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AMMONIA UREA II PROJECT DOC. NO.

: 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 1 / 16

1. AUDIT CHECKLIST FOR CONSTRUCTION HSEMS

Client : PT. ADHI KARYA (PERSERO),TBK Month Of Inspection : NOVEMBER 2017


Project : AMMONIA UREA II Project No. : 201485
Subcontractor : PT. MATRIK JAYA UNGGUL Line Item Rating Evaluation : 1
Cons. Manager : SUJONO 3 - Exceeds Minimum Requirements
Safety Coor. : CLARA 2 - Meets Minimum Requirements
Auditor : FALISTA ANGGI S 1 - Needs Minor Improvement
Date : NOVEMBER 21th, 2017 0 - Totally Unacceptable

NOTE: Use N/A for no entry NOTE: Wt. = 1 to 10 Lo = 1 / IMPACT / 10 = Hi

NO. DESCRIPTION WEIGHT SCORE

1 HSE Policy 20
1.1 s the Subcontractors Corporate HSE Policy be signed by Top
10 10
Management?
1.2 Is the Subcontractor's Corporate HSE Policy posted in prominent
10 10
locations?

2 Safety Management Organization 61


2.1 Is a HSE Organization established? 10 10
2.2 Is a full - time QHSE Mgr./Coordinator assigned? 8 8
2.3 Are the duties and responsibilities of each the following persons clearly
defined? 8 8
* Project Manager
* Construction Manager 8 8
* QHSE Manager/ Field HSE Manager 8 8
* HSE Officer 5 5
* Construction Supervisors 5 5
* Foreman 3 3
* Worker 2 2
2.4 Is the HSE Organization adequately staffed? 4 4

3 HSE Committee 39
3.1 Is a HSE Committee established with adequate representation from
5 5
Subcontractor?
3.2 Are the objectives of the Committee clearly defined? 5 5
3.3 Are the operating rules of the Committee defined? 5 5
3.4 Are the activities of the Committee carried out in accordance with the
5 5
operating rules?
3.5 Are the HSE Committee Meeting conducted regularly and in timely
7 7
manner?

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 2 / 16

NO. DESCRIPTION WEIGHT SCORE

3.6 Are matters decided at the meeting conveyed to all personnel


7 7
concerned?
3.7 Are records of the meetings and the activities of the Committee recorded
5 5
and retained?

4 HSE Administration 48
4.1 Written HSE program plus project rules 5 5
4.2 HSE program enforced by mgmt/Supervisor 10 10
4.3 HSE Coordination Mgr - Authority, Qualified 5 5
4.4 Personnel injury log - accurate, complete 2 2
4.5 Accident investigation/reports 3 3
4.6 Weekly HSE report 3 3
4.7 Loss Prevention inspections performed 5 5
4.8 Hazards anticipated 5 5
4.9 Accident Statistics 10 10

5 Jobsite Information 16
5.1 Posting jobsite warning poster 3 3
5.2 Do you have HSE internal meetings? 5 5
5.3 Are there medical service and first-aid equipment, stretchers and
4 4
emergency vehicles available?
5.4 Is Fire Fighting, Clinic/Hospital/Ambulance phone number being posted? 4 4

6 Work Permitsand JSA 22


6.1 Obtained as required / monitored 5 5
6.2 Smoking controlled 3 3
6.3 Fire extinguisher - as required on permit 2 2
6.4 Personal protective equipment used 2 2
6.5 Supervision present as required 5 5
6.6 Client requirements - HSE precautions / hazards explained to workers 5 5

7 Fire Prevention/Protection 0
7.1 Adequate fire extinguishers for hazard 0 0
7.2 Proper type and location 0 0
7.3 Fire watches trained 0 0
7.4 No smoking signs posted 0 0
7.5 Inspections & maintenance of extinguishers-monthly 0 0
7.6 Fires/Extinguisher use - reported 0 0
7.7 Storage of flammable material - labeled 0 0
7.8 Containers grounded 0 0

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 3 / 16

NO. DESCRIPTION WEIGHT SCORE

7.9 Wooden materials stored properly 0 0


7.10 Flammable Materials stored properly 0 0
7.11 Used metal jerry cans with covers 0 0
7.12 Used metal fuel drums 0 0
7.13 Fuel transfer 0 0
7.14 Muster point free from obstruction 0 0
7.15 Emergency Sirens 0 0

8 Personal Protective Equipment 21


8.1 Head protection - overhead hazards 2 2
8.2 Eye protection - chipping, grinding, etc 2 2
8.3 Foot protection - heavy, sharp object 2 2
8.4 Hearing protection - over 85 dB/8 hours 2 2
8.5 Hand protection - sharp objects, splinters 2 2
8.6 Respiratory protection - hazardous dust, gas etc. 2 2
8.7 Skin protection - acid, caustic, etc 2 2
8.8 Safety hardness (tied off) - over 2 meter high 5 5
8.9 Proper clothing 2 2

9 Safety Schedule Meetings 15


9.1 Are safety and Schedule Meetings carried out periodically with adequate
5 5
representation from subcontractors?
9.2 In addition to topics regarding coordination of the working Schedule and
problems involving conflicts of interest between Subcontractors, are all 5 5
safety topics and problems discussed at the meeting?
9.3 Are matters decided at the meeting conveyed to all personnel
5 5
Concerned?

10 Safety Procedures / Safety Rules 25


10.1 Are the following procedures and regulations prepared and available
* Safety Regulations? 10 10
* Emergency Preparedness? 10 10
* Work Execution Procedures for General work and specific work 5 5

11 Safety Education and Training 52


11.1 Are the procedures and Materials prepared and available for the training? 10 10
11.2 HSE induction for new entrant 5 5
11.3 HSE training for manager and supervisor 5 5
11.4 HSE training for specific hazardous work 5 5
11.5 Refresh Safety education 5 5

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 4 / 16

NO. DESCRIPTION WEIGHT SCORE

11.6 Fire and First Aid Training 5 5


11.7 Is the safety education and training carried out by competent instructors
5 5
in timely manner?
11.8 Are the records of safety education and training retained? 3 3
11.9 Are the workers who received safety education and training and identified
3 3
with distinguishing badge or colors
11.10 Do all workers including supervisors and foreman attend the meeting?
3 3
(e.g. safety talk/tool box meeting)?
11.11 Are the contents of toolbox meeting/safety talk appropriate to ensure safe
3 3
work activities?

12 Construction Tools and Equipment 25


12.1 Are tools and equipment inspected prior to start of the work and then
3 2
periodically by qualified mechanics?
12.2 Are defective tools & equip. immediately repaired or removed from the
2 2
work site?
12.3 Is the power disconnected and any pressure discharged before
3 2
maintenance of power tools and equipment?
12.4 Are abrasive wheels or cutting discs changed by qualified workers, and
2 2
tested a minimum of 3 minutes prior to use?
12.5 Is a cracked or damage abrasive wheel or cutting discs destroyed? 1 1
12.6 Are tools and equipment operated properly in regard to any limiting
3 2
conditions, such as permissible speed, load, etc.?
12.7 Are all electrical or mechanical safe guards for rotating or moving parts in
3 2
use?
12.8 Is proper electric wiring and grounding for power tools and tools used in
3 2
explosion hazardous locations?
12.9 Is proper personal protective equipment (gloves, safety goggles, face
3 2
shield, etc.) used?
12.10 Are workers forbidden to wear loose or frayed clothing and gloves when
handling or operating rotating or moving part tools or equipment, or when 2 2
exposed to contact with moving parts?

13 Heavy Equipment 16
13.1 Operator qualified, licensed 3 3
13.2 Regular inspection and maintenance 3 3
13.3 Wheels chocked when parked on grade 1 1
13.4 Speeding controlled as posted 1 1
13.5 Dump beds chocked up during repairs 1 1
13.6 Backup alarms provided on all equipment 3 2
13.7 Signalmen as needed 1 1

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 5 / 16

NO. DESCRIPTION WEIGHT SCORE

13.8 Fire extinguishers-minimum cover radius at the same floor with type ABC 1 1
13.9 Engine off when re-fuelling 2 2

14 Chemical Handling and Use 0


14.1 Have workers involved in handling chemicals, which are potentially
0 0
hazardous received pre-job training?
14.2 Are procedures for use and handling of the chemicals and emergency
0 0
procedures provided?
14.3 Is personal protective equipment such as safety garment, glove respirator
0 0
etc. and a shower and eye for emergency use is provided?
14.4 Are the chemicals properly stored in a non combustible warehouse with
good ventilation, an impermeable floor washing and drain facilities and air 0 0
conditioning, if required?
14.5 Is the warehouse equipped with warning signs and locked to avoid
0 0
unauthorized entree?
14.6 Are all containers libeled with the chemical's name, ingredient, and
0 0
cautions for storage and handling?
14.7 Are logs of the chemicals (names, Volume and stored, dates) retained? 0 0

15 Safety Inspection/Audit 19
15.1 Are the Safety Inspection procedure and check list Prepared and
5 5
available?
15.2 Are Safety Inspection at the site carried out regularly according to the
2 2
inspection procedures by * Site Manager / Construction Manager
* Site HSE Manager 2 2
* HSE Officer 1 1
15.3 Are the above listed individual authorized to halt operation and use
3 3
facilities in emergency or imminent danger situation?
15.4 Are the results of the safety inspection recorded and corrective actions
3 3
confirmed?
15.6 Is a safety audit by a third party or a safety consultant from
3 3
Subcontractors Home Office periodically carried out?

16 Accident Investigation and Reporting 19


16.1 Are the accident investigation procedures prepared and Available? 5 5
16.2 Is the reporting procedure for an accident established? 5 5
16.3 Is a near-miss (property damage, MVA, fire/explosion) accident log-up-to-
4 4
date, reported and is a report mandatory?
16.4 Is an analysis of cause or causes or an accident carried out and are
5 5
measures to be taken to prevent similar accident reported?

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 6 / 16

NO. DESCRIPTION WEIGHT SCORE

17 Safety Promotion (+Awards) 12


17.1 Is safety bulletin board displaying the safety performance of
3 3
Subcontractor and safety slogan etc.?
17.2 Are the following notices posted in prominent location in the site? 3 3
* Site Office Rules
* Emergency network for fires and accidents with address and telephone
numbers
17.3 Are safety posters posted in appropriate location? 3 3
17.4 Are warning signs, danger signs, caution signs and Instruction sign
3 3
appropriately displayed on the job site?

18 Explosives 0
18.1 Qualified operators and supervision 0 0
18.2 Proper transport vehicles 0 0
18.3 Local laws and regulations observed 0 0
18.4 Storage magazines constructed per regulation or as recommended 0 0
18.5 Experience personnel handling explosive at all times 0 0
18.6 No Smoking sign posted at right places 0 0
18.7 All personnel familiar with signals properly used at all times 0 0
18.8 Inspection after each shot 0 0
18.9 Proper protection and accounting for all explosive at all time 0 0
18.10 Proper Disposition of wrapping, waste and scrap 0 0
18.11 Advise residents nearby of blasting cap danger 0 0
18.12 Check radio frequency hazards 0 0

19 Motor Vehicles 11
19.1 Regular inspection and maintenance (Pre-Trip Inspection for Light
3 3
Vehicle on Daily Basis)
19.2 Lubrication Qualified Operators 1 1
19.3 Local and state vehicle laws and regulations observed 1 1
19.4 Brakes, lights, warning devices in good condition 1 1
19.5 Weight limit and load controlled 1 1
19.6 Personnel carried in a safe manner 1 1
19.7 Is all glass in good condition? 1 1
19.8 Are back-up signals provided? 1 1
19.9 Are fire extinguishers installed where required? 1 1

20 Garages and Repaired Shops 0


20.1 Fire hazard available 0 1
20.2 Dispensing of fuels and lubricants 0 1

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 7 / 16

NO. DESCRIPTION WEIGHT SCORE

20.3 Good house keeping 0 1


20.4 Lighting 0 2
20.5 Carbon Monoxide dangers. 0 1
20.6 Are all fuels and lubrications in proper containers? 0 3
20.7 Proper ventilation 0 1

21 Work Site Documentation 5


21.1 Is the following documentation prepared, updated and Retained? 5 5
*Training and education record
* Safety Inspection and audit record
* Instruction records for corrective action
* Inspection records of equipment and tools
* Equipment Maintenance records
* Hoisting/Lifting apparatus log book
* Electric Equipment log book
* Safety meeting records
* Medical Examination Records
* Accident investigation records
* Work permit records
* Workers and operators licenses log book
* Insurance Certificates

22 Ionizing Radiation 0
22.1 Are procedures for work involving ionizing radiation provided, in
0 0
accordance with statutory and / or company Regulations?
22.2 Is any work involving ionizing radiation devices mainly Executed during
0 0
off-peak hours or night, and obtained the work permit system?
22.3 Is a qualified (licensed) supervisor and experienced workers assigned to
0 0
the work?
22.4 Are all persons involved in radiation activities obliged to carry personal
0 0
radiation mattering devices at all times?
22.5 Are radiation meter evaluation and calibration intervals specified and
0 0
recorded on the site?
22.6 Is the work area protected against unauthorized entry by barricade and
0 0
warning signs?
22.7 Is a safe distance specified? 0 0
22.8 Is the handling and storage of radioactive source and emergency
procedures specified in accordance National (BATAN )or International 0 0
standards?
22.9 Are storage areas for ionizing radiation hazards equipped with relevant
0 0
warning sign and locked to avoid unauthorized entre?

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 8 / 16

NO. DESCRIPTION WEIGHT SCORE

23 Barricades 8
23.1 Floor opening planked over or barricaded 1 1
23.2 Roadways and sidewalk effectively protected 2 2
23.3 Adequate lighting provided 2 2
23.4 Traffic controlled 3 1

24 Transportation 21
24.1 Employee transport adequate seating 5 2
24.2 Seat belt use enforced 5 2
24.3 Tires, lights, etc. maintained 2 1
24.4 No riding back of open trucks without proper seats 2 1
24.5 Traffic regulation enforced 3 1
24.6 Driver qualified/licensed 2 1
25.7 Operational car passed permit 2 1

25 Concrete Construction 20
25.1 Form properly installed and braced? 3 3
25.2 Adequate shoring, plumbed, and cross-braced? 3 3
25.3 Shoring remains in place until strength as attained? 1 2
25.4 Proper curing period and procedure? 2 2
25.5 Check heating devices? 2 2
25.6 Mixing and transport equipment supported and traffic planned and noted? 3 2
25.7 Adequate runways? 2 2
25.8 Protection from cement dust? 2 2
25.9 Is the work place be kept neat and orderly 2 1

26 Steel Erection 0
26.1 Safety nets or planked floors 0 0
26.2 Taglines for tools 0 0
26.3 Fire hazards at rivet forge and welding operations 0 0
26.4 Floor opening covered and barricaded 0 0
26.5 Ladders, stairs, or other access provided 0 0
26.6 Hoisting apparatus checked 0 0

27 Scaffolding 0
27.1 Dismantling/erection supervised 0 0
27.2 Designed properly for height/loading 0 0
27.3 Connections secured 0 0
27.4 Platform and walkway min. width 40 cm 0 0
27.5 Scaffold tied to structure every 20 feet 0 0

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 9 / 16

NO. DESCRIPTION WEIGHT SCORE

27.6 Platform free of debris 0 0


27.7 Base pads used/casters locked 0 0
27.8 Guardrails in good condition no knots, splits 0 0
27.9 Mobile scaffolds use in motion, no riders 0 0
27.10 Ladders access provided/used 0 0
27.11 Suspended scaffolds-hand railed, stable 0 0
27.12 Anchored, safety belts used 0 0
27.13 Qualified Inspector Scaffolding & Qualified Scaffolder 0 0
27.14 Scaffold Tag Displayed 0 0

28 Excavation/Trenching/Shoring 21
28.1 Supervised/inspected daily- competent person 5 5
28.2 Access/egress 1 0
28.3 Shoring/sloping-Adequate for soil type 4 2
28.4 Barrier and warnings 1 1
28.5 Spoil clearance over 2 from edge 2 2
28.6 Adjacent structures shored 2 2
28.7 U/G lines identified and located hand dig 2 2
28.8 Equipment kept clear of excavation edge 2 2
28.9 Checked for flammable/toxic gas 2 2

29 Cranes and Lifting 0


29.1 Current certification 0 0
29.2 Loads/radius indicator as required 0 0
29.3 Safety latches (hooks) 0 0
29.4 Condition of wire ropes, slings, chain 0 0
29.5 Condition of shackles-no makeshift devices 0 0
29.6 Qualified rigger/Signalman 0 0
29.7 Proper use of outriggers/Supports 0 0
29.8 Tag lines used 0 0
29.9 Inspection and maintenance monthly/annual 0 0
29.10 Power lines at safe distance minimum 10 feet 0 0
29.11 Lifting Plan Calculation (Including Crane Layout Position) 0 0
29.12 Operator Lisence (SIO) 0 0
29.13 Anti Two Block System 0 0

30 Electrical System 28
30.1 Service panel: a) Fused 5 5
b) 3-Wire distribution 5 2
c) Grounding 5 5

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 10 / 16

NO. DESCRIPTION WEIGHT SCORE

30.2 Hold tags and lockout used 5 2


30.3 Warning signs posted/enforced 5 1
30.3 U/G electrical protected 3 3

31 Electric Arc Welding 0


31.1 Are all welders qualified? 0 0
31.2 Are welding machine, accessories and tool inspected at carry-in daily? 0 0
31.3 Before start of work and periodically? 0 0
31.4 Is proper insulation electrode holders used? 0 0
31.5 Is an automatic electric shock prevention devices furnished on A.C arc
welding machines? (when the arc is stopped, no load voltage on the 0 0
output becomes 30 volt or less within 5 second, see note below)
31.6 Is personal protective equipment provided for welder? 0 0
31.7 Is a welding booth or shields installed to prevent emission of welding ray,
0 0
and scatter of spark, molten melt, etc.?
31.8 Is ventilation system provided for welding work in confined space and
0 0
poorly ventilated locations?
31.9 Is the electrode disconnected from the holder when the welder leaves? 0 0
31.10 Are fire extinguishers provided near the work place? 0 0
31.11 Prior to welding work, is any combustible material around and / or under
0 0
the work place removed?

Note: Automatic electric shock prevention devices are necessary for


Welding surrounded by electric conductors, such as the inside of vessel,
Pipe, duct etc. and in wet condition.

32 Welding/Cutting 0
32.1 Secured cylinders upright 0 0
32.2 Gauges removed when moved 0 0
32.3 Hoses-condition 0 0
32.4 Fire extinguisher ABC 0 0
32.5 Operators protective equipment used 0 0
32.6 Shields and spark catchers installed 0 0
32.7 Grounding close to work station 0 0
32.8 Cable condition/roll up 0 0
32.9 Permit obtained as required 0 0
32.10 Equipment off when not in use 0 0

33 Abrasive Blasting/Painting 0
33.1 Operator hood/Air supplied 0 0

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 11 / 16

NO. DESCRIPTION WEIGHT SCORE

33.2 Air filter CO monitor, high temperature alarm 0 0


33.3 Operators PPE 0 0
33.4 Painters use of PPE 0 0

34 Health and Welfare 21


34.1 Medical facilities 4 3
34.2 Toilet facilities minimum 1 per 20 3 2
34.3 Washing facilities / sanitary conditions 3 1
34.4 Ambulance/emergency phone number posted 2 1
34.5 Rescue equipment / personnel trained 4 2
34.6 Toxic chemical protection labeled, MSDS 5 4

35 Ladders Ramps and Stairs 0


35.1 Ladders inspected frequently 0 0
35.2 Ladders designed and used for the task 0 0
35.3 Secured at top/base level and on firm footing 0 0
35.4 Side rails extend 3 above top support 0 0
35.5 Rungs not over 12 on center-req. spacing 0 0
35.6 Ramp cleaned 0 0
35.7 Stairways properly build- 0 0
35.8 Guardrails provided 0 0
35.9 Openings covered labeled or railed 0 0

36 Housekeeping/Material Handling 14
36.1 Good site layout 3 1
36.2 Site Access/Dust controlled 2 1
36.3 Trash containers/covers used 1 1
36.4 Material stacked and stable 1 1
36.5 Flammable & Combustible storage/access clear 3 1
36.6 Timber de-nailed/picked up 1 1
36.7 Passageways clear at all times 1 1
36.8 Proper manual material handling 2 1

37 Steel/Pipe Erection 0
37.1 Perimeter guarding 0 0
37.2 Platforms/floors w/in 30 0 0
37.3 Tagline used 0 0
37.4 Floor opening cover/labeled 0 0
37.5 Ladders or stair provided/used 0 0
37.6 2 connecting bolts before releasing beam 0 0

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
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HSE AUDIT SYSTEM Page : 12 / 16

NO. DESCRIPTION WEIGHT SCORE

37.7 Erection properly supervised 0 0


37.8 Vertical rebar covered 0 0
37.9 Safety hardness tied off over 6 high 0 0

38 Power Tools 7
38.1 Correct voltage 1 1
38.2 Properly grounded 1 1
38.3 Properly guarded at all times 1 1
38.4 Cable/hose, plug, connectors in good condition 1 1
38.5 Inspection/Maintenance-daily/monthly 2 1
38.6 Correct disk for grinding 1 1

39 Hand Tools 5
39.1 Correct tool for the job 1 1
39.2 Correct use 1 1
39.3 Inspection 2 1
39.4 No makeshift devices 1 1

40 Powder Actuated Tools 0


40.1 Eye protection 0 0
40.2 Ear protection 0 0
40.3 Control of cartridges authorized persons 0 0
40.4 Equipment handling manufacturer recommendation 0 0
40.5 Certified operator 0 0
40.6 Inspection and maintenance 0 0

41 Air Compressors/Generators 5
41.1 Pressure valve/Mufflers 1 1
41.2 Air pressure gauges in working order 1 1
41.3 Hoses and connection/Cords/Grounding 1 1
41.4 General condition 1 1
41.5 Correct coupling/secured 1 1

42 Flammable Cases and Liquids 0


42.1 All containers clearly identified 0 0
42.2 Proper storage practices observed 0 0
42.3 Fire hazard checked 0 0
42.4 Proper storage temperatures and protection 0 0
42.5 Proper types and number of extinguishers nearby 0 0
42.6 Carts for moving cylinders 0 0

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 13 / 16

NO. DESCRIPTION WEIGHT SCORE

43 Shut-Down or Maintenance Work 0


43.1 Are work execution procedures established? 0 0
43.2 Is a work permitting system established? 0 0
43.3 Are roles and responsibilities for work, inspection and subcontractor
0 0
clearly defined?
43.4 Have workers involved in the work received instruction and training for
0 0
the work
43.5 Are sufficient preventive measures for fire and explosion furnished? 0 0
43.6 Is an evacuation system including a warning system such as siren etc.
0 0
established?
43.7 Has any residue and pressure in vessel, tank or pipeline been
0 0
discharged?
43.8 Has the power source been cut off and the power distribution panel
0 0
boards locked?
43.9 Has blind isolation of the pipeline been installed, and confirmed and are
0 0
tags with warning exhibited?
43.10 When gas cutting is used on an existing pipeline or equipment has there
0 0
residue been discharged and gas been purged by inert gas?
43.11 Are proper tools and equipment such as explosion proof or Non-sparking
0 0
one used?
43.12 Is a meeting held daily to coordinate the work schedule and any
0 0
complicated work conditions in a limited or narrow area?
43.13 If nitrogen is used for purging or sealing are proper measures and
0 0
warning to prevent suffocation accidents provided?

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 14 / 16

2. SUMMARY OF SAFETY AUDIT

Project : AMMONIA UREA II PROJECT


Subcontractor Audited : PT. MATRIK JAYA UNGGUL
Date of Audit : AGSUTUS 21th, 2017
Location : UREA, DEMIN AREA, AMMONIA BASSIN

GENERAL :
Kesiapan Bekerja di ketinggian harus selalu diperhatikan (akses, lifeline, pengunaan full body
harness)

II. Value

NO AUDIT CHECKLIST WEIGHT SCORE VALUE

1 Safety Policy 20 20 100,00%


2 Safety Management Organization 61 61 100,00%
3 Safety Committee 39 39 100,00%
4 Safety Administration 48 48 100,00%
5 Jobsite Information 16 16 100,00%
6 Work Permits and JSA 22 22 100,00%
7 Fire Prevention/Protection 0 0 0,00%
8 Personal Protective Equipment 21 21 100,00%
9 Safety Schedule Meetings 15 15 100,00%
10 Safety Procedures / Safety Rules 25 25 100,00%
11 Safety Education and Training 52 52 100,00%
12 Construction Tools and Equipment 25 19 76,00%
13 Heavy Equipment 16 15 93,75%
14 Chemical Handling and Use 0 0 0,00%
15 Safety Inspection/Audit 19 19 100,00%
16 Accident Investigation and Reporting 19 19 100,00%
17 Safety Promotion 12 12 100,00%
18 Explosives 0 0 0,00%
19 Motor Vehicles 11 11 100,00%
20 Garages and Repaired Shops 15 10 66,67%

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 15 / 16

NO AUDIT CHECKLIST WEIGHT SCORE VALUE

21 Work Site Documentation 5 5 100,00%


22 Ionizing Radiation 0 0 0,00%
23 Barricades 8 6 75,00%
24 Transportation 21 9 42,86%
25 Concrete Construction 20 19 95,00%
26 Steel Erection 0 0 0,00%
27 Scaffolding 0 0 0,00%
28 Excavation/Trenching/Shoring 21 18 85,71%
29 Cranes and Lifting 0 0 0,00%
30 Electrical System 28 18 64,29%
31 Electric Arc Welding 0 0 0,00%
32 Welding/Cutting 0 0 0,00%
33 Abrasive Blasting/painting 0 0 0,00%
34 Health and Welfare 21 13 61,90%
35 Ladders Ramps and Stairs 0 0 0,00%
36 Housekeeping/Material Handling 14 8 57,14%
37 Steel/Pipe Erection 0 0 0,00%
38 Power Tools 7 6 85,71%
39 Hand Tools 5 4 80,00%
40 Powder Actuated Tools 0 0 0,00%
41 Air Compressors/Generators 5 5 100,00%
42 Flammable Cases and Liquids 0 0 0,00%
43 Shut-Down or Maintenance Work 0 0 0,00%
Total 586 535 91,30%

PT. ADHI KARYA (PERSERO), TBK


AMMONIA UREA II PROJECT DOC. NO. : 201485 HSE PD 006

PT PETROKIMIA GRESIK
Rev. No. : 1
GRESIK - JAWA TIMUR

HSE AUDIT SYSTEM Page : 16 / 16

Total Value = TOTAL INSPECTION VALUE X 100% = YZ %.


TOTAL INSPECTION VALUE AVAILABLE

Total Value =
535 X 100%
586

Total Value = 91,30 %

PERCENTAGE RANKING
+85% Outstanding Superior Loss Control-All
75 - 85% Good Good Loss Control/Key request
70 - 75% Marginal Needs Some Improvement

60 - 69% Poor Needs Major Improvement


00 - 59% Unacceptable

AUDITORS:

1. Name Falista Anggi Styadhika Sign _______________

2. Name Erdi Wisnu Riftianto Sign _______________

AUDITY:

1. Name Clara Sign _______________

PT. ADHI KARYA (PERSERO), TBK