Pre Commissioning Inspection Record

Heavy Equipment
( FORKLIFT )

Equipment Supplier PT. SEDANG SEDAYU PERDANA Equipment Type FORKLIFT

Equipment No. 4 Date 28/11/2017

User Department PPIC User Name

Kondisi
NO. DESCRIPTION / DESKRIPSI Komentar
Diterima Ditolak T / Tersedia

A ITEM YANG DIPERIKSA

. Visibilitas
1.1 Lampu Rotari Orange
Nomor kendaraan atau biru
terpasang terpasang
di kedua sesuaidan
sisi kabin standar
belakang serta terlihat jelas v
1.2 (kurang lebih 30 m) v

2. Dalam Kabin
2.1 Sabuk Pengaman v
2.2 Kondisi tempat duduk sesuai standar v
2.3 ROPS Manufactures v ROPS bocor
2.4 FOPS Manufactures v
2.5 Pemadam Api Ringan ( APAR ) v Apar tidak ada
2.6 Rem Tangan berfungsi v
2.8 Semua sistem electrical bekerja / berfungsi v
2.9 Klakson berfungsi v

3 Pencahayaan dan lainnya

3.1 Semua lampu bekerja v
3.2 Alarm Mundur / pergerakan alarm berfungsi v
3.3 Kondisi Steering baik v
3.4 Kondisi Ban baik v
3.6 Jalan Masuk & tangga naik kondisi baik v
3.7 Pemeriksaan General mechanical v Rem tidak pakem
3.8 Handrail memadai, safety chain & bar terpasang baik v
3.9 Cermin / Spion terpasang v

Ref Item
B ITEM TAMBAHAN YANG DIPERIKSA
1.1 Noist test < 85 db dalam kabin. Bila noist test > 85 db , noise sticker v
1.2

KEPUTUSAN : DITERIMA / DITOLAK

HSE SPV

HSE Dept Head

General Manager
Pre Commissioning Inspection Record
Unit Sarana
(LV, Minibus, Bus, ManHaul)

Equipment Supplier Equipment Type

Equipment No. Date

User Department User Name

PIK-FRM-SAF-029 (Rev.00)
Kondisi
NO. DESCRIPTION / DESKRIPSI Komentar
Diterima Ditolak T / Tersedia
1 TYRES CONDITION / KEADAAN BAN
1.1 Front Tyres / Ban Depan
1.2 Rear Tyres / Ban Belakang
1.3 Spare Tyres / Ban Cadangan
2 MIRROR / WINDSHIELD / KACA
2.1 Wings Mirror (L/R) / Kaca Spion (KR/KN)
2.2 Rear View Mirror / Kaca Spion Dalam
2.3 Windshield / Kaca Depan
3 TOOLS / PERALATAN
3.1 Jack + Handel / Dongkrak + Handel
3.2 Wheel Wrench / Kunci Ban
4 LIGHTING SYSTEM / SYSTEM PENERANGAN
4.1 Dim Lights / Lampu Kecil
4.2 Head Lights / Lampu Besar
4.3 Tail Lights / Lampu Belakang
4.4 Interior Lights / Lampu Ruangan
4.5 Reversing Lights / Lampu Mundur
4.6 Brake Lights / lampu Rem
4.7 Signal Lights (L/R) / Lampu Rething (KR/KN)
5 CAR REGISTRATION / STNK
6 SPARK ARRESTOR / PENANGKAP BARA
7 SEATS / TEMPAT DUDUK
8 SAFETY BELT / SABUK PENGAMAN
9 FRIST AID KIT / KOTAK OBAT
10 FIRE EXTINGUISHER / PEMADAM API
11 HORN / KLAKSON
12 DOOR LOCKING SYSTEM / KUNCI PINTU SYSTEM
13 WIPERS / PENGHAPUS KACA
14 WATER PUMP FOR CLEANING WINDSHIELD / POMPA WIPER
15 BATTERY / ACCU
15.1 Battery Terminal / Kepala Accu
15.2 Battery Liquid Level / Air Accu
16 ENGINE / MESIN
16.1 Lube Oil Level / Oli Mesin
16.2 Break Fluid / Minyak Rem
16.3 Cluth Fluid / Minyak Kopling
16.4 Power Steering Oil Level / Oli Power Steering
16.5 Cooling Water Reserve Tank / Tangki Air Radiator
16.6 Cleaning Water Tank for Windshield / Tangki Air Wiper
16.7 Any Oil or Fluid Leakage / Kebocoran Oli atau Minyak
17 INDICATION SYSTEM / SYSTEM INDIKASI
17.1 Fuel Tank Level / Level Bahan Bakar
17.2 Battery Volt Meter / Pengisian Battery
17.3 Engine Temperature / Panas Mesin
17.4 Tachometer / Spedometer
18 AIR CONDITIONER / AC
19 4 WD SYSTEM / DOUBEL GARDAN
20 BRAKE CONDITION / KEADAAN REM
20.1 Hand Break / Rem Tangan
20.2 Service Break / Rem Kaki
21 Others / Lain-Lain

KEPUTUSAN : DITERIMA / DITOLAK

P&M Dept. rep

HSE Dept.rep

Site Manager
PT.Perkasa Inakakerta
Bengalon Site - East Kalimantan

RESULT COMMISSIONING REPORT

No Abnormal Condition Corrective Action

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29
30

Prepared By,

P&M Spv :

HSE Spv :
Remarks
Pre Commissioning Inspection Record
Mobile Lighting Plants, Welding Machines, & Gensets
Equipment Supplier Equipment Type

Equipment No. Date

User Department User Name

PIK-FRM-SAF-029 (Rev.00)
Welding Machine √

HASIL
Genset X
--
Lighting Plant
●
Ref Item Kriteria
1. Physical & Mechanical
1.1 Penyetelan Lampu ● Handle is 1 - 1.5 m from ground (within easy reach) ● -- --
● Sistem Check Valve Hydraulic
● Hydraulic boom pengangkat
1.2* Sistem Hydraulic ● Sambungan Hose ● -- --
● Kondisi Boom
● Operator segregated from boom and lighting frame
by 0.5 m during boom stowing and opening
1.3 Hydraulic Control Levers ● Control levers respond correctly ● -- --
● Control levers clear labeled
1.4 Nomor Equipment ● Terlihat Jelas ● ● ●
2. Physical & Mechanical
● Weatherproof and locked
● Securely mounted
● Cleary labelled
2.1* Electrical Switch Board ● Wiring diagram or legend attached ● ● --
● Isolatioan point
● Emergency stop
2.2 Electrical Labeling / Tagging ● Valid inspection tag ● ● ●
● Bonding and earthing system are good condition ● ● --
● Correct cable size
● Tight connection
● Cables properly installed (Flexible conduit, cable lugs ● ● ●
2.3* Cable installation fitted correctly, cable is tidy)
● Welding cables
● Grounding Clamp Insulation in good
● Electrode holder condition -- -- ●
● Gouging torch
● Battery isolator switch
2.4* Battery (if fitted) ● Battery cover ● ● ●
● IP 55 (Weatherproof)
2.5* Lighting ● Good Condition ● -- --
● IP 55 (Weatherproof)
● Good Condition
2.6 GPO (General Power Outlet) ● Easily to be accessed ● ● --
● Earth Leakage Circuit Braker (ELCB)
3. Engine
● Chain length 75 m
● -- --
● Chain fitted to skid (for towing by mobile equipment)
3.1 General
● Apropriate machine guarding
● Structure (steel, wheel, hook, skid, wheel choke, towing) ● ● ●
Diesel engine (not required ● Electrical start
3.2 for Gensets of less than 5 ● Ignition key on outside of control box ● ● ●
KVA) ● Shutdown for high temperature and low oil pressure
● Fast fill & valve
3.3 Fuel Tank ● Fuel fill and thank vent ● -- --
● Engine oil fill / extraction
4. Tyres (if fitted) and others
 Welding Machine √

HASIL
Genset X
--
Lighting Plant
●
Ref Item Kriteria
4.1 Tyre thread & side walls All tires in good condition ● ● ●
4.2 Tyre dimension All tires within specification ● ● ●
4.3 Tyre inflation Properly inflated ● ● ●
4.4 Wheel nuts In place and tight ● ● ●
4.5 Park break system Working ● ● ●
No loose worn and damaged rungs or side rils
Access handrails & grab No damaged or corroded cage
4.6 No corroded guard, bolts and rivet heads ● -- --
handles for lighting tower
No slippery surfaces from oil
4.7 Noisi Level If noise level > 85 dB, then noise sticker needed ● ● ●
4.8 Body condition Bright color ● ● ●

KEPUTUSAN : DITERIMA / DITOLAK

P&M Dept. rep

HSE Dept.rep
PIK-FRM-SAF-029 (Rev.00)
Pass
Fail
Not Necessary
Necessary
 Pass
Fail
Not Necessary
Necessary

TERIMA / DITOLAK
Monthly Inspection Record
VEHICLE, TRUCK, TRAILER, DOZER, GRADER, LOADER, COMPACTOR, EXCAVATOR

Date of Inspection :
Type of Equipment :
SL No. :
Contractor / Sub Contractor :
Operator Name :

No. Item G F P N /A REMARKS

1 Driving Lissence / SIO

2 Certificates
3 Hydraulic Hose
4 Hydraulic Connection
5 General Condition / Clean Lines
6 Emergency Shut Down (ESD)
7 Electrical Cable Installation
8 Fuel Line
9 Injector
10 Nozzle Injection
11 Battery Conection
12 Spark Arrestor
13 Exhaust Tail / Manifold
14 Brake System
15 Hand Break
16 Bomm Light
17 Body Light
18 Brake Light
19 Tyres / Track ( Swamp Track )
20 First Aid Kit
21 Fire Extinguisher Condition
22 ID Number
23 Leak Test of Float Tank

Note : G = Good, F = Fair, P = Poor, N/A = Not Applicable

Authorized Inspector Signatures

Signatures
Name / BN
Date
Monthly Inspection Record
POWER GENERATOR

Date of Inspection :
Type of Equipment :
SL No. :
Contractor / Sub Contractor :
Operator Name :

No. Item G F P N /A REMARKS

1 Appearance / cleanliness
2 Engine Smooth Start Up
3 Engine Oil Level Indicator
4 Indicators ( Voltage, Fuel, Temp)
5 Earth Terminal / Ground
6 Cable Terminal
7 Earth Leakage Circuit Braker ( ELCB)
8 Switch ( On / Off )
9 Emergency Shut Down (ESD)
10 Safety Guards for Moving Parts
11 Fuse
12 Suply Cable Quality - Rating
13 Earth Cable / Pole
14 Industrial Plug
15 Flash Back Aresstor
16 Battery
17 Cable Hanged Properly
18 Socket Connection
19 Fuel Tank Cap
20 Electrode Holder
21 Inspection Tag Displayed
22 Machhine Placed at Safe Location
23 Fire Extinguisher
23 Dip Tray Pab

Note : G = Good, F = Fair, P = Poor, N/A = Not Applicable

Authorized Inspector Signatures

Signatures
Name / BN
Date
Monthly Inspection Record
WELDING MACHINE / ELECTRICAL EQUIPMENT

Date of Inspection :
Type of Equipment :
SL No. :
Contractor / Sub Contractor :
Operator Name :

No. Item G F P N /A REMARKS

1 Condition of the Welding Machine

2 Damage / Missing Parts
3 Body Structur
4 Control Level / Guards
5 Belts / Hoses
6 Battery / Tyres
7 Cable Terminal
8 Insulation
9 Condition of Supply Cable
10 Socket / Connection
11 Earth Cable
12 Emergency Shut Down (ESD)
13 Cable Orderly Located
14 Oil Plan
15 Fuel Tank Cap
16 Exhaust / Muffler / Aresstor
17 Fire Extinguisher
18 Condition of Cylinder Torch
19 Flash Back Aresstor
20 Condition of Cutting Torch
21 Electrode Holder

Note : G = Good, F = Fair, P = Poor, N/A = Not Applicable

Authorized Inspector Signatures

Signatures
Name / BN
Date
Monthly Inspection Record
COMPRESSOR

Date of Inspection :
Type of Equipment :
SL No. :
Contractor / Sub Contractor :
Operator Name :

No. Item G F P N /A REMARKS

1 Operator Trained
2 Certificate
3 Hydraulic Hose
4 Hydraulic Conection
5 General Condition / Cleanliness
6 Emergency Shut Down (ESD)
7 Fuel Line
8 Injector
9 Nozzel Injection
10 Battery Conection
11 Spark Aresstor
12 Exhaust Tail / Manifold
13 Condition of Pad Eyes
14 Tyre / Track
15 Condition of Air Tank
16 Condition of Air Pressure Gauge
17 Safety Relief Valve
18 Condition of Hose / Clamps
19 Condition of Belt Drives
20 Guarding of Revolving Parts
21 First Aid Kit
22 Fire Extinguisher

Note : G = Good, F = Fair, P = Poor, N/A = Not Applicable

Authorized Inspector Signatures

Signatures
Name / BN
Date
 AIR COMPRESSOR INSPECTION REPORT

Date of Inspection : Inspected by :

Location : NO.Reg :
Operator Name : Mark Machine :

No. Description Good Fair Poor N /A REMARKS

I ENGINE
1 Radiator Condition
2 Fan Condition
3 Cooling Water Hoses & Pipes Condition
4 Air Filter Element Condition
5 Alternator & Wiring Condition
6 Engine Oil Condition
7 Fuel Tank Free of Water & Dirty
8 Loose Fitting, Wire, Bolts
9 Battery Condition
10 Unload & Safety Valve Function
11 Instrument & Gauges Correct
12 Air Filter Element Condition
13 Oil Level in Hydraulic Tank
14 Muffler & Skid Mounted Condition
15 Tyre Pressure & Condition
16 Air System
17 Build Up of Pressure / Pressure Condition
18 Paint Work Condition
19 Machine Kept Clean
20 Any Crack Lost Bolt atc.
II RUNNING CHECKS
1 Correct Operation of Starter
2 All Gauges & Indicator Correct
3 Engine Fuel Leaks
4 Engine Water Leaks
5 Any Bad Noise on Machine
6 Exhaust Gases Clear
III CONSUMPTION ( liters/day)
1 Engine Oil
2 Water
3 Oil Filter 2 EA for Camp
4 Oil Filter 2 EA for Engine
Comments :

Note : G = Good, F = Fair, P = Poor, N/A = Not Applicable

Authorized Inspector Signatures

Signatures
Name / BN
Date
Monthly Inspection Record
Excavator

Date of Inspection :
Type of Equipment :
SL No. :
Contractor / Sub Contractor :
Operator Name :

No. Item G F P N /A REMARKS

1 Crawler Condition
2 Driver Lisence ( SIO )
3 Linkages / Pins
4 Driver Chain
5 Bucket
6 Hydraulic Arms
7 Hydraulic Hose
8 Operator Access
9 Control Identified
10 Engine Condition
11 Engine Exhaust Noise
12 Reversing Alarm
13 Battery Cover
14 Lighting
15 Fire Extinguisher
16 Horn
17 First Aid Kit
18 Other

Note : G = Good, F = Fair, P = Poor, N/A = Not Applicable

Authorized Inspector Signatures

Signatures
Name / BN
Date
 DAILY OPERATOR CHECKLIST
Buldozer

Satisfactory Action Required A. Maintenance Scheduled

Description
Mon Tue Wed Thu Fri Sat Sun
Crawler Condition
Linkages / Pins B. Repair / Maintenance Record Date
Drive Chain
Drive Machines
Ripper Condition Operation
Blade Condition Operation
Hydraulic Arms
Hydraulic Hose
Operator Access C. Record of Anomaly
Control Identified
Roll Protection
Engine Condition Mon Inspected By : Signature :
Engine Exhaust Noise Tue Inspected By : Signature :
Reversing Alarm Wed Inspected By : Signature :
Battery Cover Thu Inspected By : Signature :
Lighting Fri Inspected By : Signature :
Fire Extinguisher Sat Inspected By : Signature :
Horn Sun Inspected By : Signature :
Chain Track Condition Supervisor Signature :
Other
 DAILY OPERATOR CHECKLIST
Vehicle,Trailer, Grader, Compactor, Excavator

Satisfactory Action Required A. Maintenance Scheduled

Description
Mon Tue Wed Thu Fri Sat Sun
Driving License / SIO
Certificates B. Repair / Maintenance Record Date
Hydraulic Hose
Hydraulic Conection
General Condition / Clean Lines
Emergency Shut Down (ESD)
Electrical Cable Installation
Fuel Line
Injector C. Record of Anomaly
Nozzle Injection
Battery Conection
Spark Aresstor Mon Inspected By : Signature :
Exhaust Tail / Manifold Tue Inspected By : Signature :
Brake System Wed Inspected By : Signature :
Hand Brake Thu Inspected By : Signature :
Boom Light Fri Inspected By : Signature :
Body Light Sat Inspected By : Signature :
Brake Light Sun Inspected By : Signature :
Tyres / Track (Swamp Track) Supervisor Signature :
First Aid Kit
Fire Extinguisher
Id Number
Leak Test of Float Tank
Other
 DAILY OPERATOR CHECKLIST
Air Compressor

Satisfactory Action Required A. Maintenance Scheduled

Description
Mon Tue Wed Thu Fri Sat Sun
Engine
Engine Moving Parts B. Repair / Maintenance Record Date
Engine Oil / Filter / Piping
Cooling System
Fuel System
Exhaust System
Battery
Starter Motor / Dinamo
Compressor C. Record of Anomaly
Operating Setatus
Cylinder Case
Housing Mon Inspected By : Signature :
Safety Valve / Unloader Valve Tue Inspected By : Signature :
Air Receiver Wed Inspected By : Signature :
Air Cock / Drain Cock Thu Inspected By : Signature :
Miscellaneous Fri Inspected By : Signature :
House / Door Sat Inspected By : Signature :
Career / Wheels Sun Inspected By : Signature :
Gauge ( Pressure/ Temperature ) Supervisor Signature :
Safe Guards for Moving Parts
 DAILY OPERATOR CHECKLIST
Welding Machine / Electrical Equipment

Satisfactory Action Required A. Maintenance Scheduled

Description
Mon Tue Wed Thu Fri Sat Sun
Engine Condition
Exhaust Isolation B. Repair / Maintenance Record Date
Exhaust Spark Aresstor
Moving Parts Protection
Battery Cover
Control Indicator
Frame / Skid
Grounding Cable
Negative Clamps C. Record of Anomaly
Fire Extinguisher
Cable & Conection
Fuel Tank Mon Inspected By : Signature :
Emergency Shut Down (ESD) Tue Inspected By : Signature :
Cleanlines Wed Inspected By : Signature :
Thu Inspected By : Signature :
Fri Inspected By : Signature :
Sat Inspected By : Signature :
Sun Inspected By : Signature :
Supervisor Signature :
 Date : __________________________
To : HSE Coord./Mgr.
From : HSE Supv./Officer.
Location : __________________________
CC : Site Supv./Site Mgr.

DAILY HSE INFORMATION REPORT

LAPORAN HARIAN INFORMASI HSE

PERSONNAL PROTECTIVE EQUIPMENT (PPE) SAFETY EQUIPMENT AND TOOLS

ALAT PELINDUNG DIRI (APD) PERALATAN KESELAMATAN

ITEMS PPE Day Night Total Condition SAFETY EQPT. Total Unit Condition Remarks
No N0
NAMA APD Siang Malam Jumlah Good Bad Alat Keselamatan Jumlah Satuan Good Bad Keterangan

1 Safety Helmet 1 First Aid Kit Kit

2 Safety Shoes 2 Fire Extinguisher Pack

3 Safety Rubber 3 Fire Pump Ea

4 Hand Glove 4 Life Jacket Ea

5 Badge 5 Stretcher Ea

6 safety Goggles 6 Wind Shock Ea

7 Ear Muffler 7 Alarm Ea

8 Ear Plug 8 ESD Ea

9 Afron 9

10 Masker 10

11 11
12 12

Unsafe Action & Unsafe Condition : HSE Awarness / Kepedulian HSE Siang Malam Jumlah

Describtion Action Taken Who 1 Risk Assessment

2 Tool Box Meeting

3 Safety Talks

4 Others

MAN HOURS & CREW STATUS (JAM KERJA STATUS KRU): Note / Catatan / Usulan :

No Shift / Schedule MP WH MH Total Health

1 Day / Siang

2 Night / Malam

MP = Man Power, WH = Working Hour, MH = Man Hour

Reported by : Checked by : Approved by :

________________________ ______________________ ________________________

HSE Supv. / HSE Officer Site Supervisor / Supv. Site Manager
 Formulir Laporan Kesehatan dan Kebersihan
Ruang Makan / Dapur / Tempat Tinggal / Binatu

Tanggal
Waktu
Pelakasana : Lokasi

Yes / No/
A SANITASI UMUM
Belum Tersedia

Apakah persediaan air panas (82 C) dan air dingin cukup

1
memadai ?
Apakah air tersebut lulus pengujian dan boleh untuk konsumsi
manusia ? (tanggal terakhir pengujian)
2 Apakah alat pembersih cukup memadai ?
Apakah tersedia wadah yang sesuai dan bersih untuk
3
pembuangan sisa makanan dan puing - puing lainnya ?
Di dalam :

Di luar :

Apakah area sekeliling wadah pembuangan itu bersih, bebas

serangga, binatang pengerat dan binatang kecil lainnya dan
dekat dengan tempat pembuangan yang semestinya ?
Apakah semua tabung air minum dibersihkan sekali seminggu
4
?
Apakah semua mesin untuk membuat es dibersihkan sekali
5
seminggu dengan sempurna ?

B KEBERSIHAN PERORANGAN

Apakah petugas yang menangani makanan menderita infeksi

kulit, luka, flu yang berat, mata dan telinga yang
1 berair/bernanah, diare, muntah-muntah, atau penyakit lainnya
diberhentikan dari tugasnya sementara untuk menangani
makan sampai mereka sehat ?
Apakah semua petugas dapur memakai pakaian yang bersih,
2
dapat dicuci, pakaian pelindung yang berwarna terang ?
3 Apakah semua petugas dapur memakai penutup kepala topi?
Apakah semua petugas dapur berhenti merokok atau
4
mengunyah peremen karet untuk sementara ?
Apakah semua petugas dapur tidak memakai anting, jam
5 tangan, cincin atau perhiasan lainnya untuk sementara
waktu ?
 Apakah semua petugas dapur tidak memakai anting, jam
5 tangan, cincin atau perhiasan lainnya untuk sementara
waktu ?
Apakah semua petugas dapur memakai sepatu tertutup ?
6
(bukan sandal atau tanpa sepatu)
Apakah ada fasilitas untuk mencuci tangan (dengan handuk)
7
dan digunakan pada waktu :

Apakah telah dilakukan pengujian kualitas air limbah domestic

6
?
Bila "ya" apakah hasil pengujian telah sesuai dengan baku
7
mutu air limbah domestic (Kep.MENHL/No.112/Thn 2003)
C Sanitation and Waste Disposal
Apakah tersedia jadwal pembersihan AC/kipas angin, lantai
1
ruangan, dapur, ventilasi udara ?
Apakah tersedia jadwal pembersihan Frezer, kulkas, peralatan
2
memasak dan sebagainya ?
3 Apakah tersedia bak sampah khusus sisa makanan ?

4 Apakah bak sampah tersebut tertutup dan dilengkapi plastik ?

Apakah bak sampah tersedia di luar canteen sesuai jenis
5
sampah dan warna ?
Apakah jumlah bak sampah sesuai (cukup) dengan sampah
6
yang dihasilkan ?
7 Apakah tersedia program vektor control ?
Apakah sampah di bak sampah dibawa ke TPA setiap
8
harinya ?
9 Apakah area di sekitar canteen selalu bersih ?
Apakah tersedia wastafel di dapur dan di ruang makan
10
karyawan ?
Apakah tersedia WC & Kamar Mandi untuk karyawan canteen
11
?
Apakah tersedia WC & Kamar Mandi sesuai (cukup) dengan
12
jumlah karyawan ?
Apakah saluran air limbah dari WC, Kamar Mandi, Laundry
13
telah dilengkapi dengan pengolahan air limbah ?
Apakah tersedia jadwal pembersih kamar mandi, WC, dapur
14
dan sebagainya ?

Audit by, Acknowledged by,

( ____________________ ) ( ____________________ )
an Kebersihan
gal / Binatu

:
:
:

Comment
Acknowledged by,
( ____________________ )
 ENVIRONMENT AUDIT

Attendance :

Location :

A General Building and Equipment Yes No Comment

Ruang Makan
Apakah luas ruang makan karyawan telah sesuai dengan
1
jumlah karyawan yang dilayani ?
Apakah ruang makan dilengkapi dengan ventilasi udara dan
2
sirkulasi udara berjalan dengan baik ?
Apakah ruang makan telah dilengkapi dengan AC / kipas
3
angin ?
4 Apakah ventilasi udara dengan kawat kasa ?

5 Apakah penerangan di ruang makan cukup memadai ?

6 Apakah kondisi lantai ruang makan dan teras selalu bersih ?

7 Apakah rak tempat sayuran dan lauk pauk selalu bersih ?

Dapur
1 Apakah tata ruang dapur layak untuk aktifitas memasak ?
Apakah lantai dan peralatan memasak selalu dalam keadaan
2
bersih ?
3 Apakah lampu penerangan cukup memadai ?

4 Apakah ventilasi dapur cukup baik ?

5 Apakah ventilasi dapur dilengkapi dengan kawat kasa ?

Apakah tersedia jadwal pembersih peralatan dapur dan
6
memasak ?
B Drainage

1 Apakah saluran telah dibuat ?

Apakah air limbah domestik (black waste) telah dibuat septick
2
tank ?
Apakah saluran air limbah (grey waste), black waste, laundry
3
dibuat terpisah ?
Apakah saluran limbah (grey waste, black waste dan laundry)
4
telah dilengkapisistem pengolahan air limbah ?
Apakah telah dilakukan pengukuran debit air limbah (grey
5
waste, black waste,laundry) ?
Apakah telah dilakukan pengujian kualitas air limbah domestic
6
?
 Bila "ya" apakah hasil pengujian telah sesuai dengan baku
7
mutu air limbah domestic (Kep.MENHL/No.112/Thn 2003)
C Sanitation and Waste Disposal
Apakah tersedia jadwal pembersihan AC/kipas angin, lantai
1
ruangan, dapur, ventilasi udara ?
Apakah tersedia jadwal pembersihan Frezer, kulkas, peralatan
2
memasak dan sebagainya ?
3 Apakah tersedia bak sampah khusus sisa makanan ?

4 Apakah bak sampah tersebut tertutup dan dilengkapi plastik ?

Apakah bak sampah tersedia di luar canteen sesuai jenis
5
sampah dan warna ?
Apakah jumlah bak sampah sesuai (cukup) dengan sampah
6
yang dihasilkan ?
7 Apakah tersedia program vektor control ?
Apakah sampah di bak sampah dibawa ke TPA setiap
8
harinya ?
9 Apakah area di sekitar canteen selalu bersih ?
Apakah tersedia wastafel di dapur dan di ruang makan
10
karyawan ?
Apakah tersedia WC & Kamar Mandi untuk karyawan canteen
11
?
Apakah tersedia WC & Kamar Mandi sesuai (cukup) dengan
12
jumlah karyawan ?
Apakah saluran air limbah dari WC, Kamar Mandi, Laundry
13
telah dilengkapi dengan pengolahan air limbah ?
Apakah tersedia jadwal pembersih kamar mandi, WC, dapur
14
dan sebagainya ?

Audit by, Acknowledged by,

( ____________________ ) ( ____________________ )
MONTHLY SAFETY TALK EXECUTION REPORT
Laporan Bulanan Pelaksanaan Wicara Keselamatan Kerja

Date Ref
Tgl Ref

Company PT. Perkasa Inakakerta Period Januari 2008

Perusahaan Periode

Date Time # of Participant Location Title Speaker Attended by

Tanggal Jam Jumlah Peserta Lokasi Judul Pembicara Dihadiri oleh
04 Januari 2008 6.45 39 Jetty Disiplin Harapan Manurung -

07 Januari 2008 6.3 31 Blok Beruang Disiplin Sudirman Calangga Site Management
KTT
 /AM

Remarks
Keterangan
 SAFETY INSPECTION CHECK LIST
(YARD AND WORKSHOP)

Site / Location :
Supervisor :

NO. DESCRIPTION YES NO N/A REMARKS

I PENCEGAHAN DAN PERLINDUNGAN KEBAKARAN

. Alat pemadam api tersedia dan siap dipakai
. Alat pemadam diinspeksi dan ditandai
. Karyawan memahami semua prosedur
. Material kayu tersimpan dengan baik
. Material mudah terbakar tersimpan dengan baik
. Kain bekas tersempin di dalam tempat tertutup
. Ijin kerja panas

II HOUSE KEEPING
. Lokasi Kerja Nampak Rapi
. Bahan mentah tersimpan dengan baik
. Tempat berjalan rapi dan bersih
. Rute darurat bersih dan tanpa halangan
. Sampah-sampah dibuang secara teratur
. Tumpahan minyak dan greas segera dibersihkan
. Tempat sampah tersedia dan digunakan
. Tidak ada bahaya material jatuh
. "Dilarang Merokok" terpasang di tempatnya
. Tersedia air minum layak minum
. Cukup Penerangan
. Tempat kerja serta lingkungan yang sehat
. Tidak ada benda tajam berserakan

III SAFETY SIGNAL, and BARRICADES

. Daerah berbahaya dilengkapai barikade
. Daerah berbahaya ditandai dengan jelas
. Tanda khusus untuk peralatan tak aman

IV TOILET

V KEAMANAN LISTRIK
. Instalasi dan kabel-kabel yang sesuai
. Tersedia Fuse
. Kabel-kabel listrik tidak ada yang luka
. Tanda-tanda untuk peringatan bahaya listrik
. Tersedia alat pemadam yang sesuai
. Penyimpanan dan perawatan yang sesuai
. Dilaksanakan prosedur Lock/Tagout
. Gudang penyimpanan material mudah terbakar terisolir

VI ALAT PELINDUNG DIRI

. Topi pengaman digunakan
. Alat pelindung kaki yang sesuai digunakan
. Pelindung telinga digunakan pada saat diperlukan
. Prosedur Inspeksi APD dilaksanakan
. Alat pernapasan yang sesuai digunakan pada saat diperlukan
. Dilakukan fit-test pada alat pernapasan
. Alat pernapasan dibersihkan dan disimpan dengan baik
. Masing-masing memiliki alat pernapasan
. Pelindung untuk pekerja di atas 6 kaki (Hardness)

VII WALKWAYS
 SAFETY INSPECTION CHECK LIST
(YARD AND WORKSHOP)

VIII PENERANGAN
. Lampu Emergency tersedia

IX PERALATAN TANGAN & LISTRIK

. Alat diinspeksi secara berkala
. Alat yang rusak segera diperbaiki
. Sistem grounding terpasang dan bekerja dengan baik
. Peralatan terpakai dilengkapi dengan saklar
. Perkakas tersimpan rapih bila tidak dipakai
. Peralatan yang dipakai berisolasi dengan ganda
. Pelindung mesin terpasang dengan rapih

X WELDING, CUTTING, and GRINDING

. Selang-selang tidak bocor atau rusak
. Ground mesin las telah diperiksa
. Welder mengenakan tangan panjang kulit
. Kacamata dan pelindung mata dipakai
. Lokasi pengelasan terisolir, terlindungi
. Pengawasan pengelasan dan alat pemadam siap dipakai
. Daerah pengelasan bebas potensi kebakaran
. Torches dinyalakan dengan friction lighters

XI GAS BERTEKANAN
. Semua slinder gas terikat dengan rapih
. Selinder oksigen dan selinder gas terpisah
. Isi selinder ditandai dengan baik
. Penutup valve selinder terpasang selama transportasi
atau tidak dipakai
. Torches dilengkapi dengan Flashback arrestor

XII TANGGA
. Sesuai untuk digunakan
. Terpasang tempat pijakan (non-slip)
. Tangga terikat dengan baik
. Tangga cukup panjang untuk digunakan
. Parbandingan pitch kurang dari 1:4
. Pemeriksaan terhadap kondisi tangga

XIII SCAFFOLDING
. Rail pelindung dan toeboards terpasang
. Terpasang dengan baik
. Lantai rata dan kuat
. Lantai cukup kuat menyanggah perancah
. Penghalang dipasang di sekitar perancah

XIV KOMUNIKASI BAHAYA

. Program tertulis
. Daftar bahan kimia berbahaya
. Arsip MSDS terpelihara dengan baik
. Semua bahan- bahan kimia diberi label
. Material Emergency Spill Control siap dipakai

XV ALARM / SMOKE DETECTORS

 SAFETY INSPECTION CHECK LIST
(YARD AND WORKSHOP)

Comments / Action :

Inspected By : Verified :

Date : Date :

Signature : Signature :
 CHAIN BLOCK MACHINE INSPECTION CHECK LIST

Date : Location :

LOAD HANGING SAFETY

NO. NO / TYPE SWL CHAIN CONDITION REMARKS
HOOK OUT LATCH

Inspected By : Verified :
Date : Date :
Signature : Signature :
 GRINDING MACHINE INSPECTION CHECK LIST

Date : Location :

CONDITION
NO. TYPE NO. CODE REMARKS
GOOD FAIR BAD

NOTE
To be checked Inspected By : Verified :
Cable & Connection Date : Date :
Spark Protection Cover Signature : Signature :
Max. Speed
Max. RPM
Grinding Disc RPM
 ELECTRICAL EQUIPMENT INSPECTION CHECK LIST

Date : Location :

SERIAL CONDITION
NO. TYPE OF EQUIPMENT REMARKS
NUMBER GOOD FAIR BAD

Inspected By : Verified :
Date : Date :
Signature : Signature :
 WELDING MACHINE INSPECTION CHECK LIST

Date : Location :

CONDITION
NO. TYPE NO. CODE REMARKS
GOOD FAIR BAD

NOTE
To be checked Inspected By : Verified :
ESD System Date : Date :
Exhaust heat protection & spark Aresstor Signature : Signature :
Welding Cable Connection
Ground Cable Clamp
Battery Connection
General Condition of Machine
Placement of Welding Machine
 GAS CYLINDER INSPECTION CHECK LIST

Date : Location :

CONDITION
NO. DESCRIPTION / DESKRIPSI REMARKS
GOOD FAIR BAD

1 Oxygen

1.1 Bottle

1.2 Regulator Gauge

1.3 Flash back Arrestor

1.4 Cutting Touch

1.5 Hoses

2 LPG / ACETYLINE

2.1 Bottle

2.2 Regulator Gauge

2.3 Flash back Arrestor

2.4 Cutting Touch

2.5 Hoses
Comment :

Inspected By : Verified :
Date : Date :
Signature : Signature :