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Progress Report October 2012 Appendix F SE SHE FORM

Monthly Safety and Health Report


Area: SUPREME ENERGY MUARA LABOH (SEML)
Year: 2017
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Year to Date

CONTRACTOR DETAILS
Contractor's Name: PT. NURMAN MITRA SENTOSA
Contract Reference No.: 16000074-OS-10101
Contract Commencement Date: Tuesday, September 12, 2017
Contract Name/Subject (Name of Service): MUARA LABOH GEOTHERMAL POWER PROJECT
Name of Contact Person Related to Safety & Health Issue: ARJUNO
Telephone No. of the Safety & Health Related Contact Person: 82260701050
Email Address of the Safety & Health Related Contact Person: susantosimangunsong@yahoo.co.id
OHSAS 18001 Certification

Number of Contractor employee / Jumlah karyawan 22 22.00


Number of Hours Worked / Jumlah jam kerja 6336 6,336
Contractor Occupational Fatality 0 0
Contractors Occupational Lost Time Accident 0 0
Contractor Medically Treated Incident 0 0
Contractor First Aid Treatment 0 0
High Potential Serious Incidents or High Potential Near Misses/Near Hits 0 0
Hazard Identification 0 0
Safety Walks / Safety Inspection 0 0
SHE Training 0 0
SHE Weekly Meeting 0 0
P2K3 Meeting/ SHE Committee Meeting 0 0
Monthly Meeting 0 0
Toolbox Talks 18 18
INTRODUCTION
This Guideline details mandatory statistical safety and health monthly reporting requirements and associated definiti
of all stakeholders and to the continuous improvement of safety and health performance. In order to measure and be
capture and analyze various related statistics. Reporting is required to asset/business entity/construction project res

SCOPE

This Safety and Health Guideline is applicable to all Contractors (and their relevant Sub-contractor(s)) of PT Suprem
Supreme Energy Muara Laboh, PT Supreme Energy Rajabasa and PT Supreme Energy Rantau Dedap.

Supreme Energy is committed to improving safety and health performance and it is expected that every effort will be
the Contractor.

DEFINITION

Contractor Personnel

DATA ELEMENTS

Area

Contractor's Name:
Contract Reference No.:
Contract Commencement Date:
Contract Name/Subject (Name of Service):
Name of Person to Contact for Safety & Health Related Issue:
Telephone No. of the above Person:
Email Address of the above Person:
OHSAS 18001 Certification

Number of Hours Worked by Contractor Personnel

Contractor Occupational Fatality

Contractor Occupational Lost Time Accident

Contractor Medically Teated Incident

Contractor First Aid Treatment

High Potential Serious Incidents or High Potential Near Misses/Near


Hits
Near Misses/Near Hits

Safety Walks

Toolbox Talks

PROCEDURE
Safety and health reporting is performed on a monthly basis.

All reported data should refer to a calendar month. Data should not be reported on year-to-date or accumulated b

Every Contractor sends a completed Excel file to SHE and Relations Department of Supreme Energy by D+5 (5 day
address: arief-tarunaprawira@supreme-energy.com . This Excel file is a standard template, populated with all the m
Contractor and the reporting month. The same email is copied to the SHE Representative (erwin-patrisa@supreme

Once all data is available, Supreme Energy collates the data and validates them.
If the validation process shows evidence of errors, the Contractor resends a corrected Excel file to Supreme Energy

Note: At any time during the reporting year, every Contractor can send corrections for earlier months to Supreme En
particular month. As year-to-date figures are created by accumulating all individual months, such corrections are e

This is necessary to allow safety and health follow up, performance monitoring and benchmarking, etc. The data is c
without approval from Supreme Energy.
h monthly reporting requirements and associated definitions. Supreme Energy is committed to the health and safety
afety and health performance. In order to measure and benchmark safety and health performance, it is necessary to
required to asset/business entity/construction project resolution.

ctors (and their relevant Sub-contractor(s)) of PT Supreme Energy group of companies (Supreme Energy), i.e. PT
asa and PT Supreme Energy Rantau Dedap.

th performance and it is expected that every effort will be made to ensure that safety and health data is reported by

A person working for, and being supervised by a Contractor, contracted to provide services to the
Company. This includes any person employed by a sub-contractor working for a contract company
providing services to the Company.

For example, a person working for the main contractor or associated sub-contractor on a construction
project, or on a power station outage or a power station materials handling operative working for a
resident contracted service provider.

Contractors are considered for inclusion, when working within Supreme Energys sphere of control for
health and safety and:

Working on our sites, whether owned or leased, e.g. temporarily leased land for outage laydown area.
Working on our linear assets e.g. pipelines or transmission lines.

This should be either "Rajabasa" or "Muara Laboh" or "Rantau Dedap"

Already Clear
This is mentioned on the cover page of the Contract Document
This could be found in the Contract Document
This describes the service the Contractor provides for Supreme Energy and is mentioned on the cover
page of Contract Document, for example: 'Provision of Civil Works and Construction Services'
Already Clear
Already Clear
Already Clear
The OHSAS 18001 S&H management system must have been externally certified by an accredited body.
This should be either:
Yes
No

This is the actual hours worked by Contractor Personnel for Supreme Energy, including overtime.
In case there is no recording system for actual hours worked, the theoretical or contractual hours can be
used.

Means a death at the workplace as a direct result of work or asset operations. Pending the outcome of
investigations by official authorities and/or insurers, all fatalities are considered as occupational fatalities.
This is subsequently corrected if the official authorities and/or insurers decide that the fatality was not
caused by an occupational accident, e.g non-work health related fatalities, i.e. heart attacks, strokes.
An occupational accident is counted as a fatal accident when a death, related to the original accident,
occurs on the day of the accident or within 365 days of the accident.
This definition includes work-related travel, but excludes accidents on the way to/from work.

Means an accident or incident which results in a Contractor Personnel being unavailable to work, whether
scheduled to work or not, for one or more subsequent days or shifts (i.e. excluding the day or shift when
the accident occurred) due to injury or ill health sustained at work.
In cases where the Contractor Personnel works the next day or shift but is subsequently absent within the
next 7 days, as a direct result of the injury sustained or ill health caused, the accident should be counted
as a Lost Time Accident.

Means an injury or condition that, after consultation with a First-Aider, requires treatment from a Health
Care Professional at a specialist facility that may be on or off site, due to an injury or condition that
occurred in the workplace during the work period, after which the injured party returns to work. At sites
where there is an on-site Health Care Professional, some judgement will be required to differentiate
between minor treatments and those classed as Medically Treated Incidents. In these cases, a Medically
Treated Incident can be defined as a treatment beyond the capabilities of a First Aider.

Means a treatment provided to any Contractor Personnel by a nominated First Aider due to an injury or
condition that occurred in the workplace as a direct result of a work activity during the work period, which
has been formally recorded in the appropriate register or form.

An accident, incident or near miss/near hit that if materialised had a reasonable and foreseeable
probability of causing serious injury or death, but due to circumstance did not actually result in a serious
injury or fatality.
Any event, act or condition, for example:
- An incident or occurrence (e.g. an object falling from height);
- A plant or working environment condition (e.g. a pool of oil on the floor);
- An unsafe act or omission (e.g using a grinding machine without eye protection);
- A safety defect (e.g. lighting in a switchroom not working);

that had a reasonable and foreseeable probability of causing damage or injury, had the event, act or
condition been allowed to remain without corrective action, but where no plant/equipment damage, injury,
or environmental incident actually occurred.

For example, an event may have actually happened, such as a scaffold pole may have fallen from a
height, but not caused damage or injury. Similarly, a loose scaffold pole that had been identified in an
unsafe position and then moved to a safe position would also be counted.

For those using observation based behavioural safety programmes, the number of at risk observations
should also be included in these statistics.

This is a planned, regular examination of the site, plant or office, or part of the site, plant or office, with the
emphasis on health and safety issues. The examination is carried out by nominated personnel to an
established schedule and using an inspection check list, to demonstrate that the working environment and
practices have been considered and are either acceptable or not acceptable at the time of the inspection.
This should be in accordance with the contractors safety management plan requirements. Any safety
walks performed as part of an outage S&H management plan should also be included, whether or not they
were scheduled or utilised an inspection check list.

An informal team discussion or briefing to disseminate specific information relating to health and safety, as
a means of raising awareness. This does not include routine start of shift meetings or point of work
(dynamic) risk assessments carried out immediately before the work is performed.

s.

ould not be reported on year-to-date or accumulated basis.

Relations Department of Supreme Energy by D+5 (5 days after the end of the relevant month) with the email
Excel file is a standard template, populated with all the monthly data and showing the identification elements of the
ied to the SHE Representative (erwin-patrisa@supreme-energy.com).

a and validates them.


ractor resends a corrected Excel file to Supreme Energy.

or can send corrections for earlier months to Supreme Energy, just by resending a corrected Excel file for the
ccumulating all individual months, such corrections are essential in the reporting process.

ormance monitoring and benchmarking, etc. The data is considered as Internal and must not be published externally