CYD Comment On MSP-T-AK-CII-004 SHES Plan and HSE Control Procedure PDF

PT. ADHI KARYA (Persero) Tbk.
Jl. Raya Pasar Minggu KM. 18 Jakarta 12510, INDONESIA

Phone : (62-21) 797 4521 Fax (62-21) 797 4522
TRANSMITTAL
Attention to : Manyar Smelter Project
PT Chiyoda International Indonesia Pile Load Test Work
Sentral Senayan III, 15th Floor, Jl. Asia Afrika No.8 PT Freeport Indonesia
Gelora Bung Karno, Jakarta Pusat 10270, Indonesia Contract No. :
Phone : (+62-21) 2903 9255 Date : 28-Nov-20
Fax : (+62-21) 2903 9254 Transmittal No. : MSP-T-AK-CII-004
To : Mr. Takashi Matsuno Reference No. :
Project Manager
Cc : Mr. Wahyu Suryo
Site Construction Manager
From :
PT. ADHI KARYA (Persero) Tbk
Manyar Smelter Project
Telp. No.
Fax No.
From : Mr. Hari Darmojo

Project Manager
Subject : SHES Plan and HSE Control Procedure
Print X Original Photocopy
For : Review X Information Copies

Approval Construction
Stamp and Sign
Document Status : Preliminary Final Revision
No. of Copy Document No. Revision No. Title
1 MSP-HSE-PRC-001 00 Project Specific SHES Plan
1 MSP-HSE-PRC-002 00 QHSE POLICY
1 MSP-HSE-PRC-003 00 Risk Assesment and Environment
1 MSP-HSE-PRC-004 00 HSE Plan Procedure
Reviewer
Received by Hari Darmojo

Signature Date Project Manager
Notes
MANYAR SMELTER PROJECT Document No.
MSP-HSE-PRC-001
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Project Specific HSSE Plan
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PROJECT TITLE : MANYAR SMELTER PROJECT
LOCATION : GRESIK, INDONESIA
OWNER : PT FREEPORT INDONESIA
CONTRACTOR : PT CHIYODA INTERNATIONAL INDONESIA
SUBCONTRACTOR : PT ADHI KARYA (PERSERO) TBK.
PROJECT NO. :
0 FOR APPROVAL 26/12/2020
REV DESCRIPTION DATE PREPARED CHECKED APPROVED

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Table of Contents
1. INTRODUCTION.......................................................................................... 3
2. SCOPE ........................................................................................................ 3
3. OBJECTIVE ................................................................................................. 4
4. REFERENCE DOCUMENTS ....................................................................... 4
5. DEFINITION ................................................................................................. 4
6. RESPONSIBILITIES .................................................................................... 5
7. ORGANIZATION ........................................................................................ 11
8. PROCEDURE ............................................................................................ 11
8.1. General.............................................................................................11
8.2. Implementation of HSEMS .............................................................. 13
8.3. HSE Awareness............................................................................... 15
8.4. Training............................................................................................ 23
8.5. Hazard Identification Risk Assessment and Determining Control .... 27
8.6. Work Permit ..................................................................................... 30
8.7. Emergency Response Plan ............................................................. 30
8.8. Corrective and Preventive Action..................................................... 31
8.9. Documentation and Reporting ......................................................... 32
8.10. Management Review ....................................................................... 33
9. APPENDICES ............................................................................................ 34
Appendix – 01 – HSE Committee and Organization Chart
Appendix – 02 – Project HSE Policy & KPI (Performance)
Appendix – 03 – Contractor’s HSE Standard Regulation Compliance
Appendix – 04 – Sample of Job Safety Analysis (JSA)
Appendix – 05 – Equipments/Vehicle Inspection
Appendix – 06 – Hazard Identification, Risk Assessment and Determining
Control (HIRADC)
Appendix – 07 – Rewards And Punishment
Appendix – 08 – Training Matrix
Appendix – 09 – ISO 45001 & SMK3 for health and safety, and ISO 14001
for Environmental management system
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1. INTRODUCTION
This Health, Safety and Environmental (HSE) Plan is establish based on
Engineering and Construction Industry practices and will be developed
with Chiyoda before starting construction activities. The HSE
Management Plan will ensure the work process from beginning stage
through work completion, are performed healthy, safety and security
friendly. And also as a framework to ensure that the expected HSE
Performance is achieved.
Functionally this HSE Plan; Outline the expectation of Occupational

Health and Safety on the project, Specify the objective and target to be
achieved, details site project Occupational Health and Safety issues,
Specify for all personnel to ensure consistency to Occupational Health
and Safety practice, Ensure consistency in management Occupational
Health and Safety both Main-Contractor and Sub-Contractor.
2. SCOPE
The HSE Plan covers the requirements of the accident prevention rules
and safety program that developed and established to achieve the
desired result for Engineering Procurement Construction Manyar Smelter
Project Piling, Load Tes and Civil Work Category.
The primary purpose of HSE Plan is to provide a guideline for preventing

any accidents which may injure Employees or damage property of the
Chiyoda, Main-Contractor and Sub-Contractors at the construction site.
Sub-Contractors shall abide by all safety rules and other regulations

imposed at the site by the Laws of the international standard regulation
and or Indonesian government and the provisions of applicable laws,
rules and regulations, including rules and procedures as applicable from
the IFS Project
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3. OBJECTIVE
The Safety objectives of all participant of this project is Zero Accident,
Zero occupational illness, Zero environmental damage, Zero property
damage, and Zero fire accident. To achieve this Objective, Contractor will
propose Key Performance Indicator as a Contractor’s HSE Performance
which to be approved and signed by both Chiyoda and Contractor,
Appendix-02.
4. REFERENCE DOCUMENTS
 Government Regulation No. 1, 1970 about Occupational Safety.
 Government Regulation No. 11, 1979 about Occupational Safety.
 Minister Regulation No. PER. 50/ MEN/ 12 about Occupational
Health and Safety Management System.
 Government Regulation No. 23, 1997 about Environmental
Management Plan
 ITB Document Chiyoda
 BP 024 HS P01 Prosedur Penerapan Sistem Manajemen K3L edisi
1
Contractor is also committed to comply with all requirements stipulated

in Chiyoda safety regulations, industry safety practices as required for
this work and will apply the more stringent requirements between
Contractor’s standards and Chiyoda requirements.
5. DEFINITION
a HSE : Health, Safety and Environmental
b Main-Contractor : Chiyoda
c Sub-Contractor/ : Organization selected and awarded by
VENDOR MAINCONTRACTOR to perform a certain
project activity or to supply materials,
equipment’s or manpower
d Head Office : MAINCONTRACTOR’s Project Head Office
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e Project Site : CONTRACTOR’s Project Site of Indonesia

Freeport Manyar Smelter Project
6. RESPONSIBILITIES
Contractor will organize a safety committee for site work that is consisting
Project Manager, Construction Coordinator, HSE Officer, and Chief
Security as minimum member of the safety committee. As part of site
HSE Committee that arranged/ established in Project Office, the
Contractor’s Site Manager will continue all activities the Committee in
worksite, and for detail is shown on Project HSE Committee
Prior to the start of the construction work, the Project / Site Manager will
establish the site HSE organization. The responsibility of each position in
the organization is shown below:
1. PROJECT MANAGER
The Project Manager shall be responsible for the implementation of
Project HSE Plan, He must ensure that HSE activities within project
organization are undertaken with the right procedure and executed
in an efficient and controlled manner. He shall be responsible for
approving the Project HSE Plan prepared by Project HSE Manager
2. SITE MANAGER
The Site Manager has primary responsibility for the site HSE
management and performance requirements are met. The
Construction Manager also will take the initiative in ensuring that all
the construction work progresses smoothly, safely and in a security
sound manner
The Construction Manager’s major roles and responsibility are to:

a. Establish realistic HSE objectives and target on the site including
Chiyoda objectives and target fulfillment.
b. Promote the setting up of On-Site HSE implementation related to
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Chiyoda requirements and compliance such as HSE rules and

regulations, and HSE procedures/ programs, including a
comprehensive training programs, emergency procedures, work
permit system, etc.
c. Organize and preside over the Project HSE committee,
d. Patrol the site as frequently as possible to ascertain status of the
work and compliance with HSE requirements and to demonstrate
an active and visible attitude toward HSE,
e. Direct to other Managers/Coordinator, Supervisors and HSE
Officer in carrying out their roles and responsibilities.
f. Establish and direct an Accident Investigation Team (Chiyoda on
scent team) if an accident occurs, and
g. Regularly and promptly evaluate HSE reports on HSE
performance, HSE topics, and any accidents or near misses
prepared by the HSE Officer.
h. Coordinate and plan the work schedule to ensure that conflicts of
interest do not occur between Sub-Contractors,
i. Direct discipline Superintendents and line Supervisors to ensure
requirements for their roles and responsibilities for HSE are met,
j. Set up and preside over (weekly) progress meeting, which should
include HSE topics,
k. Ensure that concerned personnel and Sub-Contractors analyze
all hazardous work and identify with severity and probability (Task
Risk Assessment) of any hazards and establish work execution
procedures as necessary required,
3. HSE MANAGER
The HSE Manager will assists the Project Manager related to HSE
matters, and direct the HSE Officer and all Supervisors to promote
HSE programs and to ensure all the HSE requirements are satisfied.
His major roles and responsibility are to:
a. Set up On-site HSE organization and assign an HSE officer and
define their roles and responsibilities,
b. Set up or establish Chiyoda applicable on-site HSE standards/
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procedures and routine HSE programs including Chiyoda HSE

training program, inspection, etc.,
c. Advise the Site Construction Manager and line Superintendent/
Supervisors on HSE matters,
d. Conduct HSE training by himself or by Chiyoda or using
competent Supervisors according to necessity and specialty,
e. Patrol the site daily and audit Sub-Contractor’s activity,
equipment and facilities to determine for they are in compliance
with HSE requirements,
f. Participate in the Accident Investigation Team and Chiyoda On
Scent Team to investigate the status and cause of an accident,
and establish measures to prevent similar accidents,
g. Chair a Monthly HSE committee meeting attended by
Contractor’s Site Managements and HSE staff both for Main-
Contractor and Sub-Contractors,
h. Review the “daily HSE progress report” prior submitted to
Chiyoda and “instructions for corrective action” prepared by the
HSE Officer/ Supervisors, and make sure it will be informed to all
party involved.
i. Report daily to the Site Construction Manager on major HSE
activities and topics.
j. Prepare a “Weekly report” stating all incidents and near misses
that occurred during that week for reviewed by Site Construction
Manager. The weekly report will be maintained and forwarded to
Chiyoda,
k. Prepare a “Monthly HSE report” and an “Industrial Accident
Status Report” for the Site Construction Manager to review and
use for his own report to the Project Manager.
l. Submit accident report to Chiyoda and local labor office.
m. Report to the Site Construction Manager on any anticipated
matters of concern and relevant topics.
4. HSE OFFICER
The HSE Officer will assist the HSE Manager include HSE
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engineering matters and ensure that effective liaison and

coordination are maintained among Contractor, Chiyoda, and Sub-
Contractors. HSE Officer will have 3 major section of assignment;
Permit and Training, Inspection and Area/Subcontractor Supervision
with major roles and responsibilities are to:
a. Assist and advise the HSE to develop the HSE management
system, HSE procedures and HSE programs,
b. Ensure that work analysis, risk analysis and risk control plan
(JSA) for specific hazardous work are implemented, and work
execution procedures are provided for HSE matters,
c. Ensure that applications for work permit for the designated work
are submitted by the subcontractors, and direct an authorized
Supervisor to investigate the location and condition of the work.
Work permit should be issued according to the Chiyoda work
permit standard/ procedure,
d. Assist HSE upon Advise the Construction Manager, discipline
Superintendent/Supervisors of any unsafe conditions or
violations, remedial actions required, and record and retain the
details,
e. Coordinate Weekly Site Safety meeting & minutes for each
meeting.
f. Prepare/ Report daily (Safety Progress Report) to the HSE
Manager on major HSE activities and topics.
g. Site safety patrol daily as frequently as possible, and inspect
current activities and working conditions,
h. Direct Subcontractor’s Safetyman to ensure that HSE
requirements are implemented.
i. Participate in and assists the Accident Investigation Team to
investigate the status and cause of an accident, and take action
to prevent similar accidents,
5. DISCIPLINE SUPERINTENDENTS
The Discipline Superintendents take the initiative for the work in their
scope, and lead their sub-ordinates to ensure that the work is carried
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out effectively, safely and in a security sound manner. The discipline

Superintendent’s roles and responsibility are to:
a. Coordinate inter discipline to ensure that all the subcontractors
activities are being carried out in compliance with HSE
requirements and standards,
b. Direct and supervise the line Supervisors under their control,
c. Ensure that hazards identification, risk analysis and evaluation
(Task Risk Assessment/ TRA) are implemented, and work
execution procedures are provided incorporating risk control
measures for all hazardous work based on Hazard Zone
Category,
d. Ensure that the Sub-Contractors obtain any necessary work
permits,
e. Verify that Sub-Contractors’ work is carried out strictly in
accordance with the approved work execution procedure, and
6. LINE SUPERVISOR
The line Supervisors are responsible for ensuring that the work under
their supervision is carried out effectively and safely, in a security
sound manner, and meets schedule and quality requirements. The
line Supervisor’s major roles and responsibilities for HSE activities
are to:
a. Instruct the Sub-Contractors’ personnel under their control to
carry out their scope of work safely and without risks to health,
b. Monitor the Sub-Contractors’ work and ensure it is carried out
strictly in accordance with the approved work execution
procedures and Job Safety Analysis,
c. Ensure that all tools and equipment used by the Sub-Contractors’
meet minimum safety standard,
d. Ensure that workers properly wear and use personal protective
equipment and safety device according to requirements and the
manufacturer’s instructions,
e. Ensure that housekeeping standards are maintained, and that a
waste disposal program for waste and scrap materials is set up
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and enforced,
f. Attend and control all his subordinates in Daily Toolbox Meeting
and Weekly Safety Talks events.
g. Join the toolbox meeting as frequently as possible, and ensure
that all Sub-Contractors’ employees activity participate and
receive the necessary toolbox briefings, and
h. Repot to discipline Superintendents on any anticipated matters
of concern and relevant topic.
7. FIELD BUSINESS / GENERAL AFFAIR

The Field Business / General Affair major roles and responsibilities
regarding HSE management are to:
a. Fully Support for all HSE Program: ID Badge process, HSE
Induction, PPE purchasing, Training facility & equipment’s, etc.,
b. Establish a first aid system and a close relationship with the
nearest available hospital by communicated and coordinated to
Chiyoda team (ERT/ On Scent Team)
c. Report to the Site Construction Manager on major administrative
activities and topics.
8. SUBCONTRACTORS
All Sub-Contractors and all their personnel shall fulfill their roles and
responsibilities regarding HSE requirements, and comply with the
established HSE Chiyoda requirement and regulation, procedures
and work execution, according to their positions and work roles. The
Sub-Contractors personnel’s major roles and responsibilities are to:
a. Be aware that HSE is everyone’s responsibility,
b. Attend and participate the HSE induction and Safety Classroom
(full day) Training course conducted by Chiyoda prior to starting
their field work, and any specific training course according to the
requirements,
c. Strictly follow instructions and directions given by Management,
Supervisors and Safety staff/ officer,
d. Attend the daily toolbox meetings held every morning and weekly
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Safety Talks,
e. Wear and use personal protective equipment, safety tools and
devices, and maintain them in good condition
f. Always keep their work location neat and tidy.
7. ORGANIZATION
At the site, all sub-contractors report directly to the relevant Contractor’s
Construction Superintendent, who is responsible for planning,
coordinating and directing all site construction activities. The Contractor’s
Construction Superintendent reports to the Site Manager. The
Construction Supervisor will liaise with HSE Officer on matters relating to
safety and overall site coordination. The Supervisor will also send daily
reports to the Construction manager. The number of safety staff including
subcontractor who are assigned in the site shall basically comply with the
client requirement, the following Chiyoda standard shall be applied :
1. In case that number of direct workers is less than or equal to fifty (50),
one (1) safety staff shall be at least assigned in the site
2. When the number of direct workers is increased every one hundred
two five (125), one (1) safety staff shall be additionally assigned in
the site
HSE organization chart and HSE Committee is shown in appendix-01.
8. PROCEDURE
8.1. General
This HSE Plan shall identified Safety requirements and issue for the
project and in consultation with Chiyoda is whether to require any special
attention or not should be highlighted during early construction phase.
As the project progresses update may be required to align itself with the
design and construction plan, which will have been developed during the
initial design phase. At the detail engineering and procurement phase, all
Safety Management issues should have been addressed and
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incorporated.
Engineering phase
All engineering activities shall consider to health, safety and security
aspects. Applicable documents that satisfy health, safety and security
and technical requirement due to engineering matters shall be provided
by Contractor’s Engineering
On such conditions Chiyoda HSE policies, programs and practices, shall

be complied to satisfy all performance specifications complying with all
applicable local laws and regulations, and satisfying all Chiyoda specified
health, safety and security requirements.
Subcontractor and Purchase Control

Contractor has the HSE requirement for Sub-Contract Procedure, which
consider pre-qualified documents on safety management to screen and
observe the experienced and performance of the competent Sub-
Contractors who have positive and willing attitude towards HSE
requirements.
Contractor Project HSE Plan and Regulations include Chiyoda

compliance requirements will be mainly used to empower Sub-
Contractors and as inherent part of Sub-Contractors agreement.
Control of Subcontractors’ HSE performance will be as follows:

1. Selection of subcontractors will follow HSE Project Procedure i.e.
HSE Requirements for Subcontracts. In the process of bid.
2. Contractor will basically work hand in hand with all Sub-Contractors
in respect to HSE matters. All Sub-Contractors Site Managers will be
a member of Contractor’s Project HSE Committee, who will attend
the Monthly HSE Meetings. Project HSE performance, including
review of each individual Sub-Contractors, will be discussed in this
Monthly HSE Meeting. The meeting will be documented. Monthly
HSE Meetings will continue until project is mechanically completed
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or more, if needed.
3. Sub-Contractors shall be responsible to inform their employees to be
aware and obey the safety requirements. Failure to follow prescribed
HSE procedures and regulations by Sub-Contractors may result in
termination of the contract.
4. Prior to the commencement of the work, all personnel must attend a
project safety induction, the induction will outline the requirements of
the project.
5. During the construction phase of the project, supervisor shall manage
the performance of Sub-Contractor’s in relation with their HSE
8.2. Implementation of HSEMS

8.2.1. HSE Management System (HSEMS)
Contractor’s HSE Policy is part of Management System Policy, which is
established by Contractor Management, will be implemented on this
Project. The HSE policy reflects Contractor full commitment to HSE.
Contractor employees shall be responsible for ensuring that HSE safety

management system is properly implemented in their works. (Example
Contractor Safety Management System as shown on Appendix-10)
The HSE management system based on the concept of ISO 45001 &
SMK3 for health and safety, and ISO 14001 for Environmental
management system, certificate of the HSE management system as
Appendix 9
Contractor is committed to comply with all requirements for HSE activities

as required by Chiyoda applicable Laws and Regulations.
The principles of the HSEMS Contractor will be based on the site HSE
program on the following 5 pillars:
1. HSE Policy, Objectives and Targets

The top management of the Contractor’s project team will establish
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the HSE policy, objectives and targets and ensure the commitment
of all personnel to HSEMS requirements and ensure continual
improvement.
The Contractor Project Managements will establish the site HSE

programs which it comply with Chiyoda programs to enhance
everyone’s HSE consciousness and improve their HSE culture. This
program will be reviewed with Chiyoda and where appropriate
modified to establish an agreed Project HSE Policy.
2. Planning
The plan for the HSE policy, objectives and targets will include the
following:
a. Site location & condition (live plant site, hill site, etc.).
b. Identification of work.
c. Identify/recognize all hazards accordance with Hazard Zone
Category at operation plant, characters of the operation on
working tools, vehicle and, all kind of equipment’s.
d. Worker/labor health condition.
e. Background of people involved in construction, with respect to
safety awareness.
f. Refer to SOP (Standard Operating Procedure)
g. Provision of work execution procedures.
h. Obedience of HSE regulation (national regulatory and Chiyoda
requirements).
i. Top down commitment of the HSE policy by the top site
management.
3. Implementation
To ensure the Plan is effectively implemented, an organization will be
developed with the capabilities and support system necessary to
achieve the HSE policy, objectives and targets. This will include:
a. Organization and adequate assignment
b. Culturization of safety (safety minded) by having: safety
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message for any kind of Site Construction Meeting, HSE

Induction (conducted by Chiyoda representative), Daily Toolbox
Meeting, Monthly Safety Talk, Management Meetings,
Management Policy (shown by brochures, banners, notification
boards, bulletin, safety memo, etc.), Fire fighting and emergency
evacuation exercises, Training, Safety Promotion and awards.
c. Provision of resource: people, material, equipment/tools,
facilities and funds.
d. Inspection and maintenance.
4. Measurement and Evaluation

The organization should measure, monitor and evaluate its HSE
performance, and take preventive and corrective action, using the
following techniques:
a. Audit and measurement of HSE performance.
b. Indication of any non-conformances.
c. Instruction or recommendation for corrective action.
d. Recommendation.
5. Review and Improvement

The organization will regularly review and continually improve its
HSE management system, with the objective of improving its HSE
performance. This will include:
a. Review of HSE objectives, targets and HSE performance
evaluation system.
b. Findings of the HSE management audit.
c. Evaluation of the effectiveness of the HSEMS.
8.3. HSE Awareness

8.3.1. HSE Communication
Internal Coordination
The role of Committee Secretary is to provide guideline to the
management on the process of work, planning, implementing, monitoring
in sustaining a timely and cost effective safety system.
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The Safety Committee goal is that Contractor start top management up

to bottom level shall recognition and implemented with consistently HS
included by Suppliers, Sub-Contractors and other personnel involved.
Membership of the safety committee includes representatives from
Chiyoda, Contractor and all of Sub-Contractors Representatives that
chaired by Contractor Site Construction Manager.
This Committee should conduct safety committee meeting at least once

a month, or if any accident happen. To effectiveness of the agenda
meeting, the committee members shall carry out general safety patrol
one time in a month.
External coordination
Contractor shall establish an external coordination with the
Government/local government, local hospital, local government clinic, fire
Station etc that compromise with Chiyoda Emergency Rescue Team
(ERT)
8.3.2. HSE Meeting

According to implement good coordination and information on safety,
some site safety meeting will be conducted regularly such as:
Daily Toolbox Meeting

Contractor Site Project and Sub-Contractors workers shall perform a
safety toolbox meeting on daily basis before starting their activities.
The topics of toolbox are comprehension of potential risk/ hazard and
mitigation/ prevention related to work that will be done.
Site Safety Meeting

The site safety meeting shall perform by Safety personnel, such as
Manager, Supervisor and Safety Officer regularly prior to discuss any
violation or unsafe condition found during daily safety patrol/inspection.
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Enforcement of Contractor safety management shall be adhered to

create a problem solving and improvement in order to accident
prevention.
Attendance list and minutes of meeting should be recorded by Contractor

Safety Officer and should be reviewed at the next meeting for the
progress report.
Safety Talk
Contractor Site Project and Sub-Contractors workers shall perform a
Safety talk Rule meeting on monthly basis with the topics Enforcement
of Contractor safety management shall be adhered to create a problem
solving and improvement in order to accident prevention for the coming
month.
Each Field Manager/Superintendent/Supervisor of both Contractor ad

Subcontractor has responsible to give some advice and speaking on
safety manner related with their work scope.
8.3.3. HSE Induction.

Contractor will organize to participate of HSE induction which it
conducted by Contractor or jointly with Chiyoda for employees and
supervisors includes all workers and new comers regardless of number
of years worked in construction.
The orientation-induction program will include, but not limited to:

Personnel Identification, Basic HSE Rules, and PPE (safety glasses,
hard hat & protective Footwear, etc.), Chiyoda HSE Regulation, Fire
Prevention/ protection, Emergency Preparedness & Response, Traffic
Safety Rule, First Aid/ medical service.
8.3.4. Alcohol and Drugs

No alcoholic beverages, narcotics, mind altering drugs, or similar
substances are to be brought onto the Work Site or remain at the Work
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Site (except legal drugs and supplies by the medical staff for first aid and
medical facilities)
Sub-Contractor’s personnel and those of its Lower Tier Sub-Contractor’s

under the influence of alcohol, narcotics, mind altering drug, or other
similar substances shall not be permitted to enter the Work Site for any
reason.
Contractor reserves the right to require substance abuse testing of all

employees, including Sub-Contractor employees, as a condition of
employment and on demand when employed.
The possession or use of mood-altering drugs, both stimulants and

depressants are strictly forbidden on the job site except for legitimate
medical use by the medical staff. Such drugs include, but are not limited
to, alcoholic drinks, marijuana, hashish, crack, opium heroin, cocaine,
angel dust, barbiturates, speed, uppers, etc. Contractor reserves the right
to randomly require any employee, including Sub-Contractor employees,
to submit to a drug test at any time while on the job site.
Drug tests will be used to investigate accidents, Employees who report

for work in an obvious state of drunkenness or having obviously used
drugs, shall be sent home. Employees who are caught using, or in
possession of, drugs on the job site shall be discharged. Employees who
habitually use or possess drugs on the job site or who regularly appear
for work in a drunken or drugged state shall be discharged.
8.3.5. Poster & Signboards (Sign & Tags)

The objective of safety poster & signboard is to maintain, increase and
develop safety awareness of all project workers.
Poster and safety sign shall be adopted as visual aids for accident and
fire prevention written in Bahasa & English language which easy to be
understood by every worker.
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These signboard and poster shall be displayed at the strategic location,

and almost can be seeing by employees every day.
8.3.6. HSE Inspection

A program for the inspection of hazardous conditions is an essential part
of any active monitoring program. It is one of the best tools available to
find problems and assess their risks before accidents and other losses
occur. The purpose is to monitor HSE performance during construction,
commissioning and start-up phase
The Site HSE manager will prepare the inspection program, as an

Inspection Planning with the scope and areas of inspection shall be
dictated by the work activities.
The followings are type of HSE Inspections;
HSE Committee Inspection.

The HSE Committee will inspect the site at least once a month. The HSE
Committee
Inspection should be attended by the Chiyoda HSE personnel,

CONTRACTOR Construction Manager, Site HSE Manager, all
Subcontractors Site Manager and HSE Personnel whom are well
conversant with the Project's procedure for safe work practices, statutory
requirements
Daily HSE Inspection.

Daily Inspection will be carried out to ensure all work carried out on site
are in compliance with safe and environment friendly work practices.
Type of Inspection are, but not limited to;
a. Crane operation inspection.
b. Excavator operation inspection.
c. Lifting gears, appliances and equipment inspection.
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d. Portable electrical hand tool Inspection.

e. Temporary electrical installation inspection.
f. Gas cutting equipment inspection.
g. Excavation trench Inspection.
h. Scaffold inspection.
Special HSE Inspection.

The HSE Committee will request the Subcontractors that do not have a
good HSE performance / compliance to perform a special HSE Inspection
daily with the Contractor HSE Team.
Equipment’s/Vehicle Inspection and Maintenance

 Pre-mobilization Examination and Inspection
1. All major construction equipment and hoisting and lifting
equipment and all vehicles will be thoroughly examined by an
approved qualified person as required by local laws and Chiyoda
regulations. as shown on Appendix-05
2. A report on the result of the examination will be submitted to the
Site HSE Manager in a prescribed form before equipment is
brought onto the site.
3. All crane operators/drivers must have valid license.
4. All heavy vehicles/moving equipment’s must have flag man with
the machine to avoid accidents while reversing/driving.
 Scheduled Inspections and Maintenance

1. All Contractor and Subcontractor construction equipment, lifting
gear and vehicles are to be periodically inspected and
maintained according to the project designated maintenance
schedule.
2. Complete records of all inspections and maintenance will be
maintained by Contractor and made available to the
Environmental Management Authority (EMA) upon request
 General Requirements
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1. Before any mechanical equipment is used in a Chiyoda restricted

area, all required work permits must be obtained.
2. All machinery should be inspected before being placed in service
and at regular intervals thereafter.
3. Maintenance schedules should be established for each piece of
equipment and strictly followed.
4. No repair, adjustment, or replacement of parts on moving
machinery is permitted.
5. Before making any repairs, all equipment must be stopped and
deactivated so that it cannot be unintentionally started.
6. At the start of each shift, the operator must check oil, water, fuel,
and hydraulic levels, that all gauges are operating and that the
machine is functioning smoothly.
7. Safety equipment (e.g., guards, limit switches, governors) must
be checked daily.
8. Equipment travelling or working on the highway must have lights
and reflectors.
9. Park equipment clear of the roadway. If this is not possible, use
flashing lights, cones, or other warning devices to alert
approaching traffic.
10. When vehicles are left unattended (even overnight), engines
must be stopped, parking brakes applied and the wheels
chocked. The ignition key should be removed and/or battery
cables disconnected to avoid start-up by unauthorized personnel.
11. Unless otherwise instructed, operators must dismount from
machines while maintenance or repair work is being carried out.
12. Where the operator of a mobile machine cannot see the area all
around his machine, an attendant must be in a position to direct
and assist the operator.
13. All equipment must be located so that exhaust fumes will not
affect workers in the area.
14. Gasoline-driven equipment shall not be used inside a building or
other confined space
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8.3.7. Safety Award Program

Safety Incentive Awards is an effective tool to improve safety
management and to finally eliminate any accident, by enhancing Sub-
Contractors and their workers safety consciousness, enthusiasm, and
interesting in health and safety.
The Safety Incentive Awards Program should be established taking

account of the size and characteristics of the projects, construction
duration, budget, scheme of Sub-Contractors, etc.
Generally, this awards program classified as follows:
Excellent Worker Awards

The worker who set a good example or showing positive acts to safety,
health and security rules and requirements Or the worker, who prevented
an accident by advanced preventive acts, saved a life involved in an
emergency, prevented expansion of an accident or fire, etc.
The awards are divided by regular award and random award.
Excellent Group Awards

The group who contributed improves to safety performance, or safety
devices or incentive ideas.
The group, who completed the specific hazardous or harmful work

without an accident/incident happened, includes near misses.
For the aims of the scheme, it is advisable that excellent worker awards
and excellent group awards should be executed periodically as
agreement.
8.3.8. Disciplinary Measures

Should anybody at the site not comply with the safety measures and
practices, Contractor and Subcontractor management will apply
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corrective disciplinary measures. The severity of these will be related to

the seriousness and repetition of the unsafe acts.
A record of the safety breaches (by Work Area, Supervisor and

Subcontractor) will be kept by the Site HSE Manager. Offenders will be
identified and, depending on the seriousness and frequency of the
offences, one of the following measures will be taken:
 Warning
 1 Week Suspension and re-training
 Removal of the offender from site
The following activities will result in instant dismissal from Site:

a. Driving a vehicle in excess of the stipulated/posted speed limit on
the Site
b. Not complying with the 100% fall protection and 100% tie-off policy
c. Placing their life or the lives of others in danger
d. Alteration (both parties will be dismissed, regardless of reason).
e. Disregarding barriers
f. Violating WP (WORK PERMIT) conditions or performing work
without a WP where an approved WP is required.
g. Energizing or de-energizing a power source without proper
authorization/WP.
h. Smoking in vehicles, offices and any other unauthorized area
i. Operating or causing to operate equipment without a valid
operator’s license, valid inspection, color coding and training.
j. Performing activities and operations (where training must be
conducted by Contractor) without the required training.
8.4. Training
This section outlines the types of information and training required for all
employees and supervisors prior to the start of and during site work,
especially to develop the local workers.
Contractor will provide copies of training records or completion

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certificates for each employee, documenting date of completion for each

training session.
Safety Classroom
As continuance HSE induction, all employees and worker including new
comers should attend and participate in order to Safety Classroom
Training Course which it conducted by Chiyoda and organized by
Contractor by full-day.
The training agenda is explanation HSE concern and awareness on each

working place related to the existing facility and potential risk/ hazard
category.
Supervisor Orientation
Subjects covered during Indoctrination Sessions includes: Supervisors
Safety responsibilities, "STOP” training and enforcement of safety rules,
Safe practices for specific Work, Accident investigation, Safety Meetings,
Government requirement and Chiyoda requirements.
Supervisor / Manager Safety Training (if required)

HSE Training, who is considered to be an integral part of Contractor HSE
program and part of the productivity improvement program, is
implemented on the project.
8.4.1. Lock-Out Tag-Out (LOTO)

As usually, the locking and tagging is necessary to prevent injury by the
inadvertent operation of power equipment, the inadvertent opening of
valves, inadvertent release of stored energy, or the energizing of
electrical equipment. Once a work permit will be required an isolation of
hazardous energy, an isolation process set forth in that policy and
procedure must be accomplished prior to issuing the work permit.
Isolation of plant and equipment is required to achieve a safe and

controlled means of access for maintenance, verification, construction,
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modification and pre-commissioning/ commissioning activities and doing

to ensuring that risks are as low as reasonably practicable (ALARP).
The isolation tag is to let know that the equipment has been isolated and
locked off from hazardous sources. It also provides a list of isolation
locations and devices fitted to achieve this. It shall use to record isolations
carried out on:
 Mechanical / Gas process systems
 Electrical systems
 Safety / Emergency systems
8.4.2. Fire Protection / Prevention

In order to prevent fire from occurring, emphasis is placed on pre
planning; hot - work permit controls; flammable gas, liquid and material
control; control of smoking, training and use of warning signs; proper
electrical wiring; and proper waste storage and removal.
Fire prevention and protection devices such as firewall, hydrants and or

proper fire extinguishers shall be provided.
Specific procedures are outlined in the construction site HSE plans for
the project.
8.4.3. Sanitation and Hygiene

The overall of health & sanitary control on construction site and camps
shall be borne by Site Construction Manager, Discipline Superintendent
/ Supervisor and assisted be HSE manager to ensure the requirements
and sanitary statutory control.
The Site Construction Manager and HSE Manager shall establish the
onsite health and sanitation control rules and procedure, referring to this
document and incorporating with Chiyoda requirements.
Building such as offices, residential camps, warehouse, etc. shall be

constructed strongly enough for use and against external forces such as
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toxic, animals risk, heavy rain and shall be located on safe and sanitary
locations.
Adequate illumination and air ventilation and heating or air conditioning,

if required shall be provided An adequate supply of potable water shall
be supplied from sources approved by Chiyoda and HSE Manager shall
also make a program and facilities to promote employee’s physical and
mental health maintaining as applicable.
8.4.4. Confined Space Entry

A Confined Space is any space having a limit means of egress or limited
ventilation such that flammable vapors or gases, toxic contaminants or
an oxygen deficient atmosphere can accumulate.
Examples of confined spaces include, but are not limited to:

Vessels, Gas turbine, Steam Generators, Tanks, Trenches, Barge
Compartments, Pits, Separators.
The followings are guidance consideration to Sub-Contractors any work/

activities into employee safety, health during entry to confined spaces
without accident/incident:
a. Entry into confined spaces shall always be subjected to Work Permit
System.
b. Work in confined spaces shall be executed under qualified person's
supervision. Foremen and workers shall receive the specific training
for the work in confined spaces before their assignment to the work.
c. Before each day's work and re-start of work, an authorized person
shall measure the oxygen density or other harmful gas density in
the confined spaces.
- Oxygen : more than 18%
- Hydrogen sulfide : less than 10 ppm.
d. Working alone in confined spaces shall be prohibited.
e. At least one watchman shall stand by the entrance for an
emergency situation.
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f. Names of workers in confined spaces shall be shown at the

entrance of confined spaces.
g. Proper Personal Protective Equipment and rescue devices such as
respiration equipment, harness or Safety belts, proper goggles,
hearing protection, life line, etc., shall be prepared and used
according to the condition of the confined space.
h. A ventilation system shall be furnished for welding work, blast
cleaning work, painting work, handling of organic solvents, and
other work in confined spaces which are anticipated to become
dusty or deficient in oxygen, etc.
i. All metal parts, including metal casing of equipment, scaffolds, etc.,
shall be electrically bonded and grounded, limiting to 25 ohm
electrical resistance
8.5. Hazard Identification Risk Assessment and Determining Control

The competent person should identify the potential problem or should
asses the potential risk prior to the start of work on each workplace that
consider to hazard zone category in operated plant area. There should
be a written instruction of work for the high-risk task of work.
As usually on the project execution, the Contractor and Sub-Contractors

HSE personnel representative will prepare Job Safety Analysis (JSA) /
HIRADC (Hazard Identification Risk Assessment Determining Control)
for each major job to mitigate / eliminate potential hazard and will be
completed before work begins.
The jobs will apply HIRADC on this project are : Safety Excavation,
Safety Work at Height, Welding Work, Safety Radiation, Electrical Work,
etc.
Comprehensive HSE Job Safety Analysis (JSA) or HSE Risk Assessment

and Determining Control (HIRADC) shall be provided for this work and
comply with Chiyoda JSA system. The important Contractor’s activity
concerning Risk assessment as JSA/ HIRADC is shown in Appendix-06.
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8.5.1. Hazard Control

Methods used to control identified hazards shall consider the following
hierarchy of controls. The preferential order of action is:
1. Eliminate the hazard
2. Substitute the hazard for a lesser risk
3. Isolate the hazard (e.g. barriers, fencing, guarding etc.)
4. Engineer control (e.g. trip switches etc.)
5. Administrative control (e.g. training, procedures etc.)
6. Personal Protective Equipment.
8.5.2. Electrical Safety

The hazards arising from static electricity and lightning will be considered
in all JSA’s, with appropriate measures taken to avoid danger.
Equipment will be effectively isolated from all sources of electrical power

whenever personnel are required to work in an area where they may be
exposed to danger. Completed isolations will be made secure and
security maintained until the associated work has been completed and
the equipment is ready for return to service. Locks/Tags will be applied at
all points of isolation to indicate the purpose, date and person responsible
for the isolation.
Hand tools must be checked and tagged by a certified electrician every 6

months.
8.5.3. Fire Protection

The Contractor is to provide hand held dry chemical powder
extinguishers at each hot work permit site and an appropriate number of
spare extinguishers.
8.5.4. Manual Handling

Construction involves the handling and movement of large, heavy and
cumbersome material. The Contractor’s work procedures shall
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specifically address manual handling risks. Where appropriate,

equipment and loads should be moved with mechanical assistance.
8.5.5. Crane Lifts

Documented lift studies will be required for all lifts over 15 tones or 85%
of the crane’s rated capacity at the lift radius. These studies shall be
presented to the Construction Supervisor at least 24 hours prior to the lift.
Appropriate approval shall be obtained before the lift is attempted. Crane
certification, together with certificates of competency for crane drivers,
riggers and dog men shall be available on site. All lifts will be planned to
avoid lifting over live plant. No lifts shall be permitted to pass over any
personnel.
8.5.6. Scaffolding
Except where specifically exempt, all scaffolding shall be erected by
personnel who are in possession of the appropriate certificates of
competency. Copies of all Certificates of Competency shall be
maintained by the Contractor and made available upon request.
8.5.7. Working at Heights

Positive protection against falling shall be provided at all times while
working at height. Positive protection shall be provided by permanent or
temporary work platforms with handrails, or by fall protection devices. A
JSA shall be completed for all tasks at height, and shall consider rescue
of personnel at height.
All working at height activities must conform to relevant Standards and
any other regulatory requirements.
8.5.8. Working near overhead electrical cabling

The Contractor will be required to take particular care whilst operating in
the vicinity of the power lines and a minimum a default distance of four
meters shall be used as a limit of approach to power lines.
The Contractor must address the issue of working in close proximity to

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overhead power lines in the Job Safety Analysis. The Contractor must
also make allowances for additional personnel to act as ‘watchers’ to
ensure that the equipment does not operate within four meters of the
overhead cables.
8.6. Work Permit

Contractor and or Sub-Contractors representative personnel will prepare
Work Permit(s) for each work(s) and submit to CM/SI for Approval prior
to start the work. For the Construction activities around/inside Contractor
fencing area, Work Permit procedure will be operated by Contractor’s
HSE under control of Chiyoda HSE Project team.
Contractor's Safety personnel will review the work permit to ensure that
preventive precautionary prerequisites such as JSA/ HIRADC, Tool Box
Meeting, PPE, Fall Protection, Fire Protection, etc. will be adequately
provided with the work in order to potential hazard mitigation/ elimination.
8.7. Emergency Response Plan

Emergency response procedures are comply to Chiyoda Standard and
Procedure for all potential incidents related to existing operational
situation including fire, explosion, weather disturbances, accident/ injury/
illness which need medical evacuation, missing person, social disorder,
lightning, etc. The communication flowchart contains details on
communication between Contractor, Chiyoda Emergency Rescue Team,
fire fighting, medical, evacuation, resumption of operations and other
details as may be deemed required.
The project team may be prepare its own emergency procedure as

necessary required by developing the Chiyoda standard procedure and
taking the conditions of the site into consideration.
An emergency communication network showing a list of personnel and

parties to be contacted, available Chiyoda emergency medical services
and fire stations with telephone numbers and addresses, or other
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addresses for obtaining assistance, will be established at the

construction site.
The evacuation routes and assembly point and emergency

communication network will be prominently displayed at key points
around construction sites and in Contractor’s and Sub-Contractor’s main
offices, field offices and at the gate of the construction site.
The Plan will be communicated to all responsible managers,

superintendent and supervisors and fully explained to all employees at
the HSE induction training given by Chiyoda representative at their entry
to the Site.
An emergency response drill will be conducted during the construction

phase of the project. In consultation with the Chiyoda and the Contractors’
Construction Manager will conduct the drill at least quarterly basis.
8.8. Corrective and Preventive Action

8.8.1. Accident Investigation
All incident resulting in injury, loss, or near misses are investigated and
documented. These investigations are designed to uncover root causes
analysis and corrective action.
8.8.2. Inspections and Audits

HSE Inspections is conducted at all activities. The result of these
inspections, as with the monthly inspections is recorded on the loss
prevention inspection report. Copies of the inspections report and
summary sheet are forwarded to the appropriate manager for corrective
action as necessary.
Contractor conducts the HSE audits as part of Home Office program to

fulfill HSE certification and maintain and/or the Chiyoda audit program.
The purposes of the audits are:
a. Ensuring compliance with Contractor and record keeping
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requirements.
b. Reviewing and update training.
c. Reviewing claim management and loss prevention control efforts.
d. Discerning any potential trends in Safety Violations or injuries that
may apply to the overall project area.
8.8.3. Medical Services

Prevention is the key element used to minimize the severity of
occupational injuries and illness. However, unpredictable events do occur,
and it is important that an emergency situation which it need medical
facility shall be immediately communicated and coordinated to Chiyoda
ERT in order to medical treatment properly to an injured or ill employee.
Appropriate protocols and reporting procedures are developed and pre-
arranged agreements be established with the Chiyoda Medical Facility
and/or with the nearest emergency medical resources (paramedic,
hospital).
Contractor shall provide basic first aid for the treatment of minor injuries.
A register recording all treatments shall be maintained and made
available for inspection when requested.
The Contractor shall ensure that a suitable number of personnel are

available on the project who are qualified First Aiders, and the Contractor
is required to submit names and copies of those person(s) relevant
qualifications prior to mobilization to site.
Where the injury requires treatment beyond the scope of the Contractor
first aid facility’s capabilities, the Contractor’s Medic shall take the person
to the Site medical center for examination. If required, Medic will arrange
for the person to be transported by appropriate transport to a hospital.
8.9. Documentation and Reporting

The following documentation and records will be prepared, regularly
updated and retained at the site office:
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a. Safety Training Records

b. Safety Inspection Records
c. Safety Audit Records
d. Construction Equipment Logbook
e. Safety Meeting Records
f. Accident/investigation Records
g. Work Permit Records
h. Monthly HSE Statistic Report.
i. STOP Report Log Book
8.10. Management Review

The Management Reviews will consider the following:
a. Chiyoda satisfaction feedback,
b. Work process improvement initiatives and Lessons Learned,
c. Results of audits,
d. Project performance,
e. Work process measurements relative to environmental objectives,
f. Status of preventive and corrective actions,
g. Environmental non-conformances, and
h. Follow-up actions from previous management reviews.
The results of management reviews are documented and address as a

minimum:
a. The Project HSE Policy and environmental objectives,
b. Improvement of the effectiveness of the EMS and its processes,
c. Improvement of project operations related to Chiyoda requirements,
and
d. Resource needs.
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9. APPENDICES
Appendix – 01 – HSE Committee and Organization Chart
Appendix – 02 – Project HSE Policy & KPI (Performance)
Appendix – 03 – Contractor’s HSE Standard Regulation Compliance
Appendix – 04 – Sample of Job Safety Analysis (JSA)
Appendix – 05 – Equipment’s/Vehicle Inspection
Appendix – 06 – Hazard Identification, Risk Assessment and
Determining Control (HIRADC)
Appendix – 07 – Rewards And Punishment
Appendix – 08 – Training Matrix
Appendix – 09 – ISO 45001 & SMK3 for health and safety, and ISO
14001 for Environmental management system
Appendix -1
Committee P2K3
PROJECT MANAGER
Ketua
HSE MANAGER
Sekretaris
KEY PERSON MANAGER DISCIPLINE LEADER SUBCONT. MANAGEMENT

Anggota Anggota Anggota
Appendix -1
HSE Organization Chart
HSE MANAGER
HSE ENGINEER
HSE SUPERINTENDENT
HSE SUPERVISOR HSE SUPERVISOR HSE REPRENSENTATIVE

SUBCONTRACTOR
SAFETYMAN
PROJECT’S HSE POLICY
 PT Adhi Karya management policy, ensures will provide a safe working environment in
all operational sectors of work, free from occupational injuries and diseases, by providing
professional staff to control safety, health and environmental protection programs.
 all employees of Consortium and, subcontractors or related partners, engaged in
construction site job work, shall be able to recognize the dangers in supporting the
safety, health and environmental protection programs. and are all assuredly involved
and responsible for maintaining OHS performance, in full compliance with the
requirements of the HSSE standards and / or HSSE legislation as defined
 Consortium will conduct monitoring of compliance with this policy. And All parties
concerned in the implementation of construction work, must make re-confirmation of
company instructions and / or education for safety before the start of work, and If there
are hazards that are not entirely eliminated, personnel will be trained on the risks
involved, field of work
 The benefits of a healthy lifestyle will continue to be promoted among employees
 Consortium Site Management will continue to monitor and report conditions, control and
reduce risks wherever possible and discontinue unsafe working conditions and actions.
Similar to our HSE Policy, our objectives are:
 Zero Injuries
 Zero Accident
 Zero Property Damage
 Zero Disease and Illnesses
 Zero Adverse Environmental Impact
PT Adhi Karya
Hari Darmojo
Appendix - 2
OBJECTIVES & TARGET

Key Performance Indicators (KPI)
ANNUAL MONTHLY Weight

NO MEASURES Base Stretch Base Stretch Factor INDICATOR PIC REMARKS
1.00 1.20 1.00 1.20 %
1 Targeted Safe Hours INFO Working Hours Record PM Total number of employee hours
I LAGGING INDICATOR 30
1 Fatality 0 N/A 0 N/A 6 Case Data Records PM & HSE Number of fatalities
2 TRIR 0.5 0.250 0.042 0.021 5 Case Data Records PM & HSE TRI Rate
3 LTI 0 N/A 0 N/A 5 Case Data Records PM & HSE Number of LTI
4 Environmental Case 2 0 0.167 0 4 Case Data Records PM & HSE Number of Environmental Case
5 First Aid 15 10 4 1 5 Case Data Records PM & HSE Number of First Aid
6 Near Miss 15 10 1 1 5 Case Data Records PM & HSE Number of Near Miss
II LEADING INDICATOR 70
1 HSE Meeting 48 58 4.00 4.83 5 MOM Records HSE Weekly, Bi-Weekly & Monthly
2 HSE Awareness Training 95% 100% 95% 100% 10 Documented Training HSE
3 HSE Reporting 95% 100% 95% 100% 5 Issued Records HSE Weekly, Monthly & Other
4 Safety Patrol 45 50 3.75 4 10 Documented Joint Inspection PM Top/Senior Mngt
5 Closure Action 95% 100% 95% 100% 5 Follow Up Corrective Actions CM Alignt with action plan
6 Audit 4 6 0.33 0.50 5 Audit/Inspection Records PM & HSE Internal & External
7 Safety Observation 1,000 1,500 83 125 5 Documents Safety Observation HSE STOP Card
8 HSE Plan Implementation 80% 100% 80% 100% 10 Assessment Score HSE
9 CSMS Implementation 90% 100% 90% 100% 10 Assessment Score SM
10 Fit To Work 95% 100% 95% 100% 5 Medical Record SM Program medical service
TOTAL 100
Prepared by ADHI: Approved by :
Project Manager Adhikarya Chiyoda

Appendix -3
PROJECT COMPLIENCE EVALUATION CONCERNING REGULATION/ ACT

OF HSE/ K3LL & OTHER REQUIREMENTS
RELATED ACT/ CONTROLLING OBJECT EVALUATION

No. CONTROLLING OBJECT FULL NOT FOLLOW UP PIC TARGET REMARKS
REGULATION DESCRIPTION FILLED YET
1 Occupational Safety & PP No.50 tahun HSEMS is implemented Yes - HSEMS HSE Will be full
Health Management 2012 (SMK3) implementation filled on
System is described at project
HSE Plan
Per. 26/MEN/2014 HSEMS is implemented Yes - HSEMS HSE Will be full
(SMK3 regulation) implementation filled on
is described at project
HSE Plan
OHSAS 18001- HSEMS is implemented Yes - HSEMS HSE Will be full
2007 implementation filled on
is described at project
HSE Plan
ISO 14001-2004 Environmental Management Yes - Environmental HSE Will be full
System is Implemented Management filled on
System project
implementation
is described at
HSE Plan
ANSI/ASME B31.3 Code to set forth engineering Yes - Design & Engi Will be full
Scope & Definition requirements deemed necessary Construction of neeri filled on
300. General for safe design and construction Piping System ng project
Statements of piping installations shall comply
with applicable
Code/Standard.
Act. No. P2K3 (HSE Committee Yes - Member HSE/ N/A
04/PERMENAKER/ Organization Formulation) Licensed by HR
1987 government
(Depnaker)
No. Tata Cara Penunjukan, Yes - AK3 Member HSE/ N/A Consortium
02/PERMENAKER/ Kewajiban dan Wewenang Ahli Licensed by HR
1992 K3 government
2 Occupational Health
2.1. Environment Health Act No. 261/ Environment Health Yes - Joint with third HR/ Site Project
Appendix -3


Factor at the work MENKES/SK/II/199 Requirements at the work place/ Party to HSE Office
place 8 Building/ Office Conduct
investigation &
Test
2.2. paramedic Who Act No. 1/ 1970, healthy license letter Yes - - - - Medical Check
examine the Para. 8.2 up Institution
occupational health Per/03/Men/1982
Per/01/Men/1979 Paramedical healthy license letter - Not Yet - - - Not Applicable
Yet
2.3. Serving of the Per/04/Men/1995 Board of Healthy Examination - Not Yet Will be applied if HR - -
occupational health Act No. 01/ 1998 required
Act No. 147/1989
Per/03/Men/1982 Healthy license letter - Not Yet Will be applied if HR - -
(Health Occupation Serving) required
Permen 01/76 Doctor of Hyperkes
Permen 01/79 Paramedic of Hyperkes
2.4. Serving of the Act No. 1/ 1970, First Examination Some HR All
occupational health Para. 8. employees
are
examined
Act No. 02/ 1980 Special Examination Yes HR -
Act No. 333/1989 Periodic Examination Some - Will be fulfilled if HR All
required employees
are
examined
2.5. Nutrient of Workers SE. 86/BW/1989 Recommendation Letter of food - Not Yet - - - Not Applicable
catering management Company Yet
(Catering’s Certificate / Catering
Inspection
PMP. 7/ 1964 Certificate of occupation nutrient - Not Yet - - - Not Applicable
& food saving training Yet
Inst.01/Men/1979 Controlling on the canteen & - Not Yet - - - Not Applicable
dining room cleanliness Yet
Inst.01/Men/1988 Set up canteen & dining room - Not Yet - - - Not Applicable
Appendix -3


Yet
2.6. First Aid Act No. 03/ 1969 Number & content of First aid Will be full
Box. filled by
project
Per/03/Men/1982 Board/ Team of First Aid
3 Occupational Safety
3.1. Asbestos Per. 03/Men/1985 ; Asbestos usage ai the Works Yes - HSE Procedure/ HSE Comply to
03/Men/1992 place Risk OSHA/
Assessment SMK3
3.2. HSE Flag Kep. HSE Flag is Provided Yes - Provided Busin -
1135/Men/1987 ess
3.3. Accident Per. 03/Men/1998 Accident Report Submitted to Yes - HSE Procedure HSE No
Authorization Government Accident
Kep. 84/BW/1998 Accident has reported as form Yes - HSE Procedure HSE No
required & statistic to be made Accident
3.4. Occupational Kep. 235/Men/2003 Hazard Safety Occupational are Yes - HSE Procedure HSE - JSA Project
identified & controlled
3.5. Chemical Kep. 197/Men/1999 Chemical Hazard identified & Yes - HSE Procedure HSE -
controlled
3.5. Fire Per. 04/Men/1980; Fire Extinguishers are provided & Yes - Periodically HSE -
NFPA maintained inspected
Per. 02/Men/1983; Fire Alarm system are provided & Yes - Periodically Floor -
Kepmenaker No. maintained conduct Ward
186/ 1999 Emergency Fire en
Drill
3 3.6. Electrical & Lightning Per. 02/Men/1989 Lightning Protection are installed Yes - Building HSE Project will
& certified Lightning be full filled
Certification
Kep. 75/Men/2002 Lightning Protection are installed Yes - Building HSE Project will
& certified Lightning be full filled
Certification
3.7. Lifting Equipment Per. Operator has SIO Certificate & Yes - HSE Procedure/ HSE Operator
09/MEN/VII/2010 be valid TRA License is
verified
Appendix -3


Per. 05/Men/1985 Lifting Equipment/ Crane are Yes - HSE Procedure HSE Lifting
Certified & be valid equipments
are
inspected
3.8. BPJS Per. 01/Men/1998 All Employees are covered by Yes - Covered HR -
BPJS Insurance
3.9. Safety Radiography ASME Code Sec. V Radioscopic examination Yes - Provide HSE/ Project will
SE-1255 ARTICLE procedures shall be Radiography Sub- be full filled
22 carried out under protective Test procedure. contr
conditions so that personnel Personnel actor
will not receive radiation dose Certification : -
levels exceeding that Ahli
permitted by company, city, state, Radiography
or national regulations. and Petugas
The recommendations of the Proteksi Radiasi
National Committee on Radiation (Issued by
Protection should be the guide to BATAN)
radiation safety.
3.10. Safety PPE ANZI Z41 PT99; Safety Shoes Yes - HSE Procedure HR/ Full filled
SNI 12-1547-1989; HSE as project
BS 6159-1:1981 required
MSA Standard Safety Helmet Yes - HSE Procedure HR/ Full filled
HSE as project
required
BS EN 420 or Hand glove Rubber Loaf Yes - HSE Procedure HR/ Full filled
Equivalent HSE as project
required
BS EN 149, 2001 Dust Mask Yes - HSE Procedure HR/ Full filled
HSE as project
required
ANSI Z87 Safety Goggles, Lens color Yes - HSE Procedure HR/ Full filled
normal/ Clear, anti scratch HSE as project
required
ANSI Z359.1/ CSA Safety Body Harness Yes - HSE Procedure HR/ Full filled
Appendix -3


HSE as project
required
ANSI S3 19-1974; Easy-grip handle lets earplugs Yes - HSE Procedure HR/ Full filled
EN-352-1 (Ear slip into the ear, Air bubble in tip HSE as project
Plug; Muffler) provides cushioned comfort required
Permen PPE Yes - HSE Procedure HR/H Full filled
No.8/MEN/VII/2010 SE as project
required
3.11. Scaffolding BS 1019/ BS EN Scaffolder Certification, Type & Yes - HSE Procedure HSE/ Full filled
12811-1/ BS 1139 dimension of scaffolding, Subc as project
Part 1-2/ MIGAS : installation/ dismantling formation ontra required
UU/ 44/ 1960 ; requirement ctor
PP/ 17/ 1974
Depnaker : UU/ 1/
1970
4 Occupation
Environmental
4.1. Occupation Act No. 3/ 1969; Explanation (Emergency, Field & Yes - HSE Meeting/ HSE -
Environmental Factor No. 1/ 1970; Road) Toolbox
PMP 7/ 1964;
No. 11/Men/2013
Act No. 3/ 1969; Building Requirements Yes - Depnaker Buildi - Building
No. 1/ 1970; Certification ng Management
PMP 7/ 1964;
No. 11/Men/2013
PMP 7/ 1964; No. Dust on the workplace Yes - Periodically HR -
Clean up by
vacuum
Act No. 3/ 1985; Vibration - Not Yet Will be applied HSE - H/O is not
No. 1/ 1970; at Project site required
PMP 7/ 1964; (if required)
No. SE 01/1997
Act No. 3/ 1969; Noise - Not Yet HSE Procedure HSE - Will be applied
No. 3/ 1985; at H/ O &
Appendix -3


PMP 7/ 1964; Project

No. SE 01/1997 (if required)
Permen No. Testing of Workplace regarding - Not Yet Will be applied if HR - -
11/Men/2013 Chemical and Physics Factor required
Act No. 3/ 1969; Air Ventilation Yes - Building/ Office HR - -
No. 1/ 1970; regularly
PMP 7/ 1964; Maintained &
No. 03/1985 Inspected
PMP No. 7/ 1964 Workplace space area is feasible Yes - Building/ Office HR - -
regularly
Inspected
PMP No. 7/ 1964 Workplace roof area is feasible Yes - Building/ Office HR - -
regularly
Maintained &
Inspected
PMP No. 7/ 1964 Wall/ Partition shall be dry (not Yes - Building/ Office HR - -
moist/ wet) regularly
Inspected
PMP No. 7/ 1964 Flooring of workplace (strong Yes - Building/ Office HR - -
material, not slippery, chemical regularly
resistance, etc) Maintained &
Inspected
PMP No. 7/ 1964 Stair (safely, not slippery, etc) Yes - Building/ Office HR - -
regularly
Inspected
JOB SAFETY ANALYSIS (JSA)
ANALISIS KESELAMATAN PEKERJAAN (AKP)
Nama Pekerjaan Pile Driving/ Load Persetujuan No. JSA
/Activity Title Test /Approval /JSA No.
Departemen/Seksi Dibuat Tanggal 26 November 2020
/Dept/Section /Issued on
Unit Organisasi Revisi Tanggal
/Organization Unit /Revision date
Perusahaan PT. Adhi Karya No. JSA Terkait
/Company /Relevant JSA.
Alat Pelindung Diri (APD) yang harus Dipakai /Required Personal Protective Equipment (PPE)
Safety helm, safety shoes, Face Mask, Wool Gloves
TINDAKAN ATAU
URUTAN DARI LANGKAH-LANGKAH POKOK TUGAS RISIKO POTENSIAL PROSEDUR YANG
SEQUENCE OF CRITICAL STEPS OF THE ACTIVITY POTENTIAL RISKS DIREKOMENDASIKAN
RECCOMMENDED ACTION OR
PROCEDURE
Persiapan dan penurunan alat Drop hammer dan hammer Tertimpa alat uji Memasang barrier, mengecek
diesel kesiapan alat, mengecek SIA
(struck by Drop hammer ) alat pancang dan SIO
( Preparing and unloading pile driving and hammer operator, APD
diesel)
( Instal barrier, check tools,
check equipment and
operator, PPE)
Transportasi & Lalu lintas Kerusakan kendaraan saat • Melakukan pemeriksaan

digunakan, Kesalahan keselamatan secara teratur
pengoperasian kendaraan, oleh Dept. K3LL
(Transportation And Traffic) Kegagalan pengoperasian
peralatan / material (Crane, • Menyelenggarakan inspeksi
forklift, etc.), Kondisi Jalan harian oleh pemakai
yang tidak layak. • Memasastikan pemeliharaan
secara teratur oleh pemakai.
(Vehicle damage, vehicle • Meningkatkan kepedulian

operating errors, equipment keselamatan berlalu lintas
/ material failure (crane, melalui toolbox meeting.
etc.), improper road • Membatasi usia maximum
conditions.) kendaraan oleh direktur
sarana.
(• Conduct regular safety

checks by Dept. K3LL
• Carry out daily user
inspections
• Ensure regular maintenance
by the user.
• Increase traffic safety
awareness through toolbox
meetings.
• Limiting the maximum
vehicle age by the facility
director.)
MS-DD-3120-HSE-FRM-9006 Halaman 1
Pengangkatan material pile Pile jatuh saat akan • Meyakinkan subcontractor
diseting, Concrete pile patah untuk :
saat di eksekusi
i. Menyediakan pelatihan
(Pilling / Erection) kepada personel terkait.
(The pile fell when it was ii. Memengecek kondisi sling
about to be setup, the sebelum digunakan.
Concrete pile was broken
when it was executed) iii. Merawat tali sling.
iv. Menggunakan tali sling
yang bersertifikat.
v. Mengcecek SWL
• Check kualitase material pile
sebelum digunakan.
• Mengontrol kembali
alignment pile sebelum di
eksekusi.
(• Convince subcontractors to:

i. Provide training to related
personnel.
ii. Check the condition of the
slings before use.
iii. Take care of the sling
straps.
iv. Using a certified rope sling.
v. Checking SWL
• Check the quality of the pile
material before use.
• Control back pile alignment
before execution.)
Beban jatuh • Koordinasi yang baik dengan

pihak engineering untuk
Pemancangan dan load test (The structure (load) falls) klarifikasi data.
• Monitor akses kerja terutama
(Piling and load test) landasan yang licin atau
mengandung oli.
• Melakukan verifikasi beban
(concrete block) selama
aktifitas testing
• Menyediakan barricade
• Good coordination with

engineering for data
clarification.
• Monitor work access
especially if the base is
slippery or contains oil.
• Verify the load (concrete
block) during testing activities
• Provide a barricade
Lifting work using heavy equipment (Lifting activity)
PDA Test Tertimpa tiang pancang, Memasang barrier, mengecek

terkena pecahan beton ( fall kesiapan alat, mengecek SIA
(PDA Test) by pile, exposed to broken alat pancang dan SIO
pile) operator, APD
( Instal barrier, check tools,
check Lincence pile Tool and
operator, PPE)
Membaca hasil PDA Mata Lelah, panas Memasang tenda

(Monitoring PDA results) (eyes, heat stress) ( install tent )
Petunjuk Umum /General Guidelines:

1. Sebutkan secara berurutan hanya langkah-langkah pokok tugas yang harus dikerjakan. Gunakan kalimat aktif secara
jelas dan singkat /Describe in sequence only the main steps of the activity to be performed. Use active sentences.
2. Gunakan frasa singkat untuk mendeskripsikan Risiko Potensial, seperti: Terjepit di antara daun pintu dan kerangka
mesin, dll. /Use simple phrases to describe identified potential hazards, such as: Pinched between the door and the
machine, etc.
1. Terpukul oleh ... / Struck by ... 6. Terperangkap dalam … / Caught in … 11. Terpapar oleh … / Exposure to …
2. Membentur ... / Struct against ... 7. Terjepit di antara … / Caught between  Menghirup … / Inhaling …
3. Terkena oleh ... / Contacted by ... 8. Terpeleset … / Slip …  Kulit tubuh terkena … /Absorbing
4. Kontak dengan ... (listrik, kimia) ... / 9. Jatuh … / Fall …  Menelan … / Swallowing …
Contact with ... (Electrical, chemical) 10. Terlalu memforsir tenaga / Overexertion
5. Terkait pada … / Caught on …
3. Sebutkan Tindakan atau Prosedur yang Direkomendasikan secara jelas dan singkat, dengan menggunakan kalimat aktif
/Describe the recommended action or procedure in brief, using active sentences.
Appendix -5
INSPEKSI ALAT DAN PERALATAN
Form-I-001
CRANE CARRY-IN INSPECTION FORM
Type of Crane : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :
Capacity : Date :
Manufacturer :
Approved by :
Company User :
Certificate Number :
Reviewed by :
Month of Inspection :
This form must be completed by the crane operator and company user before entering the crane to be operated in the
site project area, and at any time of setting location. All crane condition must meet to the safety regulation and ADHI
SHE Management Plan
Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable
No Check Item Result Remarks
1 Manufacturer's operating and Maintenance

Manuals
2 Turntable/Crane Body (Upper Works)
Assure Level/Stability
Wear/Gear/Teeth/Rollers
Cracks
Bolts/Pins - Assure Securely Attached
3 Engine Housing
Cleanliness/No Rags/Trash
Gear/Machinery Guards
Clear Access/Walkways
Brakes/Clutch Adjustments
Hand Signal Illustration
Swing Break
4 Swing Clearance Protection
5 Tire condition
6 Track Crawler System
Lubrication
Connection Bolts
Drive Chain (slack & wear)
7 Braking Systems
8 Electrical system
High-Voltage Warning Sign
Appendix -5
Lighting Device.
Wiring system
9 Safety Device
Anti-Two Block Devices
Boom Backstop Devices
Swing Radius Warning Devices
10 Boom Section
Main Boom, Jib Boom, Boom Extension
Boom Stop
Jib Boom Stops
Boom Angle Indicator
Boom Hoist Disconnect,
Automatic Boom Hoist Shut off
11 Leveling Indicating Device
12 Load Rating Chart
13 Sheaves
Ensure hoist line and sheave size match
Worn
Lubrication/Move freely
14 Main Hoist and Auxiliary Drums System
Proper Size and Spoiling of Hoist lines
Drum Sides/Shields for Cracks
Dogs/Pawls/Locking Devices
Drum Rotation vs. Control Motion
Clutch and Brakes
15 Load Hooks and Hook Blocks
Sheaves Function Smoothly
Hook Rotates Freely/Lubricated
Proper Becket
Properly Reeve
Safety latch
16 Hydraulic Hoses Fittings and Tubing
17 Outriggers
Lubrication
Structural Condition
Pressure hoses/connections
18 Wire Rope
Overall Condition
End Connections
Lubrication
Clips
19 Cab
Glass/Visibility
Instruments and Controls
Appendix -5
Functioning Horn (warning signal)

Fire Extinguisher
Appropriate Load Charts and Warning Signs
Proper and Adequate Access (steps/walkway)
20 Counterweight
Proper Size
Attachment Connection/Bolts
21 Load test
INSPECTOR REPORT
Corrective Action Required
Inspection Status:  OK
 Not OK
 Order for Repair
Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Reviewer Date : Name : Signature :
Position :
SHE Manager Date : Name : Signature :
Position :
Appendix -5
Form-I-003
PILE DRIVING MACHINE INSPECTION FORM

□ Pile Driver □ Pile Drawer □ Boring Machine □ Earth Auger
Type of Equipment : CARRY-IN CERTIFICATE
Manufacturer : Date :
Company User :
Approved by :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
ADHI SHE Management Plan

1 Operator has a valid License

2 Equipment has valid certificate
3 Hydraulic system in good condition
4 Traveling system in good condition
5 Diesel hammer system in good condition
6 All electrical system are in good
7 Brake system
8 Operations Handle
9 Back Mirror
10 Lighting Device
11 Alarm System
12 Safety device
13 Boom Hoist Limiting Device
14 Wire sling is in good condition
15 Rigger man provided / qualified
16 Fork horn in good condition
17 Lubrication system
18 Oil leaking
19 Fuel Reservoir
20 Each Side of windows glasses
21 Leveling indicator devices
22 Safe Guards for moving parts
23 Fire Extinguisher
24
Appendix -5
INSPECTOR REPORT
 Not OK
Subcontractor
Position :
Position :
Contractor
Position :
Position :
Position :
Appendix -5
Form-I-004
SOIL HANDLING EQUIPMENT INSPECTION FORM
□ Bulldozer □ Backhoe/Excavator □ Road Roller/Vibro □ Power Shovel □ Drag-line

□ Clamshell □ Grader □ Scraper □ Wheel Loader
Manufacturer : Date :
Company User :
Approved by :


6 Brake system
7 Operations Handle
8 Back Mirror
9 Lighting Device
10 Alarm System
11 Safety device
12 Rigger man provided / qualified
16 Oil leaking
17 Fuel Reservoir
19
20
21
Appendix -5
22
INSPECTOR REPORT
 Not OK
Subcontractor
Position :
Position :
Contractor
Position :
Position :
Position :
Appendix -5
Form-I-005
FIRE EXTINGUISHERS INSPECTION
EXTINGUISHERS CONDITIONS
NO OK TYPE NUMBER PRESSURE GAUGE NOZLE POWDER HANDLE COMMENT
( CATRIDGE )
Subcontractor
Position :
Position :
Contractor
Position :
Appendix -5
Form-I-006
FORKLIFT INSPECTION FORM

□ Fork lift
Capacity : Date :
Manufacturer :
Approved by :
Company User :
Reviewed by :


6 Brake system
7 Operations Handle
8 Back Mirror
9 Lighting Device
10 Alarm System
11 Safety device
14 Oil leaking
15 Fuel Reservoir
18
Appendix -5
INSPECTOR REPORT
 Not OK
Subcontractor
Position :
Position :
Contractor
Position :
Position :
Position :
Appendix -5
Form-I-007
ELECTRICAL EQUIPMENT / TOOL INSPECTION FORM
□ Saw □ Planer □ Bender □ Cutter □ Grinder □ Blower □ Pump □ Stamper
Company User : Approved by :

1 Cable/Connector
2 Earth for Movable Equip.
3 Frame (body) Earth
4 Installation/Fixing
5 Abrasive Disk/Blade
6 Hand Switch
7 Pilot Lamp
8 Operations Handle
INSPECTOR REPORT
Corrective Action Required :
Inspection Status:  OK  Not OK  Order for Repair
Subcontractor
Position :
Position :
Contractor
Position :
Appendix -5
Form-I-008
ELECTRICAL DISTRIBUTION BOARD INSPECTION FORM

Equipment No. : Permit No.

1 Appearance/Structure
2 Earth Leakage Circuit Breaker
3 Frame (Body) Earth
4 Switches/Switch covers
5 Socket/Outlet
6 Light for night, dim location
7 Pilot Lamp
8 Cable Termination
9 Installation
10 User’s Tag for Each Circuit
11 Doors Lockable/Breakage
13 Warning Sign for Elec. Shock
14 Responsible Person’s Name
INSPECTOR REPORT
Corrective Action Required :


Position :
Contractor
Position :
Appendix -5

Appendix -5
Form-I-009
SCAFFOLDING INSPECTION FORM

Equipment No. : Permit No.
Location :
Reviewed by :

1 Ladder Access (Secured and clear from material)
2 Base plate (if necessary)
3 Working floor (minimum 2 boards and lashed)
4 Hand rail (1 meter above work floor)
5 Mid rails (0,5meter above work floor)
6 Toe boards
7 Bracing
8 Tied in
9 Strength Constructed
10 Barricade (if necessary)
11 Warning sign
INSPECTOR REPORT
Subcontractor
Position :
Contractor
Position :
Appendix -5
Form-I-010-1
WELDING MACHINE INSPECTION FORM
(Electric / Trafo type)
Manufacturer :
Approved by :
Company User :
Month of Inspection : Reviewed by

1 Arc Welding Machine
Appearance
Frame (Body) Earth
Skid/Wheels
Adjust Handle
Installation/Fixing
Automatic Voltage Reducer
2 Cable/Connector
Supply Cables
Earth (Return) Cable
Cable Connectors
Cable Termination/Clamp
3 Electrode Holder condition
4 Fire Extinguisher
INSPECTOR REPORT

Subcontractor
Contractor
Position :
Appendix -5

Appendix -5
Form-I-010-2
WELDING MACHINE INSPECTION FORM

Manufacturer :
Approved by :
Company User :

1 Engine Welder
Appearance
Cooling System
Fuel System
Exhaust System
Starter motor/Dynamo
2 Cable/Connector system
3 Earth (Return) Cable
5 Career/Wheels
6 Pilot Lamps
7 Meters (Ampere/Volt Meters)
8 Breaker (Emergency Stopper)
INSPECTOR REPORT

Subcontractor
Position :
Position :
Contractor
Position :
Appendix -5

Appendix -5
Form-I-011
GAS CUTTING / WELDING INSPECTION FORM


1 Gas Cylinders
2 Regulator/Hoses/Torches
Regulator
Hoses/Connector
Torches
Flash-back Arrestor
3 Miscellaneous
Fire extinguisher
Fire prevention
Overturn Prevention
Provision of Soap Liquid
INSPECTOR REPORT
Subcontractor
Position :
Position :
Contractor
Position :
Appendix -5
Form-I-012
SLING INSPECTION FORM
Inspector Subcontractor Work Team Inspect. Date Color Code Remarks
of
Number of Inspected Accepted Rejected The Month
Wire Sling
Web Sling

No Check Item Sling No.
1 2 3 4 5 6 7 8
1 Wire Sling (Size)

Location or User
a Reduction of Dia. ≧7%
b Damage of Strands≧10%
c Kink or Deformed
d Corroded
Judgment
2 Web Sling (Dimension)
Location or User
a Abrasion, Cut or Burnt
b Cut of Seam or Peeled
c Napped to seam
Judgment
 When one crack of web sling is over 10% in width, or 25% in thickness, or 5 or more
cracks are over 3% in width or 1% in thickness, The Web sling shall be rejected.
Subcontractor
Position :
Position :
Contractor
Position :
Appendix -5
Form-I-013
VEHICLE INSPECTION FORM
□ Light Vehicle □ Dump Truck □ Truck □ Trailer □ Truck Mixer □ Concrete Pump
Capacity : Date :
Manufacturer :
Approved by :
Company User :
Reviewed by :
IKPT-ADHI SHE Management Plan

1 Carrier Body/Frame
2 Wheels
3 Handle/Power Steering
4 Foot/Hand Brakes
5 Clutch/lever/Pedals
6 Engine
7 Battery/Wiring
8 Engine Oil/Filter/Piping
9 Fuel Tank/Pump/Filter/Piping
10 Radiator/Pump/Fan Belt
11 Transmission/Torque Converter
12 Muffler/Flame Arrestor
13 Lamps
14 Signal Lights
15 Horn/Reverse Alarm
16 Wiper/Washers/Mirrors
17 Door Latches/Locks
18 Seat Belts
Appendix -5
INSPECTOR REPORT
 Not OK
Subcontractor
Position :
Position :
Contractor
Position :
Position :
Appendix -5
Form-I-014
COMPRESSOR INSPECTION FORM

Manufacturer :
Approved by :
Company User :

1 Engine
Cooling & Fuel System
Exhaust System
3 Career/Wheels
4 Pilot Lamps
5 Cylinder Case
6 Housing
7 Safety Valve/ Un loader Valve
8 Air Receiver
9 Air Cock/Drain Cock
INSPECTOR REPORT

Subcontractor
Position :
Position :
Contractor
Position :
Appendix -5
Open Access RU-VII Kasim

Sorong, West Papua
PT. PERTAMINA (Persero)
Form-I-015
GENERATOR INSPECTION FORM

Manufacturer :
Approved by :
Company User :

1 Engine
Cooling System
Fuel System
Exhaust System
2 Outlet Terminal/Wires
4 Grounding for Enclosure
5 Career/Wheels
6 Pilot Lamps
7 Meters (Ampere/Volt Meters)
8 Breaker (Emergency Stopper)
INSPECTOR REPORT

Subcontractor
Position :
Position :
Contractor
Position :
Appendix -5
Form-I-016
SPREADER BEAM INSPECTION FORM
Manufacturer : Permit No. :
Company User :
Approved by :
Capacity :
Reviewed by :

1 Appearance
2 Data Calculation
3 NDT
Radiografi Test
Penetrant Test
4 Tool Has a Valid Certificate
INSPECTOR REPORT
Inspection Status:  OK  Not OK  Order for Repair
Subcontractor
Position :
Position :
Contractor
Position :
Name : Signature :
Position :
Client
Position :
Appendix -5
Form-I-017
MOBILE LIFT INSPECTION FORM

Capacity : Date :
Manufacturer :
Approved by :
Company User :

1 Career
Steering
Wheels
Brake, Brake Pedal/Lever
Clutch/Brake
Signals/Horn
Lights
Outriggers/Timber Pads
2 Lift Operating Devices
Levers
Brakes
Emergency Stopper
Telescope Cylinder
Scissors Boom
Man-basket
Basket Balance/Moving Device
3 Safety Devices
Operator’s Name
Warning Signs
Carry-in Certificate
Appendix -5
Safe Guards for moving parts
INSPECTOR REPORT
 Not OK
Subcontractor
Position :
Position :
Contractor
Position :
Position :
Appendix -5
Form-I-018
GONDOLA / CARGO LIFT INSPECTION FORM
□ Gondola □ Cargo Lift

Capacity : Date :
Manufacturer :
Approved by :
Company User :

1 Gondola/Lift
Overhang Support Arms
Wire Ropes/Shackles
Reel Winding/Sheaves
Electro/Mechanic Brakes
Hand Control Device
Stopper/Latches
Cage/Handrail
Bolts/Nuts/Bearing
Control Panel
Motor
Cab tire Cable/Earth
Over-Wind Warning Devices
Emergency Stopper
Lift: Guide Rails/Support
Shuttering Doors
Safe Guards for moving parts
2 Indication/Signs
Operator’s Name
Weight/Person No. Limitation
Warning Signs
Appendix -5
INSPECTOR REPORT
 Not OK
Subcontractor
Position :
Position :
Contractor
Position :
Position :
Appendix -5
Form-I-019
PPE INSPECTION
SAFETY SAFETY SAFETY HAND FULL BODY
NO NAMA HELMET GLASSES SHOES GLOVE HARNESS
1
2
3
4
5
6
7
8
9
10
NOTE :
G : Good
F : Fair
P : Poor
Inspected By, Acknowledged By,
……………….. ……………………
Appendix - 6
HIRADC/ RISK REGISTER

MAIN DESCRIPTION OF HAZARD & RISK SCOOR RISK ASSESSMENT
NO SCENARIO (CONDITIONS / TR HAZARD & RISK CONTROL
ACTIVITIES
SITUATION INVOLVED) HAZARD S/C F/L Tolerable / NOT S/C F/L TR TOLERABLE / NOT
• Conduct regular safety checks by Dept. K3LL
• Carry out daily user inspections
Vehicle damage, vehicle operating • Ensure regular maintenance by the user.
errors, equipment / material failure • Lack of maintenance • Increase traffic safety awareness through toolbox
1 Transportation And Traffic 3 3 9 NOT 3 1 3 YES
(crane, forklift, etc.), improper road • Overcapacity meetings.
conditions. • Limiting the maximum vehicle age by the facility
director.
• Establish procedures for safe work under special

• People slipped and fell into conditions by the construction division.
the excavation. • Specific conditions entered into the JSA.
Wet and slippery soils, Excavations • The person / personnel in • Provide an appropriate drain
2 Excavation covered with water, Landslides, the excavation were hit by 4 4 16 NOT • Provide warning boards and barricades around the 3 1 3 YES
Underground Facilities the falling equipment. excavation area.
• Heavy equipment collapsed • Implement good housekeeping
• Provide suitable personal protective equipment.
• Convince subcontractors to:

i. Provide training to related personnel.
ii. Check the condition of the slings before use.
The pile fell when it was
The pile fell when it was about to be iii. Take care of the sling straps.
about to be setup, the
3 Pilling / Erection setup, the Concrete pile was broken 3 4 12 NOT iv. Using a certified rope sling. 3 1 3 YES
Concrete pile was broken
when it was executed v. Checking SWL
when it was executed
• Check the quality of the pile material before use.
• Control back pile alignment before execution.
• Good coordination with engineering for data

clarification.
• Monitor work access especially if the base is
slippery or contains oil.
4 Piling load test The structure (load) falls The structure (load) falls 3 4 12 Tidak 3 1 3 YES
• Verify the load (concrete block) during testing
activities
• Provide a barricade
Appendix - 6
HIRADC/ RISK REGISTER

MAIN DESCRIPTION OF HAZARD & RISK SCOOR RISK ASSESSMENT
NO SCENARIO (CONDITIONS / TR HAZARD & RISK CONTROL
ACTIVITIES
SITUATION INVOLVED) HAZARD S/C F/L Tolerable / NOT S/C F/L TR TOLERABLE / NOT
Review equipment data and certificate status

• Review personnel status certificates
• Review personnel qualifications (training, etc.)
• Check equipment regularly
• Carry out daily inspections
Lifting work using heavy • Operation error • Material fell off causing • Develop SOP (standard operating tools) for heavy
9 4 4 16 Tidak 3 1 3 YES
equipment (Lifting activity) • Damage to tools and equipment serious or fatal injury lifting equipment
• Organizing pre-job meetings
• Create simulations
• Make appointment verification by check list •
Provide training for operators, by K3LL officers
• Develop standard operating procedures for
working in scaffolding.
• Carry out initial user inspections.
Appendix -7.1
Excellent Discipline Evaluation Sheet
Name of Group Leader : No. of Group Persons :
Name of Discipline : Period :
Evaluation Items Yes /

Remarks
No
(1) Has Zero Non-Induction People (include its Subcontractors)?
(2) Does the Discipline actively participate in SHE Training (min 30% of
total people)?
(3) Do they prepare SHE permit before the day’s work?
(4) Do they prepare JSA before commence the work?
(5) Do they properly wear and use the designated PPE?
(6) Do they always participate in Weekly Safety Talk?
(7) Have some of them ever to be a speaker in Safety Talk?
(8) Do they actively join Toolbox Meeting?
(9) Do they actively to keep work place tidy?
Do Supervisors/ Foremen always stay the location and properly
(10) supervise their work?
Didn’t they seriously violate safety/security rule in the past?
(11)
Didn’t one of them seriously violate safety/security rule in the past?
(12)
Were there recordable accidents within their supervision during
(13)
evaluation period?
Total “Yes”
Total “Yes” to Possible Yes (%) ………

%
Note
(1) Evaluation shall be made based on methods above
(2) Project Site Management may develop the evaluation sheet.
(3) Eliminate the evaluation point if the item is not applicable, and mark with N/A.
(4) Recommendation for awards is applied for the group that completed the hazardous
work designated in advance, without any accidents, or their overall evaluation figure
shall be 75% or more.
(5) Each subcontractor’s Construction Manager, supervisor, or Safety Representative
recommend the award candidates, filling in the above evaluation sheet, their Site
Manager shall examine and submit it to ADHI KARYA SHE Group.
Name of Recommended: Submission Date:

(Title: )
Name of Approved Person: Approve Date:

(Subcontractor’s Site Manager)
Remarks :
Appendix -7.2
Excellent Individual Evaluation Sheet
Name : Company’s Name :

I/D No : Period :
Evaluation Items Yes / No Remarks

(1) Did he/she attend in HSE Induction classroom?
(2) Does he/she always participate in Weekly Safety Talk?
(3) Has he/she ever to be a speaker in Safety Talk?
(4) Does he/she actively join Toolbox Meeting?
(5) Has he/she ever joined in a HSE Training program?
(6) Does he/she properly wear and use the designated PPE?
(7) Does he/she actively to keep work place tidy?
(8) Didn’t he/she seriously violate safety/security rule in the past?
(9) Does he/she proactively forward safety suggestion?
(10) Is the implemented improvement suggestion forwarded?
(must be specific)
Total “Yes”
Total “Yes” to Possible Yes (%) …………

.%
Notes
(1) Evaluation shall be made based on the methods above.
(2) Site Management may develop the evaluation sheet if needed.
(3) Eliminate the evaluation point if the item is not applicable, and mark with N/A.
(4) In principle, the candidate for award shall be working over three months on the site
and his overall evaluation figure shall be 75 % or more.
(5) Each subcontractor’s Construction Manager, supervisor, or Safety Representative
recommend the candidates for award, filling in the above evaluation sheet, their Site
Manager shall examine and submit it to ADHI KARYA HSE Group.
Name of Recommended: Submission Date:

(Title: )
Name of Approved Person: Approve Date:

(Company’s Site Manager)
Remarks:
Appendix -7.3
PENALTY SYSTEM
PENALTY
NO FOUL (DESCRIPTION)
OUT
1 Working at the height above 1.8m without using full body harness 3-OUT
2 Smoking at prohibited area 3-OUT
3 Open new area/ make hole/ throw barrior without safety protection 3-OUT
4 Working with scaffolding portable without safety/ not bounded 3-OUT
5 Unauthorized persons entering or near the heavy equipment during equipment operation 3-OUT
6 Fighting or traduce in rude language 3-OUT
7 Industrial acetylene & Oxigen cilinder in field without being equipped with flashback arrestor 3-OUT
8 Working without work permit 3-OUT
9 Disobey HSE team instruction in order to improve safety on site 1-OUT
10 PPE incomplete (without safety helmet/ safety shoes/ goggle/ gloves) 1-OUT
11 Welding job /cutting without face protection 1-OUT
12 Sleep on working area / rest near working area 1-OUT
13 Driving on the site above maximum speed limit / wrong parking / wrong direction 1-OUT
14 Oxygen / LPG / Acetylene Cilinder not being equipped with pressure gauge, flashback arrestor 1-OUT
15 Dumping or stacking the material not in the right place 1-OUT
16 Electric equipment not being equipped with earthing / grounding / ELCB / Double insulation cable 1-OUT
17 Use lifting equipment / takle without being equipped with certificate / certificate expired 1-OUT
18 Ignored housekeeping 1-OUT
19 Communicate with mobile on prohibited area 1-OUT
20 Use work equipment with substandard (as per international regulation) 1-OUT
21 Continually serious happen cause of housekeeping 1-OUT
22 Intentionally not attended Tool box meeting on time 1-OUT
23 Operated the heavy equipment without permit or license 2-OUT
24 Excavation without safety protection 2-OUT
25 Dismantling the safety facilities without permission 2-OUT
26 The person who are cause of near miss happen (that punish included construction SPV, SI) 2-OUT
* Information of penalty out
Verbal warning, the ID card will be punched : 1-OUT
Discuss with HSE Team and written warning, the ID card will be punched :
2-OUT
that person should attended training by contractor and the person can work after training done :
Terminated from Project : 3-OUT
Appendix -8
RENCANA TRAINING
MANDATORY FOR CERTAIN POSITIONS

HSE TRAINING MATRIX MANDATORY
VARIOUS TRAINING ITEM
Alat Bekerja di Pengangkatan JSA dan
SAFETY Bekerja di Pencegahan Tanggap Refresher
NO. TITLE COMPANY Pelindung Ruang dan Scaffolding P3K Risk
INDUCTION Ketinggian Kebakaran Darurat Training
Diri Terbatas Pengikatan Assesment
1 Project Manager ADHI x x x x
2 Site Mgr. ADHI & Subcontractor x x x
3 Construction Mgr. ADHI & Subcontractor x x x x
4 Business Mgr. ADHI & Subcontractor x x x x
5 Field Engineering Mgr ADHI & Subcontractor x x
6 Project Cont.Mgr. ADHI & Subcontractor x x
7 Precom Mgr. ADHI & Subcontractor x x x
8 QC Mgr. ADHI & Subcontractor x x x
9 SHE Mgr. ADHI & Subcontractor x x x
10 SHE Engineer. ADHI & Subcontractor x x x x x x x x x x x
11 SHE Staff ADHI & Subcontractor x x x x x x x x x x x
12 QC Leader ADHI & Subcontractor x x x
13 QC Staff ADHI & Subcontractor x x x x x x
14 Radiography staff ADHI & Subcontractor x x x x x
15 Area Superintendent ADHI & Subcontractor x x x x
16 Civil Discipline Leader ADHI & Subcontractor x x x x
17 Civil staff / Supv / Foreman ADHI & Subcontractor x x x x x x
18 Civil Worker ADHI & Subcontractor x x
19 Electric Discipline Leader ADHI & Subcontractor x x x x
20 Electric Staff / Supv. / Foreman ADHI & Subcontractor x x x x x x
21 Electric Worker ADHI & Subcontractor x x
22 Instrument Discipline Leader ADHI & Subcontractor x x x x
23 Instrument Staff / Supv. / Foreman ADHI & Subcontractor x x x x x x
24 Instrument worker ADHI & Subcontractor x x
25 Piping discipline leader ADHI & Subcontractor x x x x
26 Piping staff. / Supv. / Foreman ADHI & Subcontractor x x x x x x x
27 Piping worker ADHI & Subcontractor x x
28 Paint Insulation Discipline Leader ADHI & Subcontractor x x x x

Paint Insulation Staff / Supv. /
29 ADHI & Subcontractor x x x x x x x
Foreman
30 Paint Insulation Worker ADHI & Subcontractor x x
31 Mechanical Discipline Leader ADHI & Subcontractor x x x x
32 Mechanical Staff / Supv. / Foreman ADHI & Subcontractor x x x x x x x x
33 Mechanical worker ADHI & Subcontractor x x
34 Precom Disipline Leader ADHI & Subcontractor x x x x
35 Precom Staff / Supv. / Foreman ADHI & Subcontractor x x x x x x x
36 Precom worker ADHI & Subcontractor x x
37 Logistic leader ADHI & Subcontractor x x x x
38 Logistic staff ADHI & Subcontractor x x
39 Warehouse staff ADHI & Subcontractor x x x x
40 Adm Leader ADHI & Subcontractor x x x
41 Adm staff ADHI & Subcontractor x x x
42 Driver ADHI & Subcontractor x x
43 Operator heavy equipment ADHI & Subcontractor x x
44 Common worker / housekeeping crew ADHI & Subcontractor x x
45 Chief security ADHI & Subcontractor x x x x
46 Security guard / patrol ADHI & Subcontractor x x x x
DURASI 15 Menit 1 Hours 2 Hours 1 Hours 2 Hours 2 Hours 2 Hours 1 Hours 1 Hours 2 Hours 1 Hours
PROVIDER In-house In-house In-house In-house In-house In-house In-house In-house In-house In-house In-house
STANDARD ADHI ADHI ADHI ADHI ADHI ADHI ADHI ADHI ADHI ADHI ADHI
PILE LOAD TEST WORK MSP-PRC-HSE-002
PROCEDURE REGULATION AND K3L Rev.0

REQUIREMENT Page 1 of 3
PROJECT TITLE: MANYAR SMELTER PROJECT
LOCATION: GRESIK, INDONESIA
OWNER:PT FREEPORT INDONESIA
CONTRACTOR: PT CHIYODA INTERNATIONAL INDONESIA
SUBCONTRACTOR: PT ADHI KARYA (PERSERO) TBK.
PROJECT NO.:
0 FOR INFORMATION 21/11/2020

PT. ADHI KARYA (PERSERO) Tbk.

DEPARTMEN EPC

1. DESTINATION
To determine the requirements for the identification of Safety, Occupational Health and
Environment (K3L) regulations that are relevant to the PT Adhi Persada Beton Safety,
Health and Environmental Management System (SMK3L).
2. SCOPE
This procedure applies to all work units within the company covered by the PT Adhi
Persada Beton Safety, Health and Environment Management System (SMK3L).
3. REFERENCE
3.1 Law 1 of 1970, concerning Work Safety.
3.2 Occupational Health and Safety Management System (SMK3) PP No. 50/2012,
sub-element
2.3 concerning Laws and Regulations and Other Requirements in the OSH Sector.
3.3 Safety, Occupational Health and Environment Manual (MK3L): M 017 K3L 001.
3.4 ISO 14001: 2015 standard, clause 6.1.3 concerning the Determination of
Legislative Requirements.
3.5 ISO 45001: 2018 Standard, clause 6.1.3 concerning Determination of Legislative
Requirements.
4. DEFINITION
4.1 Legislation
Written regulations established by state institutions or competent authorities that
are binding and must be obeyed by all parties.

DEPARTMEN EPC

5. PROCESS FLOW
PROCESS DESCRIPTION OF ACTIVITIES INFORMATION

FLOW
1. 1. The QHSE manager - Legislation List Form.
identifies the HSE regulations
and requirements - Regulations are laws
2. The QHSE manager records and regulations,
the HSE regulations and regional regulations,
requirements. standards, technical
3. QHSE managers disseminate guidelines and other
K3L regulations to all requirements.
factories - Documents that are
4. QHSE Manager conducts stored can be hard or
periodic reviews regarding soft copy
compliance with and updating
the K3L regulations.
.
6. ATTACHMENT
6.1 Work Instruction Legislation: IK 017 HSE 001-01
6.2 Legislation List Form (Head Office): FM 017 HSE 001 - 01/01
6.3 Legislation List Form (Factory): FM 017 HSE 001 - 01/02

DEPARTMEN EPC
HAZARD IDENTIFICATION PROCEDURE AND Rev.0

ENVIRONMENTAL ASPECTS Page 1 of 4
OWNER:PT FREEPORT INDONESIA
PROJECT NO.:


DEPARTMEN EPC

1. DESTINATION
To identify potential hazards of Occupational Safety, Health and Environment (K3L)
systematically and carry out K3L risk assessments from activities, processes, products
and work areas at PT Adhi Persada Beton so that regulations, standards, procedures,
management and risk control are ensured to reduce risk above until it is acceptable.
2. SCOPE
This procedure applies to all work units within the company covered by the PT Adhi
Persada Beton Safety, Health and Environment System (SMK3L).
3. REFERENCE
3.2 Occupational Health and Safety Management System (SMK3) PP No. 50/2012,
sub-element
2.1 on the OSH Strategic Plan.
3.3 Safety, Occupational Health and Environment Manual (MK3L): M 017 K3L 001.
3.4 ISO 14001: 2015 standard, clause 6.1.2 concerning Identification of Environmental
Impact Aspects.
3.5 ISO 45001: 2018 standard, clause 6.1.2 concerning the Identification of K3 Impact
Aspects.
4. DEFINITION
4.1 Danger
Sources, situations / conditions or actions that have the potential to cause injury,
illness, equipment damage, cessation of the operation process and environmental
pollution.
4.2 Risk
The combination of the possible hazard or exposure and the level of danger from
injury, illness caused by the incident or exposure and the impact of environmental
pollution.
4.3 Risk Assessment
The process of assessing a risk by using parameters of the consequences and
opportunities of the hazards and impacts of existing environmental pollution.
4.4 Risk control
Control or management of any hazards that can result in injury, illness, equipment
damage and cessation of operations through a hierarchy of risk control.

DEPARTMEN EPC

4.5 Risk THAT IS ACCEPTABLE

In determining / assessing the risk score at HIRARC, there is an acceptable
risk of harm but provided additional controls are in place.
5. PROCESS FLOW
PROCESS DESCRIPTION OF INFORMATION

FLOW ACTIVITIES
- HIRARC Form
1. The QHSE Manager along - Prior to carrying out
with the work area hazard identification
Supervisor and HSE Staff for a New Plant an
identify potential hazards initial review is
and environmental required.
aspects that exist.
2. The identified hazards and
environmental aspects are
then carried out an
assessment of the existing
risk levels.
3. If the risk level is within
safe limits, there is no
need for control
4. If the risk level exceeds
the safe limit, then control
measures are given to
reduce the risk of harm.
5. The identification and
control that has been
made is disseminated to
employees and workers.
a. Implement control
measures for potential
hazard and
environmental aspects
that have high risk
6. Make changes or
additions to the
identification and control
of every new work or work
equipment.
7. Review identification and
controls annually to
assess their effectiveness
and suitability.

DEPARTMEN EPC

6. ATTACHMENT
6.1 HIRARC Work Instructions: IK 017 HSE 002 – 01
6.2 HIRARC Form (Head Office): FM 017 HSE 002 - 01/01
6.3 HIRARC Form (Factory): FM 017 HSE 002 - 01/02

DEPARTMEN EPC

OWNER: PT FREEPORT INDONESIA
PROJECT NO.:


DEPARTMEN EPC

1. DESTINATION
To determine plans and programs along with detailed budget for the PT Adhi
Persada Beton Safety, Health and Environment (K3L) program.
2. SCOPE
This procedure applies to the QHSE section of the company covered by the PT
Adhi Persada Beton Safety, Health and Environmental Management System
(SMK3L).
3. REFERENCE
3.2 Occupational Health and Safety Management System (SMK3) PP
No. 50/2012, sub-element 2.1 on the OSH Strategic Plan.
3.3 Safety, Occupational Health and Environment Manual (MK3L): M 017 K3L
001.
3.4 ISO 14001: 2015 standard, clause 6.2 on Environmental Goals and Planning
to Achieve Them.
3.5 ISO 45001: 2018 standard, clause 6.2 concerning OHS Goals and Planning
to Achieve Them.
4. DEFINITION
4.1 Planning
The process that defines the goals of the company by creating strategies to
be used to achieve these goals, as well as developing a company activity
plan.
4.2 K3L program
K3L Activity Agenda that has been compiled and will be implemented at a
predetermined period of time.
4.3 K3L budget
The budget that has been prepared is based on the K3L program planning
to support the K3L program.

DEPARTMEN EPC

5. PROCESS FLOW
PROCESS FLOW DESCRIPTION OF ACTIVITIES INFORMATION

1. The QHSE Manager - HIRARC Form
identifies the required HSE
- HSE Plan
Program requirements base
Form
on the Hazard Identification
- K3L Budget
and Control analysis.
Plan Form
2. The QHSE Manager
prepares a year-long K3L - If there are
Program. changes,
3. The QHSE Manager revisions can
prepares the K3L Program be made
Budget Plan
4. The QHSE Manager submits
the K3L Program and
Budget Plan to the Directors
at the head office level and
the Factory Heads at the
factory level for approval.
5. The QHSE section runs the
K3L Program that has been
prepared.

DEPARTMEN EPC

6. ATTACHMENT
6.1 HSE Program Work Instruction: IK 017 HSE 003 - 01
6.2 HSE Plan Form (Head Office): FM 017 HSE 003 - 01/01
6.3 HSE Plan Form (Factory): FM 017 HSE 003 - 01/02
6.4 HSE Budget Plan Form (Head Office): FM 017 HSE 003 - 01/03
6.5 K3L Budget Plan Form (Factory): FM 017 HSE 003 - 01/04

DEPARTMEN EPC

CYD Comment On MSP-T-AK-CII-004 SHES Plan and HSE Control Procedure PDF

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PT. ADHI KARYA (Persero) Tbk.

Jl. Raya Pasar Minggu KM. 18 Jakarta 12510, INDONESIA

From : Mr. Hari Darmojo

Subject : SHES Plan and HSE Control Procedure

Print X Original Photocopy

For : Review X Information Copies

Document Status : Preliminary Final Revision

No. of Copy Document No. Revision No. Title

1 MSP-HSE-PRC-001 00 Project Specific SHES Plan

1 MSP-HSE-PRC-002 00 QHSE POLICY

1 MSP-HSE-PRC-003 00 Risk Assesment and Environment

1 MSP-HSE-PRC-004 00 HSE Plan Procedure

Received by Hari Darmojo

PROJECT TITLE : MANYAR SMELTER PROJECT

LOCATION : GRESIK, INDONESIA

OWNER : PT FREEPORT INDONESIA

CONTRACTOR : PT CHIYODA INTERNATIONAL INDONESIA

SUBCONTRACTOR : PT ADHI KARYA (PERSERO) TBK.

0 FOR APPROVAL 26/12/2020

REV DESCRIPTION DATE PREPARED CHECKED APPROVED

Functionally this HSE Plan; Outline the expectation of Occupational

The primary purpose of HSE Plan is to provide a guideline for preventing

Sub-Contractors shall abide by all safety rules and other regulations

Contractor is also committed to comply with all requirements stipulated

e Project Site : CONTRACTOR’s Project Site of Indonesia

The Construction Manager’s major roles and responsibility are to:

Chiyoda requirements and compliance such as HSE rules and

procedures and routine HSE programs including Chiyoda HSE

engineering matters and ensure that effective liaison and

out effectively, safely and in a security sound manner. The discipline

7. FIELD BUSINESS / GENERAL AFFAIR

HSE organization chart and HSE Committee is shown in appendix-01.

On such conditions Chiyoda HSE policies, programs and practices, shall

Subcontractor and Purchase Control

Contractor Project HSE Plan and Regulations include Chiyoda

Control of Subcontractors’ HSE performance will be as follows:

8.2. Implementation of HSEMS

Contractor employees shall be responsible for ensuring that HSE safety

Contractor is committed to comply with all requirements for HSE activities

1. HSE Policy, Objectives and Targets

The Contractor Project Managements will establish the site HSE

message for any kind of Site Construction Meeting, HSE

4. Measurement and Evaluation

5. Review and Improvement

8.3. HSE Awareness

The Safety Committee goal is that Contractor start top management up

This Committee should conduct safety committee meeting at least once

8.3.2. HSE Meeting

Daily Toolbox Meeting

Site Safety Meeting

Enforcement of Contractor safety management shall be adhered to

Attendance list and minutes of meeting should be recorded by Contractor

Each Field Manager/Superintendent/Supervisor of both Contractor ad

8.3.3. HSE Induction.

The orientation-induction program will include, but not limited to:

8.3.4. Alcohol and Drugs

Sub-Contractor’s personnel and those of its Lower Tier Sub-Contractor’s

Contractor reserves the right to require substance abuse testing of all

The possession or use of mood-altering drugs, both stimulants and

Drug tests will be used to investigate accidents, Employees who report

8.3.5. Poster & Signboards (Sign & Tags)

These signboard and poster shall be displayed at the strategic location,

8.3.6. HSE Inspection