LAPORAN PENILAIAN HSE

Page 1

INSTRUCTIONS:
1
Nilai setiap item baris kategori dari 3 TINGGI hingga 1 RENDAH. Kurangi 1 poin untuk setiap kekurangan / pelanggaran. Nol (0) poin untuk Kurang atau Tidak Berlaku
2 List your scoring observations on Form No. HSE/FRM-26A.

PROJECT NAME : PROJECT NO.: AREA NAME :

SR. POINTS
WORK PRACTICES SCORE % CONDUCTED BY DATE / TIME REMARKS
NO. AWARDED
1 HOUSE KEEPING

a Work areas clean & organized. Area free of protruding nails, walkways unobstructed,
trash bins available & maintained, dust control, oil containment in place. 3
Material storage areas organized, safe access provided with physical barriades, entry/exit
b
identified, faded warning tape replaced. 3
Area free of tripping hazards, cords, hoses routed away from walkways or elevated 2m &
c
flagged for visibility. 3
d Rebar ends protected with caps 3
Adequate number of portable toilets available (1:20) and maintained in a clean and
e
sanitary condition including paper towel 3
f Safety signage posted in appropriate locations & containers labeled 3
Water coolers filled, lids sealed & dated, placed in shaded stands, supply with disposable
g
drinking cups and trash container. 3
POSSIBLE POINTS AWARDED 21
2 PERSONAL PROTECTIVE EQUIPMENT
Approved hard hats, safety glasses, hearing protection, face shields, safety foot wear. All
a
maintained and worn properly. 3
b Clear safety glasses worn inside buildings and poorly illuminated work area 3
Face shield worn during welding, burning, grinding, chipping, chemical handling drilling,
c
concrete pouring. 3
d
Proper foot protection worn for job performed (steel toed rubber boots for concrete) 3
e Other; respirators, gloves, chemical resistant garments. 3
POSSIBLE POINTS AWARDED 15
3 FALL PROTECTION
Personal working at 2 m & above grade trained in "working at heights" and using fall
a
protection properly. 3
b Lanyards are adequately secured to suitable anchorage 3
c
Perimeter guarding installed on elevated surfaces greater than 500mm above grade 3
d
1/2 inch wire rope (or equivalent) safety lines installed and capable of supporting 12000 lb 3
All tools, materials & equipment properly secured against falling. Canvas bags and/or
e
safety nets used. 3
Safety signs (KEEP OUT MEN WORKING ABOVE) or Barricades erected below elevated
f
work. 3
POSSIBLE POINTS AWARDED 18
 HSE ASSESSMENT REPORT
Page 2 27/07/2005

INSTRUCTIONS:
1 Rate each category line item from 3 HIGH to 1 LOW. Subtract 1 point for each deficiency/violation. Zero (0) points for Lacking or N/A Not Applicable.

2 List your scoring observations on Form No. HSE/FRM-26A.

PROJECT NAME : PROJECT NO.: AREA NAME :

SR. POINTS
WORK PRACTICES SCORE % CONDUCTED BY DATE / TIME REMARKS
NO. AWARDED

4 EXCAVATIONS
a Solid physical barricade around excavation, safe access and egress provided . 3
b Excavations 1.2 M or greater shored sloped or benched. 3
c Cross over bridges equipped with handrails, planked and cleated 3
POSSIBLE POINTS AWARDED 9
5 SCAFFOLDS AND LADDERS
a
Personnel engaged in scaffold work trained in Scaffold Erection and Fall Protection. 3
Safe access & egress provided, ladder extends 1m above landing, drop bar installed,
b rigid and stable footing, planks crack free and secured and used only to support workers
not as a pipe support or other uses. 3
c All guard rails installed - top rail, mid rail and toe boards installed as required. 3
Mobile scaffold set on level and stable surfaces, caster wheel locked & chocked. No
d
personal on board when moving or relocating. 3
e
Scaffolds 12m and above approved & inspected by a competent Scaffold Engineer. 3
f
Smoke generating equipment removed from working radius of scaffolding structures. 3
Ladder is properly secured, inspected and color coded. Set at 75 degrees, 1m past
g
landing and equipped with non-slip feet. 3
Metal ladder not used around electrical services. Job made ladders only for Below Grade
h
Work. Ladders not painted. 3
Ladders stored on racks and not left unsecured in the standing position. No materials
I
stored on ladders. 3
Two persons not allowed to ork on the same ladder unless specifically designed for that
j
purpose. 3
POSSIBLE POINTS AWARDED 30
6 HOISTING AND LIFTING EQUIPMENT

a Chainfalls, come alongs, synthetic chokers & wire rope slings in good condition with
current inspection. All hooks equipped with a functional safety latch. 3
Crane bears Prime Contractor inspection sticker, using outriggger mats and softeners
b
used as required. 3
Certified riggers equipped with an Orange Hi-visibility vest and using whistle when
c
required. 3
d Approved lift plan developed and available, and proper rigging techniques used. 3
 HSE ASSESSMENT REPORT
Page 3 27/07/2005

INSTRUCTIONS:
1 Rate each category line item from 3 HIGH to 1 LOW. Subtract 1 point for each deficiency/violation. Zero (0) points for Lacking or N/A Not Applicable.

2 List your scoring observations on Form No. HSE/FRM-26A.

PROJECT NAME : PROJECT NO.: AREA NAME :

SR. POINTS
WORK PRACTICES SCORE % CONDUCTED BY DATE / TIME REMARKS
NO. AWARDED
e Crane is safely positioned when working near excavations or power lines. 3
POSSIBLE POINTS AWARDED 15

7 VEHICLES AND MOBILE EQUIPMENT

a Lights, brakes, horns, back-up alarms working properly. 3
b Seat belts provided and used 3
c Daily equipment inspection checklist completed by Operator. 3
d Equipment used properly and as per the purpose it was designed. 3
e Licenses or certifications as required. 3
f
Other - flagman/equipment spotter available and searing GREEN Hi-visibility vest 3
POSSIBLE POINTS AWARDED 18
8 TOOLS AND EQUIPMENT
Electrical cords in good condition (no taped splices) & color coded, Elevated 2m high,
a
flagged for visibility, routed away from walkways & water. 3
b
Tools are maintained in a safe condition, inspected and color coded for the month 3
Power hand tools equipped with a DEAD MAN switch. Electrical power tools are double
c
insulated, connected to a GFCI or grounded. 3

d All protective safety guards and torque handles secured and used. Tools properly carried,
stored and maintained. The right tool is being used and used correctly for the task. 3

e Couplings of pneumatic or hydraulic hose connections properly secured. Pneumatic

hoses fitted with whipcheck arrestors or secured with a safety wire. 3
Stationary fuel driven equipment (Generators and Compressor etc.) bears the Prime
f Contractors Inspection Sticker. Hearing protection safety signs posted near high intensity
noise generating equipment. 3
g When required all material is secured and work benches utilized. 3
h
Proper adjustment on work rest and wheels properly dressed on bench grinders. 3
POSSIBLE POINTS AWARDED 24
9 FIRE PROTECTION & COMPRESSED GAS CYLINDERS
a Flammables & combustible materials stacked & stored properly 3
b Fire extinguishers inspected and located 15 meters from source. 3
c
Safely can fuel containers are equipped with self closing lids and clearly labeled 3
 HSE ASSESSMENT REPORT
Page 4

INSTRUCTIONS:
1 Rate each category line item from 3 HIGH to 1 LOW. Subtract 1 point for each deficiency/violation. Zero (0) points for Lacking or N/A Not Applicable.

2 List your scoring observations on Form No. HSE/FRM-26A.

PROJECT NAME : PROJECT NO.: AREA NAME :

SR. POINTS
WORK PRACTICES SCORE % CONDUCTED BY DATE / TIME REMARKS
NO. AWARDED
Transferring flammable liquids between containers or refueling done with electrical bond
d
apparatus 3
All storage drums maintained with lids closed, equipped with proper content/hazard lables
e
and grounded. 3
Minimum 5m distance separating Oxygen and Fuel Gasses. All cyl's upright, with caps on
f
& secured. 3
Flash Back Arrestors instaled at the Regulator (gauge) and check valves at the torch for
g
cutting torches. 3
h
Proper use of fire blankets, spark containment & welding screens where required. 3
i Regulator gauges properly attached and maintained. 3
POSSIBLE POINTS AWARDED 27
10 PLANNING FOR SAFETY & SAFE WORK PERMITS
a Daily equipment inspection checklist completed by Operator. 3
b Pre-talk-safety reviews (Toolbox Talks) available for review. 3
Evidence of safety plan being followed e.g., tie off, barricading, shoring/sloping, signage
c
etc. 3
POSSIBLE POINTS AWARDED 9
11 SAFETY RECOGNITION & AWARENESS PROMOTION
a Contractor supervisor of the month signboard posted in contractors area(s). 3
b Safety educational posters, employee slogans and suggestions posted. 3
c Contractor JSA of the month winners posted on contractors main signboard. 3
POSSIBLE POINTS AWARDED 9

POINT SCORED 195 0

DEMERIT SCORING
1 Nearmiss -4
2 Reportable Incident (fire, property damage, process upset etc.) -6
3 Recordable Incident (dedical aid or restricted work case) -9
4 Lost Time Accident -12
GRAND TOTAL

AREA ENGINEER / SUPERVISOR INCHARGE SITE HSE P.M. / S.M.