PT.

REKAYASA INDUSTRI
SUBCONTRACTOR HSE KEY PERFORMANCE INDICATOR
DOC. NO.: HSE-FF-Z.1 Health Safety & Environment
Project Name Geotermal rantau dedap project
Subcontractor PT BRE
Period Mei 2020
Implementation
No Performance Indicator Scoring System Comments from Evaluator
Max. Point Point Awarded
I. LEADERSHIP & HSE POLICY
At least once a month = 2
1 Management site visit 2 0 Not conducted within a month = 0 Belum ada site visit menagement
Percentage attendance within a month
2 Attend HSE Committee Meeting 2 1 (100% = 2, 50% = 1, 0% = 0) Avidance dan attandace list (mei)
There is socialization evidences: attendance list, orientation materials, banner, signage, and
4 Socialize HSE Policy to all workers 2 1 etc = 2
No socialization evidence = 0 Sosisalisai hse policy sign board dilapangan
Total Score 6 2
II. HSE REGULATION COMPLIANCE
Have HSE Committee Organization & attend HSE Committee Meeting = 2
1 HSE Committee Organization 2 1 HSE Committee Organization not available = 0
CV and Certification (Depnaker/Migas Certification) of HSE Personnel = 2
2 Certified/Competent HSE Personnel that drive HSE Program 2 1 Certified/Competent HSE Personnel not available = 0

CV and Certification of job skills (e.g. welder certification, heavy vehicle license, and etc.) =
3
3 Competent Key Personnel related to the scope of work 2 2 Certified/Competent Key Personnel not available = 0

Equipment completed with Calibration/Certification = 3

4 Equipment comply with regulations (Calibration, Certification) 2 2 No Calibration/Certification Equipment = 0

Fulfillment of the Social Security of Manpower (BPJS Fulfill the obligation = 3

5 2 0 Not fulfilling the obligation = 0
Ketenagakerjaan)
Total Score 10 6
III. TRAINING
All worker have been given safety induction = 2
1 HSE Induction for new worker 2 NA There are workers who have not given safety induction worked in area = 0.
Attend HSE Training = 2
2 Attend HSE Training for Manager and Supervisor(if any) 2 NA Not attend HSE Training = 0

Conducted HSE Training related scope of work = 2

3 Give HSE Training related to the scope of work 2 0 Not conducted HSE Training related scope of work = 0 belum ada bukti training yang dilakukan ke MP
Conducted HSE Training for specific hazardous work = 2
4 Give HSE Training for specific hazardous work (if any) 2 2 Not conducted HSE Training for specific hazardous work = 0

Total Score 8 2
IV. SUBCONTRACTOR MANAGEMENT
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 PT. REKAYASA INDUSTRI
SUBCONTRACTOR HSE KEY PERFORMANCE INDICATOR
DOC. NO.: HSE-FF-Z.1 Health Safety & Environment
Project Name Geotermal rantau dedap project
Subcontractor PT BRE
Period Mei 2020
Implementation
No Performance Indicator Scoring System Comments from Evaluator
Max. Point Point Awarded
Ensure subcontractor understand and complied Contractor Subcontractor complied HSE Requirement = 2
1 HSE Requirements Na NA Subcontractor not complied HSE Requirement = 0

Manage subcontractor for support and implement Contractor Subcontractor implement HSE program = 2
2 HSE Program Na NA Subcontractor not implement HSE program = 0

Total Score 0 0
V. HSE IN DESIGN, CONSTRUCTION AND COMMISSIONING
All worker not smoking on project site area= + 1
1 Smoking attitude 3 1 Smoking sign have been installed= + 1
There is specific smoking area/shelter, etc = + 1
masih ditemukan merokok di area kerja, (kabin
Work permit system has been implemented = 3
2 Implement Work Permit System 3 3 Work permit system is not always implemented = 0
There are no warning regarding PPE = 3
3 Implement Standard Instruction of PPE 3 2 One warning regarding PPE = 0 masih ditemukan MP PT Berdikari belum meng
Operator Qualified/Certified by MIGAS, = + 1
4 Lifting / Crane & Sling (if any) 3 3 Regular Inspection and Maintenance, = + 1
All safety requirement complied= + 1
Conducted regular housekeeping = 3
5 House Keeping 3 1 Housekeeping is rarely conducted = 0 wire sling di tempatkan disembarang tempat,
All equipment certified = 3
6 Equipment Certification 3 3 There is found one equipment that is not certified = 0
Certified Welder = + 1
7 Welding Safety 3 3 Pass Welding & Grinding Safety Inspection = + 1
PPE & Special PPE = + 1
All safety requirement related this work complied = 3
8 Using & Handling Compressed Gas Cylinders 3 3 There is found unsafe action/condition related this work = 0
All safety requirement related this work complied = 3
9 Electrical Safety 3 2 There is found unsafe action/condition related this work = 0 kabel masih belum diposisikan tergantung, ma
All safety requirement related this work complied = 3
10 Excavation Na NA There is found unsafe action/condition related this work = 0
All safety requirement related this work complied = 3
11 Working at High (Scaffold, Ladders & Fall Protection) 3 2 There is found unsafe action/condition related this work = 0
bekerja diketinggian masih belum menggunak
Segregation = + 1
12 Waste Management & B3 3 1 Quantity and type of waste recorded = + 1
Temporary Storage = + 1
laporan pembuangan sampah belum disubmit
TOTAL SCORE 33 24

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 PT. REKAYASA INDUSTRI
SUBCONTRACTOR HSE KEY PERFORMANCE INDICATOR
DOC. NO.: HSE-FF-Z.1 Health Safety & Environment
Project Name Geotermal rantau dedap project
Subcontractor PT BRE
Period Mei 2020
Implementation
No Performance Indicator Scoring System Comments from Evaluator
Max. Point Point Awarded
VI. MANAGEMENT OF CHANGE
Implement management of change = 2
1 Implementing management of change procedure (if any) NA NA If any change, not implemented management of change = 0

TOTAL SCORE 0 0
VII. INSPECTION
All equipment passed safety inspection = 3
1 All equipment used passed safety inspection 3 3 If there is one equipment that does not passed safety inspection = 0
All tools passed safety inspection = 3
2 All hand tools and power tools passed safety inspection 3 3 If there is one tools that does not passed safety inspection = 0

Safety Inspection recorded = + 1

3 Safety inspection recorded and corrective action confirmed 2 2 Corrective action confirmed = + 1

Defective tools & equipment immediately repaired or removed All defective tool & equipment repaired immediately = 2
4 from the work site Na NA Not removed or repaired immediately and still used (more than 2 days) = 0

TOTAL SCORE
1 Installed Safety Sign/Banners and Barricade
2 Toolbox meeting/Safety Talk program Conducted
3 Communicate Job Safety Analysis - Risk Assessment
TOTAL SCORE
1 Availability of Fire Extinguisher
8 8
VIII. COMMUNICATION
Safety sign & barricade installed = 2
2 1 Safety sign & barricade not installed = 0
minim sign board dilapangan, dan pemasangan
Conduct toolbox meeting/safety talk before start work = 2
2 0 Start work without conduct toolbox meeting/safety talk = 0
MP PT Berdikari tidak pernah mengikuti gener
Communicate JSA to all worker and record with attendance list = 2
2 0 Not always communicate JSA and no evidence communicate JSA = 0 sosialisasi JSA melalu sign board dan toolbo, U
6 1
IX. EMERGENCY RESPONSE
Fire extinguisher available and ready to use = 2
2 2 Fire extinguisher not available or in broken condition = 0

First aid kit available, ready to use and can accommodate all worker = 2
First aid kit not available or the type of first aid kit not accommodate total number of
2 Availability of First Aid Kit 2 0 workers = 0
submit liast first aid kit
Spill prevention & response kit available and ready to use = 2
3 Avalability of spill prevention and response kit 2 0 Spill prevention & response kit not available or in broken condition = 0 submit list dan avidance sudah ada spilkit di la
TOTAL SCORE 6 2

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 PT. REKAYASA INDUSTRI
SUBCONTRACTOR HSE KEY PERFORMANCE INDICATOR
DOC. NO.: HSE-FF-Z.1 Health Safety & Environment
Project Name Geotermal rantau dedap project
Subcontractor PT BRE
Period Mei 2020
Implementation
No Performance Indicator Scoring System Comments from Evaluator
Max. Point Point Awarded
X. REPORTING AND INVESTIGATION OF INCIDENT AND ENVIRONMENTAL POLLUTION
Report UAC everyday/every week = + 1
1 HSE Statistic Record and Unsafe Act & Condition reported 2 0 Record daily man hours and incident statistic = + 1
submit HSE statistis di office site
TOTAL SCORE 2 0
XI. DOCUMENTATION
Submit HSE Activity report daily/weekly/monthly = 2
1 Submit Daily/Weekly/Monthly HSE Report 2 0 Not always submit HSE Activity report daily/weekly/monthly = 0 submit report daily, weekly, montly
HSE document is well documented and easy to access = 2
2 All HSE document is well documented & easy to access 2 0 HSE document not properly maintained and difficult to access = 0
submit avidance file dan penyimpanan dokum
TOTAL SCORE 4 0
XII. EVALUATION
Conduct corrective & preventive action to close outstanding/finding = 2
Corrective and preventive actions conducted against the Not conduct corrective & preventive action if any finding comment = 0
1 2 1
findings of the audit/evaluation temuan audit tidak ada tindakan perbaikan, se
Finding result informed to management & all workers = 2
2 The implementation and results of the audit/evaluation 2 1 Finding result not informed to management & all workers = 0
informed to management and all workers hasil temuan mohon dilkukan perbaikan
TOTAL SCORE 4 2
XIII. REWARD AND PUNISHMENT
Submit evidence copy of reward or punishment for worker = 2
2 Conducting HSE Reward and Punishment 2 0 No evidence submit related reward or punishment for worker = 0
belum ada avidance telah diberikan reward ke
TOTAL SCORE 2 0

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 PT. REKAYASA INDUSTRI
SUBCONTRACTOR HSE KEY PERFORMANCE INDICATOR
DOC. NO.: HSE-FF-Z.1 Health Safety & Environment
Project Name Geotermal rantau dedap project
Subcontractor PT BRE
Period Mei 2020
Implementation
No Performance Indicator Scoring System Comments from Evaluator
Max. Point Point Awarded

Verification of Performance Indicator

Review by Date Comments from evaluator

Name
Chief HSE

Follow Up by Subcontractor
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
Prepared by N.sitorus Date 5 maret 2020
Subcontractor Construction Manager Name Rudianto

Result : Proceed
KPI SCORE : 52.81%
Not Proceed

Reviewed by Checked by Approved by

Doubit KF _______________________ _________________________________

Rekind Chief HSE CCC Rekind Construction Manager

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