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PROJECT SAFETY PLAN Customer Name Project Name Project Code Project Location Project Schedule Max Worker Activity
: : : : : :
until 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 Decsription of work: Reporting Period from to
Contract No. : Work Area:
DAY Mon Tue Wed DATE 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.
Thu
Fri
Sat
Sun
Total This week
Project Todate
Work Related Incident/Accident Report
Fatality Lost Work Day Case(s) Restricted Work Day Case(s) Medical Treatment Case(s) First Aid Case (s) Near Misses Incident Fire Incident Oil Spill Case Hazard Identification Report Motor Vehicle Crashes Equipment Incident (EI)
This Week 0 0 0 0 0 0 0 0 0 0 0
Last Week 0 0 0 0 0 0 0 0 0 0 0
Cumulative 0 0 0 0 0 0 0 0 0 0 0
Last Week 0 0 0 0 0 0 0 0 0 0 0 0
Cumulative 0 0 0 0 0 0 0 0 0 0 0 0
Remarks: Injury Formula Nos of Incident X 200,000 Total hours MVC Formula Nos of MVC X 1,000,000 Miles Driven Equipment Incident Formula Nos of EI X 100,000 Operating Hours
ORIENTATION/TRAINING AND MEETING PROGRAM This Week 0 0 0 0 0 0 0 0 0 0 0 0
Orientation DDC FSWP Incident Investigation JSA Training First Aid Training Fire Training BBS Training Others Training Tailgate Meeting Weekly Meeting Monthly Meeting
Remarks: …………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………..
Prepared by ;
(
Reviewed by ;
)
EII-HSE-FRM-08-R(0)
(
Approved by ;
)
(
)
No.Report/No.Laporan : Date / Tanggal : Project Name : Steel platform for fiber preparation No. Project/No.Proyek : 001/T/V/086/2013 Location/ Lokasi : FIBER BUILDING
No.
Man Power / Tenaga Kerja
DAILY REPORT HSE Laporan Harian K3LL
Qty
Man Hour
1
8
Equipment Safety and PPE on Used / Peralatan K3LL & APD
1
Project Manager
2
Site Manager
Tools / Alat
3
Construction Superintendent
4
HSE
5
Fabrication Coordinator
Policy Line/Garis Polisi
6
Eriction Coordinator
7
Formen
8
Operator
1
8
Body Hardness
9
Fabricationworker
4
48
Other
10
HELPER
No. Item
Qty
8
PPE
Check
Safety Head
8
Eye Protection
8
Ear Plug
8
Gloves
8
Cone
Safety Shoes
8
Other/ Lain-lain
Rain Coat
Fire Extinguisher/APAR 1
Unit
Safety Sign/Rambu K3LL 3
Dustbin/Tong Sampah
Potential Hazard / Potensi Bahaya
1
Action / Tindakan
By / oleh
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
7
Checked/ Diperiksa
8 9
Data Collision
:
Data Pelanggaran
Prepared By, Dibuat oleh, PT. ENCONA INTI INDUSTRI
Checked By, Dicek oleh,
Approved By, Disetujui oleh,
(………………Yuli w……………..)
(…………………Andy…………...…) )
EII-HSE-FRM-03-R(1)
Job Description
JSA Job Safety Analysis
Date tgl
New/ Baru
Pekerjaan Galian (Civil Work)
Revised/ Lama
Area / Location
JSA Team
Area / Lokasi
Tim JSA
Analisis Keselamatan Pekerjaan Required / Recommended PPE PPE yang dibutuhkan / disarankan
Basic Sequence of Job Steps Urutan Pekerjaan
Distribution - Original at Team Leader/Manager - Copy for HSE Coordinator - Copy for OHS HOLCIM
EII-HSE-FRM-07 - R(1)
Safety Shoes, Safety Helmet, Safety Glass, Gloves, First Aid Kit
Potential Hazards Bahaya yang terkait
Recommended Action or Procedures Langkah/Prosedur yang disarankan
Prepared by Dibuat oleh
Checked by Diperiksa oleh
ARNOLD.S .ST HSE Coordinator
RAHMAT. NE Site Manager
Approved by Disetujui oleh
OHS HOLCIM
hal. : 4 dari 17
RISK ASSESSMENT Divisi :
Proyek :
No
Kegiatan
Lokasi Pekerjaan :
Identifikasi Bahaya
Akibat
Peluang
Tgl. Penilaian :
Tingkat Resiko
Rsk dpt ditoleransi (Y/N)
Pengendalian Resiko
Akibat
Peluang
Tingkat Resiko
Rsk dpt ditoleransi (Y/N)
1
Peluang A B C D E
1
2
Akibat 3
4
5
E E
E E
E H
E H
H H
E H
= Extreme Risk = High Risk
A B
= Hampir pasti terjadi/almost certain = Cendrung untuk terjadi
A= 1 B=2
5 4
= Tidak ada cidera, kerugian materi kecil = Cidera ringan / P3K, kerugian materi sedang
L= M=
18 - 25 13 - 18
E E
H H
H M
M M
M L
M L
= Moderate Risk = Low Risk
C D
= Mungkin dapat terjadi = Kecil kemungkinan terjadi
C=3 D=4
3 2
= Hilang hari kerja, kerugian cukup besar = Cacat, kerugian materi besar
H= E=
6 - 12 1 - 5
H
H
M
L
L
E
= Jarang terjadi/rare
E=5
1
= Kematian, kerugian materi sangat besar
Tingkat Resiko
Penjelasan
Score
Disusun Oleh : Risk Rate
EII-HSE-FRM-23 - R(1)
:
Akibat
Diperiksa Oleh :
Severity of harm x Likelihood of occurrence Keparahan dari bahaya x kemungkinan terjadi
Page 5 of 17
Score Tingkat Resiko
Disetujui oleh :
Nama Proyek No. Proyek Daerah Pemantauan Periode
: : : KONSTRUKSI :
RENCANA PEMANTAUAN LINGKUNGAN Area Pemantauan
Pemantauan terhadap upaya pengelolaan
Bentuk Fisik
Prepared by :
EII-EMS-FRM-01
Sumber Dampak
Jenis Dampak
Periode Pemantauan
Pelaksana Pemantauan
Approved by :
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? Inspection Items
Yes
No*
Remarks N/A (i.e. specify location, good practices, problem observed, possible cause of 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? Inspection Items
Yes
No*
Remarks N/A (i.e. specify location, good practices, problem observed, possible cause of 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 ed professionals? 4.14. Others (please specify)
EII-EMS-FRM-03
8 of 17
Implemented? Inspection Items
Yes
No*
Remarks N/A (i.e. specify location, good practices, problem observed, possible cause of 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 LOKASI
:
PENANGGUNG JAWAB
:
TANGGAL EVALUASI
:
Konfirmasi
HSE
:
Disyahkan oleh
Project Manager
2
3
4
5
6
7
8
B3
SEVERITY Tingkat Keparahan 9
10
Luas Waktu Penyebar Pemuliha an n
Sumber Daya Alam
PEMENUHAN PERATURAN
No. Aspek
Lingkungan
Jenis dampak lingkungan
PERATURAN Perundang-undangan
ASPEK PENTING
INISIAL
11
12
13
14
NOMOR NOMOR ACTION PLAN PEMANTAUAN
15
16
SVRT
Rutin-Non Rutin
1
Spesific
Aspek
PROBABILITY Kemungkinan
Jenis
NO
Penaggung Jawab
Aktifitas -Produk Jasa
SKOR TINGKAT PENTING
No. Rec :
Keterangan Warna: : Data INPUT (Dapat Dirubah) : Hasil (Tidak Dirubah)
EII-EMS-FRM-05 - R(0)
10 of 17
SAFETY MEETING Project Subject Date Venue
: : : :
Present : 1.________________ /________ 4.________________ /________ 2.________________ /________ 5.________________ /________ 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 Lokasi Proyek Owner
1-C12-01-1-046 HOLCIM Cilacap HOLCIM Cilacap
Day / Date Speaker
-. 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
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
Name
Company Division Signature
50 Prepared by:
Acknowledge by: Mengetahui oleh :
(____________________) Safety
( Rahmat .NE ) Site Manager
EII-HSE-FRM-01 - R(0)
page : 12 of 17
HSE INVESTIGATION RECORD Proyek Project NO
: JENIS KEJADIAN / INCIDENT TYPE
NAMA / NAME
DEPARTEMEN / 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
EII-HSE-FRM-05-R(0)
(
)
(
)
Project Manager
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 )
No
EII-HSE-FRM-21- R(0)
Activity
PICA No. Date of PICA Periodical Analysis Problem
Approved by
Prepared by
1.______________ 2_______________ Caused of Problem
Initiative Corrective Action
PIC
Due date
Remark
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 :
EII-HSE-FRM-22 - R(0)
Approved by :
16 of 17
HSE INVESTIGATION RECORD Proyek Project NO 1
: CIL Dome pelletizer Truk Bullding NAMA / NAME material beam bracing, rafter
JENIS KEJADIAN / INCIDENT TYPE property damage
DEPARTEMEN / DEPARTEMENT construction
Investigasi / Investigation : (Cantumkan nama saksi bila perlu)
DENAH LOKASI KEJADIAN Location Incident Lay out
Tidak ada korban
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
: : : : : :
until 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 Decsription of work: Reporting Period from to
Contract No. : Work Area:
DAY Mon Tue Wed DATE 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.
Thu
Fri
Sat
Sun
Total This week
Project Todate
Work Related Incident/Accident Report
Fatality Lost Work Day Case(s) Restricted Work Day Case(s) Medical Treatment Case(s) First Aid Case (s) Near Misses Incident Fire Incident Oil Spill Case Hazard Identification Report Motor Vehicle Crashes Equipment Incident (EI)
This Week 0 0 0 0 0 0 0 0 0 0 0
Last Week 0 0 0 0 0 0 0 0 0 0 0
Cumulative 0 0 0 0 0 0 0 0 0 0 0
Last Week 0 0 0 0 0 0 0 0 0 0 0 0
Cumulative 0 0 0 0 0 0 0 0 0 0 0 0
Remarks: Injury Formula Nos of Incident X 200,000 Total hours MVC Formula Nos of MVC X 1,000,000 Miles Driven Equipment Incident Formula Nos of EI X 100,000 Operating Hours
ORIENTATION/TRAINING AND MEETING PROGRAM This Week 0 0 0 0 0 0 0 0 0 0 0 0
Orientation DDC FSWP Incident Investigation JSA Training First Aid Training Fire Training BBS Training Others Training Tailgate Meeting Weekly Meeting Monthly Meeting
Remarks: …………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………..
Prepared by ;
(
Reviewed by ;
)
EII-HSE-FRM-08-R(0)
(
Approved by ;
)
(
)
No.Report/No.Laporan : Date / Tanggal : Project Name : Steel platform for fiber preparation No. Project/No.Proyek : 001/T/V/086/2013 Location/ Lokasi : FIBER BUILDING
No.
Man Power / Tenaga Kerja
DAILY REPORT HSE Laporan Harian K3LL
Qty
Man Hour
1
8
Equipment Safety and PPE on Used / Peralatan K3LL & APD
1
Project Manager
2
Site Manager
Tools / Alat
3
Construction Superintendent
4
HSE
5
Fabrication Coordinator
Policy Line/Garis Polisi
6
Eriction Coordinator
7
Formen
8
Operator
1
8
Body Hardness
9
Fabricationworker
4
48
Other
10
HELPER
No. Item
Qty
8
PPE
Check
Safety Head
8
Eye Protection
8
Ear Plug
8
Gloves
8
Cone
Safety Shoes
8
Other/ Lain-lain
Rain Coat
Fire Extinguisher/APAR 1
Unit
Safety Sign/Rambu K3LL 3
Dustbin/Tong Sampah
Potential Hazard / Potensi Bahaya
1
Action / Tindakan
By / oleh
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
7
Checked/ Diperiksa
8 9
Data Collision
:
Data Pelanggaran
Prepared By, Dibuat oleh, PT. ENCONA INTI INDUSTRI
Checked By, Dicek oleh,
Approved By, Disetujui oleh,
(………………Yuli w……………..)
(…………………Andy…………...…) )
EII-HSE-FRM-03-R(1)
Job Description
JSA Job Safety Analysis
Date tgl
New/ Baru
Pekerjaan Galian (Civil Work)
Revised/ Lama
Area / Location
JSA Team
Area / Lokasi
Tim JSA
Analisis Keselamatan Pekerjaan Required / Recommended PPE PPE yang dibutuhkan / disarankan
Basic Sequence of Job Steps Urutan Pekerjaan
Distribution - Original at Team Leader/Manager - Copy for HSE Coordinator - Copy for OHS HOLCIM
EII-HSE-FRM-07 - R(1)
Safety Shoes, Safety Helmet, Safety Glass, Gloves, First Aid Kit
Potential Hazards Bahaya yang terkait
Recommended Action or Procedures Langkah/Prosedur yang disarankan
Prepared by Dibuat oleh
Checked by Diperiksa oleh
ARNOLD.S .ST HSE Coordinator
RAHMAT. NE Site Manager
Approved by Disetujui oleh
OHS HOLCIM
hal. : 4 dari 17
RISK ASSESSMENT Divisi :
Proyek :
No
Kegiatan
Lokasi Pekerjaan :
Identifikasi Bahaya
Akibat
Peluang
Tgl. Penilaian :
Tingkat Resiko
Rsk dpt ditoleransi (Y/N)
Pengendalian Resiko
Akibat
Peluang
Tingkat Resiko
Rsk dpt ditoleransi (Y/N)
1
Peluang A B C D E
1
2
Akibat 3
4
5
E E
E E
E H
E H
H H
E H
= Extreme Risk = High Risk
A B
= Hampir pasti terjadi/almost certain = Cendrung untuk terjadi
A= 1 B=2
5 4
= Tidak ada cidera, kerugian materi kecil = Cidera ringan / P3K, kerugian materi sedang
L= M=
18 - 25 13 - 18
E E
H H
H M
M M
M L
M L
= Moderate Risk = Low Risk
C D
= Mungkin dapat terjadi = Kecil kemungkinan terjadi
C=3 D=4
3 2
= Hilang hari kerja, kerugian cukup besar = Cacat, kerugian materi besar
H= E=
6 - 12 1 - 5
H
H
M
L
L
E
= Jarang terjadi/rare
E=5
1
= Kematian, kerugian materi sangat besar
Tingkat Resiko
Penjelasan
Score
Disusun Oleh : Risk Rate
EII-HSE-FRM-23 - R(1)
:
Akibat
Diperiksa Oleh :
Severity of harm x Likelihood of occurrence Keparahan dari bahaya x kemungkinan terjadi
Page 5 of 17
Score Tingkat Resiko
Disetujui oleh :
Nama Proyek No. Proyek Daerah Pemantauan Periode
: : : KONSTRUKSI :
RENCANA PEMANTAUAN LINGKUNGAN Area Pemantauan
Pemantauan terhadap upaya pengelolaan
Bentuk Fisik
Prepared by :
EII-EMS-FRM-01
Sumber Dampak
Jenis Dampak
Periode Pemantauan
Pelaksana Pemantauan
Approved by :
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? Inspection Items
Yes
No*
Remarks N/A (i.e. specify location, good practices, problem observed, possible cause of 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? Inspection Items
Yes
No*
Remarks N/A (i.e. specify location, good practices, problem observed, possible cause of 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 ed professionals? 4.14. Others (please specify)
EII-EMS-FRM-03
8 of 17
Implemented? Inspection Items
Yes
No*
Remarks N/A (i.e. specify location, good practices, problem observed, possible cause of 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 LOKASI
:
PENANGGUNG JAWAB
:
TANGGAL EVALUASI
:
Konfirmasi
HSE
:
Disyahkan oleh
Project Manager
2
3
4
5
6
7
8
B3
SEVERITY Tingkat Keparahan 9
10
Luas Waktu Penyebar Pemuliha an n
Sumber Daya Alam
PEMENUHAN PERATURAN
No. Aspek
Lingkungan
Jenis dampak lingkungan
PERATURAN Perundang-undangan
ASPEK PENTING
INISIAL
11
12
13
14
NOMOR NOMOR ACTION PLAN PEMANTAUAN
15
16
SVRT
Rutin-Non Rutin
1
Spesific
Aspek
PROBABILITY Kemungkinan
Jenis
NO
Penaggung Jawab
Aktifitas -Produk Jasa
SKOR TINGKAT PENTING
No. Rec :
Keterangan Warna: : Data INPUT (Dapat Dirubah) : Hasil (Tidak Dirubah)
EII-EMS-FRM-05 - R(0)
10 of 17
SAFETY MEETING Project Subject Date Venue
: : : :
Present : 1.________________ /________ 4.________________ /________ 2.________________ /________ 5.________________ /________ 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 Lokasi Proyek Owner
1-C12-01-1-046 HOLCIM Cilacap HOLCIM Cilacap
Day / Date Speaker
-. 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
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
Name
Company Division Signature
50 Prepared by:
Acknowledge by: Mengetahui oleh :
(____________________) Safety
( Rahmat .NE ) Site Manager
EII-HSE-FRM-01 - R(0)
page : 12 of 17
HSE INVESTIGATION RECORD Proyek Project NO
: JENIS KEJADIAN / INCIDENT TYPE
NAMA / NAME
DEPARTEMEN / 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
EII-HSE-FRM-05-R(0)
(
)
(
)
Project Manager
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 )
No
EII-HSE-FRM-21- R(0)
Activity
PICA No. Date of PICA Periodical Analysis Problem
Approved by
Prepared by
1.______________ 2_______________ Caused of Problem
Initiative Corrective Action
PIC
Due date
Remark
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 :
EII-HSE-FRM-22 - R(0)
Approved by :
16 of 17
HSE INVESTIGATION RECORD Proyek Project NO 1
: CIL Dome pelletizer Truk Bullding NAMA / NAME material beam bracing, rafter
JENIS KEJADIAN / INCIDENT TYPE property damage
DEPARTEMEN / DEPARTEMENT construction
Investigasi / Investigation : (Cantumkan nama saksi bila perlu)
DENAH LOKASI KEJADIAN Location Incident Lay out
Tidak ada korban
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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