TEP Self Verification Record Sheet Rev.

Date: Purpose
Location:

Task / Activity : The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at the Tangguh Greenfield Site is executed in line with
the Greenfield Construction Control of Work/TEP-930-PRC-
Name of Verifiers : HS-BP4-0002 Procedure and associated relevant
Persons Interviewed or Supervisor: documentation under the CSTS Management System
Sub-Contractor:

Doc. Compliance
Bypassing Safety Controls Comments / Remarks
Reference YES / NO / NA

Do I see evidence of equipment such as fire suppression, detection, pressure controls,

electrical systems clearly identified & well maintained?Apakah saya melihat bukti
1
peralatan seperti pemadam kebakaran, deteksi, kontrol tekanan, sistem kelistrikan yang
diidentifikasi dengan jelas & terpelihara dengan baik?

Are personnel aware of the safety critical equipment that is present within their work
2 location and understand its use?Apakah personel mengetahui peralatan kritis
keselamatan yang ada di lokasi kerja mereka dan memahami penggunaannya?

Do I observe unauthorised override/ bypass of safety critical systems, e.g. disabling of

limit switches, alarm cancelled etc.?Apakah saya mengamati override/bypass yang tidak
3
sah dari sistem kritis keselamatan, mis. menonaktifkan sakelar batas, alarm dibatalkan,
dll.?

Are any safety critical systems that have been disabled/ overridden & alternative control
measures clearly communicated to personnel during appropriate moments, e.g. tool-box
4 talk?Apakah ada sistem kritis keselamatan yang telah dinonaktifkan/diganti & tindakan
pengendalian alternatif dikomunikasikan dengan jelas kepada personel pada saat yang
tepat, mis. pembicaraan kotak alat?

Ask personnel what procedure/s should be employed if safety critical equipment needs to
5 be isolated Tanyakan kepada personel prosedur apa yang harus digunakan jika peralatan
kritis keselamatan perlu diisolasi

Ask the supervisor to explain what alternative control measures will be provided if a safety
critical system is isolated to allow work to be performed. Minta penyelia untuk
6
menjelaskan tindakan pengendalian alternatif apa yang akan diberikan jika sistem kritis
keselamatan diisolasi untuk memungkinkan pekerjaan dilakukan.

Are safety critical systems inspected, tested & recorded in compliance with standard
7 operating procedures?Apakah sistem kritis keselamatan diperiksa, diuji & dicatat sesuai
dengan prosedur operasi standar?

Are system overrides authorised & recorded in appropriate documentation?Apakah

8
penggantian sistem diotorisasi & dicatat dalam dokumentasi yang sesuai?

Are there records of Safety Critical Equipment being bypassed? Apakah ada catatan
9
Peralatan Kritis Keselamatan yang dilewati?

10

11

12

13

14

15

16

17

18

19

20

21

22

23

Percentage of Implementaion #DIV/0!

RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
1
2
3
4
5
 TEP Self Verification Record Sheet Rev.0

Date: Purpose
Location:

Task / Activity : The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at the Tangguh Greenfield Site is executed in line with
the Confined Space Entry/TEP-930-PRC-HS-BP4-0016
Name of Verifiers : Procedure and associated relevant documentation under the
Persons Interviewed or Supervisor: CSTS Management System
Sub-Contractor:

Doc. Compliance
Confined Space Entry Comments / Remarks
Reference YES / NO / NA

Have considerations been given to the possibility of eliminating the need for
1 confined space entry?Apakah pertimbangan telah diberikan untuk kemungkinan
menghilangkan kebutuhan untuk masuk ruang terbatas?

Have the necessary permits, entry certificate(s) and isolation documents been
2 completed and posted at the worksite?Apakah izin, sertifikat masuk, dan dokumen isolasi
yang diperlukan telah dilengkapi dan dipasang di tempat kerja?

is the Isolaction Control Certificate approved by Isolated Authority, designated by

3 Commissioning Manager?Apakah Sertifikat Kontrol Isolasi disetujui oleh Otoritas
Terisolasi, yang ditunjuk oleh Manajer Komisioning?

4 Has a risk assessment been completed? Apakah penilaian risiko telah selesai?

Are all personnel involved in the task aware of the hazards and controls? Apakah semua
5
personel yang terlibat dalam tugas sadar akan bahaya dan pengendaliannya?

Has the Responsible Person (RP) been designated and identified on the permit? Apakah
6
Penanggung Jawab (RP) telah ditunjuk dan diidentifikasi dalam izin?

Are all persons involved in the confined space entry competent and trained? Apakah
7
semua orang yang terlibat dalam entri ruang terbatas kompeten dan terlatih?

Have suitable atmospheric tests been conducted, verified and repeated as

required? These may include O2, LEL, H2S, etc. Apakah pengujian atmosfer yang sesuai
8
telah dilakukan, diverifikasi, dan diulangi jika diperlukan? Ini mungkin termasuk O2, LEL,
H2S, dll.

Where required, have the neceesary checks on the breathing apparatus been
9 conducted and is it being used? Jika diperlukan, apakah pemeriksaan yang diperlukan
pada alat bantu pernapasan telah dilakukan dan apakah alat tersebut digunakan?

Have the employee obtained authorization to enter the confined space? Sudahkah
10
karyawan memperoleh otorisasi untuk memasuki ruang terbatas?

Is there an attendant assigned, continually on-station and in communication

11 while personnel are in the confined space? Apakah ada petugas yang ditugaskan, terus-
menerus di stasiun dan berkomunikasi saat personel berada di ruang terbatas?

Has clear communication been established between the entrants and attendant, and
between the attendant and rescue personnel? This may be voice contact, radio, pre-
12 arranged signals, whistles etc. Apakah komunikasi yang jelas telah terjalin antara
pendatang dan petugas, dan antara petugas dan petugas penyelamat? Ini mungkin
kontak suara, radio, sinyal yang telah diatur sebelumnya, peluit, dll.

Have barriers and signage been put in place to prevent unauthorized entry? Apakah
13 penghalang dan tanda telah dipasang untuk mencegah masuknya orang yang tidak
berwenang?

Is a rescue plan in place and responders notified and available? Apakah ada rencana
14
penyelamatan dan responden diberitahu dan tersedia?

Have SIMOPS issues that may conflict with this work been considered? Apakah masalah
15
SIMOPS yang mungkin bertentangan dengan pekerjaan ini telah dipertimbangkan?

Is change management (MOC) used to manage any scope or permit changes? Apakah
16 manajemen perubahan (MOC) digunakan untuk mengelola ruang lingkup atau
mengizinkan perubahan?

Do employees understand that they have the authority and expectation to stop activity if
feel unsafe or find unsafe condition? Apakah karyawan memahami bahwa mereka
17
memiliki wewenang dan harapan untuk menghentikan aktivitas jika merasa tidak aman
atau menemukan kondisi tidak aman?

Did the risk assessment or pre-job discussion include any lessons from past
18 incidents from similar work? Apakah penilaian risiko atau diskusi pra-pekerjaan
memasukkan pelajaran dari kecelakaan kerja serupa?

Has the work crew received positive feedback on raising concerns and
information on what is being done related to concerns raised? Apakah kru kerja
19
menerima umpan balik positif dalam menyampaikan kekhawatiran dan informasi tentang
apa yang sedang dilakukan terkait dengan masalah yang diangkat?

Is there STARRT card for the activity, properly filled and communicated to the crew?
20 Apakah ada kartu STARRT untuk kegiatan tersebut, diisi dengan benar dan
dikomunikasikan kepada kru?

Percentage of Implementaion #DIV/0!

RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
1
2
3
4
5
 TEP Self
Date:

Location:

Task / Activity / aktivitas

Permit Number / Nomor Permit

Name of Verifiers / Pemeriksa

Persons Interviewed or Supervisor:

Sub-Contractor:

Process, Plan or Procedure to be Verified

WORKING AT HEIGHT Procedure (TEP-930-PRC-HS-BP4

DOCUMENTS/ADMINISTRATION /POLICY/ PROCEDURE

 Is there a validated permit available adequately describing th
out containing all manadatory signatures, dates, location, equ
etc? (Grating/Handrail Removal & Open Hole Work Permit)
Apakah permit yang divalidasi tersedia dan menjelaskan den
1 tugas yang sedang dilakukan yang berisi semua tanda tanga
tanggal, lokasi, peralatan yang digunakan.(Grating/Pemindah
kerja membuka lubang)
No. Reference :
(………………………………………………………………………

Is there a validated JSA avaialble adequately describing the t

out which identifes the relevant hazards and controls to carry
( SCAFFOLDING, and other Task that required working at he
Apakah JSA yang divalidasi tersedia secara memadai mengg
2 yang sedang dilakukan yang mengidentifikasi bahaya dan ko
untuk melaksanakan pekerjaan dengan aman? (Perancah, da
yang dibutuhkan untuk pekerjaan ketinggian)
No. Reference : (……………………………………………………
…………..)

Is there a validated Method Statement available which adequ

task being carried out?
3
Apakah Method Statement yang divalidasi tersedia yang cuku
menjelaskan mengenai pekerjaan?
 Are all other supplementary certificates referenced in the abo
available for review? E.g Lifting plan, MSDS, Gas Check, Res
Underground Clearance, etc( ISOLATION CERTIFICATE , LI
UPDATED AND reviewed )
4
Apakah semua sertifikat tambahan lainnya dirujuk dalam dok
tersedia untuk ditinjau? Seperti renacana pengangkatan, MS
Rencana penyelamatan, Izin pekerjaan underground ( Sertifik
terbaru dan direview )

Has SIMOPS been assessed, and all relevant parties notified

MATRIx regarding work at height shall be attached in work pe
5
Apakah SIMOPS telah dinilai, dan semua pihak terkait diberit
MATRIX mengenai bekerja di ketinggian harus dilampirkan k

Pre Start Communication to the Workers (Sometimes referred to

Was a STARRT meeting held with the workforce prior to the w

1
Apakah diskusi STARRT diadakan dengan pekerja sebelum

Has the STARRT Card been signed by all relevant personel?

(Workers/Supervision)
2
Apakah Kartu STARRT telah ditandatangani oleh semua pers
(Pekerja/Pengawasan)

Has the STARRT Card been filled correctly and verified all re
3
Sudahkah Kartu STARRT diisi dengan benar dan diverifikasi
 Does the Description of the STARRT adequately reflect the w
4 out?
Apakah Deskripsi STARRT cukup mencerminkan pekerjaan y

Do the Hazards and Controls identified on the STARRT shee

the task?
5
Apakah Bahaya dan Kontrol yang diidentifikasi pada lembar S
mencerminkan tugas?

Has the person who held the STARRT meeting received train
6
Apakah orang yang mengadakan pertemuan STARRT mene

Are at least 2 members of the work force able to identify at le

hazards and controls on the STARRT sheet? (Not counting th
INDEPENDANTLY questioned?
7
Apakah setidaknya 2 anggota angkatan kerja dapat mengide
50% dari bahaya dan kontrol pada lembar STARRT (Tidak te
dipertanyakan secara INDEPENDEN?

WORK EXECUTION - WORKING AT HEIGHT

Have all workers who are involved in the working at height ta

at height training? (If possible check their training passport)
1
Sudahkah semua pekerja yang terlibat dalam tugas ketinggia
menghadiri pelatihan ketinggian? (Jika mungkin periksa pasp
 Are worker wearing full body harnesses when they work at he
meter) and tied off when they were exposed to the fall throug
2 Apakah pekerja mengenakan full body harness ketika mereka
ketinggian (lebih tinggi dari 1,8 meter) dan terikat ketika ada r
celah?

Has the personal fall arrest system follow the project requirem
lanyard, shock absorber,double latch self- locking snap hooks
of synthetic fiber) are they inspected and color coded as per p
3 Apakah personal fall arrest system sesuai dengan persyarata
lanyard, shock absorber, double latch self-locking snap hooks
made of synthetic fiber), apakah diinspeksi dan dikode warna
prosedur proyek?

Are any anchor points available on the working plaform to be

people falling? (It should not sharp edges, and it should be ab
4 height)
Apakah anchor points tersedia diatas platform untuk dikaitkan
terjatuh? (Seharusnya tidak tajam, dan harus di atas ketinggi

Do workers NOT tie off to the line of fire, gas lines, instrumen
work less than 3 inches in diameter?
5
Apakah pekerja TIDAK mengikat harness ke jalur berbahaya
instrumen, atau pipa apa pun yang berdiameter kurang dari 3
 Are temporary platforms, been inspected regurally by compet
inspection tag being displayed at the main entry?
6
Apakah platform sementara, telah diperiksa secara berkala o
kompeten dan tanda inspeksi ditampilkan di jalur masuk utam

Are temporary platforms, such as scaffolding platform, mobile

prevented to move during work at height?
7
Apakah platform sementara, seperti platform perancah, platfo
dicegah untuk bergerak saat bekerja di ketinggian?

Are all the opening covered or protected by scaffolding barrie

warning signs displayed to minimize people to fall or accident
opening?
8
Apakah semua bukaan tertutup atau dilindungi oleh penghala
apakah tanda peringatan ditampilkan untuk meminimalkan or
sengaja memasuki bukaan?

Are areas below where working at height are conducted barri

required, such as scaffolding task, welding, cutting, or lifting?
9
Apakah area di bawah pekerjaan di ketinggian dibarikade saa
pekerjaan perancah, pengelasan, pemotongan, atau pengang

Have portable ladder/step ladder been inspected and color co

10
Sudahkah tangga portabel/anak tangga diperiksa dan diberi k
 Are portable ladders placed at not slippery surface (with anti s
angle 75 degree, secured the top and the bottom, and 1m of
protruded for 1m? (If a ladder is 4 meter long, it should be pro
above the platform( 4:1 ))
11
Apakah tangga portabel ditempatkan pada permukaan yang
anti slip), dengan sudut 75 derajat, diamankan bagian atas da
tangga menonjol diatas sepanjang 1 m? (Jika sebuah tangga
meter, itu harus menonjol sejauh 1 meter di atas platform (4:

Do workers follow the 3 points contact rule when they are usi
12 Apakah pekerja mengikuti aturan 3 titik kontak ketika mereka
tangga?

Do workers carry documents and equipment with back pack o

carrying by hands?
13
Apakah pekerja membawa dokumen dan peralatan dengan ta
tas alat daripada membawa dengan tangan?

Are all equipment, which are less than 5 kg, attached with ma
lanyards when working at height? (for tools weight 5 kg shall
wire use as tools lanyard )
14
Apakah semua peralatan, yang kurang dari 5 kg, terpasang d
yang diproduksi saat bekerja pada ketinggian? (untuk alat be
menggunakan kawat bersertifikat 4 mm sebagai alat lanyard)
 Are tool bags for lifting/hoisting attached SWL and rope with d
and proper safe knot for manual hoisting? And are the areas
exclusive zone/dropped zone?
15
Apakah tas peralatan untuk mengangkat tercantum SWL dan
dengan diameter 12 -15 mm dan simpul aman untuk pengang
apakah area di bawah ini dibarikade untuk zona eksklusif/zon

Are all opening, such as grating and handrail removal, or pen

with hard barricades with scaffolding tubular and wrapped wit
and safety sign in Bahasa and English?
16 Apakah semua bukaan, seperti pemindahan grating dan mem
penetration, dibarikade dengan hard baricade dengan tubular
dibungkus dengan pita merah putih dan tanda keselamatan d
Bahasa Inggris?

Are cables, hoses, and leads elevated above 1.8 meter with p
to minimize tripping and tangling hazards, and blocking acces
17 Apakah kabel, selang, dan timah dinaikkan di atas 1,8 meter
kabel yang tepat untuk meminimalkan bahaya tersandung da
memblokir akses?

Are there any sparks or slug catcher (containment) below the

if possible the area below the hot work shall be barricaded wi
tape)?
18
Apakah ada percikan api atau slug catcher (penampung) di b
pekerjaan panas? (atau jika mungkin area di bawah pekerjaa
dibarikade dengan pita merah dan putih)?
 Are materials or waste kept/stored in designated area to avoi
or becoming potential drop object?
19
Apakah bahan atau sampah disimpan di tempat khusus untu
tertendang atau menjadi potensi benda terjatuh?

Are tool bags or boxes available to store any small materials,

during working at height? (bolt, nuts, nails, wrench, or such m
drop through small opening)
20
Apakah tas peralatan atau kotak alat tersedia untuk menyimp
yang dibawa selama bekerja di ketinggian? (baut, mur, paku,
bahan semacam itu yang bisa jatuh melalui celah kecil)

Are Mobile Elevating Works Platform (MEWP) carrying overs

be an obstruction or potential dropping object inside the bask
21 Apakah Mobile Elevating Works Platform (MEWP) membawa
besar yang bisa menjadi penghalang atau benda menjatuhka
keranjang?

Are MEWP equiped with fall prevention, such as guard rail wi

boards, anti slip floor, or anchor points?
22
Apakah MEWP dilengkapi dengan pencegahan jatuh, seperti
tengah dan toe board, lantai anti slip, atau titik angkur?

Is banksman/flagman to assist the movement of the MEWP?

23
Apakah bankman/flagman membantu gerakan MEWP?

EMERGENCY PREPAREDNESS/WORKER PROTECTION

 Is all emergency equipment identified and required for the sp
in cetification and ready for use? e.g Spill Kit, Fire extinguishe
Aid Kit, Stretcher etc (Tripod, Gottcha rescue kits, etc)
1
Apakah semua peralatan darurat diidentifikasi dan diperlukan
yang tersedia, dalam sertifikasi dan siap digunakan? Contoh
extinguisher, Eye Wash, First Aid Kit, Stretcher dan sebagain

Have persons received adeqaute training or familiarisation in

specificed emergency equipment or duties for the task. E.g. D
Aider, Firewatcher. Emergency Auxilary team .
2
Sudahkah personel menerima pelatihan atau pengenalan yan
penggunaan peralatan darurat atau tugas tertentu untuk tuga
First aider yang ditunjuk, firewatcher, tim darurat tambahan

Do workers know what to do in the event of an emergency? -

of the team (1) how to raise the alarm/notify emergency (2) th
contact number, (3) where their muster point is. Put "Yes" onl
answers are correct)
3
Apakah pekerja tahu apa yang harus dilakukan jika terjadi ke
Tanyakan pada 2 anggota tim (1) bagaimana cara meningkat
memberitahukan darurat (2) nomor kontak darurat, (3) di man
mereka. Masukkan "Ya" hanya jika semua jawaban sudah be
 Is all PPE stated on the Permit or JSA being worn? Worn cor
condition
4 Apakah semua APD yang tercantum pada Izin atau JSA dike
benar? Dan dalam kondisi baik (Pekerja dapat menjelaskan d
cara memakai dan menggunakan seluruh tubuh dengan bena

NO ACTION
1
2
3
4
5
 TEP Self Verification Recor

s, Plan or Procedure to be Verified

HT Procedure (TEP-930-PRC-HS-BP4-0047_B04)

ION /POLICY/ PROCEDURE

mit available adequately describing the task being carried
datory signatures, dates, location, equipment being used
Removal & Open Hole Work Permit)
validasi tersedia dan menjelaskan dengan cukup mengenai
kukan yang berisi semua tanda tangan yang wajib,
an yang digunakan.(Grating/Pemindahan handrail/ Ijin
)

……………………………………………………….…..)

A avaialble adequately describing the task being carried

relevant hazards and controls to carry out the work safely?
other Task that required working at height )
idasi tersedia secara memadai menggambarkan tugas
yang mengidentifikasi bahaya dan kontrol yang relevan
ekerjaan dengan aman? (Perancah, dan pekerjaan lainnya
pekerjaan ketinggian)
…………………………………………………………………...

thod Statement available which adequately reflects the

ment yang divalidasi tersedia yang cukup untuk

pekerjaan?
ntary certificates referenced in the above documents
g Lifting plan, MSDS, Gas Check, Rescue Plan,
e, etc( ISOLATION CERTIFICATE , LINE DIAGRAM
ed )
at tambahan lainnya dirujuk dalam dokumen di atas
Seperti renacana pengangkatan, MSDS, Gascheck,
n, Izin pekerjaan underground ( Sertifikat isolasi, diagram

essed, and all relevant parties notified? ( SIMOPS

k at height shall be attached in work permit pack )
dinilai, dan semua pihak terkait diberitahu? (SIMOPS
erja di ketinggian harus dilampirkan kedalam permit)

the Workers (Sometimes referred to as the TBT)

ng held with the workforce prior to the work starting?

RT diadakan dengan pekerja sebelum pekerjaan dimulai?

been signed by all relevant personel?

telah ditandatangani oleh semua personel yang relevan?

been filled correctly and verified all requirement in place?

RT diisi dengan benar dan diverifikasi semua persyaratan?
f the STARRT adequately reflect the work being carried

RRT cukup mencerminkan pekerjaan yang dilakukan?

ontrols identified on the STARRT sheet adequately reflect

ontrol yang diidentifikasi pada lembar STARRT cukup

ld the STARRT meeting received training?

ngadakan pertemuan STARRT menerima pelatihan?

of the work force able to identify at least 50% of the

n the STARRT sheet? (Not counting the Supv) when
stioned?
nggota angkatan kerja dapat mengidentifikasi setidaknya
ontrol pada lembar STARRT (Tidak termasuk Supv) ketika
NDEPENDEN?

NG AT HEIGHT

re involved in the working at height task attended working

ossible check their training passport)
rja yang terlibat dalam tugas ketinggian bekerja
etinggian? (Jika mungkin periksa paspor pelatihan mereka)
body harnesses when they work at height (higher than 1.8
n they were exposed to the fall through an opening?
nakan full body harness ketika mereka bekerja di
dari 1,8 meter) dan terikat ketika ada resiko jatuh melalui

rest system follow the project requirement (twin tail

r,double latch self- locking snap hooks, or webbing made
hey inspected and color coded as per project procedure?
rest system sesuai dengan persyaratan proyek (twin tail
r, double latch self-locking snap hooks, atau webbing
), apakah diinspeksi dan dikode warna sesuai dengan

available on the working plaform to be hooked in case of

d not sharp edges, and it should be above the waist

ersedia diatas platform untuk dikaitkan bila ada orang

tidak tajam, dan harus di atas ketinggian pinggang)

to the line of fire, gas lines, instrument lines, or any pipe

s in diameter?
mengikat harness ke jalur berbahaya, jalur gas, jalur
pa pun yang berdiameter kurang dari 3 inci?
 s, been inspected regurally by competent person and
splayed at the main entry?
ntara, telah diperiksa secara berkala oleh orang yang
speksi ditampilkan di jalur masuk utama?

s, such as scaffolding platform, mobile scaffolding platform

ng work at height?
ntara, seperti platform perancah, platform perancah seluler
k saat bekerja di ketinggian?

ered or protected by scaffolding barrier and are the

d to minimize people to fall or accidentally enter the

tertutup atau dilindungi oleh penghalang perancah dan

an ditampilkan untuk meminimalkan orang jatuh atau tidak
aan?

working at height are conducted barricaded when it is

olding task, welding, cutting, or lifting?
pekerjaan di ketinggian dibarikade saat diperlukan, seperti
engelasan, pemotongan, atau pengangkatan?

ep ladder been inspected and color coded?

abel/anak tangga diperiksa dan diberi kode warna?
aced at not slippery surface (with anti slips), with correct
ed the top and the bottom, and 1m of the ladder being
ladder is 4 meter long, it should be protruded for 1 meter
))
el ditempatkan pada permukaan yang tidak licin (dengan
75 derajat, diamankan bagian atas dan bawah, dan
sepanjang 1 m? (Jika sebuah tangga memiliki panjang 4
jol sejauh 1 meter di atas platform (4: 1))

3 points contact rule when they are using ladders?

kuti aturan 3 titik kontak ketika mereka menggunakan

ments and equipment with back pack or tool bag instead of

awa dokumen dan peralatan dengan tas punggung atau

bawa dengan tangan?

h are less than 5 kg, attached with manufactured tools

at height? (for tools weight 5 kg shall be 4 mm certified
rd )
an, yang kurang dari 5 kg, terpasang dengan alat lanyard
ekerja pada ketinggian? (untuk alat berat 5 kg harus
ersertifikat 4 mm sebagai alat lanyard)
hoisting attached SWL and rope with diameter 12 -15 mm
r manual hoisting? And are the areas below barricaded for
d zone?
ntuk mengangkat tercantum SWL dan tali terpasang
5 mm dan simpul aman untuk pengangkat manual? Dan
ni dibarikade untuk zona eksklusif/zona benda jatuh?

s grating and handrail removal, or penetration, barricaded

th scaffolding tubular and wrapped with red and white tape
asa and English?
, seperti pemindahan grating dan membuka handrail, atau
dengan hard baricade dengan tubular perancah dan
merah putih dan tanda keselamatan dalam Bahasa dan

leads elevated above 1.8 meter with proper cable hangers

d tangling hazards, and blocking access?
dan timah dinaikkan di atas 1,8 meter dengan gantungan
meminimalkan bahaya tersandung dan tersangkut, dan

r slug catcher (containment) below the hot work area? (or

ow the hot work shall be barricaded with red and white

pi atau slug catcher (penampung) di bawah area

u jika mungkin area di bawah pekerjaan panas harus
merah dan putih)?
 kept/stored in designated area to avoid being kicked down
drop object?
mpah disimpan di tempat khusus untuk menghindari
di potensi benda terjatuh?

available to store any small materials, which are carried

t? (bolt, nuts, nails, wrench, or such materials that could
ning)
tau kotak alat tersedia untuk menyimpan bahan kecil,
ekerja di ketinggian? (baut, mur, paku, kunci pas, atau
ng bisa jatuh melalui celah kecil)

Works Platform (MEWP) carrying oversize loads that could

tential dropping object inside the basket?
ng Works Platform (MEWP) membawa muatan yang terlalu
di penghalang atau benda menjatuhkan potensial di dalam

h fall prevention, such as guard rail with mid rail and toe
r anchor points?
api dengan pencegahan jatuh, seperti handrail dengan rel
antai anti slip, atau titik angkur?

o assist the movement of the MEWP?

man membantu gerakan MEWP?

ESS/WORKER PROTECTION
ment identified and required for the specific task avaialble,
y for use? e.g Spill Kit, Fire extinguisher, Eye Wash, First
ripod, Gottcha rescue kits, etc)
an darurat diidentifikasi dan diperlukan untuk tugas khusus
ertifikasi dan siap digunakan? Contoh Spill Kit, Fire
h, First Aid Kit, Stretcher dan sebagainya.

adeqaute training or familiarisation in the use of any

equipment or duties for the task. E.g. Designated First
mergency Auxilary team .
nerima pelatihan atau pengenalan yang memadai tentang
darurat atau tugas tertentu untuk tugas tersebut? Seperti
k, firewatcher, tim darurat tambahan

to do in the event of an emergency? - Ask at 2 members

aise the alarm/notify emergency (2) the emergency
ere their muster point is. Put "Yes" only if the all of the

pa yang harus dilakukan jika terjadi keadaan darurat? -

ota tim (1) bagaimana cara meningkatkan alarm /
at (2) nomor kontak darurat, (3) di mana titik keramaian
" hanya jika semua jawaban sudah benar)
e Permit or JSA being worn? Worn correctly? and in good

ng tercantum pada Izin atau JSA dikenakan? Apakah

disi baik (Pekerja dapat menjelaskan dan menunjukkan
nggunakan seluruh tubuh dengan benar)

RECOMMEND
ACTION
ation Record Sheet
Purpose

The purpose of this Self Verification is to ensure th

Activity at the Tangguh Greenfield Site is executed in
the Working at Height Procedure and associated r
documentation under the CSTS Management Sy

Doc.
Reference
 CoW
Procedure

CoW
Procedure

CoW
Procedure
 CoW
Procedure

CoW
Procedure

CoW
Procedure

CoW
Procedure

CoW
Procedure
 CoW
Procedure

CoW
Procedure

CoW
Procedure

CoW
Procedure

5.1.1.
5.4

5.4.4

5.4.4

5.5.6
5.1.3

5.3.1

5.7

5.8

5.3.6
 Appendix 3
Ladder safety

Appendix 3
Step-ladder

5.6.1

5.5.3
5.6.1.

5.7

5.3.1.

5.5.2
 5.7

5.6.2

5.3.5.

5.3.5.

5.3.5.
Actual Check
on-site

Actual Check
on-site

Actual Check
on-site
Actual Check
on-site

RECOMMENDATION
Record Sheet
Purpose

e purpose of this Self Verification is to ensure that Work

ity at the Tangguh Greenfield Site is executed in line with
e Working at Height Procedure and associated relevant
ocumentation under the CSTS Management System.

Comments / Remarks
 Percentage of Implementaion

ECOMMENDATION
RESPONSIBLE PERSON
 Rev.0

Compliance
YES / NO / NA
#DIV/0!

TARGET DATE
 TEP Self
Date:
Location:
Task / Activity / aktivitas
Permit Number / Nomor Permit
Name of Verifiers / Pemeriksa
Persons Interviewed or Supervisor:
Sub-Contractor:
Process, Plan or Procedure to be Verifie
CONTRACTOR CONTROL of WORK for GREEN
(TEP-930-PRC-HS-BP4-0002_B07)
DOCUMENTS/ADMINISTRATION /POLICY/ PROCEDU

Is there a validated permit available adequately describing th

carried out containing all mandatory signatures, dates, locatio
being used etc?
1 Apakah permit yang divalidasi tersedia dan menjelaskan den
mengenai tugas yang sedang dilakukan yang berisi semua ta
wajib, tanggal, lokasi, peralatan yang digunakan.
No. Reference : (……………………………………………………
 Is there a validated JSA available adequately describing the t
out which identifes the relevant hazards and controls to carry
safely?
2 Apakah JSA yang divalidasi tersedia secara memadai mengg
yang sedang dilakukan yang mengidentifikasi bahaya dan ko
relevan untuk melaksanakan pekerjaan dengan aman?
No. Reference : (……………………………………………………

Is there a validated Method Statement available which adequ

task being carried out?
3 Apakah Method Statement yang divalidasi tersedia yang cuku
menjelaskan mengenai pekerjaan?

Are all other supplementary certificates referenced in the abo

available for review? E.g Lifting plan, MSDS, Gas Check, Res
Underground Clearance, etc
4 Apakah semua sertifikat tambahan lainnya dirujuk dalam dok
tersedia untuk ditinjau? Seperti renacana pengangkatan, MS
Rencana penyelamatan, Izin pekerjaan underground

Has SIMOPS been assessed, and all relevant parties notified

MATRIX)
5 Apakah SIMOPS telah dinilai, dan semua pihak terkait diberit
MATRIX)
 Are Daily Works/SIMOPs board available and displayed visua
activities?
6 Apakah papan pekerjaan harian/SIMOP tersedia dan menam
hari ini?

Does low risk activity use Generic Risk Assessment (GRA) in

to Work?
7 Apakah aktifitas resiko rendah menggunakan Generic Risk A
(GRA) ketimbang menggunakan Permit to Work?

Are the high risk activities mention in Section 6 CoW Procedu

Work?
8 Apakah aktifitas resiko tinggi seperti yang disebutkan pada S
Procedure menggunakan Permit to Work?

Is there STARRT card for the activity, properly filled and com
9 crew?
 Are at least 2 members of the work force able to identify at le
hazards and controls on the STARRT sheet (Not counting the
INDEPENDANTLY questioned?
10 Apakah setidaknya 2 anggota angkatan kerja dapat mengide
setidaknya 50% dari bahaya dan kontrol pada lembar STARR
termasuk Supv) ketika dipertanyakan secara INDEPENDEN?

Has The Permit to Work been reviewed, and signed by Area

(AIA) and Operating Authority (OA)?
11 Sudahkah Surat Ijin Kerja direview, dan ditanda tangani oleh
Authority (AIA) dan Operating Authority (OA)?

Has the high-risk permit been showed on the mimic board in

12 Apakah ijin kerja yang berisiko tinggi sudau ditampilkan di mi
PTW Office?
 For High Risk activity. Has the subcontractor work pack docu
completed during check? such as?
a. PTW
a. Method Statement
b. JSA
c. STARRT Card
13 d. All required supplementary documents (checklist, MSAS, E
Certificate, etc etc)
Untuk aktifitas risiko tinggi. Apakah dokumen paket kerja sub
lengkap pada saat diperiksa? Seperti: MOS, JSA, STARRT C
lainnya yag dibutuhkan

For medium risk activity. Are the required document already c

as:
a. JSA
b. Approved Method Statement or construction procedure
c. STARRT Card
Untuk pekerjaan risiko menengah. Apakah dokumen yang di
14 lengkap, seperti:
a. JSA
b. MOS atau prosedur konstruksi yang sudah disetujui
c. STARRT Card
 For low risk activity the permit is not required. Are the require
already completed such as:
a. An approved generic risk assessment
b. STARRT Card
c. Approval Procedures
Untuk pekerjaan risiko rendah ijin kerja tidak dibutuhkan. Ap
15 yang dibutuhkan sudah lengkap, seperti:
a. GRA yang sudah disetujui
STARRT Card
c. Prosedur yang sudah disetujui

Does the copy of Permit to Work available at the Site PTW O

original available at workplace?
16 Apakah copy Permit to Work disimpan di Site Permit Offices d
tersedia di lokasi kerja?

Has STARRT CARD Meeting been conducted In the specific

which is the task will be executed and lead by Permit Holder (
from subcontractor?
17 Sudahkah pertemuan Kartu STARRT dilakukan di lokasi dima
akan dijalankan dan dipimpin oleh Permit Holder (PH) dan Su
supervisor?

Are Permit Holder (PH) able to explain what task will be carrie
the requirement is to conduct the work in safe manner?
18 Apakah Permit Holder (PH) menjelaskan tentang pekerjaan y
dilaksanakan dan persyaratan kerja amannya?
 Have Permit Holder (PH) and Operating Authority (OA) visited
location prior to sign or renew the Permit to work as per Proce
19 requirement?
Sudahkah Permit Holder (PH) dan Operating Authority (OA) m
kerja sebelum menandatangani sesuai dengan persyaratan ?

Is Permit to Work, which is being used on site, still valid as pe

Work procedure? (Check the validity when was the 1st date t
verified)
- 14 days for Cold work;
- 7 days for Hot Work, Confined Space Entry, and Excavation
- 1 shift for Radiography and Create Opening.
20 Apakah Permit to Work, yang digunakan di lokasi, masih valid
prosedure Control of Work? (periksa validitas kapan hari pert
diverifikasi?)
- 14 hari untuk Pekerjaan Dingin;
- 7 hari untuk Pkerjaan Panas, Ruang Terbatas, dan Ijin Peng
- 1 shift untuk Radiografi dan Create Opening.

Has the hot work inside the confined space been completed w
permit and attached to a confined space entry permit? (if any
21 Apakah kerja panas di dalam ruang terbatas sudah dilengkap
kerja panas tambahan dan dilampirkan di ijin kerja masuk rua

NO ACTION
1
2
3
4
5
 TEP Self Verification Recor

an or Procedure to be Verified
ONTROL of WORK for GREENFIELD
30-PRC-HS-BP4-0002_B07)
TRATION /POLICY/ PROCEDURE

mit available adequately describing the task being

all mandatory signatures, dates, location, equipment

validasi tersedia dan menjelaskan dengan cukup

sedang dilakukan yang berisi semua tanda tangan yang
peralatan yang digunakan.
………………………………………………………...….)
A available adequately describing the task being carried
relevant hazards and controls to carry out the work

lidasi tersedia secara memadai menggambarkan tugas

yang mengidentifikasi bahaya dan kontrol yang
nakan pekerjaan dengan aman?
………………………………………………………...)

thod Statement available which adequately reflects the

ment yang divalidasi tersedia yang cukup untuk

i pekerjaan?

ntary certificates referenced in the above documents

.g Lifting plan, MSDS, Gas Check, Rescue Plan,
e, etc
at tambahan lainnya dirujuk dalam dokumen di atas
? Seperti renacana pengangkatan, MSDS, gas check,
n, Izin pekerjaan underground

sessed, and all relevant parties notified? (SIMOPS

dinilai, dan semua pihak terkait diberitahu? (SIMOPS

Ps board available and displayed visually for today

an harian/SIMOP tersedia dan menampilkan aktivitas

se Generic Risk Assessment (GRA) instead of Permit

rendah menggunakan Generic Risk Assessment

ggunakan Permit to Work?

ies mention in Section 6 CoW Procedure use Permit to

tinggi seperti yang disebutkan pada Section 6 CoW

an Permit to Work?

for the activity, properly filled and communicated to the

s of the work force able to identify at least 50% of the
n the STARRT sheet (Not counting the Supv) when
estioned?
nggota angkatan kerja dapat mengidentifikasi
ahaya dan kontrol pada lembar STARRT (Tidak
dipertanyakan secara INDEPENDEN?

k been reviewed, and signed by Area Issuing Authority

uthority (OA)?
rja direview, dan ditanda tangani oleh Area Issuing
erating Authority (OA)?

it been showed on the mimic board in the PTW Office?

berisiko tinggi sudau ditampilkan di mimic board di
Has the subcontractor work pack document been
k? such as?

entary documents (checklist, MSAS, ERP, isolation

ggi. Apakah dokumen paket kerja subkontraktor sudah

eriksa? Seperti: MOS, JSA, STARRT Card, dokumen

y. Are the required document already completed such

atement or construction procedure

menengah. Apakah dokumen yang dibutuhkan sudah

konstruksi yang sudah disetujui

 permit is not required. Are the required document
h as:
c risk assessment

s
rendah ijin kerja tidak dibutuhkan. Apakah dokumen
h lengkap, seperti:
setujui

h disetujui

it to Work available at the Site PTW Offices and the

rkplace?
Work disimpan di Site Permit Offices dan aslinya
?

Meeting been conducted In the specific work location,

e executed and lead by Permit Holder (PH) or Supv.

Kartu STARRT dilakukan di lokasi dimana pekerjaan

pimpin oleh Permit Holder (PH) dan Subcontractor

) able to explain what task will be carried out and what

onduct the work in safe manner?
(PH) menjelaskan tentang pekerjaan yang akan
yaratan kerja amannya?
 H) and Operating Authority (OA) visited the work
renew the Permit to work as per Procedure

er (PH) dan Operating Authority (OA) memeriksa lokasi

atangani sesuai dengan persyaratan ?

h is being used on site, still valid as per Control of

ck the validity when was the 1st date that PTW was

k;
Confined Space Entry, and Excavation Permit;
y and Create Opening.
k, yang digunakan di lokasi, masih valid sesuai
Work? (periksa validitas kapan hari pertama PTW

an Dingin;
Panas, Ruang Terbatas, dan Ijin Penggalian;
afi dan Create Opening.

e the confined space been completed with a hot work

a confined space entry permit? (if any)
dalam ruang terbatas sudah dilengkapai dengan ijin
dan dilampirkan di ijin kerja masuk ruang terbatas?

RECOMMEND
ACTION
ication Record Sheet
Purpose
The purpose of this Self Verification is to ensure t
Activity at the Tangguh Greenfield Site is executed in
Contractor Control of Work for Greenfield and as
relevant documentation under the CSTS Manageme

Doc.
Reference

Section 3.1
Section 8.2
Appendix 4

Section 8.2

Section 8.2

Section 4.5
Section 4.5

Section 3.1

Section 3.1
Section 6

Section 5.3
Section 8.3

Section 4.5
Section 8.2

Section 7
Section 7

Section 8.4

Section 5.3

Section 4.2
Section 4.2

Section 8.5

Section 3.2

RECOMMENDATION
Record Sheet
Purpose
purpose of this Self Verification is to ensure that Work
at the Tangguh Greenfield Site is executed in line with the
ntractor Control of Work for Greenfield and associated
nt documentation under the CSTS Management System

Comments / Remarks
COMMENDATION
RESPONSIBLE PERSON
 Rev.2
Updated 02 May 2021

Compliance
YES / NO / NA
TARGET DATE
 TEP Self Verification Record Sheet Rev.0

Date: Purpose
Location:

Task / Activity : The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at the Tangguh Greenfield Site is executed in line with
the Lifting Procedure/TEP-930-PRC-HS-BP4-0032 Procedure
Name of Verifiers : and associated relevant documentation under the CSTS
Persons Interviewed or Supervisor: Management System
Sub-Contractor:

Doc. Compliance
Safe Mechanical Lifting Comments / Remarks
Reference YES / NO / NA

1 Has a risk assessment been completed? Apakah penilaian risiko telah selesai?

2 Is there a lifting plan in place? Apakah ada perencanaan pengangkatan?

Are all controls implemented where required? Apakah semua kontrol diimplementasikan
3
jika diperlukan?

Do all workers fully understand the lifting operation and control measures
4 applicable for the lift? Apakah semua pekerja sepenuhnya memahami operasi
pengangkatan dan tindakan pengendalian yang berlaku untuk lift?

Are all personnel involved in the lifting operations competent and trained Apakah semua
5
personel yang terlibat dalam operasi pengangkatan kompeten dan terlatih?

Has SIMOPs been considered before beginning this type of operation? Apakah SIMOP
6
telah dipertimbangkan sebelum memulai jenis operasi ini?

Has a pre-use inspection of the lifting equipment and load been carried out? Apakah
7
pemeriksaan pra-penggunaan peralatan pengangkat dan beban telah dilakukan?

Are the lifting accessories tagged or marked/color coded (to provide a visual
8 indicator of certification status)? Apakah aksesori pengangkat diberi tag atau diberi
tanda/kode warna (untuk memberikan indikator visual status sertifikasi)?

9 Is the lifting equipment free from defects? Apakah alat pengangkat bebas dari cacat?

10 Is the safe working load marked? Apakah beban kerja aman ditandai?

Where required, do lifting equipment certifications match the unique number /

11 serial number? Jika diperlukan, apakah sertifikasi alat pengangkat cocok dengan nomor
unik/nomor seri?

Is the lift area controlled and is everyone clear of the load? Apakah area lift terkontrol dan
12
semua orang bebas dari beban?

Are signalling methods and communication agreed and clear between the
13 banksman and crane operator? Apakah metode pensinyalan dan komunikasi disepakati
dan jelas antara petugas bank dan operator derek?

Do frontline employees only operate equipment that they are qualified to use? Apakah
14 karyawan garis depan hanya mengoperasikan peralatan?bahwa mereka memenuhi
syarat untuk digunakan?

Have exclusion zones been established and obeyed? Apakah zona eksklusi telah
15
ditetapkan dan dipatuhi?

Are frontline employees aware of the hazards and never walk under a
16 suspended load? Apakah karyawan garis depan sadar akan bahaya dan tidak pernah
berjalan di bawah beban yang ditangguhkan?

Is change management (MOC) used to manage any scope or permit changes? Apakah
17 manajemen perubahan (MOC) digunakan untuk mengelola?ruang lingkup atau izin
perubahan?

Are Contractor SV or BP Oversight checks completed to confirm that work is

18 conducted as per process? Apakah pemeriksaan Pengawasan SV atau BP Kontraktor
telah selesai untuk memastikan bahwa pekerjaan telahdilakukan sesuai proses?

Do employees understand that they have the authority and expectation to stop
unsafe work? Can they give an example of when this happened? Apakah pemeriksaan
19
Pengawasan SV atau BP Kontraktor telah selesai untuk memastikan bahwa pekerjaan
telahdilakukan sesuai proses?
Did the risk assessment or pre-job discussion include any lessons from past
20 incidents from similar work? Apakah penilaian risiko atau diskusi pra-pekerjaan
memasukkan pelajaran dari masa lalu?insiden dari pekerjaan serupa?

Is there STARRT card for the activity, properly filled and communicated to the crew?
21 Apakah ada kartu STARRT untuk aktivitas, dengan benardiisi dan dikomunikasikan
kepada kru?

Percentage of Implementaion #DIV/0!

RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
1
2
3
4
5
 TEP Self Verification Record Sheet Rev.0
Date: Purpose

Location:

Task / Activity :
The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at the Tangguh Greenfield Site is executed in line with
Name of Verifiers : the Greenfield Construction Control of Work/TEP-930-PRC-
HS-BP4-0002 Procedure and associated relevant
Persons Interviewed or documentation under the CSTS Management System
Supervisor:

Sub-Contractor:

Doc. Compliance
Line of Fire Reference Comments / Remarks
YES / NO / NA

Do I see evidence of equipment properly guarded/protected? Apakah saya

1
melihat bukti peralatan dengan benardijaga/dilindungi?

Are risk areas clearly defined and barriers and signs in use to warn personnel of
2 dangers? Apakah area risiko didefinisikan dengan jelas dan hambatan dantanda-
tanda yang digunakan untuk memperingatkan personel tentang bahaya?

Are pedestrian corridors available to allow safe passage of personnel around

3 their work location? Apakah koridor pejalan kaki tersedia untuk memungkinkan
keamanan?lintas personel di sekitar lokasi kerja mereka?

Do I see evidence of the use of drops protection equipment, e.g. tool lanyards,
4 tool bags etc.? Apakah saya melihat bukti penggunaan perlindungan tetes?
peralatan, mis. alat lanyard, tas alat dll?

Do I see evidence of collective drops protection measures, e.g. netting, toe-

5 boards etc.? Apakah saya melihat bukti perlindungan tetes kolektif?langkah-
langkah, misalnya jaring, papan kaki dll.?

Do I see evidence of work being planned to avoid the risk of dropped objects
6 occurring? Apakah saya melihat bukti pekerjaan yang direncanakan untuk
dihindari?risiko benda jatuh terjadi?

Do I see evidence of work planned to avoid the risk of accidental contact with
overhead power lines?Apakah saya melihat bukti pekerjaan yang direncanakan
7
untuk menghindaririsiko kontak yang tidak disengaja dengan saluran listrik di
atas kepala?

Are plant & equipment operators observant of overhead risks that could
negatively impact on safety? Apakah operator pabrik & peralatan
8
memperhatikanrisiko overhead yang dapat berdampak negatif pada
keselamatan?

Are plant & equipment operators observant of overhead risks that could
9 negatively impact on safety? Apakah operator pabrik & peralatan memperhatikan
risiko overhead yang dapat berdampak negatif pada keselamatan?

Potential pathways of energy release within their working environment, e.g.

pneumatic, hydraulic, stored energy under tension, trapped between etc.? Jalur
10
potensial pelepasan energi di dalam lingkungan kerja, mis. pneumatik, hidrolik,
energi yang tersimpan di bawah tegangan, terjebak di antara dll?

Are personnel observant of vehicle movements & ensure that they remain visible
to drivers & equipment operators? Apakah personel memperhatikan pergerakan
11
kendaraan?& memastikan bahwa mereka tetap terlihat oleh pengemudi &
operator peralatan?

Ask personnel to describe examples of locations/activities which may present the

risk of a line of fire incident occurring if not managed effectively. Mintalah
12
personel untuk menjelaskan contoh lokasi/kegiatan yang dapat menimbulkan
risiko rangkaian kejadian kebakaran terjadi jika tidak dikelola secara efektif.

Is there STARRT card for the activity, properly filled and communicated to the
13 crew? Apakah ada kartu STARRT untuk aktivitas, dengan benardiisi dan
dikomunikasikan kepada kru?

Percentage of Implementaion #DIV/0!

RECOMMENDATION

NO ACTION RESPONSIBLE PERSON TARGET DATE

4
5
 TEP Self Verification Record Sheet Rev.0

Date: Purpose
Location:

Task / Activity : The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at the Tangguh Greenfield Site is executed in line with
the Hot Work/TEP-930-PRC-HS-BP4-0026 Procedure and
Name of Verifiers : associated relevant documentation under the CSTS
Persons Interviewed or Supervisor: Management System
Sub-Contractor:

Doc. Compliance
Hot Work Comments / Remarks
Reference YES / NO / NA

Does the risk assessment address all risks and controls relevant to the activity?
1 Apakah penilaian risiko menangani semua risiko danpengendalian yang relevan dengan
aktivitas?

If the PTW requires a gas test or gas monitoring, has this been completed/ in place and
recorded?
2
.Jika PTW memerlukan uji gas atau pemantauan gas, apakah ini sudah selesai/
dalamtempat dan dicatat?

Has a Fire Watch been appointed and do they know their duties?
3
Apakah Fire Watch telah ditunjuk dan apakah mereka tahutugas mereka?

Has authorization been obtained prior to commencing hot work?

4
Apakah otorisasi telah diperoleh sebelummemulai pekerjaan panas?

Is a daily, pre-use, visual inspection conducted of tools and equipment?

5
Apakah inspeksi visual harian, pra-penggunaan, dilakukan?dari alat dan perlengkapan?

Are flashback arrestors in all oxygen and fuel gas lines.

6
Apakah penangkal kilas balik di semua oksigen dan bahan bakarsaluran gas.

Where required, are workers properly using controls for metal fumes? I.e. masks,
forced ventilation, etc.
7
Jika diperlukan, apakah pekerja menggunakan kontrol asap logam dengan benar? Yaitu.
topeng,ventilasi paksa, dll.

Is adequate lighting in place?

8
Apakah pencahayaan yang memadai tersedia?

Has the area been cleared of combustible/flammable materials?

9
Apakah area tersebut telah dibersihkan dari bahan yang mudah terbakar/terbakar?

Are the correct fire extinguishers available in close proximity to the hot work activity?
10
Apakah alat pemadam kebakaran yang benar tersedia di dekat tempat kerja panas?

Have the welding cables, fuel gas lines and electrical cables been run to avoid damage
and slips, trips and falls?
11
Apakah kabel las, saluran bahan bakar gas dan kabel listrik telah dijalankan untuk
menghindarikerusakan dan terpeleset, tersandung dan jatuh?

Has the correct PPE been identified and used?

12
Apakah APD yang benar telah diidentifikasi dan digunakan?

Are barriers and/or warning signage in place?

13
Apakah ada pembatas dan/atau rambu peringatan?

Is habitat used where required and according to requirements?

14
Apakah habitat digunakan jika diperlukan dan sesuai dengan persyaratan?

Has body positioning to undertake the task been reviewed / considered?

15
Apakah posisi tubuh untuk melakukan tugas telahditinjau / dipertimbangkan?

If Hot Work is being performed at height, has protection been provided to prevent
dropped objects, sparks and hot metal?
16
Jika Pekerjaan Panas dilakukan di ketinggian, apakah perlindungan telah diberikan untuk
mencegah benda jatuh, percikan api, dan logam panas?

If there is a requirement for tool lanyards and barriers, are these in use?
17
Jika ada persyaratan untuk lanyard dan penghalang alat, apakah ini digunakan?

Have all sources of ignition been identified and controlled?

18
Apakah semua sumber penyulutan telah diidentifikasi dandikendalikan?

Has gas testing been completed prior to starting hot work in a hazardous area?
19 Apakah pengujian gas telah diselesaikan sebelum memulai pekerjaan panas di area
berbahaya?

Is there continuous gas monitoring in place, where required?

20
Apakah ada pemantauan gas terus menerus, jika diperlukan?

Do employees understand that they have the authority and expectation to stop unsafe
work? Can they give an example of when this happened?
21 Apakah karyawan memahami bahwa mereka memiliki wewenang dan harapan untuk
menghentikan pekerjaan yang tidak aman? Bisakah mereka memberi contoh kapan ini
terjadi?

Did the risk assessment or pre-job discussion include any lessons from past incidents
from similar work?
22
Apakah penilaian risiko atau diskusi pra-pekerjaan mencakup pelajaran dari insiden masa
lalu dari pekerjaan serupa?

Is there STARRT card for the activity, properly filled and communicated to the crew?
23 Apakah ada kartu STARRT untuk kegiatan tersebut, diisi dengan benar dan
dikomunikasikan kepada kru?

Percentage of Implementaion #DIV/0!

RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
1
2
3
4
5
 TEP Self Verification Record Sheet Rev.0

Date: Purpose
Location:

Task / Activity : The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at the Tangguh Greenfield Site is executed in line with
the Energy Isolation/TEP-930-PRC-HS-BP4-0021 Procedure
Name of Verifiers : and associated relevant documentation under the CSTS
Persons Interviewed or Supervisor: Management System
Sub-Contractor:

Doc. Compliance
Energy Isolation Comments / Remarks
Reference YES / NO / NA

Are isolation controls managed by a responsible person (RP)?

1
Apakah kontrol isolasi dikelola oleh orang yang bertanggung jawab (RP)?

Are permits and isolation plans accessible to the workforce?

2
Apakah izin dan rencana isolasi dapat diakses oleh tenaga kerja?

Is the responsible person performing the isolations documented on the permit?

3
Apakah orang yang bertanggung jawab melakukan isolasi didokumentasikan pada izin?

Does the RP(s) have the required training and competency to perform the task?
4 Apakah RP memiliki pelatihan dan kompetensi yang diperlukan untuk melakukan tugas
tersebut?

Was a risk assessments completed for the job?

5
Apakah penilaian risiko telah diselesaikan untuk pekerjaan itu?

Are isolation points labelled to show: Permit Number, Device Number, Lock Number and
Isolation Position?
6
Apakah titik isolasi diberi label untuk menunjukkan: Nomor Izin, Nomor Perangkat, Nomor
Kunci, dan Posisi Isolasi?

Have applied isolations been effectively secured (e.g., locks, chains, wire locks)?
7 Apakah isolasi yang diterapkan telah diamankan secara efektif(misalnya, kunci, rantai,
kunci kawat)?

Did the responsible party sign the Permit for application or removal of each isolation
control?
8
Apakah penanggung jawab menandatangani Izin untuk penerapan atau penghapusan
setiap kontrol isolasi?

Was a test carried out to ensure the isolation is effective (in confirming a zero energy
state)?
9
Apakah tes dilakukan untuk memastikan isolasi efektif (dalam mengkonfirmasi keadaan
energi nol)?

Is there a process to communicate this work to the next shift where applicable?
10
Apakah ada proses untuk mengomunikasikan pekerjaan ini ke shift berikutnya jika ada?

Have SIMOPS issues have been considered and addressed in the risk assessment?
11
Apakah masalah SIMOPS telah dipertimbangkan dan ditangani dalam penilaian risiko?

Have all energy sources been identified?

12
Apakah semua sumber energi telah diidentifikasi?

Have hazardous energy sources been isolated, locked, and tagged ?

13
Apakah sumber energi berbahaya telah diisolasi, dikunci, dan diberi tag?

Have lessons learnt from similar tasks been incoporated into this activity?
14
Apakah pelajaran yang dipetik dari tugas serupa telah dimasukkan ke dalam kegiatan ini?

Do employees understand that they have the authority and expectation to stop unsafe
work? Can they give an example of when this happened?
15 Apakah karyawan memahami bahwa mereka memiliki wewenang dan harapan untuk
menghentikan pekerjaan yang tidak aman? Bisakah mereka memberi contoh kapan ini
terjadi?

Isolation Authority (IA) is approved by Letter of Designation?

16
Otoritas Isolasi (IA) disetujui oleh Surat Penunjukan?

Is there STARRT card for the activity, properly filled and communicated to the crew?
17 Apakah ada kartu STARRT untuk kegiatan tersebut, diisi dengan benar dan
dikomunikasikan kepada kru?

Percentage of Implementaion #DIV/0!

RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
1
2
3
4
5
 TEP Self Verification Record Sheet Rev.0

Date: Purpose
Location:

Task / Activity : The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at the Tangguh Greenfield Site is executed in line with
the Transportation Safety/TEP-930-PRS-HS-BP4-0003
Name of Verifiers : Procedure and associated relevant documentation under the
Persons Interviewed or Supervisor: CSTS Management System
Sub-Contractor:

Doc. Compliance
driving Safety Comments / Remarks
Reference YES / NO / NA

Observe vehicle operations. Are personnel using seat belts provided correctly?
1 Perhatikan pengoperasian kendaraan. Apakah personel yang menggunakan sabuk
pengaman disediakan dengan benar?

Look for instances of personnel intervening when seat belts are not used correctly.
2 Cari contoh personel yang melakukan intervensi ketika sabuk pengaman tidak digunakan
dengan benar.

Do I see evidence of practices used to bypass the correct use of the seat belt? E.g. seat
belt is permanently fastened but not worn, allowing user to sit on top without being
secured.
3
Apakah saya melihat bukti praktik yang digunakan untuk mengabaikan penggunaan
sabuk pengaman yang benar? Misalnya. sabuk pengaman diikat secara permanen tetapi
tidak dipakai, memungkinkan pengguna untuk duduk di atas tanpa diamankan.

Does the driver remind the passengers to fasten their seat belts prior to departing?
4 Apakah pengemudi mengingatkan penumpang untuk memasang sabuk pengaman
sebelum berangkat?

Do I see evidence of drivers using cell phones while manoeuvring vehicles?

5 Apakah saya melihat bukti pengemudi menggunakan ponsel saat melakukan manuver
kendaraan?

Are speed limits displayed in the work location & observed by drivers?
6
Apakah batas kecepatan ditampilkan di lokasi kerja & diperhatikan oleh pengemudi?

Do drivers demonstrate a cautious attitude to driving operations?

7
Apakah pengemudi menunjukkan sikap hati-hati terhadap operasi mengemudi?

Do drivers use hands-free phone functions while driving?

8
Apakah pengemudi menggunakan fungsi telepon handsfree saat mengemudi?

Do I see evidence of intervention if drivers violate the rule?

9
Apakah saya melihat bukti intervensi jika pengemudi melanggar aturan?

Does the driver comply with conditions of the plan?

10
Apakah pengemudi mematuhi ketentuan rencana?

Do I find evidence of random screening/testing facilities? Are they equipped with the
correct equipment to perform the task?
11
Apakah saya menemukan bukti fasilitas penyaringan/pengujian acak? Apakah mereka
dilengkapi dengan peralatan yang benar untuk melakukan tugas?

Ask personnel to describe the potential negative consequences that may occur as a result
of failing to use a seat belt while travelling inside a moving vehicle.
12 Minta personel untuk menjelaskan potensi konsekuensi negatif yang mungkin terjadi
akibat kegagalan menggunakan sabuk pengaman saat bepergian di dalam kendaraan
yang bergerak.

Percentage of Implementaion #DIV/0!

RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
1
2
3
4
5