ADITYA DWI C QHSE 081316645066 1 1

ANDI AGUNG P PM
NOPAN SM 08176361956 1 1
ADIETIYA RANGGA SITE ENG 1 1
TRIAS EDI K SITE ENG 1 1
BENI ANDRIANA DRAFTER 1 1
HENDRI E DRAFTER 1 1
HIRHAM S STAFF GUDANG 1 1
RANDHY AZHARA ADMIN T3 1 1
PARMONO FOREMAN 1 1
SUPRIADI SKILL 1 1
YANUAR SUPRIANTO SKILL 1 1
RACHMAD DWI RIDHO SKILL 1 1
PERMADI IRAWAN SKILL 1 1
CAHYONO HELPER 1 1
ARDY AGUS W HELPER 1 1
RIO BAGUS GUMELAR HELPER 1 1
MARYONO HELPER 1 1
 26/04/21 09:35
Owner : Member : PROBLEM

October-2013 Monitoring Take 5 Berdasarkan Department

Argincourt Resources Safety NKE

Take 5 Per Department

Man Power Actual

Cause
78

58

Corective Action
no Activity PIC D/L

35 35 34

10

4 3 4 4
2 1 0 0
ACTIVITY PLAN
BP 1 Crusher HSE PRO ENG WORK GAF
NO ACTIVITY RESULT

MONTH BP 1 Crusher HSE PRO ENG WORK GAF

Man Power 4 4 35 78 35 34 58
Actual 3 2 4 10 1 0 0
% 75% 50% 11% 13% 3% 0% 0%
 26/04/21 09:35
Owner : Member : PROBLEM

October-2013 Monitoring Take 5 Berdasarkan Department

Argincourt Resources Safety NKE

Take 5 Per Department

Plan Actual

Cause

117

87

72 Corective Action
no Activity PIC D/L

53 53
51

19
14

6 5 6
2
0 0
ACTIVITY PLAN
BP 1 Crusher HSE PRO ENG WORK GAF
NO ACTIVITY RESULT

MONTH BP 1 Crusher HSE PRO ENG WORK GAF

Plan 6 6 53 117 53 51 87
Actual 5 14 19 72 2 0 0
% 83% 233% 36% 62% 4% 0% 0%
 26/04/21 09:35
Owner : Member : PROBLEM

October-2013 Monitoring Take 5 Berdasarkan Department

Argincourt Resources Safety NKE

Take Berdasarkan Checklist

Plan Actual

15

Cause

12 12

Corective Action
no Activity PIC D/L

1 1

0 0 0 0 0 0 0 0 0 0 0 0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 ACTIVITY PLAN
NO ACTIVITY RESULT

Kondition Checklist
Plan
Actual 12 1 0 5 0 0 0 0 0 15 12 1 0 0 0 0 0 0 0

PLAN 1.5
 MONTHLY REPORT HSE
PT CIGADING HABEAM CENTRE
THAMRIN NINE PHASE 0NE

FEBRUARI
2021
 THAMRIN NINE PROJECT PHASE ONE
HSE MONTHLY REPORT
Apr-21
I Catatan Jumlah Pekerja & Jam Kerja (Manpower & Manhours)
JAM KERJA RILL Jam Hilang
Jumlah Jam Kerja
No. Man power Jumlah Jam Lembur Cuti Ijin Alfa Sakit Total
W.1 W.2 W.3 W.4
1 Staff 14 952 952 952 952 0 0 0 0 0 0
2 Pekerja 18 1224 1224 1224 1224 0 0 0 0 0 0
TOTAL 32 8704 0 0 0 0 0 0

II Kejadian Kecelakaan Kerja

No Kejadian Kecelakaan Kerja Bulan Lalu Bulan Ini ∑ Bulan Ini

1 Fatality 0 0 0
2 Loss Time Injury 0 0 0
3 Property Damage 0 0 0
3 Medical Treatment 0 0 0
4 First Aid 0 0 0
5 Near Miss 0 0 0

III Hazard Report

No Penyebab langsung Kecelakaan Bulan Lalu Bulan Ini ∑ Bulan Ini
1 Tindakan Tidak Aman 0 0 0
2 Kondisi Tidak Aman 0 0 0
0 0 0
IV Kegiatan K3
No Kegiatan K3 Bulan Lalu Bulan Ini ∑ Bulan Ini
1 TBM 31 28 59
2 Inspection Protokol Kesehatan 31 28 59
3 Inspection Equipment 2 4 6
4 Surat Ijin Kerja 31 28 59
5 JSA 31 28 59
242
V APD
No Nama Barang Stock Awal Out Stock Stock Akhir
1 Helmet 20 0 20
2 Ear Plug 15 0 15
3 Full Body Harnes 50 23 27
4 Face Shield 16 3 13
5 Sarung Tangan Welding 8 4 4
6 Apron Welding 12 4 8
7 Sarung Tangan Fitter 8 4 4
8 Sarung Tangan Cotton/Polkadot 25 12 13

VI EQUIPMENT SUPPORT
No Nama Barang Stock Awal Out Stock Stock Akhir
1 APAR 3.5 KG 4 0 4
2 APAR 6 KG 12 3 9

Disiapkan Oleh : Disetujui Oleh :

HSE OFFICER SITE MANAGER

 PROJECT SAFETY STATISTIC
PT.CIGADING HABEAM CENTRE
Period : April 2021
This Month
No Description Cummulative to Previous Month Total
( APRIL )
Total Continuous Hours in Safety
1 NO LTI PT CIGADING HABEAM - - -
CENTRE

FAT : 0

LTI : 0

MTC: 0

FAC: 0

PDA: 0

NMI : 0

HZD 0

TOTAL : 156,699 MANHOURS

Fat : Fatality FAFAC : First Aid Case

LTI : Lost Time Injury PD : PROPERTY DAMAGE

MTC : Medical Treatment Case NM : NEAR MISS

HZD : Hazard
 INSPECTION RECORD
Period April 2021

TYPE OF
NO. REQUEST DATE DESCRIPTION unit
INSPECTION
1 7-Feb-21 Inspeksi Equipment Gerinda 4
2 7-Feb-21 Inspeksi Equipment Travo las 3
3 14-Feb-21 Inspeksi Equipment Lifting gear (shackle) 2 pasang
4 14-Feb-21 Inspeksi Equipment Lifting gear (Webbing) 1 pasang 6T, 1 pasang 3 T
5 21-Feb-21 Inspeksi Equipment Jet Broach 2
6 28-Feb-21 Inspeksi fire fighting equipment APAR 4
 CHECKLIST ALAT KERJA PT. CIGADING HABEAM CENTRE PHASE ONE
NO NAMA ALAT KONDISI JUMLAH DOKUMENTASI REMARKS

5 Full Body Harness BAIK 23 SAFETY

6 APAR BAIK 4 SAFETY

7 Travo las BAIK 3 SAFETY

Dibuat, Disetujui,

HSE OFFICER SITE MANAGER

 PRE START MEETING
( Period Januari 2018 )

CONDUCTED BY
TOTAL
NO Date TOPIC LOCATION REMARKS
ATTENDANCES
NAME POSITION

1 1-Jan-18
2 2-Jan-18
3 3-Jan-18
4 4-Jan-18
5 5-Jan-18
6 6-Jan-18
7 7-Jan-18
8 8-Jan-18
9 9-Jan-18
10 10-Jan-18
11 11-Jan-18
12 12-Jan-18
13 13-Jan-18
14 14-Jan-18
15 15-Jan-18
16 16-Jan-18
17 17-Jan-18
18 18-Jan-18
19 19-Jan-18
20 20-Jan-18
21 21-Jan-18
22 22-Jan-18
23 23-Jan-18
24 24-Jan-18
25 25-Jan-18
26 26-Jan-18
27 27-Jan-18
28 28-Jan-18
29 29-Jan-18
30 30-Jan-18
31 31-Jan-18

1 22 Jan 2018 - 26 Jan 2018 Penyebab langsung kecelakaan kerja Aditya DC HSE OFFICER Utility 28
2 29 Jan 2018 - 2 Feb 2018 Siapa saya ? "kesembronoan" Aditya DC HSE OFFICER Utility 44

Checked by,

Ibrahim Rendra

HSE ENGINEER GMF

Area : Thamrin Nine Phase One

Month : April 2021

UNSAFE CONDITIONS

Februari 2021
No Simbol UNSAFE CONDS
W1 W2 W3 W4 Total

Peralatan pengaman tidak memadai

1 0 0 0 0 0
Inadequate guarding or safety device

Peralatan / material yang rusak

2 0 1 0 0 1
Defective eqpt or materials

Prosedur tidak aman / tidak ada

3 0 0 0 0 0
Unsafe Work Procedure (or none)

Kebersihan area yang buruk

4 0 2 0 0 2
Poor Housekeeping

Pencahayaan / ventilasi area kerja yang

5 buruk 0 0 0 0 0
Poor lighting or ventilation

Lantai basah / miring / berlubang

6 0 0 0 0 0
Perforated / sloping / Wet Floor

Area Kerja Terbatas / Sempit

7 0 0 0 0 0
Incapacius / Restricted Working Area

Cuaca Buruk (hujan, angin, terik,petir)

8 0 0 0 0 0
Bad Weather

Total 0 3 0 0 3
Area : Thamrin Nine Phase One

Month : April 2021

UNSAFE ACTIONS

Februari
No Simbol UNSAFE ACTS
W1 W2 W3 W4 Total

Pengoperasian mesin tanpa

1 kewenangan 0 0 0 0 0
Operating equipment without authority

Menggunakan Peralatan Rusak

2 0 0 0 0 0
Using defective equipment

Menggunakan Peralatan Kerja dengan

3 tidak aman 0 0 0 0 0
Using Equipment Unsafely

Melepas Pengaman Mesin

4 0 0 0 0 0
Disconnecting safety devices

Penempatan Barang/Material dengan

5 tidak aman 0 0 0 0 0
Unsafe placement of Materials or Eqpt

Berperilaku Kasar
6 0 0 0 0 0
Horseplay

Mengambil Jalan Pintas

7 0 0 0 0 0
Taking shortcuts

Tidak Memakai APD

8 0 0 0 0 0
Not wearing PPE

Total 0 0 0 0 0
 Kegiatan phase one Kegiatan phase one

TBM TBM Unsafe Condt (Junction box rusak) Pemasangan Anchor

Erection Jackating lt. 70 Loading unloading material Area Kerja berantakan Area kerja rapih

Assembling struktur baja lt.7A Assembling struktur baja lt.7A tightening & Bolting Inspeksi Alat