saja yang diperlukan? (Seluruh pekerja harus mengenali peralatan
tersebut)
- Gunakan lifeline dan alat bantu pernafasan
- Kenali peralatan khusus yang diperlukan dan masukkan kedalam lampiran prosedur
- Kenali alat penerangan yang diperlukan

518349178.xls Page 9
 Written procedures specific to the confined space to be entered, must be prepared and
followed 10.1.16.
40 2
Prosedur khusus tertulis untuk ruang terbatas yang akan dimasuki, harus disiapkan
dan dipatuhi
Where the confined space requires workers to wear selfcontained or air-supplied
breathing apparatus, or where rescue in an emergency may be difficult, workers must
be provided with a body harness and life-line attached
10.1.16.
41 Pada ruang terbatas dimana pekerja diharuskan untuk memakai selfcontained atau 3
alat bantu pernafasan, atau pada ruang dimana proses penyelamatan dalam keadaan
darurat akan sulit dilakukan, pekerja harus memakai body harness dan life-line yang
disediakan
There must be a standby person at the confined space entrance at all times 10.1.16.
42 4
Seseorang harus siaga di pintu masuk ruang terbatas sepanjang waktu
All lighting and electrical equipment used inside a confined space must be approved for
the conditions present. All circuits must be equipped with approved ground fault
interrupters
10.1.16.
43 5
Semua kelistrikan dan penerangan yang digunakan dalam ruang terbatas harus
disetujui untuk kondisi pada saat itu.Seluruh rangkaian kelistrikan harus dilengkapi
dengan grounding yang disetujui.

A written rescue plan must be developed and followed 10.1.17.

44 1
Rencana penyelamatan tertulis harus dibuat dan dipatuhi

it is essential to have rescue personnel and equipment at or near the work location
10.1.17.
45 2
Adalah penting untuk menjaga kesiagaan regu dan peralatan penyelamat didekat area
kerja

At the end of the job, a thorough check should be made to ensure that:
- No tools or equipment have been left behind.
- All personnel are accounted for.
- All work permits have been returned.
- All blinds have been removed and valves returned to their correct positions.
- All records and permits are filed as required.
46 10.1.18
Di akhir periode kerja, pemerikasaan menyeluruh harus dilakukan untuk memastikan:
- tidak ada pekerja ataupun peralatan yang tertinggal
- seluruh pekerja terhitung
- seluruh izin kerja telah dikembalikan
- seluruh blind telah dibuang dan katub-katub telah dikembalikan ke posisi semula
- seluruh kegiatan telah dicatat dan izin kerja diisi sesuai ketentuan

518349178.xls Page 10
Audit Checklist Summary

No Description Ref Yes No

Checked :
Specific procedures must be developed for every confined
space to be entered, including :
- Responsibilities,
- Training Requirements,
1 4.1
- Hazards Commonly Encountered,
- Pre-entry Procedures,
- Rescueand Emergency Procedures,
- Permitting Requirements,
- Job Completion.

Checked : Site-specific procedures will minimize the risks of

2 4.2
confined space entry.
Checked : All work conducted in or around a confined
space must be under the direction of a Supervisor who is
3 4.3
completely familiar with the recommended procedures and
equipment.
Checked : All workers have been trained to ensure that safe
4 5.1
work procedures are followed.
5 Checked : Training should be conducted annually. 5.2
Checked :
A trained personshould be further trained to handle
the:
• Use of communication equipment,
6 6.1
• Use of atmospheric monitoring equipment,
• Ventilation requirements,
• Use of emergency equipment,
• Rescue and emergency procedures.

518349178.xls Page 11
 Checked : Only workers physically capable of working in a
7 6.2
confined space.
Checked : A minimum of two members must be trained in
8 cardio-Pulmonary resuscitation and emergency first-aid. 7
Training must be documented and maintained on file.

Checked : Sludge and other materials found adhering to

9 8.2
walls should be removed and tested to ensure they are safe.

Checked : Appropriate personal protective equipment must

10 9.1
be worn.
Checked : The supervisor responsible for determining what
11 9.2
personal protective equipment is required.
Checked : Before enters a confined space, it must be
12 10.1.1
isolated by blanking, blinding or separating and plugging.
Checked : Water, steam or inert gas may be used to
13 10.1.2
displace or purge hazardous products or atmosphere.
Checked : All power driven internal equipment and power
14 10.1.3
sources must be locked in the off position.
Checked : Confined spaces must be opened and
15 10.1.4.1
thoroughly ventilated.
Checked : A positive method of mechanical ventilation is
16 desirable so that a sufficient quantity of fresh air may enter 10.1.4.2
to remove contaminants from all pockets or corners.
Checked : After cleaned and ventilated, the mechanical
17 ventilation equipment should be kept operating to provide 10.1.4.3
secondary protection in case.
Checked : Before entering a confined space, the space
18 10.1.5.1
should be emptied of all residual material.

518349178.xls Page 12
 Checked : Depending on the nature and the contents it
19 could be drained, or pumped out and cleaned by flushing, 10.1.5.2
steaming, chemical neutralization, or purging.
Checked : Sludge and spent cleaning fluids must be
20 10.1.6
disposed of in a safe.
21 Checked : Confined space atmospheres must be tested. 10.1.7

Checked : The percentage of oxygen for unprotected shall

22 10.1.8.1
be no less than 19.5% nor greater than 25%, at sea level.

Checked : Entry into a confined space prohibited when

23 testing indicates the presence of flammable gas above a 10.1.9.1
reading of 0% (LEL).
Checked : SCBA or SABA must be used while the task is
24 being performed and continuous atmospheric monitoring 10.1.9.2
shall be conducted.
Checked : Where toxic contaminants may be present,
25 10.1.10.1
measurements shall be taken prior to entry.
Checked : Monitoring, will depend upon the service of the
26 10.1.10.2
confined space.
Checked : Employees shall not be allowed to enter without
27 the proper protective equipment if the concentration of any 10.1.10.3
toxic contaminant.
Checked : Entry into a hazardous or potentially hazardous
28 10.1.11.1
will be by permit only.
Checked : Permit is an authorization specifying work
29 10.1.11.2
location and type of work to be done.
30 Checked : Permit is valid only for a specified period of time. 10.1.11.3
Checked : Permit must be prepared and signed by the
31 10.1.11.4
supervisor.
Checked : A copy of this permit is to be conspicuously
32 10.1.11.5
posted.

518349178.xls Page 13
33 Checked : Record must be kept. 10.1.11.6
Checked : All permits must be returned upon completion or
34 10.1.11.7
when expired.
Checked : Permits must be retained for a minimum of one
35 10.1.11.8
year.
Checked : If hot work is to take place, a hot work permit
36 10.1.12
must be issued.
Checked : Atmospheric monitoring and the re-issue of
37 10.1.13
permits is required before re-entry, after a lapse of time.
38 Checked : Portable caution signs must be posted. 10.1.14
Checked : Before anyone enters the confined space, a pre-
39 10.1.15
entry safety meeting must cover.
Checked : Written procedures specific must be prepared
40 10.1.16.2
and followed.
Checked : Workers must be provided with a body harness
41 10.1.16.3
and life-line attached.
Checked : There must be a standby person at t entrance at
42 10.1.16.4
all times.
Checked : All lighting and electrical equipment must be
43 10.1.16.5
approved for the conditions present.
44 Checked : Rescue plan must be developed and followed. 10.1.17.1
Checked : Rescue personnel and equipment at or near the
45 10.1.17.2
work location.
Checked :
At the end of the job, a thorough
check :
- No tools or equipment have been left behind,
- All personnel are accounted for,
46 10.1.18
- All work permits have been returned,
- All blinds have been removed and valves returned to their
correct positions,
- All records and permits are filed as required.

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