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PROJECT SAFETY PLAN

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

EII-HSE-FRM-04 - R(0) page : 1 of 17


WEEKLY HSE PERFORMANCE REPORT

Contractor name: PT. Encona Inti Industri Contract No. :


Decsription of work: Work Area:
Reporting Period from to

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.

Work Related Incident/Accident Report

This Week Last Week Cumulative Remarks:


Fatality 0 0 0 Injury Formula
Lost Work Day Case(s) 0 0 0 Nos of Incident X 200,000
Restricted Work Day Case(s) 0 0 0 Total hours
Medical Treatment Case(s) 0 0 0
First Aid Case (s) 0 0 0 MVC Formula
Near Misses Incident 0 0 0 Nos of MVC X 1,000,000
Fire Incident 0 0 0 Miles Driven
Oil Spill Case 0 0 0
Hazard Identification Report 0 0 0 Equipment Incident Formula
Motor Vehicle Crashes 0 0 0 Nos of EI X 100,000
Equipment Incident (EI) 0 0 0 Operating Hours

ORIENTATION/TRAINING AND MEETING PROGRAM

This Week Last Week Cumulative


Orientation 0 0 0
DDC 0 0 0
FSWP 0 0 0
Incident Investigation 0 0 0
JSA Training 0 0 0
First Aid Training 0 0 0
Fire Training 0 0 0
BBS Training 0 0 0
Others Training 0 0 0
Tailgate Meeting 0 0 0
Weekly Meeting 0 0 0
Monthly Meeting 0 0 0

Remarks:
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..

Prepared by ; Reviewed by ; Approved by ;

( ) ( ) ( )

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

Prepared By, Checked By, Approved By,


Dibuat oleh, Dicek oleh, Disetujui oleh,
PT. ENCONA INTI INDUSTRI

(………………Yuli w……………..) (…………………Andy…………...…)


)

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

Analisis Keselamatan Pekerjaan


Required / Recommended PPE
PPE yang dibutuhkan / disarankan Safety Shoes, Safety Helmet, Safety Glass, Gloves, First Aid Kit

Basic Sequence of Job Steps Potential Hazards Recommended Action or Procedures


Urutan Pekerjaan Bahaya yang terkait Langkah/Prosedur yang disarankan

Distribution Prepared by Checked by Approved by


- Original at Team Leader/Manager Dibuat oleh Diperiksa oleh Disetujui oleh
- Copy for HSE Coordinator
- Copy for OHS HOLCIM

ARNOLD.S .ST RAHMAT. NE


HSE Coordinator Site Manager OHS HOLCIM

EII-HSE-FRM-07 - R(1) hal. : 4 dari 17


RISK ASSESSMENT

Divisi : Proyek : Lokasi Pekerjaan : Tgl. Penilaian :

Rsk dpt Rsk dpt


Tingkat Tingkat
No Kegiatan Identifikasi Bahaya Akibat Peluang ditoleransi Pengendalian Resiko Akibat Peluang ditoleransi
Resiko Resiko
(Y/N) (Y/N)

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

Disusun Oleh : Diperiksa Oleh : Disetujui oleh :


Risk Rate : Severity of harm x Likelihood of occurrence
Keparahan dari bahaya x kemungkinan terjadi

EII-HSE-FRM-23 - R(1) Page 5 of 17


Nama Proyek :
No. Proyek :
Daerah Pemantauan : KONSTRUKSI
Periode :

RENCANA PEMANTAUAN LINGKUNGAN

Pemantauan terhadap Periode Pelaksana


Area Pemantauan Bentuk Fisik Sumber Dampak Jenis Dampak Pemantauan
upaya pengelolaan Pemantauan

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)

1. Air Pollution Control


1.1.      Are the construction sites watered to
minimize dust generated?
1.2.      Are stockpiles of dusty materials
(size with more than 20 bags cement)
covered or watered?
1.3.      Cement debagging process
undertaken in sheltered areas
1.4.      Are all vehicles carrying dusty loads
covered/watered over prior to leaving the
site?
1.5.     Are demolition work areas watered?
(e.g. trimming activities by using breaker)
1.6.      Are dusty roads paved and/or
sprayed with water?
1.7.      Are dust controlled during
percussive drilling or rock breaking?
1.8.      Are plant and equipment well
maintained? (any black smoke observed,
please indicate the plant/equipment and
location)

1.9.    Is dark smoke controlled from plant ?


1.10.   Are there enclosures around the
main dust-generating activities ?
1.11.   Hoarding (not <2.4m) provided along
boundaries and properly maintained (any
damage / opening observed, please
indicate the location).
1.12.   Are speed control measures
applied? (e.g. speed limit sign)
1.13.   Others (please specify)

2. Water Pollution Control

2.1.      Are water discharge licenses valid?

2.2.     Are conditions of the license


compiled with? (check the monitoring
records and observe physically)

2.3.      Are wastewater treatment system


being used and properly maintained on
site? (e.g. desilting tank)
2.4.      Are there any wastewater
discharged to the stormdrains? Is the
wastewater being treated?
2.5.      Are measures provided to properly
direct effluent to silt removal facilities?
(e.g. provide earth bunds / U-channels)
2.6.      Are u-channels and manholes free
of silt and sediment?
2.7.      Are sedimentation traps and tanks
free of silt and sediment?
2.8.      Are all manholes on-site covered
and sealed?

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)

2.9.      Are sandbags/earth bund adopted to


prevent washing away of sand/silt and
wastewater to drains, catchpit, public road
and footpath?
2.10.   Are vehicles and plants cleaned
before leaving the site?
2.11.   Are wheel washing facilities well
maintained to prevent overflow, flooding
sediment?
2.12.   Is sand and silt settled out in wheel
washing bay and removed?
2.13.   Is the public road/area around the
site entrance and site hoarding kept clean
and free of muddy water?
2.14.   Is domestic water directed to septic
tanks or chemical toilets?
2.15.   Others (please specify)

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?

3.8.      Others (please specify)

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?

4.4.      Are construction wastes / recyclable


wastes and general refuse removed off
site regularly?
4.5.      Are construction wastes collected
and disposed of properly by licensed
collectors?
4.6.      Are chemical wastes, if any,
collected and disposed of properly by
licensed collectors?

4.7.      Does chemical waste producer


license covers all major chemical wastes
produced on site?
4.8.      Are chemical wastes properly stored
and labelled?
4.9.      Are oil drums and plants/equipments
provided with drip trays?
4.10.   Are drip trays free of oil and water?
4.11.   Is there any oil spillage? Clean-up
the contaminated soil immediately?
4.12.   Is litter, foam or other objectionable
matters in nearby water drain/sewer
cleaned?
4.13.   Are asbestos wastes handled by
registered professionals?
4.14.   Others (please specify)

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)

5. Storage of Chemicals and


Dangerous Goods (DG)
5.1.      Are chemicals stored and labelled
properly?
5.2.      Does storage of DG comply with
license conditions (include types and
quantities if DG store is available, check
the DG store license)?
5.3.      Are proper measures to control oil
spillage during maintenance or to control
other chemicals spillage? (e.g. provide drip
trays)

5.4.      Are spill kits / sand / saw dust used


for absorbing chemical spillage readily
accessible?
5.5.      Others (please specify)

6. Protection of Flora, Fauna and


Historical Heritage
6.1.      Are disturbance to terrestrial flora
minimized (e.g. plants to be preserved)?
6.2.      Are disturbance to terrestrial fauna
minimized (if rare species identified)?
6.3.      Any historical heritage exists on
site? If yes, ensure appropriate measures
taken to preserve it

6.4.      Others (please specify)

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)?

7.7.      Are pesticides used under the


requirement of Agriculture, Fishers and
Conservation Department?
7.8.      Others (please specify)

8. Emergency Preparedness and


Response
8.1.        Are fire extinguishers / fighting
facilities properly maintained and not
expired? Escape not blocked / obstructed?
8.2.        Are accidents and incidents
reported and reviewed, and corrective &
preventive actions identified and
recorded?
8.3.        Others (please specify)

*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

Signature of Site Inspector : Date :

Reviewed by Project Manager : Date :

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 :

Aktifitas -Produk Jasa

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

lingkungan Tingkat Keparahan


Aspek
Lingkungan
Rutin

No.

Spesific

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Luas Waktu Sumber

SVRT
B3 Penyebar Pemuliha Daya
an n Alam

Keterangan Warna:
: Data INPUT (Dapat Dirubah)

: Hasil (Tidak Dirubah)

EII-EMS-FRM-05 - R(0) 10 of 17
SAFETY MEETING
Project : Present :
Subject : 1.________________ /________ 4.________________ /________
Date : 2.________________ /________ 5.________________ /________
Venue : 3.________________ /________ 6.________________ /________

MATTERS DISCUSSED ACTION DUE DATE


SAFETY:

QUALITY :

RESULTI/PLANING/PROBLEM/OTHER :

EII-HSE-FRM-02 - R(0) page : 11 of 17


TOOLBOX MEETING
Daily
Code Proyek 1-C12-01-1-046 Day / Date
Lokasi Proyek HOLCIM Cilacap Speaker
Owner HOLCIM Cilacap

-. Pemakaian APD yang sesuai dengan jenis pekerjaan

-. Sosialisasi Job Safety Analysis (JSA)

-. Konsentrasi pada saat bekerja & selalu waspada terhadap sekitaran Lokasi Kerja
Topic
-. Selalu waspada dan perhatikan langkah didalam lokasi kerja

No Name Company Division Signature No Name Company Division Signature


1 26
2 27
3 28
4 29
5 30
6 31
7 32
8 33
9 34
10 35
11 36
12 37
13 38
14 39
15 40
16 41
17 42
18 43
19 44
20 45
21 46
22 47
23 48
24 49
25 50
Prepared by: Acknowledge by:
Mengetahui oleh :

(____________________) ( Rahmat .NE )


Safety Site Manager

EII-HSE-FRM-01 - R(0) page : 12 of 17


HSE INVESTIGATION RECORD

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

Tindakan lanjutan / Continuation Action

( ) ( ) ( )
Staff HSE Project Manager

EII-HSE-FRM-05-R(0) hal. : 13 dari 17


INCIDENT STATEMENT
LAPORAN KEJADIAN

Kronologi Kejadian - Chronology Incident

Pernyataan dari Saksi : Tanda Tangan


Statement of Witness Signature

1.

2.

Pernyataan dari Pelaku : 1.


Statement of Principals

2.

Pernyataan dari Pelaku : 1.


Statement of the Victim

2.

EII-HSE-FRM-05-R(0) hal. : 14 dari 17


PROBLEM IDENTIFICATION AND CORRECTIVE ACTION
( PICA )
PICA No. Approved by Prepared by
Date of PICA
1.______________ 2_______________
Periodical Analysis
No Activity Problem Caused of Problem Initiative Corrective Action PIC Due date Remark

EII-HSE-FRM-21- R(0) 15 of 17
Project Name :
No. Project :
Location :
Day / Date :

EMERGENCY DRILL REPORT

-. 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

Proyek : CIL Dome pelletizer Truk Bullding


Project
JENIS KEJADIAN /
NO NAMA / NAME DEPARTEMEN / DEPARTEMENT
INCIDENT TYPE
1 material beam property damage construction
bracing, rafter

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

Tindakan lanjutan / Continuation Action


Di perlukanya inspection secara berkala dan dlm pelaksanaan pekerjaan selalu mengikuti prosedur
keselamatan kerja perkakas alat angkat dan angkut.

( ) ( )
Staff HSE Site manager

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