MONTHLY REPORT

HEALTH, SAFETY & ENVIRONMENT

PROJECT

UBS - 2B & CONVEYOR SYSTEM

CLIENT

PT PUPUK SRIWIDJAJA PALEMBANG

LOCATION

PALEMBANG, SUMATERA SELATAN

PERIOD

Sep-16

For Report

25-Sep-16

Rev.

Description

Date

BGS
Prepared

OFS
Checked

ASH
Approved

UBS - 2B & CONVEYOR SYSTEM PROJECT

2.

SAFETY PERFORMANCE

Safety Performance Report

No.

Item

Aug-16
I

II

III

IV

Total

Total Manpower

52

52

52

52

208

Total Manhours

2912

2912

2912

2912

11648

Total Days of Work

30

Total Accident

Total Hearmess

Total BBS/SWAT

Total HSE Meeting Dev.

Palembang, 25 September 2016

Bagus Tresno
QHSE

SAFETY MONTHLY REPORTING FORM

Doc. No.

UBS2B & CS PROJECT

Date :

Rev. No.
Sep-16

IMPLEMENTATION HSE MANAGEMENT SYSTEM

Period :

26 August 2016 up to 25 September 2016

No.
I.

Description
POLICY & LEADERSHIP AWARENESS

II.

COMPLY WITH REGULATION AND STANDARD

IMPLEMENTATION

III.

TRAINING

IV.

CONTRACTOR SAFETY MANAGEMENT SYSTEM

V.

HSE IN DESIGN, CONSTRUCTION & COMMISSIONING,

(WORK PERMIT, JSA, HSE STATEMENT FOR DESIGN)

VI.

MANAGEMENT OF CHANGES

VII. INSPECTION

VIII. COMMUNICATION

IX.

EMERGENCY RESPONSE PLAN

X.

ACCIDENT REPORTING & INVESTIGATION

XI.

DOCUMENTATION

XII. AUDIT AND EVALUATION

XIII. FUNISHMENT AND REWARD

Activity

Remarks

Daily Toolbar Meeting at Site

Weekly internal construction safety meeting every Tuesday
Safety patrol and weekly safety meeting with company every Friday
Monthly Meeting Internal (Adhi)
Monthly Meeting Adhi with Pusri
Safety moment every safety meeting
Top Management Safety Commitment
MDU and Druct and Alcohol for every worker

Continue

Periodically

HSE Passport Training (Head Office)

HSE Matric Training (on Site)
Basic First Aid Training
Fire Fighting Training
Safety Training related competency as per job
Socialization CSMS to all Sub-Contractor
Subcon must be passed CSMS assessment

Periodically
Periodically
Periodically
Periodically
Periodically
Periodically
Periodically

Review and Register PTW

Review and Register JSA
Daily Site Inspection and Coordination
Instalation of the speed, limit sign on every vehicle operation project
Instalation of stiker safety induction every worker's helmet who had
safety induction at site
Provide First Aid facilities include Doctor and Paramedic
Provide Gas Monitoring Equipment for each drilling equipment
Provide PPE for workers at site as per equipment
None

As per Job
As per Job
Daily
All Vehicle
All Personnel

Inspection for tools and equipment used at site :

Drilling Machine Inspection
Lifting Gear Inspection (Web Sling, Sackle, Wire Sling)
Fire Extinguisher Inspection
Implementation Colour Code System
Ambulance Inspection and Team Medic at Site
Personal Protective Equipment Inspection
Vehicle Inspection
Site Inspection (workplace)
Check the condition of gas monitoring
Coordination and Inspection with mechanic Adhi and Pusri Representative
Safety Induction/ Orientation for newcomer worker and visitor
HSE weekly meeting head office
HSE weekly meeting site office
Daily Toolbox meeting
Weekly Safety Talk
Instalation of HSE Information Board and Statistic Board
Safety Pre-Job Meeting project activity
Safety Moment (Head Office)
Instalation of safety sign
Execute strategic emergency preparedness plan
Execute incident notification plan
Execute project specific emergency response plan
Kin of daughter
Record UAC
All Documented SACIC and Deliverable
Prepare Daily Activity HSE and Reported to PHSEM
Prepare Weekly HSE and Reported to PHSEM
Socialization and Implementation UAC Observation Card
Prepare PPE Distribution Record
None

As per Job
As per Job
As per Job
None
Finished
Monthly
Monthly
Quarterly
Monthly
Daily
Monthly
Daily
Daily
Daily
As per Job
Weekly
Weekly
Daily
Weekly
Once
As per Job
As per Job
Monthly
Once
Once
Once
Daily
Done
Daily
Weekly
Periodically
Periodically
None

Awarding of reward for worker on the job with the result of observation were trying Monthly
to make work area in safe conditions

Approved by,

Prepared by,

Andika Shandra HM., ST

Project Manager

Bagus Tresno
QHSE

SAFETY MONTHLY REPORTING FORM

UBS2B & CS PROJECT

Rev. No.

Doc. No.

HEALTH SAFETY ENVIRONMENT

MONTHLY ACCIDENT SUMMARY REPORT

Report Period
Report by
Date
Report to
Copies to

No.

:
:
:
:
:

26 August 2016 up to 25 September 2016

Bagus Tresno
25-Sep-16
Project Manager, Corporate HSE Officer
Construction Manager, HSE Officer

REPORTED DATA

Project
Contractor
Location
Owner

TOTAL THE ACCIDENT

TOTAL
THIS MONTH
CUMMULATIVE

COMPANY

1 First Aid Cases

2 Medical Cases

3 Fatalities

4 Number of near miss

5 Number of fires

6 Equipment accident

7 Auto mobile accident

8 Environment accident

9 Government Complain

10 Property/ Equipment Damage

11 Unsafe Act/ Condition

TITLE OF THE
JOB

:
:
:
:

UBS - 2B & CONVEYOR SYSTEM

PT ADHI KARYA (Persero) Tbk.
Palembang, South Sumatera
PT PUPUK SRIWIDJAJA PALEMBANG

DESCRIPTION OF ACCIDENT

IMPACT (A-S)

Description of Accident :
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Falls of person from height floor, buildings, scaffolds, ledders,

machines vehicles
Falls to depth (inside, others, excavations, holes in the ground)
Falls of person on the same level
Slides and once-ins (berth, rocks, stones, snow)
Dolapas (buildings, walls, scaffolds, ladders, piles of goods)
Struck by taking objects during handling
Struck by taking objects, not the where classified
Slapping on objects
Struck by moving objects groundcing trying trigments and
patching excavation
Striking against stationary objects (accept impacts due to
a previous fall)
Striking against moving object
Drugs and alcohol abuse
Caught between a stationary object and moving object
Contact with hot substances or objects
Contact by installation, ignition or strongtion of hernid
substance (chemical hazard)

IMPACT
A.
B.
C.
D.
E.
F.
G.
H.
I.

Fracture
Dislocation
Be spraned
Cramp
Bruised
Hearing Loss
Blind
Inflamed/ Burn Injury
Amputation

16 Caught between moving objects (except trying

or being objects)
17 Overexertion installing objects (manual handling)
18 Overexertion in pushing or pulling object (manual
handling)
19 Overexertion in handling or throwing objects
(handling manual)
20 Exposure to heat (atmosphare or environment)
21 Exposure to cold (atmosphare or environment)
22 Exposure to or contact with electric current
23 Exposure to or contact with harmful substance
or relations
24 Contact with very cold substance or objects
25 Exposure
26 Machinery activity (step on the hole, caught on
drilling machine, stuck try into machine)
27 Exposure to relations non ... (..., infra-red, radio
frequency, ...)
28 Traffic accident, inland tranportation, sea insight,
.. Insight (crust by truck, tank)

29
30
31
32
33
34
35
36
37
38
39
40
41

Noise
Environment ... (..., dust, cold, .., ...)
Biological hazard (... Bacteria, virus a
Psyhological hazard (monitoring, ...,
Other equipment (mechanical, plum
be .., electrical applicances, ladder, e
Haracious substance (instalation, the
explore, tools, etc)
Comfield space group at voltage tan
oxygen during ...)
Elevated place (plat form, schafoldin
Work environment (outdoor, indoor,
darkness)
Animal stuck
Loading and unloading material
Over speed, overuse and overload
Other Other types of accident, rot clo
classified, including accident not cla
of sufficient area

APPENDAGE
J. Open Injury
K. Iritation
L. Trauma
M. Polsoning
N. Radiation Influence
O. Fatality
P. Property damage
Q. Equipment damage
R. Stop process
S. Etc.

AA. Head
AB. Eyes
AC. Mouth
AD. Nose
AE. Neck
AF. Body
AG. Superior (shoulder, hand, chest, back)
AH. Imperior (stomach, waist, behind, leg)
AI. Other

Approved by,

Prepared by,

Andika Shandra HM., ST

Project Manager

Bagus Tresno
QHSE

SAFETY MONTHLY REPORTING FORM

DENT SUMMARY REPORT

PT PUPUK SRIWIDJAJA PALEMBANG

APPENDAGE (AA-AI)

ption of Accident :
30
31
32
33

Environment ... (..., dust, cold, .., ...)

Biological hazard (... Bacteria, virus and lang)
Psyhological hazard (monitoring, ..., store, litre)
Other equipment (mechanical, plumbing, ...,
be .., electrical applicances, ladder, etc)
34 Haracious substance (instalation, thermable,
35 Comfield space group at voltage tank, emergancy
36 Elevated place (plat form, schafolding)
37 Work environment (outdoor, indoor, under ground,

39 Loading and unloading material

40 Over speed, overuse and overload
41 Other Other types of accident, rot close here
classified, including accident not classified to lack

SAFETY MONTHLY REPORTING F

Doc. No.

UBS2B & CS PROJECT

SAFETY PERFORMANCE STATISTICS OF ADHI KARYA

SUB-CONTRACTOR
No.

TIME

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

Month
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15

TOTAL
EXPOSURE
HOURS (Project
Site)

TOTAL
EMPLOYEES

a1

a2

3,276
9,672
1,680
1,920
2,480
992
5,040
6,448
7,200
12,400
13,640
10,080
11,160
6,960
7,192
7,192
7,192
8,432
19,440
20,088
19,440
27,776
52,864
58,528
56,640
58,528
49,200
50,840
50,840
50,096

39
39
7
8
10
4
21
26
30
50
55
45
45
29
29
29
29
34
81
81
81
112
236
236
236
236
205
205
205
202

PERIOD :
RECORDABLE WORKDAYS
LOST
RESTRICTED
WORKDAYS
WORKDAYS

NUMBER OF RECORDABLE WORK INJURIES

FATAL

LWDC

MT

TOTAL LTI

TOTAL RECORD
CASES

f=b+c

g=d+e+f

10

11

12

RWDC

34
35
36
37
38
39
40
41
42
43
44
45

Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
CUMMULATIVE

50,096
30,256
24,480
25,544
19,840
18,560
19,840
10,560
10,819
6,989
1,064
1,064
856,348

202
122
102
103
80
80
80
44
44
44
19
19
3,584

LWDC
RWDC

:
:

Lost Work Days Cases

Restricted Work Days Cases

Accident Summary

MT
LTI

:
:

Medical Treatment
Lost Time Injury

1. Accident Frequency Rates = (Total Record Case * Total Man-Hours)/ 1.000.00

2. Accident Saverity Rates = (Total Lost Work Day * Total Man-Hours)/ 1.000.00

LTIR
FR

:
:

Lost Time Injury Rate

Frequency Rate

3. Incident Rate = (Total LTI * Total Man-Hours)/ 1.000.000

SR

Saverity Rate

Approved by,

Prepared by,

Andika Shandra HM., ST

Project Manager

Bagus Tresno
QHSE

SAFETY MONTHLY REPORTING FORM

Rev. No.

MANCE STATISTICS OF ADHI KARYA

26 August 2016 up to 25 September 2016
FREQUENCIES
SEVERITY
LTIR

FR

SR

j=(f*a1)/10

k=(g*a1)/10

l=(h*a1)/10

13

14

15

1. Accident Frequency Rates = (Total Record Case * Total Man-Hours)/ 1.000.000

2. Accident Saverity Rates = (Total Lost Work Day * Total Man-Hours)/ 1.000.000

SAFETY MONTHLY REPORTING FORM

Rev. No.

Doc. No.

UBS2B & CS PROJECT

SAFETY PERFORMANCE STATISTICS CONTRACTOR AND SUB CONTRACTOR

CONTRACTOR

PERIOD :
NUMBER OF RECORDABLE WORK INJURIES

No.

TIME

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Month
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15

TOTAL EXPOSURE
HOURS (Project Site)

TOTAL
EMPLOYEES

a1

a2

2,520
7,936
8,400
8,400
7,552
9,176
8,880
11,160
12,720
17,608
17,360
21,280
34,472
44,160
45,623
39,744
45,623
65,968
63,840
66,960
64,800
66,960
21,504
23,808
23,040
23,808
19,200

30
32
35
35
51
37
37
45
53
71
70
95
139
184
184
184
184
266
266
270
270
270
96
96
96
96
80

FATAL

LWDC

RECORDABLE WORKDAYS

MT

TOTAL LTI

TOTAL
RECORD
CASES

f=b+c

g=d+e+f

10

RWDC

LOST
WORKDAYS

26 August 2016 up t

FREQUENCIES

RESTRICTED
WORKDAYS

LTIR

j=(f*a1)/10

11

12

13

31
32
33
34
35
36
37
38
39
40
41
42
43
44
44

Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
CUMMULATIVE

19,840
19,840
19,840
19,840
19,840
19,200
19,840
9,920
9,280
9,920
9,600
7,213
7,213
2,688
1,736
978,312

80
80
80
80
80
80
80
40
40
40
40
37
37
48
31
4,145

LWDC

: Lost Work Days Cases

RWDC
MT

: Restricted Work Days Cases

: Medical Treatment

Accident Summary
1. Accident Frequency Rates = (Total Record Case * Total Man-Hours)/ 1.000.000

LTI
LTIR
FR

: Lost Time Injury

: Lost Time Injury Rate
: Frequency Rate

2. Accident Saverity Rates = (Total Lost Work Day * Total Man-Hours)/ 1.000.000
3. Incident Rate = (Total LTI * Total Man-Hours)/ 1.000.000

SR

: Saverity Rate

Approved by,

Prepared by,

Andika Shandra HM., ST

Project Manager

Bagus Tresno
QHSE

SAFETY MONTHLY REPORTING FORM

ICS CONTRACTOR AND SUB CONTRACTOR

26 August 2016 up to 25 September 2016
FREQUENCIES

SEVERITY

FR

SR

k=(g*a1)/10

l=(h*a1)/10

14

15

1. Accident Frequency Rates = (Total Record Case * Total Man-Hours)/ 1.000.000

2. Accident Saverity Rates = (Total Lost Work Day * Total Man-Hours)/ 1.000.000

SAFETY MONTHLY REPORTING FORM

Rev. No.

Doc. No.
Date :

JETTY, CH & CS PROJECT

Sep-16

SAFETY PERFORMANCE STATISTICS CONTRACTOR AND SUB CONTRACTOR

CONTRACTOR AND SUB-CONTRACTOR

PERIOD :
NUMBER OF RECORDABLE WORK INJURIES

No.

TIME

1
2
3
4
5
6
7
8
9
10
11
12

TOTAL EXPOSURE
HOURS (Project Site)

TOTAL
EMPLOYEES

a1

a2

Month
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15

CUMMULATIVE THIS YEAR

3,808
4,256
4,816
4,376
4,800
6,240
9,424
9,120
11,160
15,600
14,105
11,648

17
25
25
19
20
26
38
38
45
65
65
65

99,353

448

LWDC
RWDC
MT
LTI

:
:
:
:

Lost Work Days Cases

Restricted Work Days Cases
Medical Treatment
Lost Time Injury

LTIR
FR
SR

:
:
:

Lost Time Injury Rate

Frequency Rate
Saverity Rate

FATAL

LWDC

RECORDABLE WORKDAYS

MT

TOTAL LTI

TOTAL
RECORD
CASES

f=b+c

g=d+e+f

10

RWDC

26 August 2016 up to 25 September 2016

LOST
WORKDAYS

FREQUENCIES

SEVERITY

RESTRICTED
WORKDAYS

LTIR

FR

SR

j=(f*a1)/10

k=(g*a1)/10

l=(h*a1)/10

11

12

13

14

15

Accident Summary
1. Accident Frequency Rates = (Total Record Case * Total Man-Hours)/ 1.000.000
2. Accident Saverity Rates = (Total Lost Work Day * Total Man-Hours)/ 1.000.000
3. Incident Rate = (Total LTI * Total Man-Hours)/ 1.000.000

Approved by,

Prepared by,

Andika Shandra HM., ST

Project Manager

Bagus Tresno
QHSE