HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 1 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 2 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 3 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 4 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 5 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 6 of 60
Pneaumatic, hydraulic, electrical, no
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 7 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 8 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 9 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 10 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 11 of 60
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 12 of 60
No Prepared by : Sign :
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 13 of 60
1. Saiful Anham
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 14 of 60
2. Syafril Abdillah
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 15 of 60
3. Achmad Muchlis
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 16 of 60
4. Isna Habibie P
HIRAM NO :

System / Project / Activity to be

1.
evaluated :
Description of the System/
2.
Project/ Activity :
Objective of the System/
3.
Project/ Activity :
Others System / Project /
4.
Activity may be influenced :

Hazard Description
No
Form No. GMF/ Q-286 R2 Page 17 of 60
5. Siti Alifah
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 18 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 19 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 20 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 21 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 22 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 23 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 24 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 25 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 26 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 27 of 60
 Hazard Identification a
DATE : 1 April 2019

Engine Services on site support

Perform Engine Services on site support

Performed Engine Services on site support refer to maintenance

Manpower, Tool & equipment, facility, maintenance Instruction, IT

Current
Consequence Risk
Index
Form No. GMF/ Q-286 R2 Page 28 of 60
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 29 of 60
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 30 of 60
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 31 of 60
Coordinate with GMF logistic Every
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 32 of 60
provide standart packaging of Every
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 33 of 60
coordinate with Out station to
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 34 of 60
Every
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 35 of 60
coordinate with GMF logistic
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 36 of 60
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 37 of 60
coordinate with GMF logistic Every
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 38 of 60
Coordinate with Out station to
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 39 of 60
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 40 of 60
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 41 of 60
Is there any residu
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 42 of 60
Issue HIR
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 43 of 60
Verified by :
 Identification and Risk Assessment

port

upport refer to maintenance manual and comply with regulation

y, maintenance Instruction, IT system, material, capability

Expected Follow up Action

Mitigation Plan Risk
Index UIC Target
Form No. GMF/ Q-286 R2 Page 44 of 60
Sign & Date :
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 45 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 46 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 47 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 48 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 49 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 50 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 51 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 52 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 53 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 54 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 55 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 56 of 60
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 57 of 60
y residual risk? : YES / NO
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 58 of 60
sue HIRAM NO :
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 59 of 60
Approved by :
ent & Mitigation (HIRAM)

on

Verification (fill by Safety Inspection) Final

Risk
A R U Reason Index
Form No. GMF/ Q-286 R2 Page 60 of 60
Sign & Date :