Policy/Plan/Program: ID-G-BU-00000-00362 Rev.5 Contractor Health, Safety & Environmental Management System (C-HSE MS) XXX Page 1 of 75

Policy/Plan/Program: ID-G-BU-00000-00362 Rev.
5
Contractor Health, Safety & Environmental Management System (C-HSE MS)
XXX Page 1 of 75
Contractor HSE Plan
Contractor’s Name : PT. XXXX –

Contract Number : 15612286
Engineering Service for Instrumentation and Automation
Contract Title :
System
Contract Period : June 2011 – June 2014
Job Location : Offshore and Onshore
Risk Level : Medium
CONTENTS OF HSE PLAN
CONTENTS 2
Policy/Plan/Program: ID-G-BU-00000-00362 Rev.5
XXX Page 2 of 75
1 PURPOSE......................................................................................................................................... 4
2 APPLICATION.................................................................................................................................. 4
3 DEFINITION........................................................................................................................................ 4
4 RESPONSIBILITY............................................................................................................................... 8
5 PROGRAMS........................................................................................................................................ 8
5.1. LEADERSHIP AND COMMITMENT................................................................................................... 8
6 POLICY AND STRATEGIC OBJECTIVE........................................................................................... 9
6.1. HSE POLICY STATEMENT................................................................................................................ 9
6.2. STRATEGIC OBJECTIVES................................................................................................................10
7 ORGANIZATION, RESPONSIBILITIES, RESOURCES, STANDARDS AND DOCUMENTATION 11
7.1. ORGANIZATION............................................................................................................................... 11
7.2. SUBCONTRACTOR 14
7.3. HSE COMMUNICATION AND MEETING PROGRAM 16
7.4. HSE PROMOTION AND AWARENESS PROGRAM 20
7.5. HSE TRAINING, COMPETENCY AND MINIMUM REQUIREMENT FOR ENTRY TO COPI FACILITIES
23
7.6. HSE LEGISLATIONS AND STANDARDS 26
8 EVALUATION AND RISK MANAGEMENT 30
8.1. METHODE AND PROCEDURE FOR HAZARDS AND EFFECTS MANAGEMENT 30
8.1.1. HAZARD IDENTIFICATION 31
8.1.2. RISK ASSESSMENT 31
8.1.3. DETERMINING RISK CONTROL 32
8.2. PPE REQUIREMENT 35
8.2.1. MINIMUM PPE STANDARD 41
8.2.2. SPECIFICATION PPE STANDARD 42
8.2.3. DURATION USE OF PPE 42
9 PLANNING AND PROCEDURE 44
9.1. HSE PROCEDURES 44
9.1.1. XXXX HSEMS MASTER LIST 44
9.1.2. COMPANY HSE STANDARD AND PROCEDURE 45
9.2. EMERGENCY RESPONSE PROCEDURE 46
9.2.1. ORGANIZATION RESPONSIBILITIES 46
9.2.2. INSTRUCTION FOR EVACUATION 49
9.2.3. RESPOND CHART OF EMERGENCY CASE 50
9.2.4. EMERGENCY TELEPHONE NUMBER 51
9.3. EQUIPMENT CONTROL, MAINTENANCE AND INSPECTION 51
9.4. OCCUPATIONAL HEALTH AND MEDICAL FACILITIES 52
9.5. ENVIRONMENTAL PROGRAM 57
9.5.1. SPILL CONTINGENCY PLAN 57
9.5.2. MITIGATION PLAN 57
9.5.3. MONITORING PROGRAM 58
XXX Page 3 of 75
9.5.4. IMPROVEMENT PLAN 59

9.5.5. PRE-IDENTIFIED WASTES AND DISPOSAL SYSTEM 59
9.6. TRANSPORTATION (LAND, SEA, OR AIR TRANSPORTATION) 60
10 IMPLEMENTATION AND PERFORMANCE MONITORING 60
10.1. HSE PERFORMANCE MONITORING 60
10.2. INCIDENT REPORT AND INVESTIGATION 66
10.2.1. INCIDENT REPORT 66
10.2.2. INCIDENT INVESTIGATION 67
10.2.2.1. PROCEDURE OF INCIDENT INVESTIGATION 67
11 HSE INSPECTION, AUDIT AND REVIEW 70
11.1. HSE INSPECTION 70
11.2. HSE AUDIT 72
11.3. HSE MANAGEMENT REVIEW 800
1 PURPOSE
These XXXX Health, Safety and Environment (HSE) Management System framework
summary prepare to describe how XXXX HSE activities and consistently deliver HSE
XXX Page 4 of 75
performance improvement in the office area and client premises area to be implemented by all
business lines.
Indeed these health, safety environment management system framework is a summary of the
rules and regulations that requires to follow in their program of incident prevention. They are
not intended to be an all-inclusive set of rules, but are indicative of the level of care and
attention to HSE that all personnel shall follow when working for the COMPANY.
The work shall not proceed until the proper precautions have been taken to protect the safety
and health of all workers involved. Incidents and injuries are not a necessary part of any job
and can be prevented by following the appropriate safe work practices.
2 APPLICATION
This HSE plan applies to XXXX employees and subcontractors that working under / within
XXXX premises at Project of Engineering Services For Instrumentation and Automation
System.
XXXX specified in Engineering Service for Instrumentation and Automation System is
managed by the Director who supported by Engineers, Accountant and QA & HSE Manager
who has functional responsibility for departmental employees. As shown, the line
responsibility and accountability for HSE lies with the Director for showing the commitment of
Company.
3 DEFINITION
For the purpose of the implementation of this HSEMS, the terms and definitions apply based
on XXXX standard and specification as follows:
Acceptable risk:
Risk that has been reduced to a level that can be tolerated by the organization having regard
to its legal obligations and HSE policy of XXXX.
Audit:
Systematic, independent and documented process for obtaining "audit evidence" and
evaluating it objectively to determine the extent to which "audit criteria" are fulfilled
[ISO9000:2005] NOTE 1 Independent does not necessarily mean external to the organization.
In many cases, particularly in smaller organizations, independence can be demonstrated by
the freedom from responsibility for the activity being audited.
Continual improvement:
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Recurring process of enhancing the HSE Management System in order to achieve

improvements in overall HSE Performance consistent with the XXXX HSE policy
NOTE 1 The process need not take place in all areas of activity simultaneously.
NOTE 2 Adapted from ISO 14001:2004.
CONTRACTOR:
CONTRACTOR will be interpreted as XXXX
COMPANY:
COMPANY will be interpreted as XXX
Corrective action:
Action to eliminate the cause of a detected nonconformity or other undesirable situation.
NOTE 1 There can be more than one cause for a nonconformity.
NOTE 2 Corrective action is taken to prevent recurrence whereas preventive action is taken to
prevent occurrence.
Document:
Information and its supporting medium NOTE. The medium note can be paper, magnetic,
electronic or optical computer disc, photograph or master sample, or a combination thereof.
Hazard:
Source, situation, or act with a potential for harm in terms of human injury or ill health, or a
combination of these
Hazard identification:
Process of recognizing that a hazard exists and defining its characteristics
Ill health / Occupational Illness:

Identifiable, adverse physical or mental condition arising from and/or made worse by a work
activity and/or work-related situation
Incident:
Work-related event(s) in which an injury or ill health (regardless of severity) or fatality
occurred, or could have occurred
NOTE 1 : An accident is an incident which has given rise to injury, ill health or fatality.
NOTE 2 : An incident where no injury, ill health, or fatality occurs may also be referred to as a
“near-miss”, "near-hit", "close call" or "dangerous occurrence".
XXX Page 6 of 75
NOTE 3 : An emergency situation is a particular type of incident.
Interested party:
Person or group, inside or outside the workplace, concerned with or affected by the XXXX’s
HSE Performance
Nonconformity:
Non-fulfillment of a requirement [ISO 9000:2005 ; ISO 14001]
NOTE : A nonconformity can be any deviation from:
 relevant work standards, practices, procedures, legal requirements,
etc.
 HSE Management System requirements.
Health, Safety and Environment (HSE):

Conditions and factors that affect, or could affect, the health, safety and environment of
employees or other workers (including temporary workers and contractor personnel), visitors,
or any other person in the workplace
NOTE XXXX can be subject to legal requirements for the health, safety and environment of
persons beyond the immediate workplace, or who are exposed to the workplace activities
HSE Management System:

Part of an organization's management system used to develop and implement its HSE Policy
and manage its HSE risks
NOTE 1 A management system is a set of interrelated elements used to establish policy and
objectives and to achieve those objectives.
NOTE 2 A management system includes organizational structure, planning activities
(including for example, risk assessment and the setting of objectives), responsibilities,
practices, procedures, processes and resources.
NOTE 3 Adapted from ISO 14001:2004
HSE Objective:
HSE goal, in terms of HSE Performance, that an organization sets itself to achieve
NOTE 1 Objectives should be quantified wherever practicable.
NOTE 2 requires that HSE objectives are consistent with the HSE Policy
HSE Performance:
Measurable results of an organization's management of its HSE risks
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NOTE 1 OH&S performance measurement includes measuring the effectiveness of the

organization's controls
NOTE 2 In the context of HSE Management Systems, results can also be measured against
the organization's HSE Policy, HSE Objectives, and other HSE Performance requirements.
HSE Policy:
Overall intentions and direction of an organization related to its HSE Performance as formally
expressed by top management NOTE 1 The HSE Policy provides a framework for action and
for the setting of HSE Objectives NOTE 2 Adapted from ISO 14001:2004.
Organization:
Company, corporation, firm, enterprise, authority or institution, or part or combination thereof,
whether incorporated or not, public or private, that has its own functions and administration
NOTE For organizations with more than one operating unit, a single operating unit may be
defined as an organization.
[ISO14001:2004]
Preventive Action:
Action to eliminate the cause of a potential nonconformity or other undesirable potential
situation.
NOTE 1 There can be more than one cause for a potential nonconformity.
NOTE 2 Preventive action is taken to prevent occurrence whereas corrective action is taken
to prevent recurrence.
[ISO 9000:2005]
Procedure:
Specified way to carry out an activity or a process
NOTE Procedures can be documented or not.
[ISO 9000:2005]
Record:
Document stating results achieved or providing evidence of activities performed
[ISO 14001:2004]
Risk:
Combination of the likelihood of an occurrence of a hazardous event or exposure(s) and the
severity of injury or ill health that can be caused by the event or exposure(s).
XXX Page 8 of 75
Risk assessment:
Process of evaluating the risk(s) arising from a hazard(s), taking into account the adequacy of
any existing controls, and deciding whether or not the risk(s) is acceptable
Workplace:
Any physical location in which work related activities are performed under the control of the
organization NOTE When giving consideration to what constitutes a workplace, the
organization should take into account the HSE effects on personnel who are, for example,
traveling or in transit (e.g. driving, flying, on boats or trains), working at the premises of a
client or customer, or working at home
4 RESPONSIBILITY
The Director is ultimately responsible for the HSE of the company and to ensure it is properly
implemented and performs to requirements within the offices and facilities.
The Lead of departments are responsible for the operation of HSE within their departments.
Job Description shall be provided to all personnel outlining their responsibilities and duties.
5 PROGRAMS
5.1. LEADERSHIP AND COMMITMENT
PT. XXXX’s senior management demonstrates Management’s commitment to an HSE
culture, but not limited to :
- Personally sign the HSE Policy, HSE Manual, HSE Procedure and
annual HSE objective, target and program
- HSE Work Instruction and perform HSE management tours to work site.
- Project Managers are responsible to ensure all of HSE Plan implemented well, HSE
projects
- documents and reports and monitor the HSE performance for SR and FR at the
project level
- HSE figures are reported monthly at head office via the corporate accounting system
- Company implements HSE improvements programs and socialization to company
employees
- Top management will involve in supervision of Engineering Services For
Instrumentation and Automation System project by conducting site HSE tour/visit to
the project
- Top management involve in every Safety Campaign at site
PT. XXXX will provide adequate resources to comply with COMPANY HSE minimum
requirement which applicable to our activities
XXX Page 9 of 75
6 POLICY AND STRATEGIC OBJECTIVE

6.1. HSE POLICY STATEMENT
PT. XXXX is established since 2003 in Indonesia as a Contractor in Automation Control
System Integration, Telecommunication Integration, Instrumentation and Electrical Turn Key
Solution and being a subsidiary of Vinci Energies International Group.
PT. XXXX is recognizing that the effective management of health, safety and environmental
(HSE) matters is fundamental to the welfare of our employees and the long-term prosperity of
the company. PT. XXXX must therefore so far as it is reasonably practicable, put the
protection of HSE of its own employees, visitors, subcontractors and the public.
In order to support this policy, PT. XXXX will:

 Develop, implement and maintain the PT. XXXX HSE Management System;
 Adopt suitable standards for selection and assessment of employees and contractors to
ensure that they are capable, competent and have a positive attitude towards HSE;
 Promote a strong HSE culture, workforce empowerment and individual HSE responsibility
via the visible commitment of senior management and the active participation of all
employees;
 Prevent, monitor and cope the ill health related work through the medical check up
 Implement controlled HSE procedures that comply with legislative requirements and
international standards, and are regularly updated to reflect best industry practices;
 Adopt a systematic approach to the identification, assessment and management of
workplace hazards to eliminate or control HSE risks in order to prevent accidents;
 Establish and maintain contingency plans for emergency preparedness to mitigate the
consequences of major accidents;
 Conduct regular audit and inspection of company;
 Measurable goals promoting continuous improvement toward zero accident and protect
the environment;
 Seek means to prevent environmental pollution, facilitate and encourage to propose and
implement operational procedure in order to respect and improve the Environment;
 Declare the right of his Employees to stop the works should the above HSE conditions and
means not be met.
 Provide employees with job related training and appropriate personal protective
equipment;
All employees and contractors for their part will be required to:
 Comply with relevant standards specified by statute, industry or the PT. XXXX;
 Passed the medical check up fitness certification
 Contribute the planning process, actively participate in assisting the company in achieving
its stated goals and targets;
 Report and actively subsequent investigation of all accidents, incidents, hazards and near
misses that have the potential to impact on PT. XXXX operations;
 Accept responsibility for protecting themselves, visitors and members of the public who
may be affected by their activities.
 Recognition by all employees and contractors that safety and environmental protection is
a condition of the employment and they are responsible for their safety and the safety of
those around them;
 Stop undesired events from taking place and leading to harm such as injury, property
damage or environment pollution.
 Employee right to stop work if all HSE conditions are not proper.
Director is responsible for enacting this policy and giving the HSE equal priority with all
other business issues. Implementation will involve employees in the achievement of the
objectives
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XXXX HSE policy communicated to all employees and visitors through the display on
strategic area and via HSE Induction to new employees and subcontractors
6.2. STRATEGIC OBJECTIVES

Senior management XXXX together with HSE continually monitor the annual HSE
objective, target and program in every 6 month and make sure that XXXX HSE OTP
aligned with COMPANY HSE OTP.
Objective and Target of XXXX for this project are :
1. Achieving and maintaining zero accident at all workplace undertaken by XXXX with
the target 0 Fatality, 3 max for Number of LTI > 3 occurred, 25 max for Number of
Medical Treatment Case (MTC) occurred, 20 max for Number of First Aid Case (FAC)
occurred, 20 max for Number of Nearmiss occurred, 5 max for Frequency rate (LTI >
3 days), 300 max for Severity Rate (SR). HSE Manager is PIC of this objective and
target
2. Monitoring and evaluate the compliance of HSE Legal and Other Requirement, with
target 75 % compliance to HSE regulation on June 2011. HR Manager is PIC of this
objective and target
3. Monitoring HSE Training realization, with target 65 % on June 2011. HSE Manager is
PIC of this objective and target
4. Conduct office HSE Inspection with target 4x / month for the implementation. HSE
Manager is PIC of this objective and target
5. Conduct annual medical check up for staff employees with target min 80 % for
compliance. HR Manager is PIC of this objective and target
XXX Page 11 of 75
7 ORGANIZATION, RESPONSIBILITIES, RESOURCES, STANDARDS AND

DOCUMENTATION
ORGANIZATION
XXXX is managed by the Director who supported by Engineers, Accountant and QA &
HSE Manager who has functional responsibility for departmental employees. As shown,
the line responsibility and accountability for HSE liaise with the Director for showing the
commitment of Company.
XXXX Organization Chart
Director will:
 Formulate HSE Policy and ensure it is given the full backing of the
Company
 Ensure adequate resources are available to ensure effective
implementation of the HSEMS
 Implement and support the HSE Policy and ensure that all employees
fully understand and comply with its requirements
 Ensure that specific responsibilities for HSE within their scope are
adequately defined and delegated
 Take personal interest in, and support where applicable, meetings
convened by XXXX to discuss or resolve matters relating to HSE
XXX Page 12 of 75
 Review incident reports with a view to improving and/or maintaining the

standards of HSE within their area of responsibility, and report such actions to the
Director
 Ensure that subordinates receive all necessary training, information and
encouragement to enable them to carry out their duties in a safe manner.
QA & HSE Manager will:

 Certified in AK3U/HSE Expert
 Check and ensure that project HSE plan still in line of XXXX HSEMS
 Setup, plan and conduct HSE audit to the project
 Participate actively in the incident report, investigation, corrective action,
preventive action and communicate the safety alert/lesson learnt to all department
to prevent the recurrence
 Setup, plan and conduct HSE training, campaign and another HSE
promotion and communication
 Check and review HSE report to the COMPANY and XXXX internal
 Implement and maintain the HSEMS implementation both of in corporate
and project
 Collate all incident, personal injury and near miss records within XXXX
workplaces
 Keep up to date with all relevant legislation and promulgate as necessary
Office Manger and Admin Staff will:

 Ensure that all relevant premises occupied by XXXX, and all fixtures,
fittings or equipment in them, are of safe design and are so maintained to minimize
risk to HSE
 Ensure that office electrical equipment is tested and maintained
 Act as appropriate on the findings of any safety inspection of XXXX
premises.
Project Manager will:

 Organize all of HSE aspect that related to HSE objective, target and
program realization
 Promote and maintain the HSE awareness for all personnel involved
 Ensure that all project staff has trained
 Persuade the all element to involve in HSE activities
 Manage and monitor standard of safe work practice
XXX Page 13 of 75
QHSE Engineer will:

 Coordination and cooperation with project manager in regard to HSE
implementation
 Transfer recommendation to all engineer and technician in regard to HSE
procedures
 Ensure the coordination and organization complied with HSEMS like HSE
meeting, inspection, training, drill simulation, work permit
 Ensure that HSE statistic kept and reported every time to the COMPANY
and QA and HSE manager of XXXX
 Always take coordination with project team in regard to establishment
hazard identification, risk assessment and determining control to get the safe
condition
 Always updating and reviewing project HSE plan if needed
Engineer will:
 Participate in every HSE activities
 Ensure all team in good health before start the activities
 Ensure that all team understood and care to HSE plan and objective,
target, program
 Ensure all equipments received in good condition, comply with
requirement and has certified
All of Project Team:

 Ensure that all of acts and conditions not too risk to injure themselves,
colleagues, environment, tools and equipments
 Ensure the PPE that proper with their work risk has use and fasten
properly
 Ensure before start the activities tools and equipments that used in good
condition
 Report in every incident case and damage in plant, equipment, tools,
material, etc.
 Follow all of HSE regulations, legal and other requirement
XXX Page 14 of 75
 Respect with XXXX HSE procedure and work instruction, if there is not
applicable team shall report to their engineer for follow up
Beside of corporate organization chart XXXX formed also the P2K3/HSE Committee to
comply with Permenaker No.05/1996, please see below the P2K3/HSE Committee
organization chart :
P2K3/HSE Committee Organization Chart
Every change of member on XXXX P2K3 Organization chart will be communicated to all
member of P2K3 on HSE Management Review Meeting
SUBCONTRACTOR
Generally, XXXX not employ subcontractor for project of Engineering Services for
Instrumentation and Automation System. But if there is subcontractor for scope of work
of XXXX, HSE requirement also included in requirement that must be comply by
candidate of vendor or subcontractor in pre-qualification phase.
XXX Page 15 of 75
Vendor contract, work order or purchase order must be available and include HSE
requirement clausal to be complied.
Performance evaluation conducted routinely, to ensure that vendor conduct HSE

requirement and other requirements that have been determined in contract.
HSE Department of XXXX must accompany information and HSE requirement including
completeness of MSDS requirement to material supplier to project area.
Procurement section must check all material while delivery to ensure all material
received had complied to the requirement, including HSE requirement and purchasing
specification. Material achieved are in good condition, all documentation needed are
available at material supplied example MSDS for hazardous waste.
Subcontractor/vendor under XXXX will:

 Assessed by XXXX HSE before selected, refer to HSE pre-requisite
procedure
 Subcontractor/vendor required in the contract for conduct and follow
XXXX HSE procedure that integrated in the XXXX HSE regulation and COMPANY
HSE regulation
 Subcontractor/vendor shall provided and submitted method statement
and risk management to the XXXX
 Prepare the project HSE plan and inspect regularly
 Prepare HSE training matrix and realization
 Participate actively in every XXXX and COMPANY HSE events
 Report the HSE performance to XXXX
 Get the HSE induction prior the work
XXX Page 16 of 75
JI/FORM/HSE/09/01
Rev. 0
Rev. 0/ October 2010

Attachment of PURCHASE ORDER
Annex 2 : Comply to the requirements of Health, Safety and Environment according PT. JI HSE standard
Mengikuti persyaratan Keselamatan dan Kesehatan Kerja sesuai standard PT. Jetec Indonesia
* All HSE activities, administration & documentation shall be coordinated by PT. JI HSE Department
Seluruh aktivitas, administrasi & dokumentasi HSE dikoordinasikan oleh HSE Departemen PT. JI
No Conditions / Persyaratan
1 Follow all project HSE rules & regulations, as well as safety signs
Wajib mengikuti Tata Tertib K3LL proyek, serta mematuhi rambu-rambu di proyek
2 Driver, assistant and loading-unloading worker must wear a project helmet and shoes ever since entering the project site
Supir, pendamping, maupun pekerja bongkar-muat wajib mengenakan helm proyek dan sepatu kerja sejak masuk gerbang proyek
3 Location for unloading material shall follow direction from Logistic of PT. JI
Lokasi penurunan material harus mengikuti arahan dari Logistik PT. JI
4 Driver, assistant and loading-unloading worker may only enter as far as unloading location; It is prohibited to enter other project area
without permit from HSE Representative of PT. JI
Sopir, pendamping, maupun pekerja bongkar-muat hanya boleh sampai lokasi penurunan material; Dilarang memasuki area proyek lain
tanpa ijin dari perkailan HSE PT. JI
5 Provide all hazardous materials with MSDS (Material Safety Data Sheet)
Wajib melengkapi semua material B3 dengan MSDS / LDKB (Lembar Data Keselamatan Bahan)
6 All hazardous materials brought into the project shall be reported to HSE Department
Wajib melaporkan semua material B3 yang akan dibawa masuk ke dalam proyek kepada Departemen HSE
7 Any special requirement/condition of hazardous material storage must be informed to the Logistic/Storekeeper
Wajib menginformasikan persyaratan khusus penempatan material B3 (jika ada) ke bagian Logistik/Gudang
8 Every vehicle leaving project site will be checked by Security
Setiap kendaraan yang keluar dari lokasi proyek akan diperiksa oleh Security
9 If any violation of HSE rules & regulations which cause material return or transportation prohibited to enter, Supplier shall be fully
responsible for any cost impact both directly and indirectly, including third party liabilities
Jika terjadi pelanggaran peraturan dan Tata Tertib HSE yang mengakibatkan material dikembalikan atau kendaraan pengantar dilarang
masuk, maka Supplier menanggung sepenuhnya segala kerugian yang ditimbulkan baik secara langsung maupun tidak langsung,
termasuk apabila sampai menimbulkan kerugian pada pihak lain
HSE COMMUNICATION AND MEETING PROGRAM

XXXX will conduct the HSE communication and meeting periodically, refer to corporate
agenda.
Monthly HSE Meeting :
 This meeting held once a month by HSE in the corporate office or project by the
appointed time on regular basis, so that this meeting does not need an invitation
 This meeting attended by Director, HSE Manager, Project Manager, Supervisor /
Engineer, and subcontractor or vendor’s member team
 This meeting will be leaded by HSE Manager
 Agenda of monthly HSE meeting discuss :
 Achievement of HSE Performance
 Current HSE Issue
XXX Page 17 of 75
 HSE minutes of meeting status from last month

 Finding status of recent HSE inspection, incident and corrective action if
exist, violation and also issues or others HSE information
Corporate HSE Committee Meeting
 This meeting will be held at head office of PT. XXXX and headed by Director and
organized by HSE Manager
 All members of the committee / P2K3 must attend and participate actively in the
meeting, this meeting will be held in every 6 month along with HSE management
review meeting.
HSE Management Review Meeting
 This meeting will be held at head office of PT. XXXX and conducted every 6
months
 Concept of this meeting is Top management shall review the organization’s HSE
management system at planned interval, to ensure continuing suitability,
adequacy and effectiveness
 This meeting attended by Director, Technical Director, Office Manager, QA & HSE
Manager, QA & HSE Engineer, Project Manager, Tax and Accounting Manager,
Sales Manager, HSE Internal Auditor
 Management Review input agenda is
1. Results of HSE internal audit and evaluations of compliance with applicable

legal and others requirement
2. The results of HSE participation and consultation
3. Relevant HSE communication(s) from external interested parties, including
complain
4. HSE Performance during a certain period
5. The extent to which HSE objective have been met
6. Status of incident investigations, corrective actions and preventive action
7. Follow up actions from previous management review
8. Changing circumstances
9. Recommendations of improvement
 Output of Management Review is

1. Effectiveness improvement of HSE MS and implementation
2. HSE performance
3. HSE policy and objective
4. Other elements of HSE MS
XXX Page 18 of 75
XXXX will participate also in the HSE communication and meeting event that conducted
by COMPANY.
PT JI have HSE Meeting procedure which explain role and responsibility of each Top
Management and Employee both internal HSE Meeting and External HSE Meeting
Senior Management
 Attend and active in HSE Committee Meeting at Corporate of PT. XXXX
 Consider, support and implement the recommendation and corrective action of
HSE Management System which was decided in the HSE Committee Meeting at
corporate level
Project Manager
 Attend and be active in the HSE Meeting, project HSE Committee Meeting and
Corporate HSE Meeting at PT. XXXX’s Head Office
 Consider, support and implement the recommendation and corrective action to
improve HSE implementation in the project which was decided in the HSE
Committee Meeting project level and corporate level
HSE Department
 Project HSE Engineer provide agenda which will be used in weekly HSE
Meeting and HSE Committee Meeting
 Creating and maintain departmental records and minutes of meeting at all HSE
Meeting and Committee Meeting
The attendance list and minute of meeting to monitor the action plan resulted from the
meeting and communication will be recorded.
XXXX commit to make minute of meeting on every HSE Meeting both in internal meeting
and external meeting with COMPANY
PT JI have HSE Meeting calendar and agenda for period time, This calendar and agenda
explain the execution and agenda of each HSE Meeting as explained below :
XXX Page 19 of 75
HSE MEETING CALENDER AND AGENDA
HSE PROMOTION AND AWARENESS PROGRAM

XXX Page 20 of 75
HSE promotion and awareness program will cover the whole operation area of PT. XXXX
to educate, communicate and motivate all personnel and others who related to PT.
XXXX’s operation.
Director and Project Manager are responsible for the provision of adequate facilities,
equipments, materials and human resources provided in effective implementation of HSE
promotional program at the workplace, such as :
 Displaying HSE Policy of PT. XXXX in the workplace which signed by Director
of PT. XXXX :
 HSE Policy as a commitment from Director of PT. XXXX shall be displayed
clearly prominent at notice board and also site office. As far as practicable,
the policies statement could be translated in various languages to
understood by all employees / workers at site project
 This promotion could be extended through the briefing during HSE Induction
training for new employees and subcontractor or vendor who work on site
under PT. XXXX.
 HSE Poster / Banner / Sign Board / Flag
(a) HSE Poster / Banner / Sign Board and Flag are meant to motivate personnel
toward good HSE practice. It also serves as tool to warn work personnel of
hazard and precautionary measures related to particular trade of work
carried out at site project
(b) HSE Poster / Banner and Sign Board shall be displayed at prominent
location where worker could gather for certain activities such as the
workshop, rest area, canteen, training room, along the road within the work
site
(c) PT. XXXX’s Flag, red-white flag, and HSE flag could be erected and displayed in
front of site office.
(d) HSE Sign Board and Banner, sign board and banner either custom or ready-made
are easily available and if less / need again can be made immediately
(e) Weekly HSE Talk
HSE talk is one of medium promotion activity held every once a week for
approximately 30 minutes. Every employees must follow these activity whitout
exception. HSE talk is different with toolbox meeting, all material discussed about
HSE, and also there are some additional activities conducted in addition to
directing, such as cleaning activities, structuring the work environment, checking
PPE, fitness examination of worker, as well as physical fitness exercises.
HSE talk agenda :
 All employees gathered in a row according to their group, leaded by HSE
engineer
XXX Page 21 of 75
 The on duty HSE engineer explain general information about work

implementation on today. The HSE Engineer can be rotated to
representative from each department and subcontractor or vendor, speech
systematically from project manager level untill supervisor. If speaker difficult
to find material, HSE Engineer can prepare the material which can be
discussed based on JRA
 Follow by standard PPE Checking (helmet, hand glove, ear plug, glasses,
and safety shoes), if there are damaged or not proper for worker, the PPE
will be divided as to be replaced witk new PPE by supervisor and HSE
Engineer
 Gymnastic or stretching (10 minutes) lead by HSE Engineer
 Pray together and close with HSE yel-yel « SAFETY FIRST »
 Tool Box Meeting

For dynamic work environment with a high level of risk and overtime working. TBM
can be held in the morning only, or on each change shift, day shift and night shift.
TBM was facilitated by the HSE Engineer and must involve all elements of project
team, such as project manager, subcontractor or vendor, supervisor as speaker.
TBM agenda are :
 All employees gathered in a row according to their group, prepared by HSE
Engineer
 HSE on duty will explain the general information about work implementation
on these day. The HSE Engineer can be rotated to representative from each
department and subcontractor or vendor, speech systematically from project
manager level untill supervisor. If speaker difficult to find material, HSE
Engineer can prepare the material which can be discussed based on JRA
 Follow by general briefing about hazard of the job at that day and the
prevention by HSE Engineer
 Pray together and after yel-yel line dissolved to form a owrking group circle
each to discuss work readiness, equipment readiness, work methode and
more specifically the hazard, leaded by their each subcontractor or vendor’s
supervisor or project manager
 As general guidance, are also incidental possible to convey the corrective
action of the incident or non conformity that had just happened by competent
personnel and directly related to incident.
 Topic discussed and list of attendance shall noted and recorded.
 HSE Award for Employee with Best HSE Awareness
XXX Page 22 of 75
(f) HSE award is given in the form of gift-giving of the best worker to all the
people involved in the project, regardless of status, or organizational level
(PT. XXXX’s lemployee and subcontractor or vendor) to give credit to the
implementation of regulation, awareness and discipline good HSE. This
award was held in every month which its ceremonial carried out together
with HSE Campaign
(g) Selection of the best employee could be done through meeting of certain
criteria set by the management shall be in accordance with candidate
proposed from groups of worker ( daily, foreman, sub contractor) refer to
HSE award assessment forms.
(h) Winners in the safety awards could be given with gifts or award from
management also certificate / charter. Winner photo set in strategic place to
motivate other worker.
 HSE Award for Best Employee
(i) Anomaly form is a form prepared by HSE Management as one means of
participation, consultation and communication between employee and HSE
management. All employees and guests are asked to fill out the form and
inserted into the anomaly Box that had been prepared. The contents of
anomalies can be suggested, enter, finding discrepancies in the
implementation of HSE
(j) HSE award given to participant with best filling on the anomaly
(k) Criteria in selection of the best anomaly form participant could be selected 3
best form shall be in accordance with anomaly form which filled in anomaly
box
(l) Selection of the best anomalies conducted by HSE Committee (Project HSE
Committee). 3 Winner of best anomaly given a gift or other award from
management. The 3 best anomaly Form strategically placed locations to
motivate other workers to fill the anomalies form
 HSE Award for Workplace with Best Housekeeping
(m) HSE award was also given to the workshop, warehouse, fabrication and
overall work area of PT. XXXX and subcontractor and vendor for the best
housekeeping conducted once every month
(n) Criteria in selection of the workplace with best housekeeping could be
assessed every workplace in accordance with HSE inspection form
(o) Winners of HSE Awards are given prizes or other awards and certificates
from the management. Photo location with the house keeping work best
placed in strategic locations with another award.
 HSE Campaign
XXX Page 23 of 75
(p) HSE Campaign is an activity to promote HSE in order to regenerate or

increase the worker awareness and knowledge to work safely, more sharply
in the recognize of danger and be able to prevent action
(q) HSE campaign was followed by all staff components in the project,
conducted at a sufficient location. The main subject can be a campaign
demonstration, exercises, discussions, presentations, safety film, safety
awards, special medical check up etc.
(r) Continue with Activity for giving award for the best workers, the workplace
with the best housekeeping and 3 best participants filling anomalies can be
held in conjunction with HSE Campaign.
(s) To add the spirit and to improve health status while implemented safety
campaign, provided a healthy drink menu to all workers, such as milk, etc.
(t) Each end of the event safety campaigns can be asked questions to
determine how far the material can be absorbed by the participants of the
campaign. Participants who can answer the question correctly can be given
a gift
 HSE Punishment and Violation
(u) HSE Engineer will make recommendations for any workers who were caught
carrying out work in an unsafe manner or endangering the life or safety of
others.
(v) Any employee or sub-contractor’s employee who does not use the required
PPE when the job requires them to do so or infringes any of the safety rules
and regulations shall be dealt within accordance with the disciplinary.
7.5. HSE TRAINING, COMPETENCY AND MINIMUM REQUIREMENT FOR ENTRY TO

COPI FACILITIES
XXXX will comply with minimum and mandatory requirement for entry to COMPANY
facilities. See below mandatory HSE training matrix for Engineering Services for
Instrumentation and Automation System project :
TITLE PROVIDER TARGETED PARTICIPANT APPLICABILITY
MANDATORY REQUIREMENT FOR ENTRY TO COMPANY SITE FACILITIES

First aid & CPR, basic Public/in-house  SPOC/PM
 Senior system engineer
 System engineer
 Instrument engineer
 Database/Software engineer
 Network engineer
 Process control engineer
 Support Services
XXX Page 24 of 75
 HSE Engineer
Fire fighting, basic Public/in-house  SPOC/PM
 System engineer
 HSE Engineer
HSE orientation In-house (CBT)  SPOC/PM
 System engineer
 HSE Engineer
TBOSIET/TFOET Public  SPOC/PM
 System engineer
 HSE Engineer
PPE Public / external by  SPOC/PM
COMPANY  Senior system engineer
 System engineer
 HSE Engineer
STOP CARD Public / external by  SPOC/PM
COMPANY  Senior system engineer
 System engineer
 HSE Engineer
XXX Page 25 of 75
TITLE PROVIDER TARGETED PARTICIPANT APPLICABILITY
OTHER HSE TRAINING REQUIRED BY XXXX

OHSAS 18001 : 2007 External  SPOC/PM
Recognition  Senior system engineer
 System engineer
 HSE Engineer
Permit to Work External  SPOC/PM
 System engineer
 HSE Engineer
HIRADC (Hazard External  SPOC/PM
Identification, Risk  Senior system engineer
Assessment and  System engineer
Determining Control)  Instrument engineer
 HSE Engineer
ELECTRICAL WORK External  SPOC/PM
(HO/LR/L2V)  Senior system engineer
 System engineer
 HSE Engineer
Defensive Driving External  XXXX Driver
Emergency Response External  SPOC/PM
and Preparedness  Senior system engineer
 System engineer
 HSE Engineer
XXX Page 26 of 75
7.6. HSE LEGISLATIONS AND STANDARDS

XXXX will comply with applicable HSE legislation (national and or regional) for scope of
work of Engineering Services For Instrumentation and Automation System such as :
 Law No 1 Year 1970 pertaining to Occupational Safety

 Law No. 32 Year 2009 pertaining to Environmental Management and Protection
XXXX will comply with applicable HSE standard (international or national) which
applicable with scope of work of XXXX, such as :
 SNI
 OSHA
 ANSI
 NFPA
 IMCA
 Etc
XXXX also identify HSE Standard and legislation which applicable with scope of work of
Corporate XXXX
List of HSE Regulation related to XXXX’s activities as follow:
No Nomor Peraturan Tentang

I. Deklarasi Umum tentang Hak-hak Asasi Manusia PBB
1 Pasal 3
II. UUD 1945
1 Pasal 27 ayat 2
III. Undang-undang (UU)
1 UU No. 14/1969 Ketentuan-ketentuan Pokok mengenai Tenaga Kerja
2 UU No. 1/1970 Keselamatan Kerja
3 UU No. 14/1969 Ketentuan-ketentuan Pokok Mengenai tenaga Kerja
4 UU No. 4/1982 Ketentuan-ketentuan Pokok Pengelolaan Lingkungan hidup
5 UU No. 18/1999 Jasa Konstruksi
5 UU No. 23/1997 Pengelolaan Lingkungan Hidup.
6 UU No. 23/1992 Kesehatan
7 UU No. 21/2003 Pengesahan Konvensi ILO NO. 81 mengenai Pengawasan
Ketenaga-kerjaan dalam Industri dan Perdagangan
8 UU th 1930 LN No. 225 Undang-undang Uap (Stoom Ordonnantie)
9 UU th 1933 LN No. 53 Petasan
10 UU th 1931 LN No. 59 Timah Putih
11 UU No. 10/1961 Peredaran Barang dalam Perdagangan
12 UU No. 10/1997 Ketenaganukliran
13 UU No. 32 th. 2009 Perlindungan dan pengelolaan lingkungan hidup
XXX Page 27 of 75
IV. Peraturan Pemerintah (PP)

1 PP Th 1930 Peraturan Uap (Stoom Ordering)
2 PP No. 7 / 1973 Pengawasan atas peredaran, Penyimpanan dan Penggunaan
Pestisida.
3 PP No. 19 / 1973 Pengaturan dan Pengawasan K3 di bidang Pertambangan
4 PP No. 11 / 1979 K3 pada Pemurnian dan Pengolahan Minyak dan Gas Bumi
5 PP No. 19 / 1994 Pengelolaan Limbah Bahan Beracun dan Berbahaya
6 PP No. 14 / 1993 Program Jamsostek
7 PP No. 18 / 1999 Pengelolaan Limbah Berbahaya dan Beracun (B3)
8 PP No. 20 / 1990 Pengendalian Pencemaran Air
9 PP No. 27 / 1999 Analisis Dampak Lingkungan
10 PP No. 19 / 1999 Pengendalian Pencemaran dan/atau Perusakan Laut
11 PP No. 41 / 1999 Pengendalian Pencemaran Udara
12 PP No. 74 / 2001 Pengelolaan Bahan Berbahaya dan Beracun
13 PP No. 63 / 2000 Keselamatan dan Kesehatan terhadap Pemanfaatan Radiasi
Pengion
14 Stbl 1949 No 337 Ordonansi Bahan Berbahaya
15 PP No. 28 / 2000 Usaha dan Peran Masyarakat Jasa Konstruksi
16 PP No. 29 / 2000 Penyelenggaraan Jasa Konstruksi
V. Keputusan Presiden (Keppres)
1 Keppres No. 22/1993 Penyakit akibat Kerja.
2 Keppres No. 2 / 2002 Pelestarian lingkungan dan pembangunan berkelanjutan
3 Keppres No. 51/1989 Perubahan Keputusan Presiden No 28/1988 tentang besarnya
Jaminan Kecelakaan Kerja dan jaminan Kematian Asuransi Sosial
Tenaga Kerja
4 Keppres No. 83/1998 Pengesahan Konvensi ILO No. 87 mengenai Kebebasan Beserikat
dan Perlindungan Hak untuk Berorganisasi
VI Peraturan Menteri (Permen)

1 Permenaker No. Pembentukan Panitia Pembina K3 (P2K3).
02/1970
2 Permenaker No. Wajib Latihan bagi Dokter Perusahaan
01/1976
3 Permenaker No. Penunjukan, Wewenang dan Kewajiban Pegawai Pengawas K3 dan
03/1978 Ahli K3.
4 Permenaker No. K3 dalam Penerbangan dan Pengangkutan Kayu
01/1978
5 Permenaker No. Penunjukan dan Wewenang serta Kewajiban Pegawai
03/1978
6 Permenaker No. Syarat-syarat K3 pada pemakaian lift listrik untuk orang dan barang..
05/1978
7 Permenaker No. K3 pada konstruksi Bangunan
05/1978
8 Permenaker No. Wajib Latihan Hyperkes bagi Paramedis Perusahaan
01/1979
9 Permenaker No. K3 Pada Konstruksi Bangunan
01/1980
10 Permenaker No. Pemeriksaan Kesehatan Tenaga Kerja dalam Penyelenggaraan K3
02/1980
11 Permenaker No. Syarat-syarat Pemasangan dan Pemeluharaan Alat Pemadan Api
04/1980 Ringan.
12 Permenaker No. Kewajiban Melapor Penyakit Akibat Kerja
01/1981
13 Permenaker No. Bejana Bertekanan
XXX Page 28 of 75
01/1982
14 Permenaker No. Kualifikasi Juru Las
02/1982
15 Permenaker No. Pelayanan Kesehatan Tenaga Kerja
03/1982
16 Permenaker No. Instalasi Alarm Kebakaran Otomatik
02/1983
17 Permenaker K3 dalam Penggunaan Bahan Asbes
No..03/1985
18 Permenaker No. Pengawasan Ketenagakerjaan Terpadu
03/1984
Permenaker No. K3 Pemakaian Asbes di Tempat Kerja
03/1985
19 Permenaker No. K3 Pesawat Tenaga dan Produksi
04/1985
20 Permenaker No. K3 Pesawat Angkat dan Angkut.
05/1985
21 Permenaker No. Biaya Pemeriksaan dan Pengawasan K3 di Perusahaan
02/1986
22 Permenaker No. K3 pada Penyimpanan dan Pemakaian Pestisida
03/1986
23 Permenaker No. Tata cara Pembentukan P2K3 dan Penunjukan Ahli K3
04/1987
24 Permenaker No. Kwalifikasi dan Syarat-syatrat Operator Pesawat Uap
01/1988
25 Permenaker No. Biaya Pemeriksaan dan Pengawasan K3 di Perusahaan
02/1988
26 Permenaker No. Berlakunya SNI-225-1987 mengenai PUIL 1987 di Tempat Kerja
04/1988
27 Permenaker No. Kwalifikasi dan Syarat-syarat Operator Keran Angkat.
01/1989
28 Permenaker No. Pengawasan Instalasi Penyalur Petir
02/1989
29 Permenaker No. Syarat-syarat K3 Pesawat Karbid
01/1992
30 Permenaker No. Tata Cara Penunjukan, Kewajiban dan Wewenang Ahli K3
02/1992
31 Permenaker No. Perusahaan Jasa K3
04/1995
32 Permenaker No. Sistem Manajemen K3 (SMK3)
05/1996
33 Permenkes No. 453/ Bahan Berbahaya
Menkes/ Per/XI/1983
34 Permen PU No. Panitia Tata Pengaturan Air Propinsi Daerah Tingkat I
67/1993
35 Permenaker No. Penyelenggaraan Pemeliharaan Kesehatan bagi Tenaga Kerja
01/1998 dengan Manfaat Lebih Baik dari Paket Jaminan Pemeliharaan
Kesehatan Dasar Jamsostek
36 Permenaker No. Tata Cara Pelaporan dan Pemeriksaan Kecelakaan
03/1998
37 Permenaker No. Pengangkatan, Pemberhentian dan Tata Kerja Dokter Penasehat
04/1998
38 Permenaker No. Syarat-syarat K3 Lift untuk Pengangkutan Orang dan Barang
03/1999
VII. Keputusan/Instruksi Menteri & Keputusan Bersama Menteri
XXX Page 29 of 75
1 Kepmenaker No.1135/ Bendera K3

1987
2 Kepmenaker Diagnosis dan Pelaporan Penyakit Akibat Kerja
No.333/1989
3 Kepmenaker Penyediaan Data Bahan Berbahaya terhadap K3
No.612/1989
4 Kepmenaker Hari K3 Nasional
No.245/1990
5 Kepmenaker Pedoman Diagnose dan Evaluasi Cacat Karena Kecelakaan /
No.62A/1992 Penyakit akibat Kerja
6 Instruksi Menaker No Pengawasan Khusus K3 Penanggulangan Kebakaran
11/M/BW /1997
7 Kepmenaker Pelaksanaan Audit SMK3
No. 19/M/BW/1997
8 Kepmenaker Penunjukan PT Sucofindo Sebagai Audit SMK3
No. 103/MEN/1997
9 Kepmenaker No Nilai Ambang Batas Faktor Fisika di Tempat Kerja
61/1999
10 Kepmenaker No Unit Penanggulangan Kebakaran di tempat kerja
186/1999
11 Kepmenaker No Pengendalian Bahan Kimia Berbahaya di Tempat Kerja
187/1999
12 Kepmen PU No Ketentuan Teknis terhadap Bahaya Kebakaran pada Bangunan
10/KPTS/ 2000 Gedung dan Lingkungan
13 Kepmen PU No. Ketentuan Teknis Manajemen Penanggulangan Kebakaran di
11/KPTS/ 2000 Perkotaan
14 Keputusan Bersama Keselamatan Kerja pada Kegiatan Konstruksi.
Menaker dan Men PU
No Kep/ 174/
MEN/1986
15 Keputusan Menhankam Perijinan Bahan Peledak
No
SKEP/198/MTT/1984
16 SK Men LH 127 / 2002 PROPER
17 SK Men LH 122 th 2004 Baku Mutu Limbah Cair (Pupuk)
18 Keputusan Bersama Penggunaan Air dan/atau Sumber Air Untuk Kegiatan Usaha
Men PU dan Pertambangan Termasuk Pertambangan Minyak Dan Gas Bumi Dan
Mentamben No. O4 / Pengusahaan Sumber Air
1991 dan 76/ 1991
VIII. Surat Edaran Menteri
1 SE Menaker No Nilai Ambang Batas (NAB) Kebisingan dan iklim kerja
01/1978
2 SE Menaker No NAB Bahan Kimia
02/1978
IX. Keputusan Direktur Jendral Binawas Depnaker
1 Kep Dirjen Binawas No. Cara Pengisian Formulir Laporan dan Analisis Statistik Kecelakaan
Kep.84/BW/1998
X. Pedoman dan Standar /Siatem Manajemen K3
1 SMK3 Sistem Manajemen Keselamatan dan Kesehatan Kerja (SMK3)
Permenaker No 5 /
1996
2 OHSAS 18001:1999 Occupational Health and Safety Assessement Series 18001:1999
British Standard, 1999
3 OHSAS 18002: 2000 Guidelines for the implementation of OHSAS 18001:1999
British Standard, 2002
XXX Page 30 of 75
4 Guidelines on OSHMS The Guidelines on Occupational Safety and Health Management

ILO, June 2001 System. ILO-OSH 2001
5 ISRS-7 International Safety Rating System (ISRS)-7
Det Norske Veritas
(DNV)
XI. Peraturan Daerah (PERDA)
1 Perda No. 88 Tahun Larangan merokok di dalam gedung
2010
Up Date Tgl : 30 Agustus 2010

Revisi : 0
Dibuat Oleh :
Gusman Triady
QA & HSE Manager
8 EVALUATION AND RISK MANAGEMENT

During the execution of this project, XXXX will comply with ID-G-BU-00000-00000-00463 –
Risk Assessment
8.1. METHODE AND PROCEDURE FOR HAZARDS AND EFFECTS MANAGEMENT

Risk evaluation and management is a key component in the Management System that
identifies, evaluates and determines the means of reducing risks to an acceptable level
across a wide range of factors to protect people, the environment, assets and to avoid
loss.
PTJI has procedures to systematically identify and evaluate the hazards and effects that
might arise from our activities and from the materials that are used or encountered in
them. The scope of the risk management process ranges from Design through to
Construction, Commissioning and Operation.
Risk evaluation, and the subsequent decision-making, can range from an individual
conducting the process mentally, through to the application of formal methods which are
documented and follow set protocols. The main steps in risk management however are
common, whatever approach is employed and we apply the process equally to health,
safety, security and the environment.
Sometimes, the residual risk may not always be reduced to the lowest possible factor, but
identification of these risks will ensure that procedures reflect their severity and allow
them to be effectively managed.
PT JI commits to conduct HIRADC (Hazard Identification, Risk Assessment and
Determining Control) before conduct work activities is Engineering Services For
Instrumentation and Automation System
XXXX will also follow COMPANY standard of Risk assessment to assess hazard and risk
on scope of work XXXX in Engineering Services For Instrumentation and Automation
System, Refer to procedure ID-G-BU-00000-00000-00463 – Risk Assessment at COPI
Facilities
XXX Page 31 of 75
8.1.1. HAZARD IDENTIFICATION

All PT. XXXX’s workplace must process hazard identification, risk assessment and its
control. The team appointed to conduct hazard identification should have the competence
to conduct hazard identification and use reference work :
 Map of business process
 Flowchart of process
 Checklist and observation of hazard identification, risk assessment
and determining control
 Legal aspect and other requirement according hazard potential
Hazard identification must include :
 Routine and non routine activities
 Activities of all persons having access to the workplace (including
contractors and visitors)
 Human behavior, capabilities and other human factor
 Identified hazard originating outside the workplace capable of
adversely affecting the health safety and environment under control of PT. XXXX in
workplace
 Hazard created in the vicinity of the workplace by work related
activities under control of PT. XXXX
 Infrastructure, equipment and material at the workplace, whether
provide by organization and other
 Changes of proposed change in the organization, its activities, or
materials
 Modification to the HSE Management System, including temporary
changes, and their impacts on operations, processes and activities
 Any applicable legal obligation relating to risk assessment and
implementation of necessary controls
 The design of work areas, processes, installations,
machinery/equipment, operating procedures and work organization, including their
adaptation to human capabilities
The organization’s methodology for hazard identification and risk assessment shall :
 Determined with respect to its scope, nature and timing to ensure it
is proactive than reactive, and
 Provided for the identification, prioritization and documentation of
risk, and the application of control, as appropriate.
Identification result recorded in form Hazard Identification Risk Assessment and
Determining Control.
XXX Page 32 of 75
8.1.2. RISK ASSESSMENT

Conduct assessment based control has been done by measuring the risk/impact of the
correspondence between the possibilities and consequences.
Phase 1. assessment based on consequence
Can be conducted with selection of biggest consequence toward human with minor
choice with point 1 and major with point 5, with detail as follow :
Human consequence
5 : fatality, as follow death
4 : serious injury or cause permanent disability or injury which must be given help at the
hospital for long time or work related accident that need treatment at hospital in a long
time period
3 : injury which cause lost part of body and lost time of work day
2 : injury which need medical treatment but not cause loss time injury
1 : minor injury which need first aid treatment
Phase 2. assessment based on likelihood
Can be conducted with selection on major likelihood from level of a selection 5 till the
minor of 1 selection with detail :
5 : almost certain/almost occur, where can occur many incident every year
4 : likely/likely occur, where the possibility occur 1-2 times in 1 year
3 : possible/possible occur where the possibility occur only 1-2 times in 5 years
2 : unlikely/low possibility occur, where the possibility only 1-2 times in 10 years
1 : rare / nearly impossible
Having obtained the numbers and the likelihood of human consequence, to determine the
level of risk (risk rank) performed by the formula : human consequence (C) x likelihood (L)
= score, then set the risk level (high, medium or low risk)
Score/rank value in risk can be classified into 3 levels of risk, namely :

1.4 : low risk (L)
5.10 : medium risk (M)
11.25 : high risk (H)
Then, based on activity, potential hazard and determining the control need to consider
legal and other requirement of HSE, so legal and other requirement of HSE written on
legal field within the form that made HIRADC.
8.1.3. DETERMINING RISK CONTROL

XXX Page 33 of 75
According to assessment result above, existing risk assessment conduct, determine

control by using risk control hierarchy so that residual risk can be acceptable with control
as follows
 Elimination
Cope with the hazard by eliminating or erasing material, work equipment, work method
which can cause hazard
 Substitution
Cope with the hazard by substituting material/equipment/work method which can
cause hazard with material/equipment/work method which not cause hazard
 Engineering and isolation
Cope with the potential hazard/impact by conducting re-engineering or isolate hazard
 Administrative control
Cope with potential hazard by setting up manual, SOP, JSA, training, shift work
arrangement and etc.
 Personal Protective Equipment
Cope with the potential hazard by using PPE for all employees
Determination of risk control can also be determined by reviewing the risk control of
existing or been done in previous activities. When determining the level of risk found in
areas with high risk category, whether or not are HSE regulation, these activities should
be controlled by making procedures or work instruction. when determining the level of
risk found in areas with medium risk category, whether or not there is HSE legislation, it
still must be controlled. When determining risk areas have found there is low risk
category, then the area can still be tolerated by the implementation of existing conditions,
but if there is HSE regulation or other HSE requirement that regulate the activity and the
potential hazard, it remains to be determined the control.
XXXX determine control with time timeline of implementing the control in order to
minimize risk
XXXX has the generic HIRADC form, please see below HIRADC form for Engineering
Services For Instrumentation and Automation System Project :
XXX Page 34 of 75
8.2. PPE REQUIREMENT

XXXX has setup the specific procedure in regard to PPE requirement, we establish and
implement this procedure to establish minimum site wide standards for personal protective
equipment in order to protect all personnel and visitor from potential site hazards.
To ensure that supplying, distributing, wearing and controlling of personal protective
equipment are conducting consistently, properly and orderly.
XXXX also comply with COMPANY minimum PPE requirement for entry to COPI Facilities
refer to Doc No ID-G-BU-00000-00000-00477-Minimum Requirement for Entry to
Engineering Services For Instrumentation and Automation System Project, as explained
below :
No Activities Potential Body PPE Standards Remarks

Hazards Part Reference
1 Minimum PPE for Flash Fire Whole Long-sleeved EN 533 and Distinctive color (e.g
General Activities body fire-retardant ANSI / SEA red, yellow, orange
*) coveralls (c/w 107 – 1999 is recommended)
reflective COPI coveralls is
stripes RED
XXX Page 35 of 75
Falling objects Head Hard Hats ANSI Z89.1- Hard hats shall be
1987, Type 1, completed with chin
Class E & G straps for working at
height
Falling / Sharp Foot and Safety shoes, ANSI Z41.1 or
objects leg or Safety boots DIN 4843
(for potential
ankle injury)
Impact from flying Eyes Safety glasses ANSI Z87.1- * For personnel
particles (c/w side 1989 or DIN wearing glasses, an
shield EN 166-167 approved
prescription safety
glasses is required.
The use of overfit
safetyglasses/gogge
s over the safety
glasses is
acceptable
* Dark lenses safety
glasses shall not be
worn at night or
indoor areas
2 Working in noisy Excessive noise > Ear Ear muff or Ear NRR value minimum
environment 82 dBA plug (may be 24 Db
(also refer to combined with
COPI-HS-ST- communication
00001-Hearing head set)
Protection
3 Light duty Lightweight, Hands Tight-fitting
general work (e.g Slippery objects cotton cloth
laboring, brick with nitrile/ pvc
laying, paving, dots
manual handling)
4 Handling Mid to Hands Combination of Used in conjunction
rough/abrasive heavyweight, heavy-duty with no 13, 14, 15
materials, mid to rough/abrasive thick cotton
heavyweight objects with nitrile
materials (e.g coated or with
scaffolding, leather
powered tools,
manual handling)
5 Welding-electric Hot sparks and Hands Specialized Used in conjunction
arc, gas cutting, molten metal leather with no 16
torch brazing, gauntlet (long
torch soldering gloves)
6 Assembly Hand injury Hands Tight-fitting, Only to be used
operations where fingerless where potential
a high level of gloves injury to fingers is
XXX Page 36 of 75
manual dexterity very minimal

is required (eg
mechanical and
finishing trades,
electrical and
instrumentation
assembly)
7 High voltage Electrical shock Electrical ASTM D 120 -
electricity and burns insulated 87
gloves, made
up of rubber
and worn
underneath
leather gloves
8 Grass cutting Flying objects Safety glass & ANSI Z87.1-
goggles 1989 or DIN
Safety shoes & EN 166-167
glass shine
protector
9 Chipping Flying objects, Eyes Safety goggles ANSI Z87.1-
powered particle sand, dirt, 1987
fastening/riveting/ etc
sanding
10 Grinding (both Flying objects, Eyes Safety goggles ANSI Z87.1-
handheld or particle sand, dirt, 1989
bench type), etc
grass cutting
Flying fragment, Eyes and Full Faceshield ANSI Z87.1-
large chips face over safety 1989
glassess
11 Welding-electric Optical radiation, Eyes and Welding ANSI Z87.1-
arc, gas hot sparks face helmets 1989
12 Working at height Falls Whole Full body ANSI A10.14- To be used when
body harness + 1991 or ANSI working on elevated
shock Z359.1-1992 position of 6 feet
absorber (1.8 meters) where
lanyard + there is no physical
anchorage protection, such as
connectors platform or handrails
and are at risk of a
fall or need both
hands free while
performing the
works
13 Activities Falls, overboard, Whole Life/work vest US Coast PFD label must be
over/near water drowning body guard – Type checked and
1 life vest (for confirmed for the
offshore purposed it serves
facilities) or and its limitation :
XXX Page 37 of 75
Type III life Vessel type

vest (for (commercial or
onshore recreational), water
facilities) or conditions (rough –
Type V work open water/offshore
vest or calm-inland
water/river/harbour
8.2.1. DURATION USE OF PPE
Safety Safety Vest and

No Title Helmet Ear Plug Dust Mask
Shoes Glass rain coat
1 Board of Director 3 years 1 year 1year 6 month 1 day 3 years
2 Office Manager 3 years N/A N/A N/A 1 day 3 year

QA & HSE
3 3 years 1 year 1 year N/A 1 day 3 years
Manager
4 Project Manager 3 years 1 year 1year 6 months 1 day 3 years
Tax & Accounting

5 N/A N/A N/A N/A 1 day 3 years
Manager
6 Administration N/A N/A N/A N/A 1 day 3 years
7 Project Secretary N/A N/A N/A N/A 1 day 3 years
8 Accounting Staff N/A N/A N/A N/A 1 day 3 years

Control System
9 3 years 1 year 1 year 6 month 1 day 3 years
Engineer
10 Electrical Engineer 3 years 1 year 1year 6 month 1 day 3 years
Telecommunication
11 3 years 1 year 1year 6 month 1 day 3 years
Engineer
12 Site Management 3 years 1 year 1 year 6 month 1 day 3 years
13 HSE Engineer 3 years 1 year 1 year 6 month 1 day 3 years
8.2.2. PPE TRAINING

Before XXXX employee assigned these duties to COMPANY area, XXXX employee will
receive PPE training refer to document ID-G-BU-00000-00000-00417 Rev. 3 page 19 of
27
CONTRACTOR will attend PPE training which held by COMPANY.
9 PLANNING AND PROCEDURE

XXX Page 38 of 75
9.1. HSE PROCEDURES

9.1.1. XXXX HSEMS MASTER LIST
XXX Page 39 of 75
9.1.2. COMPANY HSE STANDARD AND PROCEDURE

XXX Page 40 of 75
9.2. EMERGENCY RESPONSE PROCEDURE

XXX Page 41 of 75
In time of an emergency occurred at the Office and this project, positives measure must be
taken to ensure the safest and best ways to evacuate the personnel from the building to the
designated assembly area. Thus, it is extremely important for all personnel to understand
this procedure.
This procedure is prepared to provide information and guidelines to all Office personnel the
emergency response plan available and actions to be taken by the Emergency Team.
This procedure applies to all activities of PT. XXXX’s Corporate Office at Graha Surya
Internusa Building, 7th Floor Suite 701, Jl. H.R. Rasuna Said Kav X-0, Jakarta 12950. This
procedure should be used in conjunction with GSI specific procedures for the management
of emergency.
XXXX Emergency Response procedure has been developed to cater for various
emergencies. The implementation of the procedure involves the deployment of dedicated
personnel and coordinated with security or officer GSI Building to evacuate occupants to
the designated muster point. All employees are made aware of emergency response
procedure during the induction training or safety briefing for long term visitors.
9.2.1. ORGANIZATION RESPONSIBILITIES

During the project all Managers have a direct involvement in the implementation of HSE
objectives and are required to ensure that all their decisions and practices are in-line with
the HSE Policy and Objectives. Specific responsibilities of individuals are detailed below:
 HSE Manager
The HSE Manager shall have overall accountability and responsibility during
Emergencies to direct his staff and for taking all necessary precaution to prevent
inducing an emergency
His major duties and responsibilities are to:
 Establish and make public Emergency and Evacuation Plan. When establishing
this plan, he shall obtain information on the GSI Building Management
requirements and system for emergencies evacuation.
 Issue the Emergency Alert according to the alert system
 Issue the evacuation order to all personnel on the office
 Issue the call off of the emergency after confirming it
 Liaise closely with the GSI Building Management during an emergency
 Ensure fire fighting and evacuation training
 Discipline Manager and Engineer

XXX Page 42 of 75
The Discipline Manager and Engineer shall assist the HSE Manager.
 Inform the GSI Emergency Control Centre of the status of the emergency and
its location and to receive further instructions for evacuation, etc.
 Assist HSE Manager in directing the Prevention Team to establish measures to
prevent and minimize emergencies
 Lead the Prevention Team in establishing measures against the recurrence
and containment of the emergency
 HSE Coordinator
The HSE Coordinator shall assist and advise the HSE Manager
 Prepare the Emergency and Evacuation Plans for the HSE Manager
 Plan and conduct Training and Drills for fire fighting, rescue and evacuation at
least once a year
 Prepare equipment for emergency use
 Instruct new staff and workers during the new comer orientation regarding the
Emergency Communication System and how to act during emergencies and how
to carry’s out evacuation
 Coordinate with Security to control office access for unauthorized personnel
and ensure accountability of personnel entering and leaving the site
 Report to the HSE Manager on the status of the evacuation, etc.
 Floor Warden (HSE Officer)

The Floor Warden (Safety Officer) shall act under the direction of the Discipline
Manager and HSE Manager.
 Instruct personnel on other levels to proceed to the assembly area and to await
further instruction
 Instruct personnel to evacuate when receiving evacuation instruction
 Assist the Fire Fighting and Evacuation Team
 Instruct and ensure that all personnel stop work and switch off all electrical
equipment
 Administration Manager
The Administration Manager shall assist the Project Manager
XXX Page 43 of 75

 Manage all administrative affairs during emergencies
 Provide all measures necessary for transportation and communication
 Record emergencies and the action taken in a sequential manner
 Employees at Office
Employees at Office shall cooperate with Project Manager, Discipline Manager and
Discipline Engineer during emergencies
 Join Training and Drills for fire fighting, rescue and evacuation
 Carry’s out evacuation during and emergency under the direction of Project
Manager, Discipline Manager and Discipline Engineer
9.2.2. INSTRUCTION FOR EVACUATION

XXX Page 44 of 75
9.2.3. RESPOND CHART OF EMERGENCY CASE

XXX Page 45 of 75
9.2.4. EMERGENCY TELEPHONE NUMBER

XXX Page 46 of 75
PT. XXXX 021 526 2599

Graha Surya Internusa Building
021 5272144
Contact Person : Putri
Hospital :
Medicare Clinic, Menara Kadin, Jl
021-5274556
Rasuna Said Kav. 2-3
Medistra, Jl. Jend. Gatot Subroto 021-5210200
MMC, Jl. Rasuna Said C 21 0215203435
Fire Department HQ 021-3450595 / 3441309 / 3450494
French Embassy, MH. Thamrin No. 20 021 314 2807
Police, Setiabudi 021 5273601
Police, Patra Kuningan 021 5279536
Police Headquarters, Jl. Jend.
021-5234000
Sudirman
HSE Manager – Gusman Triady -
081239436396
Office Manager – Susana Y. – 0811986123
Person Emergency Call
Technical Director – Antoine Gaconnet –
08121997846
Director – Olivier Vifflantzeff – 0811984023
9.3. EQUIPMENT CONTROL, MAINTENANCE AND INSPECTION

 Equipment Operational
Before operating equipment in project area, it must be ensured the equipment own
approval certificate of equipment from authorized party (Client’s HSE,
DEPNAKERTRANS and another HSE institution)
 Copy of valid equipment certificate must be handed to PT. XXXX’s HSE
Department before the equipment permitted to enter project area
 Before equipment permitted to be operated, it must be conduct re-assessment
by Client’s HSE, Local Suku Dinas Tenaga Kerja or another HSE institution.
For lifting equipment (Crane, PH, etc) during re-assessment, it shall be ensured
that loading test must be conducted and documented. After that, signage of
maximal load must be installed based on loading test result
 After there are permit from Suku Dinas Tenaga Kerja, the equipment permitted
to be operated
 Every operation, operator must conduct pre-operation inspection toward
equipment to ensure equipment are always in good condition
XXX Page 47 of 75
 During equipment operation, HSE Department will place proper signage, install
barricade and make protection toward operational of heavy equipment also
light equipment and conduct periodic inspection of readiness of the equipment
 Equipment Maintenance
 Maintenance of light machine conducted periodically by the mechanics every
150 hours of use or is determined by replacing lubricants and filter
 At PT. XXXX’s project which including equipment such as : chain block,
scaffolding, forklift, mobile crane, etc.
 Daily Maintenance on heavy equipment carried by operator of the equipment.
9.4. OCCUPATIONAL HEALTH AND MEDICAL FACILITIES

All incident and ill health must be reported. Whoever see incident occur must
immediately report it to HSE Engineer or Supervisor must immediately report incident
orally to Project Manager, Project Engineer quickly (in 15 minutes). This aimed so that
Management can soon take action if needed. After situation, condition and victim is good,
HSE engineer must immediately report written report in 1 x 24 hours. After investigation
conducted, investigation report must be finished in 2 x 24 hours HSE Engineer along with
Administration will take victim of incident to referral hospital if can not be helped with first
aid treatment at project. For further, Administration section will coordinate with HSE
Engineer and hospital staff for incident report or ill health establishment which can be
used for claim of incident treatment cost to insurance
 Medical Check Up Principal

Confidentiality: All information will be treated as strictly confidential in accordance
with the recognized code of medical ethics. Individual’ health details of findings should
be provided only to the examinee, unless reporting is required by law or by overriding
public health considerations, or to other physicians at the written request of the
individual.
Any person involved in the conduct of medical examinations, including those who
encounter medical examination forms, laboratory result and other medical information,
should ensure the right of privacy of the examinee.
Medical examination reports should be marked as confidential and so treated. All
confidential health information, whether on paper or in computer files, must be kept in
a secure location, only accessible to authorized health personnel.
XXX Page 48 of 75
Non Discrimination: MCU will purely asses the fitness to work in any designated job.
The same treatment will be applied for all personnel regardless position, nationality,
etc. If there are some different medical assessments, it is purely because of the
specific requirement to determine the fitness to work, such as age, job type, working
conditions, etc.
Acceptance: Contractor will only accept a MCU and fitness to work certificated form
certified physician from an approved medical facility. Contractor will consult with
COMPANY to get approval of their medical facilities.
Validity: All MCU and fitness to work certificates from the contractor’s employee will
be verified by COMPANY.
 Medical Check Up Assessment

Beside refer to the XXXX MCU standard, we are respecting MCU standard of the
COMPANY.
All XXXX employees who assigned at Engineering Services for Instrumentation and
Automation System Project will get MCU standard which respect to MCU standard of
the COMPANY as follow :
Medical Check Up Package (xxx Standard)

Male Employee Office Staff Pre Employee Field Staff
a. Physical examination + Yes Yes Yes

consultation
b. Eye examination by Yes Yes Yes
Opthalmologist
c. Dental examination by Dentist Yes Yes Yes
d. ENT examination by Yes Yes Yes
Otorhynolaringologist
e. Chest X-Ray Yes Yes Yes
f. ECG Yes Yes Yes
g. Treadmill If required/referred If required/referred by If required/referred
Specialist by Specialist
by Specialist
h. Spirometery No Yes If required/referred
by Specialist
i. Audiometry No Yes If required/referred
by Specialist
j. USG abdomen If required/referred If required/referred by If required/referred
by Specialist Specialist by Specialist
Laboratory Examination
Hematology
6. Hb Yes Yes Yes
7. Rbc Yes Yes Yes
8. WBC Yes Yes Yes
9. Hematocrite Yes Yes Yes
10. Platelet Yes Yes Yes
XXX Page 49 of 75
11. Differential Count Yes Yes Yes

12. LED Yes Yes Yes
13. Blood type
Blood Sugar
1. Glucosa Fasting Yes Yes Yes
2. Glucosa Post Prandial Yes Yes Yes
Liver Function
1. Total Bilirubin Yes Yes Yes
2. Ohospatase Alkali Yes Yes Yes
3. Gamma GT Yes Yes Yes
4. AG / Ratio Yes Yes Yes
5. Total Protein Yes Yes Yes
6. Albumin Yes Yes Yes
7. Globulin Yes Yes Yes
8. SGPT Yes Yes Yes
9. SGOT Yes Yes Yes
Renal Function
1. Ureum Yes Yes Yes
2. Creatinin Yes Yes Yes
3. Urin Acid Yes Yes Yes
Lipid Profile
1. Total cholesterol Yes Yes Yes
2. HDL Yes Yes Yes
3. LDL Yes Yes Yes
4. Trigliceride Yes Yes Yes
Routine Urine Analysis

1. Berat Jenis Yes Yes Yes
2. PH Glucose Yes Yes Yes
3. Urobilin Yes Yes Yes
4. Bilirubin Yes Yes Yes
5. Keton Yes Yes Yes
6. Protein Yes Yes Yes
7. Nitrite Yes Yes Yes
8. Sedimen Yes Yes Yes
Serology
1. VDRL Yes Yes Yes
Immunology
1. HBs Ag No Yes No
2. Anti HBs Ag No Yes No
Drug and Alcohol Screening

1. Amphetamine If needed Yes If needed
2. Benzodiazepine If needed Yes If needed
3. Barbiturate If needed Yes If needed
Fit Criteria Scoring System No If needed Yes

* (Not Performed yet)
10 Frequency of Examination
Based on the Indonesian regulation, every person will be examined prior to
employment and the thereafter at least once every year. The interval between
assessments will vary, depending on:
 Type of proposed employment and duty,
XXX Page 50 of 75
 Work environment (geographical risk, exposure to potential occupational

health hazards, travel and or health risk)
 Medical history
To the persons with cronic but not disqualifying conditions, the examining
physician may recommend increased frequency of periodic assessments.
An individual’s medical fitness to work must be also be assessed prior to
returning to work following absence due to injury, ilness, or surgery. This does
not automatically involve further medical examination.
11 Medical History
Medical history questionnaire should include:
 Administrative information (name, address, date of birth, sex, etc)
 Proposed/ Current position
 Occupational History
 Past medical and dental history
 Current medical complaints
 Known allergies
 Current medications
 Lifestyle (smoking, use of alcohol and other drugs, exercise)
 Family medical history
 Immunizations received
All positive answers in the questionnaire must be discussed with the employee,
and the results recorded.
The employee must sign the completed questionnaire as being complete and
true record and should recognize the significance of doing so.
12 Medical Examination
A full physical examination should be conducted, including evidence of dental
health and neurological examination for all type of MCU.
Other medical diagnostic tests such as urinalysis, chest x-ray, blood test, etc.
will be conducted based on the type of MCU performed.
13 Certificate and Fitness to Work

Upon completion of the annual medical assessment, certified doctors must
reach a conclusion on the employee’s fitness to work. Where doubt about the
fitness arises, consultation with other certified doctors and specialists should
take place.
XXX Page 51 of 75
On a prospective candidate certificate only his fitness to work status is

mentioned while on an employee, not only his fitness to work but also his
health category appears. Therefore, different certificate will be issued
depending on the type of MCU carried out.
Specific MCU are intended for employees in certain position or facing specific
health hazard, precaution action for specific position will be stated upon MCU
request.
Certificates of MCU from contractor will be approved by Company doctor to
maintain Company standard.
 Record Storage and Reporting

All MCU and fitness to work of contractor employees will be stored by
contractor for at least 20 (twenty) years after the employee resignation or
termination.
The result of pre-employment and employment MCU keep by Office Manager
(Human Resources Administration) and should be treated as strictly
confidential.
Contractor’s Management is entitled to advice about the medical fitness of
individuals in relation to work, but is not entitled to diagnosis or details of the
specific nature of an individual’s medical condition.
If restrictions are being imposed on an individuals’ fitness for a particular
position, further information may need to be disclosed. The disclosure of
information should maintain medical confidentially.
9.5. ENVIRONMENTAL PROGRAM

An Environmental Management Procedure (EMP) for our Project shall be prepared to
outline the Environmental management system, organization, procedures and plans that
will be followed during the execution of the works on the projects.
Fundamental to this Plan is we are commitment to the vision of completing the Project
with all risks identified and controlled to the extent that there are zero injuries and zero
damage to plant, equipment and the environment.
EMP is developed to provide a sound basis for communication and the participation of all
personnel on the project in the preservation of the health and safety of personnel,
protection of the environment and the prevention of asset loss.
XXXX will comply with COMPANY waste management program refer to ID-G-BU-00000-
00000-00455 – Waste Management
9.5.1. SPILL CONTINGENCY PLAN

XXX Page 52 of 75
Although the potential for oil spill is practically zero since there will be no oil involvement
during the execution of all PT. XXXX Project other than insignificant amount of diesel
fuel for marine transportation & construction purposes. However in case of spill or any
other applicable cases the emergency response as outlined in the Emergency
Response Plan will apply.
9.5.2. MITIGATION PLAN

Any environmental deficiencies found during the routine inspections and / or shall be
reported and addressed the issues during the toolbox meeting. The report shall include
the recommended corrective actions, the responsible person, expected completion date
and progress status monitoring plan until all deficiencies are closed-out. All the
historical records shall be documented and reported by any PT. XXXX sub contractor.
IMPACT
SOURCE
POTENTIA (IS)
L / IMPACT RESIDUAL
ACTIVITY MITIGATION
IMPACT ENV. SIGNIFICANCE IMPACT
ON SENSITIV
ITY
(ENV)
System IS:
documentati Excessive 1 – Low
Conduct 3R
on and use of paper
Medium Program (Reduce, Low
document and ink
Reuse, Recycle)
verification / cartridge ENV:
update 2-Medium
IS: 1 –
Excessive
Creating or Medium
use of paper Conduct 3R
updating
and ink Medium Program (Reduce, Low
manuals / ENV:
cartridge Reuse, Recycle)
procedures 3 - High
Data Excessive IS: 1 – Medium Conduct 3R Low

analysis, use of paper Low Program (Reduce,
data and ink Reuse, Recycle)
reconcilation cartridge ENV:
XXX Page 53 of 75
/validation
and
optimization 2 -Medium
system
development
IS:
Data tags
Excessive 1 – Low
tracing, Conduct 3R
use of paper
mapping and Medium Program (Reduce, Low
and ink ENV:
documentati Reuse, Recycle)
cartridge 2 -Medium
on
IS:
Replacement
Excessive 1 – Low
/revamp/new Conduct 3R
use of paper
control Medium Program (Reduce, Low
and ink ENV:
system Reuse, Recycle)
cartridge 2 -Medium
design
9.5.3. MONITORING PROGRAM

The HSE Coordinator who assign for project is responsible for conducting a routine
inspection within the site location to ensure the project goals are achieved. All HSE
activities, performance including Environmental Statistics shall be reported on monthly
basis (HSE Monthly Statistic and Performance)
9.5.4. IMPROVEMENT PLAN

PT. XXXX HSE improvement program includes:
 Analysis of HSE performance versus objectives
 Effective corrective actions to findings / incidents
 HSE training for personnel
 Displays of HSE messages
 Establishment and modification of HSE procedures
 Feedback from employees
 Up dating affiliate standard and requirement
(A) PRE-IDENTIFIED WASTES AND DISPOSAL SYSTEM

XXXX also have conduct pre-identified waste and disposal system both for Office and
Site, as follow :
Location
No Waste
Office Site
1 Paper (organic) To be handled local recycle Handled by COMPANY
company
2 Plastic, Bottle, Cans (non To be handled local recycle Handled by COMPANY
organic) company
XXX Page 54 of 75
3 Metal Scrap (non organic) None Handled by COMPANY

4 Food Garbage Building Trash point Handled by COMPANY
(organic)
5 Oil residue (non organic) None Handled by COMPANY
6 Waste water (organic) Building Management Handled by COMPANY
7 Sewage (organic) Building Management Handled by COMPANY
8 Hazardous substance
* Toner cartridges (copy To be handled local recycle Handled by COMPANY
machine, printer) company, or send back to
the
manufacturer
* Used Batteries To be handled local recycle Handled by COMPANY
company, or send back to
the
manufacturer
*Paint, Thinners, Solvents, None Handled by COMPANY
etc
*Chemicals, Chemical drums None Handled by COMPANY
*Contaminated rags, gloves, None Handled by COMPANY

etc
9.6. TRANSPORTATION (LAND, SEA, OR AIR TRANSPORTATION)

On the job execution, The CONTRACTOR will use COMPANY’s vehicle, but in case of
emergency and CONTRACTOR shall use CONTRACTOR’s vehicle. Then CONTRACTOR
shall follow COMPANY’s standard for vehicle and driver.
Requirement for vehicle and driver of CONTRACTOR in this project refer to document
ID-G-BU-00000-00000-00399 Rev. 1 Page 10,11 of 18 and Page 8,9 of 18 – Journey
Management
XXXX has adopted the following golden rules that must be observed by all personnel and
subcontractors:
Always:
 Comply with the traffic legislation, be conscious of road safety and demonstrate safe
driving and other good road safety habits
 Avoid driving when fatigued or when unfamiliar with the location/country
XXX Page 55 of 75
 Wear a safety belt whenever you drive or are driven
 Take frequent breaks and rest stops
 Keep within the speed limit
 Drive defensively and courteously
 Wear a cycle helmet or a motorcycle helmet when on two wheels
 Expect the unexpected
 Always review whether the journey can be avoided or conducted more safely.
Never:
 Drive when under the influence of alcohol
 Continue a journey with a driver that is driving recklessly
 Conduct a telephone conversation while driving
 React to the aggressive behavior of other drivers.

Remember life is precious.
14 IMPLEMENTATION AND PERFORMANCE MONITORING

10.1. HSE PERFORMANCE MONITORING
XXXX always record the HSE performance with the standard indicator refer to
COMPANY standard of HSE Performance Record, that are :
1. Total manhour
2. Total recordable rate
3. Number of fatality
4. Number of Lost workday case (LWC)
5. Number of Restricted workday case (RWC)
6. Number of Medical treatment case (MTC)
7. Number of First aid case (FAC)
8. Number of property damage case
9. Number of motor vehicle incident
10. Number of Environmental / Spill Case
11. Occupational Illness
12. Number of nearmiss
13. Number of STOP Card
Below is XXXX HSE Performance for last three years (2008 – 2010).
XXXX HSE PERFORMANCE 2008

XXX Page 56 of 75

XXX Page 57 of 75

XXX Page 58 of 75
For Project of Engineering Services for Instrumentation and Automation System 2011 -
2014 XXXX will use CONTRACTOR HSE Performance Record Form, refer to COMPANY
HSE Form standard.
XXX Page 59 of 75
Below is The Blank CONTRACTOR HSE Performance Record Form
HSE Department along with referred department conducts Identification of HSE

characteristic which will be checked and monitored. The characteristic list involved which
must be monitored:
 HSE Performance Indicator
 Achievement of HSE Objective and Program
Objectives and programme(s) measurement to see comparison between
objective and programme(s) determined with actual result
 HSE Performance Report
Measurement of HSE performance / statistic indicators by looking at the
frequency rate, severity rate, incident rate and work manhour.
 HSE Management System Implementation
This parameter used to see how the percentage of HSE Management System
implementation in company
 HSE Program
XXX Page 60 of 75
HSE program measurement conducted with measuring existing HSE program

to ensure how far the achievement of the program implementation, such as
HSE Inspection, HSE Committee Meeting, HSE training, HSE campaign, filling
of anomaly card and other
 Measurement and monitoring of HSE condition also conducted through external
parties, especially for environment work indicator, such as:
 Drinking Water Quality
Parameter of drinking water quality consist of chemical parameter such as pH,
Calsium (Ca), Magnesium, Barium (Ba), Besi (Fe), Tembaga (Cu), Seng (Zn)
and other, and for physic parameter such as color, temperature, smell, taste,
and other To ensure the drinking water used at project is safe, health and
hygiene, all drinking water parameter in certificate given by supplier comply
with existing standard
 Workplace Temperature and Humidity
Temperature measurements made using the swing gauge globe thermometer
and a calibrated thermometer. This measurement is done on the space where
there are peoples working routinely. An example can be done in the
conference room, general office, warehouse, living room, study, and others.
The results of these measurements will be compared with the threshold value
of the work climate
Workplace humidity measured to see the effect of humidity toward employee
health at project area or office and compared with proper legal
 Illumination Lighting Measurement
Illumination / lighting measurement conducted to see how the effect of lighting
and measurement at project area or office toward productivity of work. This
measurement can be conducted with measurement equipment Lux meter
 Dust
Dust can be measured at project area which estimated contain high
concentration of dust. Measurement result compared with standard of limit
exposure value refer to valid OHS regulation. Dust value can be measured
with Dust Meter
 Noise
Noise can be measured on areas that have high noise levels with noise
measuring instruments such as the sound level meter or noise dosimeter. If
the noise measurements performed in the project area that compared with
standard threshold value in accordance with applicable regulations.
 Bacteria and Germ
XXX Page 61 of 75
The place where a lot of work done in the static work, especially the lack of
ventilation and sunlight, and using floor mats should be checking the number
of germs and bacteria colonies in the study. Measurement results are then
compared with a threshold value that allowed for the colonies of bacteria and
germs in the air space. If the results of measurements obtained results that
exceed the threshold value, then the necessary corrective and preventive
action to prevent employees suffering from diseases, especially respiratory
infection (infection of the respiratory tract)
10.2. INCIDENT REPORT AND INVESTIGATION

10.2.1. INCIDENT REPORT
XXXX will comply with COMPANY standard for reporting and investigation of incident
refer to ID-G-BU-00000-00000-00467 – Incident Reporting and Investigation
Procedure
XXXX also have incident reporting procedure which explain about :
 All parties responsible to inform about incident or ill health
 Management of project must ensure that reoccurrence possibility of incident occur
and ill health in the future time after the incident and ill health occur must be
minimized with corrective and preventive action
 All type of incident and ill health must be classified correctly and investigation
conducted
 Incident classification which must be made the investigation is with minimal
classification of FAC or Nearmiss with the same event over and over min. 3x
 Incident classification which must be made its corrective and preventive action is
minimal of MTC or FAC and reoccurrence Nearmiss with min. 3 times
 Incident investigation team must be effort different base on type of incident
 Incident investigation report must be checked and approved by OM/ PM/ DPM of
each workplace, before the incident explained closed
 All corrective and preventive action plans toward incident and ill health must be
followed up immediately quickly and effectively
 After incident occur, HSE Department must review HIRADC to see weather
assessment have been conducted toward incident
 Incident & ill health record must be made toward all incident and ill health
 Incident and Ill health at Project
All incident and ill health must be reported. Whoever see incident occur must
immediately report it to HSE Engineer or Supervisor must immediately report
incident orally to Project Manager, Project Engineer quickly (in 15 minutes). This
aimed so that Management can soon take action if needed. After situation,
XXX Page 62 of 75
condition and victim is good, Safety Officer must immediately report written report
in 1 x 24 hours. After investigation conducted, investigation report must be finished
in 2 x 24 hours HSE Engineer along with Administration will take victim of incident
to referral hospital if can not be helped with first aid treatment at project. For
further, Administration section will coordinate with HSE Engineer and hospital staff
for incident report or ill health establishment which can be used for claim of
incident treatment cost to insurance
(A) INCIDENT INVESTIGATION

The investigation is an investigation conducted by the competent authorities to
determine the root cause of system improvement approach by looking for complete
information on the cause directly or indirectly to the accident, then set a conclusion
based on the data and make effective recommendations based on available facts.
Purpose of incident investigation are :
 To identify the root cause of the incident, either direct cause and the cause is not
immediately in order to determine the best method to prevent similar incidents
happening in the future.
 Provide valuable information in the event of an insurance claim or legal action.
 Provide a standard procedure for investigation of all incidents.
10.2.2.1. PROCEDURE OF INCIDENT INVESTIGATION

14. Planning
(b) Determine Purpose and Objective
Which includes the purpose and objectives must be determined in previous
investigations, among others: a commitment to implement corrective action
plan will be recommended
(c) Reference Document
Procedure / stage of investigation, forms which will be completed, legal aspects
and other related references (work instructions, check lists, induction,
examination certificates, licenses etc.)
(d) Selection and Debriefing of Investigation Team
 Top Management or Project Management based on input from HSE
Department immediately determine investigation team immediately set to
incident occurs, up to 24 hours after the incident
 Members of the regular investigation team for the category M (Medium) and
H (High) is included Office Manager, Project Manager, HSE Department,
one member of the HSE Committee / HSE unit, Section Head where the
incident occurred and a labor / staff who work in the same job where the
XXX Page 63 of 75
accident occurred or has knowledge of the job, if necessary, may also be

involved specific personnel who have relevant knowledge (see attachment)
 Accident investigation team leader should have the knowledge and
authority to make recommendations, and are usually chosen from the ranks
of Operation Manager, Project Manager, Project Deputy Manager, Project
Engineer, HSE Manager and HSE Engineer. The team leader should have
the authority to regulate the accident investigation team.
(e) Prepare Investigation Completeness
 Evidence notebook
 Magnifying Glass
 Camera
 Tape Recorder
 Graph Paper
 Clip board and Stationary
 Plastic Bag
 Label of Evidence
 Compass
15. Implementation
Implementation of investigation pursued an approach based on P 4 techniques,
namely People, Parts, and Position Paper.
(f) Conduct Investigation
 HSE Department to prepare the equipment and ensure investigation scene
awake and seek the documentation photographs of the scene, initial
reports the incident, witnesses data and photographs of the victim can be
recorded prior to the preliminary data presented to the investigation team
 Observation area at the scene by identifying, protecting and collecting
sources of evidence through 4P : People, parts, paper and Position
 People : involved person, victim, etc.
 Parts : goods evident condition, material, incident location,
equipment, etc
 Paper : documents, procedures, work instruction, induction,
TBM attendance, certificate, licenses, inspection, physical description
place of work / lay out, sirens, hazard, etc.
 Position : location of physical evidence, the sign on the road or
trace (e.g. trace of brake), PPE location, operating condition, etc.
(g) Interview the Witness
XXX Page 64 of 75
The investigators team will conduct interviews of the witness directly and
indirectly by preparing a list of questions.
At the beginning of interview, investigator will explain about :
 Purpose of investigation
 Request honesty for explaining information
 Convince health condition of victim at the time of interview
Ask the witnesses directly and indirectly to tell pre-incident, during the
incident and post incident
16. Start to Prepare Data Map and Evidence

From the results of observation and interview, collect relevant data so that incident
can be known, WHAT happened, HOW it happens, and most importantly WHY is
this happening. So that these results can be learning to avoid the same incident.
17. Analysis
In this process stage, the information collected is organized and analyzed in order
to identify the direct cause (this incident would not have happened if ....) and
indirect causes (this incident might not happen if ... ..) This analysis can also
eliminate possible causes. This is particularly important if the incident resulted in
damage and insurance claims later. The important thing to be noted at the time of
the incident investigation is :
 Sequences of chronologies must be made
 an analysis of the causes of the causes must be made. In many cases, the
cause of the cause providing a more effective way because avoiding the cost of
repetition. Analysis of the causes of the causes can also identify problems that
contribute to the incident range wider
 Give serious attention to the possible problems of people, equipment,
environment or system that may have a role in the incident, either directly or
indirectly.
18. Discussion of The Result of Investigation and Incident Report

All data obtained at the incident scene and examination of witnesses with direct
and indirect analysis, the results of data analysis will be under discussion at the
meeting to be attended by the entire team and leader of investigators related to
incidents (Subcontractor head when the accident occur on subcontractors
manpower) The meeting will discuss the findings in the field and the examination of
witnesses to lead to a conclusion. The results of the investigation will be made in
the form of report and Project Manager will review the incident investigation report
XXX Page 65 of 75
has been completed, and signed an approval on the report. Specifically for the
project, the entire incident report, investigation and correction and prevention
measures should be reported to the HSE Manager at each end of the month.
19. Recommendation
Based on the findings and have determined the cause of the Investigation Team
makes a recommendation for follow up recommendations given should be short
and clear solid so it is easy to implement in the field and should consider HSE
elements that does not affect processes already underway. All recommendations
will be made in form and Corrective Action Report (CAR) to be followed up by the
relevant department
20. Verification of Corrective and Preventive Action

To ensure the recommendations issued by the team of investigators conducted,
HSE Department will monitor and verify the improvements made to the sure and
certain that the recommendations are implemented properly and correctly. If the
result of the recommendations not yet implemented in accordance suggested. HSE
Department would ask related Supervisor / manager to seek clarification or
evidence of implementation and continuously monitoring the course of
improvement as recommended.
15 HSE INSPECTION, AUDIT AND REVIEW

11.1. HSE INSPECTION
Purpose of HSE Inspection is one of media which can be used to assess Occupational
Health Safety and Environment condition. Management participation in the inspection is
very important to show commitment and support from top management. It is essential
that the inspection was carried out in a manner which not to show negative effect as fault
finding. Instead, it should be communicated as together responsibility to reduce risk level
of hazard from occupational health safety and environment
a. Weekly Office HSE Inspection
Weekly Office HSE inspection around the office room to find discrepancies or
potential dangers such as ergonomic, humidity, lighting, emergency equipment, and
signs are not install, not good or damaged. Inspection conducted by the
administration staff in guidance of HSE Manager. The findings are recorded in the
checklist form and then socialized on the HSE bulletin board. Findings if possible
immediately followed up by administration on the same day, if not possible, the
location or unsafe condition given warning signs, labels and Barricade.
b. Work Inspection
XXX Page 66 of 75
Inspection with check list on work implementation, conducted with HSE Engineer. If
found any unsafe condition and unsafe action while inspection HSE Engineer can
request to stop work for a while until corrected, controlled hazard and safe condition.
c. Approval Evidence Lifting Equipment
Approval evidence of lifting equipment, contain equipment, installation and power
machine by Authorized agency. Conducted based on requirement in government
regulation by competent officer or agency. Before conduct procurement or rent an
equipment, Logistic must check administration completeness of the equipment.
Administration equipment as follow : SILO and SIO, if needed, can request
equipment history and manual book. Lifting equipment, contain equipment and
power machine which will enter project should show approval certificate from
competent agency (official of ministry of manpower and transmigration or Service
company of HSE. If new equipment or equipment which don’t have approval
certificate must be finished immediately. Every year or if project location move to
other area, lifting equipment, contain equipment, generator set and other equipment
based on government regulation must be re-checked to authorized agency Operator
license certificate is valid for 5 years, after that must be re-certificate to official of
Ministry of manpower and transmigration. Beside having Operator license
certificate, Lifting equipment and contain equipment must be conducted with an
interview and see their work experiences to ensure the operator have skill which
required with work risk level
d. Pre-Use Equipment Checklist
Pre-use equipment check list conducted by each equipment operator while operate
lifting equipment, transport equipment and machine. While weekly equipment
inspection, HSE Engineer must inspect by using pre-use check list and make
corrective note to be done.
e. HSE Assessment
The team of HSE Committee conduct assessment on HSE implementation level.
Grade of HSE implementation level must be made on statistic. Assessment result
will be reported to Director and sent to all project, and discussed in weekly HSE
meeting in corporate of PT. XXXX
f. Housekeeping Inspection
Weekly inspection with check list on housekeeping in project or site office which
conducted by Safety Inspector. In HSE Campaign, location with best housekeeping
given proper award.
g. Emergency Equipment Inspection
Emergency equipment inspection : All emergency equipment must be inspected
every month to ensure the readiness of that equipment if there are emergency
XXX Page 67 of 75
condition and incident. Equipment to be inspected such as : fire extinguisher, first

aid box, first aid bag, map and evacuation route, muster point, emergency contact
list. The inspection conducted by administration staff in guidance with HSE Manager
by using check list form.
h. Electrical Temporary Inspection
Temporary electrical installation in project must be checked monthly. Electrical
installation inspection in project conducted by Safety inspector with HSE Expert of
electrical
i. PPE Inspection
PPE Inspection is Inspection on standard PPE used by employee. Inspection
conducted by all HSE Engineer and usually conducted on HSE talk. Damaged PPE
or not meet requirement shall be changed immediately. While the employee have
not get substituted PPE yet, the employees are not permitted to work
11.2. HSE AUDIT

XXXX will comply with HSE Audit program by COMPANY to CONTRACTOR and refer to
document ID –G-BU-00000-00000-00466 – HSE Auditing
XXXX also have HSE audit procedure which have the purpose to :
 Ensure that the audit process in order to implement the HSE Management System can
walk in accordance with OHSAS 18001:2007 standard procedure
 Ensure the implementation of audit of HSE management system effectively in
evaluating the level of compliance with the HSE policies, objectives, targets, work plans
and programs and procedures
Below are XXXX HSE audit procedure :
a. Arrange Annual Internal Audit Program
 HSE Manager preparing annual HSE Internal Audit Programs and submit to the
Director for approval.
In the implementation of the audit, the annual audit program detail to be Audit
Detail Plan.
 Duration of Yearly Audit
HSE internal audit of PT. XXXX conducted minimal 2 times in 1 year
HSE audit of PT. XXXX conducted at least 2 times a year. For internal audit on
the projects underway, auditing the implementation schedule is as follows :
 Projects with schedule 3 – 6 months : 1 time of audit as progress 50%
 Projects with schedule 6 – 12 months : 2 times of audit when progress audits
20% and 60%
XXX Page 68 of 75
 Projects with schedule of more than 1 year: the audit conducted when
progress at 20% and 60% with the provision of not less than 6 months
 Project on schedule less than 3 months do not need to be conducted HSE
internal audit
 The program explained above should cover all section and projects of PT. XXXX
which involved in implementation of OHSAS 18001:2007 management system
 If necessary, Director could order to conduct audit beside determined audit
program, both comprehensive for whole section or any part of section or project.
Please see the our internal audit program during project execution :
b. Auditor Competency of OHSAS 18001 : 2007

 Internal Auditor for audit of HSE Management System based on OHSAS
18001:2007 is the employee of PT. XXXX who has passed OHSAS 18001:2007
internal audit training and have good knowledge of HSE system and process in
PT. XXXX
 Internal auditors mentioned above is that the auditor has been appointed by the
Company to conduct internal audits of HSE Management System throughout the
project area of company.
 Internal HSE Auditor team should be made, if the auditor person more than one
person and one of member appointed as a lead auditor.
 For HSE internal audit, the auditor shall not have direct responsibility for the
activity being audited.
XXX Page 69 of 75
c. Checklist Audit
. All the plan of HSE internal audit implementation will use a check list refers to standard
OHSAS 18001:2007. Check list that will be used must be appropriate to the program and
HSE Management Systems in Company.
Please see the our check list audit at the next page :
XXX Page 70 of 75
RECORD COMPLY
NO DESCRIPTION RESPONSIBILITY
FORM OTHER EVIDENCE/ REMARK YES NO N/A
Clause 4.2. HSE Policy
HSE Policy
Put HSE Policy with the frame and hang at the strategic
1 Put Policy at strategic place (Meeting room, Visitor room etc) HSE Coordinator
place (receptionist room, meeting room)
Clause 4.3. Planning

4.3.1. HIRADC
JI/HSE/P/02 : Risk Evaluation and Management System

Procedure
Develop of Hazard Identification, Risk Assessment and
2 JI/FORM/HSE/02/01 Attendance list of HIRADC set-up participation HSE Department & PM
Determining Control (HIRADC)
3 Evidence of HIRADC Socialization HIRADC socialization by an e-mail HSE Department
4.3.2. Legal and Others Requirement / 4.5.2. Evaluation of

Compliance
JI/HSE/P/03 : Legal & Other Requirement Procedure

Availibility of HSE Regulation list that match with PT. JI
4 HSE Regulation List JI/FORM/HSE/03/01 HSE Department
scope
5 Monitoring / Evaluation of HSE Regulation Compliance JI/FORM/HSE/03/02 HSE Department
4.3.3. Objective & Programme(s)

JI/HSE/P/04 : HSE Policy and Objective Procedure
6 Monitoring of objective target and program JI/FORM/HSE/04/02 Signed by Project Manager PM and HSE Coord.
Clause 4.4. Implementation & Operation

4.4.1. Resources, Roles, Responsibility, Accountability and Authority
7 Project Organization chart Project Organization Structure Project Administration
Job description (Roles, responsility, accountability and
8 HSE aspect at the Job Description of every position Project Administration
authority) for all employees
4.4.2. Competence, Training and Awareness

JI/HSE/P/05 : HSE Training Matrix and Record Procedure
9 Training matrix (job description and risk identification based) JI/FORM/HSE/05/02 Available the annual HSE Training Matrix HR Manager
10 Training program/plan and realization JI/FORM/HSE/05/03 Available the HSE Training Realization Matrix HR Manager
11 Training evaluation JI/FORM/HSE/05/04 Every trainee fill the evaluation sheet HR Manager
PERSONAL COMPETENCY (JI belonging)
12 OHSAS 18001 : 2007 Recognition Certificate / attendance list HR Manager
13 OHSAS 18001 : 2007 Internal Auditor Certificate / attendance list HR Manager
14 Oil and Gas OHS Expert Certificate / attendance list HR Manager
15 NEBOSH Certificate / attendance list HR Manager
16 QHSE MR Foundation Certificate / attendance list HR Manager
17 CSMS Course Attendance list HR Manager
18 HSE Induction Attendance list HSE Dept.
19 HSE Awareness Attendance list HR Manager
20 Assignment Orientation Attendance list HSE Dept.
21 Permit to Work Attendance list HSE Dept.
22 Job Risk Assessment Attendance list HSE Dept.
23 Non Conformance Reporting Attendance list HSE Dept.
24 Incident Investigation Certificate / attendance list HSE Dept.
25 First Aid Certificate / attendance list HR Manager
26 Fire Fighting Certificate / attendance list HR Manager
27 Working at Height Certificate / attendance list HR Manager
28 Lifting and Rigging Certificate / attendance list HR Manager
29 Electrical Work (HO/LR/L2V) Certificate / attendance list HR Manager
30 Defensive Driving Certificate / attendance list HSE Dept.
31 Emergency Response Evacuation Attendance list HSE Dept.
32 Basic Sea Survival Certificate / attendance list HR Manager
33 HUET Certificate / attendance list HR Manager
XXX Page 71 of 75
4.4.3. Communication, participation and Consultation

JI/HSE/P/06 : Communication, Participation and Consultation Procedure
34 HSE Information Board Updating the HSE Information Board (visual) HSE Coordinator
HSE Committee Report to DISNAKER RI in every
35 HSE Committee Report HSE Coordinator
3 month
4.4.4. Documentation
4.4.5. Control of Documentation
JI/HSE/P/07 : HSE Document Control Procedure
Distribution list of Document (Policy, Manual, Prosedur,
36 JI/FORM/HSE/07//01 Transmittal Record Project Doc. Controller
Form)
4.4.6. Operation Control

JI/HSE/P/08 : HSE Aspect at the Project Planning Phase Procedure
37 Project HSE Plan Approved Project HSE Plan PM/DPM
38 List of input document planning phase JI/FORM/HSE/08//01 Record of List PM/DPM
39 Planning phase checklist JI/FORM/HSE/08//02 Record of checklist PM/DPM
40 Verifikasi form of HSE aspect in planning phase JI/FORM/HSE/08//03 Record of verification PM/DPM
41 Preliminary risk assesment-Planning phase JI/FORM/HSE/08//04 Record of risk assessment PM/DPM
JI/HSE/P/09 : HSE Pre-requisite for Vendor Pre-qualification Procedure
45 Clauses of HSE req. in Vendors pre-qualification HSE Req. attached at the next page of PO DPM/Project Engineer
Clauses of HSE requirement in vendor contracts (in
46 HSE Req. attached at the next page of PO DPM/Project Engineer
Work Order and PO)
JI/HSE/P/10 : Control of subcontractors procedure
47 Vendor determination check list JI/FORM/HSE/10//02 Record of Questionnaire that filled by Sub Cont. DPM/Project Engineer
48 Vendor monitoring / evaluation JI/FORM/HSE/10//01 Record of evaluation DPM/Project Engineer
JI/HSE/P/11 : Operational, maintenance & service of equipment procedure

JI/HSE/P/12 : Working permit procedure
49 Working permit JI/FORM/HSE/12/01 Evidence record of work permit prior the work Engineer
JI/HSE/P/13 : HSE Meeting Procedure
50 Attendance List of HSE Committee Meeting JI/FORM/HSE/13/01 Attendance list HSE Dept./PE
51 HSE Committee Minutes Meeting JI/FORM/HSE/13/01 Minutes of Committee Meeting HSE Dept./PE
JI/HSE/P/14 : HSE Promotion Procedure
52 Toolbox Meeting ( TBM ) Record JI/FORM/HSE/14/01 Attendance list from site only Engineer
53 HSE Talk Record JI/FORM/HSE/14/02 Attendance list and material HSE Coordinator
54 HSE Campaign Record JI/FORM/HSE/14/03 Campaign Report and Documentation HSE Coordinator
JI/HSE/P/15 : HSE L.O.T.O. Procedure
JI/HSE/P/16 : HSE Inspection Procedure
55 Site Office Housekeeping Program JI/FORM/HSE/16/01 Record of Programme HSE Coordinator
56 Site Office Housekeeping Record JI/FORM/HSE/16/02 Record of checklist HSE Coordinator
57 Fire extinguisher JI/FORM/HSE/16/03 Monthly Checklist HSE Coordinator
58 First aid box JI/FORM/HSE/16/04 Weekly Checklist HSE Coordinator
59 Vehicle Safety Inspection JI/FORM/HSE/16/05 Monthly Checklist HSE Coordinator
60 Office HSE Inspection JI/FORM/HSE/16/06 Weekly Checklist HSE Coordinator
61 General HSE Inspection JI/FORM/HSE/16/07 Monthly Checklist for site only HSE Coordinator
JI/HSE/P/17 : PPE Procedure
62 PPE Inventory List JI/FORM/HSE/17/01 Inventory list update Administration
63 PPE Inspection Sheet JI/FORM/HSE/17/02 Record of PPE Inspection Administration
64 PPE Distribution List JI/FORM/HSE/17/03 Record of PPE Distribution Administration
4.4.7. Emergency Response
JI/HSE/P/18 : Emergency Preparedness and Response Procedure
65 Emergency response plan JI/FORM/HSE/18/01 Evacuation route HSE Coordinator
66 ER Organization chart & responsibility JI/FORM/HSE/18/01 ER Org. Structure HSE Coordinator
67 Emergency drill program JI/FORM/HSE/04/01 Emergency Drill Program HSE Coordinator
68 Flow chart emergency response JI/FORM/HSE/18/01 Flowchart of Emergency Response HSE Coordinator
Communication register / coordination to
69 Communication list of emergency bodies emergency bodies (Building Management, Fire HSE Coordinator
Brigade, Police, etc.)
List of Emergency equipment (First aid bag, first
70 List of emergency facility at site office JI/FORM/HSE/18/01 aid box, stretcher, fire extinguisher, sprinkler, HSE Coordinator
telephone)
71 Emergency minutees drill at site JI/FORM/HSE/18/01 Report from Building Management or Internal HSE Coordinator
72 Emergency response handled report JI/FORM/HSE/18/01 HSE Coordinator
73 Emergency evaluation JI/FORM/HSE/18/01 HSE Coordinator
74 Emergency facility check list JI/FORM/HSE/18/01 HSE Coordinator
75 Refill programmes of Fire extinguisher JI/FORM/HSE/18/01 Administration
Put of the Fire Extinguisher, comply to regulation
76 JI/FORM/HSE/18/01 Visual, requirement : Height 120 cm Administration
(1:200m2 or distance 1:15m)
77 Monthly/6th a Month/ Annual checklist of Fire JI/FORM/HSE/18/01 Fire extinguisher inspection record Administration
Extinguisher
78 Check list kelengkapan Tas Besar First Aid JI/FORM/HSE/18/01 Monthly checklist Administration
XXX Page 72 of 75
Clause 4.5. Checking

4.5.1. Performance, Measurement and Monitoring
JI/HSE/P/19 : HSE Monitoring Procedure
79 HSE Performance JI/FORM/HSE/19/01 Manhour, FR, SR, IR HSE Coordinator
Measurement programme for physical, chemical
80 Measurement & Monitoring workplace program HSE Coordinator
and biological factor
81 Water Measurement of Water HSE Coordinator
82 Indoor air quality Measurement of indoor air quality HSE Coordinator
JI/FORM/HSE/19/02
83 Lumen/ lighting meausrement Measurement of Lighting HSE Coordinator
84 Climate Measurement of Dust HSE Coordinator
85 Noise Measurement of Noise HSE Coordinator
86 Bacteria in the air Measurement of Bacteria in the Air HSE Coordinator
Statistic Graphic attached at HSE Performance
87 Monthly HSE Statistic report JI/FORM/HSE/19/03 HSE Coordinator
Report
JI/HSE/P/20 : Medical Check up Procedure
88 Medical check up program JI/FORM/HSE/20/01 Table of MCU schedule HR Manager
89 Medical check up result From Medicare Fit certification from MediCare HR Manager
90 Record of MCU Record and keeping the certificate HR Manager
91 Recommendation of MCU result Record of recommendation follow up HR Manager
JI/HSE/P/21 : Evaluation of Compliance Procedure
92 List of HSE Regulation JI/FORM/HSE/21/01 Availability of list at Project HSE Plan HSE Coordinator
93 Monitoring of Regulation (percentage of comply) JI/FORM/HSE/21/02 Percentage of HSE regulation compliance HSE Coordinator
4.5.3. Incident investigation, NC, CA & PA.

JI/HSE/P/22 : Incident & illhealth procedure
94 Incident report (Accident & Nearmiss) JI/FORM/HSE/22/01 Record of report HSE Coordinator
95 List of Incident JI/FORM/HSE/22/02 Recap list of incident HSE Coordinator
96 HSE alert JI/FORM/HSE/22/03 Alert evidence to all employees in every incident HSE Dept.
JI/HSE/P/23 : Incident investigation procedure
97 Incident investigation (Accident & Nearmiss) JI/FORM/HSE/23/01 Record of Incident Investigation HSE Dept.
JI/HSE/P/24 : NC, CA & PA procedure
Every NC can raise from : Audit finding, special
finding from HSE Inspection that didn't close after
twice inspection, complaint from
98 Non conformity request raise from site JI/FORM/HSE/24/01 HSE Coordinator
client/neighbour/employee, result of monitoring and
measurement, evaluation of HSE regulation
compliance
Every NCR and incident shall provided by CAR.
99 Corrective Action request raise from site JI/FORM/HSE/24/02 Nearmiss is not necessary except the recurrence HSE Coordinator
until 3 time or there is any special request
Potential NC when audit or based on 3 month
100 Preventive Action raise from site JI/FORM/HSE/24/03 HSE Coordinator
evaluation to potential NC and incident
Potential NC when audit or based on 3 month
101 Register of NCR/CAR/PAR raise from site JI/FORM/HSE/24/04 HSE Coordinator
evaluation to potential NC and incident
4.5.4. Control of Record

Method of record keeping the all evidence in the HSE Coord. and Doc.
102 How to keep the record of HSE activity
ordner Controller
There is available and filled the ordner that covered
Doc. Controller
evidence implementation of all HSE procedure ?
4.5.5. Internal Audit

JI/HSE/P/25 : Internal Audit Procedure
103 Annual internal audit program JI/FORM/HSE/25/01 Audit program / schedule HSE Manager
104 Audit check list JI/FORM/HSE/25/02 Audit checklist HSE Manager
105 Detail Audit plan JI/FORM/HSE/25/03 Audit plan to the auditee HSE Manager
106 Audit report JI/FORM/HSE/25/04 Report of audit HSE Manager
107 Audit notes/ observation JI/FORM/HSE/25/05 Audit notes HSE Manager
109 Status of follow up action JI/FORM/HSE/25/07 CAR and PAR status HSE Manager
Clause 4.6. Management Review

JI/HSE/P/26 : Management review procedure
110 Management Review Schedule Schedule acknowledged by Top Management Director
111 Management Review Agenda JI/FORM/HSE/26/01 Top Management understood the agenda Director
112 Management Review Minutees Meeting Top Management understood the minutes Director
113 Attendance list, invite letter, distribution list Top Management invite all of department head Director
XXX Page 73 of 75
d. Internal Audit Implementation

 Audit Plan and Preparation Stage
 Two week prior to audit activity, HSE MR establish auditor team and HSE
Audit Detail Plan
 One week prior to the implementation of the audit, Audit Detail Plan must be
submitted to the auditee
 Conduct meeting before initial day of audit activity or can be in nearest weekly
HSE meeting, Director or HSE Manager shall explain the important of internal
audit activity to Section managers or section chief and all project manager, and
in order to develop support from all parties
 Execution Stage
 At the appointed time, auditor began to carry out audit activities as follows :
- Opening meeting which consist of introduce the auditor, confirmation of
audit detail plan, explain the observation of non conformity finding category
(major, minor and observation), explain audit objective, fill attendance list,
give permit to auditee to ask everything that not clear in audit activity
- Verification of previous audit finding, if exist. If the finding has not been
followed up, the previous finding can be closed and moved to the
publishing of new finding
- Audit implementation
- Recording all checking result toward HSE Management system
implementation in Audit Notes form
- Evaluation of checking result, if found any deviation or non conformity
toward HSE Management system from audit activity is called as a finding
- If the findings are known to cause that do not comply with OHSAS
18001:2007 in the document, then declared a non conformity and non
conformity were recorded on corrective action request form (CAR).
If auditors find possible of irregularities on future conditions, then preventive

action request (PAR) form can be published.
- If both parties, auditee and auditor accept with the nonconformity finding,
auditee and auditor sign the CAR for, and auditee must write the plan of
corrective action and determine target of its finishing time.
- If audit finding is not approved by auditee, HSE representative must be
informed and HSE representative has authority to complete that problem
- Every finding of HSE internal audit collected to Lead auditor after the audit
activitty completed
XXX Page 74 of 75
- Closing meeting which consist of express thanks to auditee of the

cooperation of audit activity, fill attendance list, inform audit result that have
been conducted, give temporary copy of CAR to auditee so that auditee
can immediately conduct follow up from the finding
- Then lead auditor give to HSE Manager to be made the internal audit
report
- HSE Manager give a copy of finding of HSE internal audit to related
manager to conduct corrective action
 finding can be categorized with major category, minor, and observation)
Nonconformity finding can be categorized as a MAJOR finding if found there
are no work evidence which indicate the document or HSE Management
system are not implemented with the result that endanger Occupational health
and safety, or the available document has not comply with minimum standard
which obligated by Management system standard of OHSAS 18001:2007
Nonconformity Finding categorized as a MINOR finding if there imbalance
which not be danger of the implementation of HSE Management system
OHSAS 18001:2007 and or the implementation has not been consistent in
some place
Finding can be categorized as OBSERVATION finding if there are findings
which need attention from management although they are not contradictive
with requirement of OHSAS 18001:2007 Management system, but there are
indications that the finding can be the MINOR finding.
 Corrective Action
 Corrective action plan that have been approved must be conducted by auditee
based on determined time.
 Verification of corrective action conducted by auditor who publish finding of
HSE internal audit or other auditor appointed by HSE Manager.
 If the result of corrective action undertaken to the section audited is not
satisfactory, then the auditor's findings may raise new HSE internal audit
which refers to the finding of HSE internal audit is not solved
 Audit declared finished after corrective actions are verified correct by the
auditors
 Corrective actions verification that have been conducted and have been
effectively closed by stamping the "CLOSED".
e. Audit Report
 After audit activity in one period finished, HSE Manager establish Audit Report.
XXX Page 75 of 75
 Results of audit report from the findings reports or audit verification report will be
one of the studies in management review meetings
11.3. HSE MANAGEMENT REVIEW

a. Arrange Plan of Management Review
HSE Manager to arrange plan and schedule for implementation and Management
Review Agenda to be conducted every six month
b. Invite for Meeting

Based on the schedule for implementation, HSE Manager invite Top Management and
safety committee member to attend management review meetings
c. Input to Management Review

 Results of internal audit and evaluations of compliance with applicable legal and
others requirement
 The results of participation and consultation
 Relevant communication(s) from external interested parties, including complain
 HSE Performance during a certain period
 The extent to which objective have been met
 Status of incident investigations, corrective actions and preventive action
 Follow up actions from previous management review
 Changing circumstances
 Recommendations of improvement
d. Report
The outputs from management review shall be consistent with the corporate of PT.
XXXX commitment to continual improvement and shall include any decisions and
actions related to possible changes to :
 HSE Performance
 HSE Policy
 Resources
 Other Elements of HSE Management System
Result of decision on management review meeting, include minutes of meeting and report
of meeting will be record and controlled refer to document control procedure and
distributed to communication and consultation of interest party.

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Policy/Plan/Program: ID-G-BU-00000-00362 Rev.

Contractor HSE Plan

Contractor’s Name : PT. XXXX –

CONTENTS OF HSE PLAN

9.5.4. IMPROVEMENT PLAN 59

Recurring process of enhancing the HSE Management System in order to achieve

Ill health / Occupational Illness:

NOTE 3 : An emergency situation is a particular type of incident.

Health, Safety and Environment (HSE):

HSE Management System:

NOTE 1 OH&S performance measurement includes measuring the effectiveness of the

6 POLICY AND STRATEGIC OBJECTIVE

In order to support this policy, PT. XXXX will:

6.2. STRATEGIC OBJECTIVES

7 ORGANIZATION, RESPONSIBILITIES, RESOURCES, STANDARDS AND

XXXX Organization Chart

 Review incident reports with a view to improving and/or maintaining the

QA & HSE Manager will:

Office Manger and Admin Staff will:

Project Manager will:

QHSE Engineer will:

All of Project Team:

P2K3/HSE Committee Organization Chart

Performance evaluation conducted routinely, to ensure that vendor conduct HSE

Subcontractor/vendor under XXXX will:

Rev. 0/ October 2010

HSE COMMUNICATION AND MEETING PROGRAM

 HSE minutes of meeting status from last month

1. Results of HSE internal audit and evaluations of compliance with applicable

 Output of Management Review is

HSE MEETING CALENDER AND AGENDA

HSE PROMOTION AND AWARENESS PROGRAM

 The on duty HSE engineer explain general information about work

 Tool Box Meeting

(p) HSE Campaign is an activity to promote HSE in order to regenerate or

7.5. HSE TRAINING, COMPETENCY AND MINIMUM REQUIREMENT FOR ENTRY TO

TITLE PROVIDER TARGETED PARTICIPANT APPLICABILITY

MANDATORY REQUIREMENT FOR ENTRY TO COMPANY SITE FACILITIES

TITLE PROVIDER TARGETED PARTICIPANT APPLICABILITY

OTHER HSE TRAINING REQUIRED BY XXXX

7.6. HSE LEGISLATIONS AND STANDARDS

 Law No 1 Year 1970 pertaining to Occupational Safety

List of HSE Regulation related to XXXX’s activities as follow:

No Nomor Peraturan Tentang

IV. Peraturan Pemerintah (PP)

VI Peraturan Menteri (Permen)

1 Kepmenaker No.1135/ Bendera K3

4 Guidelines on OSHMS The Guidelines on Occupational Safety and Health Management

Up Date Tgl : 30 Agustus 2010

8 EVALUATION AND RISK MANAGEMENT

8.1. METHODE AND PROCEDURE FOR HAZARDS AND EFFECTS MANAGEMENT

8.1.1. HAZARD IDENTIFICATION

8.1.2. RISK ASSESSMENT

Score/rank value in risk can be classified into 3 levels of risk, namely :

8.1.3. DETERMINING RISK CONTROL

According to assessment result above, existing risk assessment conduct, determine

8.2. PPE REQUIREMENT

No Activities Potential Body PPE Standards Remarks

manual dexterity very minimal

Type III life Vessel type

8.2.1. DURATION USE OF PPE

Safety Safety Vest and

1 Board of Director 3 years 1 year 1year 6 month 1 day 3 years