Beruflich Dokumente
Kultur Dokumente
Customer Name :
Project Name :
Project Code :
Project Location :
Project Schedule : until
Max Worker Activity : Worker
Plan
No Description Yes No Remarks
1 Safety Officer Organization
2 Safety Emergency Procedure and Organized Rescue Tim
3 Safety regulation and Procedure
1 House Keeping
2 Trafic Control and Transportation
3 Fire Prevention Precaution and Fire Fighting Equipment
4 Working in Confined Space
5 Excavation
6 Hot Working (welding, cutting operation & Equip.)
7 Electrical Equipment
8 Crane
9 Hoist
10 Other Lifting ( Takle/Jimpole)
11 Manual Lifting ( L Jack, H Pallet)
12 Scaffolding and work Flat Form
13 Ladders
14 Powers tool
15 Hand tools and Portables power Driven tolls
16 Hazardous Substance
17 Working at Height
18 Structural Steel Erection
19 Floor and Wall Opening & Stair ways
20 Lighting
21 Protection Againt Damage Material
4 Clotching & Equipment Safety Devices
1 Working clutches
2 Safety Helmet
3 Clutching and Equipment Safety Devices
4 Safety Belt / Full Body Harness
5 Hand Gloves Cotton / Leather
6 Masker
7 Earning Protection
8 ID Card
5 Insurance / jamsostek
6 Lock Out Safety System
1 Card Note
2 Key Procedure
7 Document record
1 Accident Report ( if any )
2 Safety Activity
3 Safety Box meeting
4 Toolbox meeting
5 Safety Schedule
DAY Mon Tue Wed Thu Fri Sat Sun Total Project
DATE This week Todate
Number of Personnel
Expat
Staff
Non-Staff
Number of Man Hours
Illness
Number of Light Vehicles
KMs Driven
Number of Heavy Vehicles
KMs Driven
Number of Equipment
Operating Hours
Notes:
Light vehicles: Sedan, minibus, pick-up, ect.
Heavy vehicles: Dump truck, crane truck, semitrailer, ect.
No. of personnel to include all Managers, Supervisors, and Crafts.
Remarks:
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
( ) ( ) ( )
EII-HSE-FRM-08-R(0)
No.Report/No.Laporan :
Date / Tanggal :
Project Name : Steel platform for fiber preparation DAILY REPORT HSE
No. Project/No.Proyek : 001/T/V/086/2013
Location/ Lokasi : FIBER BUILDING Laporan Harian K3LL
No. Man Power / Tenaga Kerja Qty Man Hour Equipment Safety and PPE on Used / Peralatan K3LL & APD
1 Project Manager Tools / Alat Unit Qty PPE Check
2 Site Manager 1 8 Safety Sign/Rambu K3LL Safety Head 8
3 Construction Superintendent Fire Extinguisher/APAR 3 Eye Protection 8
4 HSE 1 8 Dustbin/Tong Sampah Ear Plug 8
5 Fabrication Coordinator Policy Line/Garis Polisi 1 Gloves 8
6 Eriction Coordinator Cone Safety Shoes 8
7 Formen Other/ Lain-lain Rain Coat
8 Operator 1 8 Body Hardness 7
9 Fabricationworker 4 48 Other
10 HELPER
No. Item Potential Hazard / Potensi Bahaya Action / Tindakan By / oleh Checked/
Diperiksa
1 Miscomunication/salah instuksi Koordinasi antar departemen yuli wantana
2 Tersandung Selalu hati-hati&perhatikan langkah yuli wantana
3 Tangan terjepit padasaat penurunan material Berhati-hati&perhatikan langkah yuli wantana
4 Tabrakan saat berkendaraan ke area kerja selalu berhati hati dan konsentrasi yuli wantana
5 Tertimpa material Selalu hati-hati&perhatikan langkah yuli wantana
6 Terperosok Selalu hati -hati yuli wantana
7 Trabrakan di area kerja Selalu hati-hati&perhatikan langkah yuli wantana
8
9
Data Collision :
Data Pelanggaran
EII-HSE-FRM-03-R(1)
Job Description Date New/
tgl Baru
JSA Pekerjaan Galian (Civil Work) Revised/
Lama
Area / Location JSA Team
Job Safety Analysis
Area / Lokasi Tim JSA
Akibat
Peluang Tingkat Resiko Penjelasan Score Akibat Score Tingkat Resiko
1 2 3 4 5
A E E E E H E = Extreme Risk A = Hampir pasti terjadi/almost certain A= 1 5 = Tidak ada cidera, kerugian materi kecil L= 18 - 25
B E E H H H H = High Risk B = Cendrung untuk terjadi B=2 4 = Cidera ringan / P3K, kerugian materi sedang M= 13 - 18
C E H H M M M = Moderate Risk C = Mungkin dapat terjadi C=3 3 = Hilang hari kerja, kerugian cukup besar H= 6 - 12
D E H M M L L = Low Risk D = Kecil kemungkinan terjadi D=4 2 = Cacat, kerugian materi besar E= 1 - 5
E H H M L L E = Jarang terjadi/rare E=5 1 = Kematian, kerugian materi sangat besar
Prepared by : Approved by :
EII-EMS-FRM-01 6 of 17
ENVIRONMENTAL SITE INSPECTION CHECK LIST
Project :
Site Location :
Construction stage/status during inspection :
Inpection Date :
Inpection Time :
Weather :
Note : This form is designed for general use and may not be exhaustive.Modifications and additions may be necessary to suit individual projects
and to address specific environmental issues and associated mitigation measures.
Implemented? Remarks
Inspection Items N/A (i.e. specify location, good practices, problem observed, possible cause of
Yes No*
nonconformity and/or proposed corrective/preventative actions)
EII-EMS-FRM-03 7 of 17
Implemented? Remarks
Inspection Items N/A (i.e. specify location, good practices, problem observed, possible cause of
Yes No*
nonconformity and/or proposed corrective/preventative actions)
3. Noise Control
3.1. Is the CNP (Construction Noise
Permit) valid for work during restricted
hours?
3.2. Are copies of the valid Construction
Noise Permits posted at site entrance/exit?
3.3. Do air compressors and generators
operate with doors closed?
3.4. Is idle plant/equipment turned off or
throttled down?
3.5. Do air compressors and hand-held
breakers have valid noise emission labels
(NEL)?
3.6. Any noise mitigation measures
adopted (e.g. use noise barrier /
enclosure)?
3.7. Are silenced equipments utilized?
4. Waste Management
4.1. Is the site kept clean and tidy? (e.g.
litter free, good housekeeping)
4.2. Are separate chutes used for inert
and non-inert wastes?
4.3. Are separated labelled containers /
areas provided for facilitating recycling and
waste segregation?
EII-EMS-FRM-03 8 of 17
Implemented? Remarks
Inspection Items N/A (i.e. specify location, good practices, problem observed, possible cause of
Yes No*
nonconformity and/or proposed corrective/preventative actions)
7. Resource Conservation
7.1. Is water recycled wherever possible
for dust suppression?
7.2. Is water pipe leakage and wastage
prevented?
7.3. Are diesel-powered plants and
equipments shut off while not in use to
reduce excessive use?
7.4. Are energy conservation practices
adopted?
7.5. Are metal or other alternatives used
to minimize the use of timber?
7.6. Are materials stored in good
condition to prevent deterioration and
wastage (e.g. covered, separated)?
*Any “No” recorded represents the potential breach of regulation or improvement needed and details of nonconformity (NC)
shall be recorded in the Remarks.
* Report NC in the following forms. Each NC should make reference into the checklist as coded. Th
EII-EMS-FRM-03 9 of 17
IDENTIFIKASI , PENGENDALIAN DAN PEMANTAUAN ASPEK LINGKUNGAN
Status / Revisi :
Diajukan oleh Konfirmasi Disyahkan oleh
LOKASI :
PENANGGUNG JAWAB :
TANGGAL EVALUASI : HSE Project Manager
No. Rec :
PEMENUHAN
PERATURAN
PROBABILITY
Kemungkinan
Penaggung
PENTING
TINGKAT
Jenis PERATURAN ASPEK NOMOR NOMOR
SEVERITY
Jawab
SKOR
NO
Jenis dampak INISIAL
Aspek Perundang-undangan PENTING ACTION PLAN PEMANTAUAN
Rutin-Non
No.
Spesific
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
SVRT
B3 Penyebar Pemuliha Daya
an n Alam
Keterangan Warna:
: Data INPUT (Dapat Dirubah)
EII-EMS-FRM-05 - R(0) 10 of 17
SAFETY MEETING
Project : Present :
Subject : 1.________________ /________ 4.________________ /________
Date : 2.________________ /________ 5.________________ /________
Venue : 3.________________ /________ 6.________________ /________
QUALITY :
RESULTI/PLANING/PROBLEM/OTHER :
-. Konsentrasi pada saat bekerja & selalu waspada terhadap sekitaran Lokasi Kerja
Topic
-. Selalu waspada dan perhatikan langkah didalam lokasi kerja
Proyek :
Project
JENIS KEJADIAN / INCIDENT DEPARTEMEN /
NO NAMA / NAME
TYPE DEPARTEMENT
Investigasi / Investigation :
(Cantumkan nama saksi bila perlu) DENAH LOKASI KEJADIAN
Location Incident Lay out
Penyebab :
Cause of
Tindakan Koreksi :
Corrective Action
Tindakan Pencegahan :
Precaution
Tindakan / Action
Pertolongan pertama / First Aid
( ) ( ) ( )
Staff HSE Project Manager
1.
2.
2.
2.
EII-HSE-FRM-21- R(0) 15 of 17
Project Name :
No. Project :
Location :
Day / Date :
-. Fires, explosions ;
-. Chemical Spillage or leakage ;
-. Accidents as a result of equipment failure
Type of Emergency Drill
Department / Section
Starting Time
Completion Time
Number of participants
(name list attached)
Participation Rate
Name of Fire Officer
Suggestion Items
Action Plan
Prepared by : Approved by :
EII-HSE-FRM-22 - R(0) 16 of 17
HSE INVESTIGATION RECORD
Investigasi / Investigation :
(Cantumkan nama saksi bila perlu) DENAH LOKASI KEJADIAN
Tidak ada korban Location Incident Lay out
Penyebab :
Cause of
Crew crane pada hr kamis jam 07.35 mema
nasi mesin crane dan bersih-bersih kabin
crew crane tidak mengetahui kalau stick up
boom tersenggol. Karena begitu istirahat
tahu-tahu mesin mati.Setelah di lihat keatas boom crane menggenai beam bracing shg rafter no 4
Tindakan Koreksi : s/d no 7melengkung di akibatkan oleh keteledaron crew crane .
Corrective Action
Di pastikan orang yang berkompenten untuk melakukan aktifitas di kabin crane tersebut.
Tindakan Pencegahan :
Precaution
Safety dan Supervisor memastikan crew crane yang berkompenten untuk melakukan aktifitas di
kabin crane .
Tindakan / Action
Pertolongan pertama / First Aid
( ) ( )
Staff HSE Site manager