Standard Format Laporan HSE

PROJECT SAFETY PLAN Customer Name Project Name Project Code Project Location Project Schedule Max or!er Acti"it#

: : : : : :

No

until Worker Description

Yes

Plan No

Remarks

1 Safety Safety Office Officerr Organiza Organization tion 2 Safety Emergenc Emergency y Proceure Proceure an Organize Organize Rescue Rescue !im !im " Safety Safety regula regulation tion an an Proceu Proceure re 1 #ouse #ouse $eep $eeping ing 2 !rafic !rafic %ontrol an !ranspor !ransportation tation " &ire Pre'ention Pre'ention Precaution Precaution an &ire &ig(ting E)uipment E)uipment * Working in %onfine %onfine Space + E,ca' E,ca'at ation ion - #ot Working Working ./eling0 cutting cutting operation operation  E)uip3 4 Electrical Electrical E)uipment E)uipment 5 %ran %rane e 6 #ois #oistt 17 Ot(er 8ifting 8ifting . !akle9i !akle9impole3 mpole3 11 ;anual 8ifting 8ifting . 8 ack0 # Pallet3 Pallet3 12 Scaffoling Scaffoling an an /ork &lat &orm 1" 8ae 8aers rs 1* Po/ers Po/ers tool tool 1+ #an tools tools an Portaelt 9 &ull >oy #arness + #an ?lo'es ?lo'es %otton %otton 9 8eat(er 8eat(er - ;ask ;asker er 4 Earning Earning Protecti Protection on 5 @D %ar %ar + @nsuran @nsurance ce 9 Aams Aamsost ostek ek - 8ock Out Safety Safety System System 1 %ar %ar Note Note 2 $ey Proceur Proceure e 4 Docum Document ent recor recor  1 =ccient Report . if any 3 2 Safety Safety =cti' =cti'ity ity " Safety Safety >o, >o, meeting meeting * !ool
EII-HSE-FRM-04 - R(0)

page : 1 of 17

EE$LY %SE PERFORMANCE REPORT

Contractor name& PT' Encona (nti (ndustri )ecsri*tion o+ ,or!& Re*ortin- Period +rom

Contract No' & or! Area& to

)AY Mon Tue ed )ATE Num
Thu

Fri

Sat

Sun

Total This ,ee!

Project Todate

or! Related (ncident.Accident Re*ort

&atality 8ost Work Day %ase.s3 Restricte Work Day %ase.s3 ;eical !reatment %ase.s3 &irst =i %ase .s3 Near ;isses @ncient &ire @ncient Oil Spill %ase #azar @entification Report ;otor Ce(icle %ras(es E)uipment @ncient .E@3

This ee! 7 7 7 7 7 7 7 7 7 7 7

Last ee! 7 7 7 7 7 7 7 7 7 7 7

Cumulati"e 7 7 7 7 7 7 7 7 7 7 7

Last ee! 7 7 7 7 7 7 7 7 7 7 7 7

Cumulati"e 7 7 7 7 7 7 7 7 7 7 7 7

Remarks: @nAury &ormula Nos o+ (ncident / 0112111 Total hours ;C% &ormula Nos o+ M3C / 421112111 Miles )ri"en E)uipment @ncient &ormula Nos o+ E( / 4112111 O*eratin- %ours

OR(ENTAT(ON.TRA(N(N5 AN) MEET(N5 PRO5RAM This ee! 7 7 7 7 7 7 7 7 7 7 7 7

Orientation DD% &SWP @ncient @n'estigation S= !raining &irst =i !raining &ire !raining >>S !raining Ot(ers !raining !ailgate ;eeting Weekly ;eeting ;ont(ly ;eeting

Remarks:    

Prepare
.

Re'ie/e
3

EII-HSE-FRM-08-R(0)

.

=ppro'e
3

.

3

NoReport9No.Laporan : Date 9 anggal : ProAect Name : Steel platform for fiER >F@8D@N?

No'

Man Po,er . Tenaga Kerja

6t#

)A(LY REPORT %SE Laporan Harian K3LL

Man %our

E7ui*ment Sa+et# and PPE on 8sed . Peralatan $9LL : AP)

1

ProAect ;anager

Tools . Alat

2

Site ;anager

"

%onstruction Superintenent

*

#SE

+

&a
Policy 8ine9,ar$# Pol$#$

-

Eriction %oorinator

4

&ormen

5

Operator

1

5

>oy #arness

6

&a
*

*5

Ot(er

17

#E8PER

1

6t#

Safety Sign9Ra%&' LL

5

PPE

Chec!

Safety #ea

5

Eye Protection

5

Ear Plug

5

?lo'es

5

%one

Safety S(oes

5

Ot(er9 8ainBlain

Rain %oat

&ire E,tinguis(er9 *P*R 1

No' (tem

5

8nit

"

Dust
Potential %a;ard . Potensi
1

4

Action . Tinda!an

<# . oleh

1 ;iscomunication9sala( instuksi

$oorinasi antar epartemen

yuli /antana

2 !ersanung

Selalu (atiB(atiper(atikan langka(

yuli /antana

" !angan terAepit paasaat penurunan material

>er(atiB(atiper(atikan langka(

yuli /antana

* !a
selalu
yuli /antana

+ !ertimpa material


yuli /antana

- !erperosok

Selalu (ati B(ati

yuli /antana

4 !ra

yuli /antana

Chec!ed. )i*eri!sa

5 6

Data %ollision

:

Data Pelanggaran

Prepare >y0 D$&'at ole+ P! EN%ON= @N!@ @NDFS!R@

%(ecke >y0 D$e" ole+

=ppro'e >y0 D$#et'/'$ ole+

.Yuli /3

.=ny3 3

o& De#r$pt$on

Date tgl

Ne23 >aru

Pe!erjaan 5alian =Ci"il or!>

o& Safet! *nal!#$#

Re$#e3 8ama

*rea 3 Loat$on

S* ea%

=rea 9 8okasi

!im S=

=nalisis $eselamatan PekerAaan Re5'$re 3 Reo%%ene PPE PPE yang i
Basic Sequence of Job Steps 8rutan Pe!erjaan

D$#tr$&'t$on B Original at !eam 8eaer9;anager B %opy for #SE %oorinator B %opy for O#S #O8%@;

Safety S(oes0 Safety #elmet0 Safety ?lass0 ?lo'es0 &irst =i $it

Potential Hazards
Recoended !ction or Procedures Lan-!ah.Prosedur #an- disaran!an

Prepare &! Di
6+e"e &! Diperiksa ole(

=RNO8DS S! #SE %oorinator

R=#;=! NE Site ;anager

*pproe &! DisetuAui ole(

O#S #O8%@;

R(S$ ASSESSMENT Di'isi :

Proyek :

No

$e-iatan

8okasi PekerAaan :

(denti+i!asi
A!i?at

Peluan-

!gl Penilaian :

Tin-!at Resi!o

Rs! d*t ditoleransi =Y.N>

Pen-endalian Resi!o

A!i?at

Peluan-

Tin-!at Resi!o

Rs! d*t ditoleransi =Y.N>

1

PeluanA < C ) E

A!i?at 4

0

9

@



E

E

E

E

#

Tin-!at Resi!o E

G E,treme Risk

Penjelasan =

G #ampir pasti terAai9almost certain

Score =G1 >G2

A!i?at +

8G

15 B 2+

E

#

#

#

#

G #ig( Risk

>

G %enrung untuk terAai

%iera ringan 9 P"$0 kerugian materi seang

;G

1" B 15

E

#

#

;

;

;

G ;oerate Risk

%

G ;ungkin apat terAai

%G"

"

G

#ilang (ari kerAa0 kerugian cukup
#G

- B 12

E

#

;

;

8

8

G 8o/ Risk

D

G $ecil kemungkinan terAai

DG*

2

G

%acat0 kerugian materi
EG

1 B +

#

#

;

8

8

E

G arang terAai9rare

EG+

1

G

$ematian0 kerugian materi sangat
Disusun Ole( : &

G

Score Tin-!at Resi!o

!iak aa ciera0 kerugian materi kecil

E

Ris! Rate

*

G

Diperiksa Ole( :

DisetuAui ole( :

Se"erit# o+ harm x Li!elihood o+ occurrence Keparahan dari baha"a # $eung$inan terjadi


Page 5 of 17

Nama Pro#e! No' Pro#e! )aerah Pemantauan Periode

& & & $ONSTR8$S( &

RENCANA PEMANTA8AN L(N5$8N5AN Area Pemantauan

Pemantauan terhadap upaya pengelolaan

Bentuk Fisik

Pre*ared ?# &

EII-EMS-FRM-01

Sumber Dampak

Jenis Dampak

Periode Pemantauan

Pelaksana Pemantauan

A**ro"ed ?# &

6 of 17

Nama Pro#e! No' Pro#e! )aerah Pemantauan Periode

& & & $ONSTR8$S( &

RENCANA PEMANTA8AN L(N5$8N5AN Area Pemantauan

Pemantauan terhadap upaya pengelolaan

Bentuk Fisik

Sumber Dampak

Pre*ared ?# &

Jenis Dampak

Periode Pemantauan

Pelaksana Pemantauan

A**ro"ed ?# &

EII-EMS-FRM-01

6 of 17

EN3(RONMENTAL S(TE (NSPECT(ON C%EC$ L(ST Project Site Location Construction sta-e.status durin- ins*ection (n*ection )ate (n*ection Time eather

& & & & & &

Note : !(is form is esigne for general use an may n ot
(m*lementedB (ns*ection (tems

4' Air Pollution Control 11 =re t(e construction sites /atere to minimize ust generateH 12 =re stockpiles of usty materials .size /it( more t(an 27
Yes

No

Remar!s N.A .ie specify location0 goo practices0 pro
EN3(RONMENTAL S(TE (NSPECT(ON C%EC$ L(ST Project Site Location Construction sta-e.status durin- ins*ection (n*ection )ate (n*ection Time eather

& & & & & &

Note : !(is form is esigne for general use an may n ot

Yes

No

4' Air Pollution Control 11 =re t(e construction sites /atere to minimize ust generateH 12 =re stockpiles of usty materials .size /it( more t(an 27
0' ater Pollution Control 21 =re /ater isc(arge licenses 'aliH 22 =re conitions of t(e license compile /it(H .c(eck t(e monitoring recors an o
EII-EMS-FRM-03

7 of 17


Yes

No

26 =re san
9' Noise Control   Permit3 'ali for /ork uring restricte "2 =re copies of t(e 'ali %onstruction Noise Permits poste at site entrance9e,itH "" Do air compressors an generators operate /it( oors closeH "* @s ile plant9e)uipment turne off or t(rottle o/nH "+ Do air compressors an (anB(el
Ot(ers .please specify3

@' aste Mana-ement *1 @s t(e site kept clean an tiyH .eg litter free0 goo (ousekeeping3 *2 =re separate c(utes use for inert an nonBinert /astesH *" =re separate la
EII-EMS-FRM-03

8 of 17


Yes

No

' Stora-e o+ Chemicals and )an-erous 5oods =)5> +1 =re c(emicals store an la

' Protection o+ Flora2 Fauna and %istorical %erita-e -1 =re istur

D' Resource Conser"ation 41 @s /ater recycle /(ere'er possi

' Emer-enc# Pre*aredness and Res*onse 51 =re fire e,tinguis(ers 9 fig(ting facilities properly maintaine an not e,pireH Escape not

J=ny KNoL recore represents t(e potential
Si-nature o+ Site (ns*ector

&

)ate &

Re"ie,ed ?# Project Mana-er

&

)ate &

EII-EMS-FRM-03

9 of 17

IDENTIFIKASI  PEN!ENDA"IAN DAN PE#ANTA$AN ASPEK "IN!K$N!AN Status / Revs

"a u$a% o&e'

"%KASI

&

PENAN!!$N! JA'AB

&

TAN!!A" E(A"$ASI

&

o%f*as

)SE

!

"s a'$a% o&e'

Pro*e+t #anager ,o Re. !

Akti,itas -Produk Jasa N%

.

Jenis n o n N - i t n u i t 8 u 8

Spesi,i+

/

> k o e p N s A

0

1

Aspek "ingkungan

2

g n u b g a g < a a n J e P

3

= n T a I n " i I k B g A n B u % m 8 e P K

4

Jenis dampak lingkungan

SE(E8IT= Tingkat Keparahan

5

6

B0

"uas 'aktu Penyebar Pemuliha an n

T ! N 8 A I % K T K ! N S N I E T P .7

Sumber Daya Alam

N N A A ) 8 $ $ N T E A 8 # E E P P

..

PE8AT$8AN Perundang-undangan

ASPEK PENTIN!

INISIA"

./

.0

.1

N%#%8 N%#%8 A;TI%N P"AN PE#ANTA$AN

.2

.3

T 8 ( S

etea%ga% a%a! & Data INP$T 9Dapat Dirubah:

& )asil 9Tidak Dirubah:

EII-EMS-FRM-05 - R(0)

10 of 17

SAFETY MEET(N5 Project Su?ject )ate 3enue

: : : :

Present & 1MMMMMMMMMMMMMMMM 9MMMMMMMM *MMMMMMMMMMMMMMMM 9MMMMMMMM 2MMMMMMMMMMMMMMMM 9MMMMMMMM +MMMMMMMMMMMMMMMM 9MMMMMMMM "MMMMMMMMMMMMMMMM 9MMMMMMMM -MMMMMMMMMMMMMMMM 9MMMMMMMM

MATTERS )(SC8SSE) SAFETY&

68AL(TY &

=%!@ON

DFE D=!E

SAFETY MEET(N5 Project Su?ject )ate 3enue

: : : :

Present & 1MMMMMMMMMMMMMMMM 9MMMMMMMM *MMMMMMMMMMMMMMMM 9MMMMMMMM 2MMMMMMMMMMMMMMMM 9MMMMMMMM +MMMMMMMMMMMMMMMM 9MMMMMMMM "MMMMMMMMMMMMMMMM 9MMMMMMMM -MMMMMMMMMMMMMMMM 9MMMMMMMM

MATTERS )(SC8SSE)

=%!@ON

DFE D=!E

SAFETY&

68AL(TY &

RES8LT(.PLAN(N5.PRO

page : 11 of 17

TOOL
1B%12B71B1B7*#O8%@; %ilacap #O8%@; %ilacap

Day 9 Date Speaker

B Pemakaian =PD yang sesuai engan Aenis pekerAaan B Sosialisasi o< Safety =nalysis .S=3 B $onsentrasi paa saat
!opic B Selalu /aspaa an per(atikan langka( ialam lokasi kerAa

No

Name

Com*an# )i"ision Si-nature No

1

2-

2

24

"

25

*

26

+

"7

-

"1

4

"2

5

""

6

"*

17

"+

11

"-

12

"4

1"

"5

1*

"6

1+

*7

1-

*1

14

*2

15

*"

16

**

27

*+

21

*-

22

*4

2"

*5

2*

*6

2+

+7

Name

Com*an# )i"ision Si-nature

Prepare
=ckno/lege
.MMMMMMMMMMMMMMMMMMMM3 Safety

. Ra(mat NE 3 Site ;anager


page : 1 of 17

)SE IN(ESTI!ATI%N 8E;%8D Po+e$ Po#e.t ,

! E,IS E4"I4, / I,1I"E,8 89PE

,4M4 / ,4ME

"EP4REME, / "EP4REME,

In?estigasi @ In?estigation & (a%tu*$a% %a*a sa$s &a e&u)

"E,4H 4SI E4"I4, 5o.ato% I%.7e%t 5a out

Pe%+ea ! 1ause of

%a$a% oe$s ! 1oe.tve 4.to%

%a$a% Pe%.ega'a% Pe.auto%

!

Tindakan @ A+tion Peto&o%ga% eta*a / Fst 47 %a$a% &a%#uta% / 1o%t%uato% 4.to%

Staff HSE

EII-HSE-FRM-08-R(0)

Po#e.t Ma%age

+al. : 1 ar$ 17

IN;IDENT STATE#ENT "AP%8AN KEJADIAN Kronologi Ke*adian - ;hronology In+ident Pernyataan dari Saksi &

Tanda Tangan

Statement o, 'itness

Signature

1

2

Pernyataan dari Pelaku &

1

Statement o, Prin+ipals

2

Pernyataan dari Pelaku &

1

Statement o, the (i+tim

2

EII-HSE-FRM-08-R(0)

+al. : 14 ar$ 17

PRO

No

Acti"it#

P@%= No Date of P@%= Perioical =nalysis Pro?lem

=ppro'e
(nitiati"e Correcti"e Action

EII-HSE-FRM-21- R(0)

Project Name No' Project Location )a# . )ate

& & & &

B &ires0 e,plosions  B %(emical Spillage or leakage  B =ccients as a result of e)uipment failure

)e*artment . Section Startin- Time Com*letion Time Num?er o+ *artici*ants

P(C

)ue date

Remar!

15 of 17

EMER5ENCY )R(LL REPORT

T#*e o+ Emer-enc# )rill

Prepare
Project Name No' Project Location )a# . )ate

& & & &

EMER5ENCY )R(LL REPORT B &ires0 e,plosions  B %(emical Spillage or leakage  B =ccients as a result of e)uipment failure T#*e o+ Emer-enc# )rill

)e*artment . Section Startin- Time Com*letion Time Num?er o+ *artici*ants =name list attached> Partici*ation Rate Name o+ Fire O++icer

Su--estion (tems

Action Plan

Pre*ared ?# &


A**ro"ed ?# &

16 of 17

)SE IN(ESTI!ATI%N 8E;%8D Po+e$ Po#e.t , 1

! I "o*e e&&et:e u$ ;u&&%g ,4M4 / ,4ME *atea& ea* a.%g> afte

E,IS E4"I4, / I,1I"E,8 89PE oet+ a*age

"EP4REME, / "EP4REME, .o%stu.to%

In?estigasi @ In?estigation & (a%tu*$a% %a*a sa$s &a e&u)

a$ aa $oa%

"E,4H 4SI E4"I4, 5o.ato% I%.7e%t 5a+ out

Penyebab ! 1ause of e< .a%e aa ' $a*s #a* 0735 *e*a %as *es% .a%e a% es'-es' $a% .e< .a%e ta$ *e%geta'u $a&au st.$ u oo* tese%ggo& ae%a egtu sta'at ta'u-ta'u *es% *atSete&a'  &'at $eatas oo* .a%e *e%gge%a ea* a.%g s'g afte %o = Tindakan Koreksi & s/ %o 7*e&e%g$u%g  a$at$a% o&e' $ete&eao% .e< .a%e  1oe.tve 4.to% " ast$a% oa%g +a%g e$o*e%te% u%tu$ *e&a$u$a% a$tftas  $a% .a%e teseut

Tindakan Pen+egahan ! Pe.auto% Safet+ a% Suevso *e*ast$a% .e< .a%e +a%g e$o*e%te% u%tu$ *e&a$u$a% a$tftas  $a% .a%e  Tindakan @ A+tion Peto&o%ga% eta*a / Fst 47 %a$a% &a%#uta% / 1o%t%uato% 4.to% " e&u$a%+a %se.to% se.aa e$a&a a% &* e&a$sa%aa% e$e#aa% se&a&u *e%g$ut oseu $ese&a*ata% $e#a e$a$as a&at a%g$at a% a%g$ut

Staff HSE

Ste *a%age

Standard Format Laporan HSE

Recommend Documents