METHODE OF STATEMENT

PROJECT : Install FM-200 ER 7 TQ1

Revision – 0
REVISION STATUS :
INSTALLATION OF: Site Office Preparation/Container Positioning
(Location)
METHOD PTJ-SBI-MS-01
STATEMENT & Lembar 1 of 5
RISK ASSESSMENT
No.
RISK LEVEL
ν
HIGH MEDIUM LOW
Complete all parts, use N / A on the part that is not appropriate
( If a more complete plan is needed, attach a separate sheet )

1.0 Decreption Of Work Scope :

Contractor : PT. Prima Tunggal Javaland

Supervisor : Syatori

Plan date to start : 27 Oktober 2021

Plan date completed : 27 Oktober 2021

Planning and preparation site office :

To discuss with User for the access to avoid any disruption with the production activity
2. Required Work Yes No DETAILS/NOTES
Permit

General Work Permit: ν

Hot Work: ν

Working at high ν

Lifting Activity ν

Excavation ν
 No. : PTJ-SBI-MS-01
WORK METHOD Rev. : 0
Dept. : HSE
SITE OFFICE Date : 27 October 2021
Page : 2 of 6

Energy Isolation

3.0 ENDORSMENT DATE NAME SIGNATURE

Preparation by: 26/10/2021 Syatori
Checked by: 26/10/2021 Anggis Ega F
Approved by: 26/10/2021 Hermansyah

4.0 ACCESS YES NO DETAILS/NOTES

Closed Main Road ν

Pedestrian ν

Roofing ν

Next Platform ν

Details ν

5.0 EXCAVATION YES NO DETAILS/NOTES

Underground Cable If there is excavation work,

ν make sure there is no
underground facility
Buried cables that can
be electrically
insulated
ν
( If not, equipment with high
risk, including hand tools
with edges / sharp edges,
must be avoided as far as 1
meter from the location of
suspected buried cables)

Attach required details

(image, physical / wide
marking or detection using a
detection cable, etc.)

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WORK METHOD Rev. : 0
Dept. : HSE
SITE OFFICE Date : 27 October 2021
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6.0 Vehicle and Lifting YES NO DETAILS/NOTES

Vehicle:

Lifting Operating: Refer to Drawing Lifting

ν Study Attached.

Refer to Drawing Container

Attach detail as needed: ν Access Attached

7.0 SAFETY Yes No DETAILS/NOTES

Fire Fighter/Emergency:
ν
Lock Out Tag Out:

Pengawas Safety: ν Anggis Ega F.

Fire Watcher ν
Additional equipment ν
and PPE

8.0 LINKAGE YES NO DETAILS/NOTES

Drainase/Water ν
Disposal:
Production Proccess: ν
Utility: ν
Other:
ν

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 No. : PTJ-SBI-MS-01
WORK METHOD Rev. : 0
Dept. : HSE
SITE OFFICE Date : 27 October 2021
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9.0 Use of Chemicals Yes No DETAILS/NOTES

Solvent to use:: ν

Dangerous Material has ν

be disposal:

Use of hazardous
chemicals
ν

If YES to any of the

above, provide a
separate explanation

10.0 Special Equipment/ Equipment (Register)

Equipment
1. Forklift

HSE Item
Item 1 : Barricade Line
Item 2 : PPE mandatory (helm, Safety Glass, Safety Vest, Hand Glove, Safety Shoes)
Item 3 : Safety Sign

11.0 RESTRAINTS (Anticipated List)

Item 1 : Forklift collapse

Item 2 : Hit during the swing Site Office process
Item 3 : Pinched
Item 4 : Site Office fall

12.0. Roles and Responsibilities

List of names and contact :

Site Manager :Hermansyah 0819 – 0613 - 5117

Site Supervisor : Syatori 0821 – 1160 - 8791

Safety Officer : Anggis Ega F. 0888 – 0555 - 9832

First Aider : Anggis Ega F. 0852 – 1980 – 2021

SBI Representative : Sugeng 0813 – 8455 – 0572

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WORK METHOD Rev. : 0
Dept. : HSE
SITE OFFICE Date : 27 October 2021
Page : 5 of 6

13.0 Description Of Work Methods

Work Description:

1. Preparation Works
a. Cleaning the area from all rubbish
b. Marking the Container positioning and base level For Container
c. Barricade the container area.

2. Unloading Container
a. To Make sure The PTW has been approved by SBI.
b. Forklift has been inspected and approved (Equipment Inspection
Form Attached)
c. Container delivery to site follow the Container Access (As
attached)
d. Open the twist lock on the trailer.
e. Make sure forklift position placed in lifting point/ Center of Gratify
(COG) area.
f. Forklift forks must be up to the end of the container.
g. Lift low and hold to see the balance of the container and the lift
strength of the forklift.
h. Container positioning to around follow the marking.

Finish

Notes:

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WORK METHOD Rev. : 0
Dept. : HSE
SITE OFFICE Date : 27 October 2021
Page : 6 of 6

Lampiran

LIFTING PLAN

6
 ACCESS STUDY

FOR SITE OFFICE, STEEL STRUCTURE DELIVERY & UNLOADING

1. GENERAL

Untuk semua fasilitas bongkar muat SITE OFFICE, TOOLS dan EQUIPMENTS penggunaan area yang
ditetapkan sebagaimana ditentukan disini, fasilitas pembongkaran seperti areanya, jenis alat angkat
salah satunya seperti forklift, mobile crane atau telescopic crane harus di sediakan.

2. SITE PLAN LOCATION

Jalur Masuk Trailer

Kontainer PTJ
Contractor Site Temporary facility Area

3. SAFETY REQUIRED ON SITE

a. Pastikan jadwal kedatangan untuk unloading sudah terkordinasi dengan pihak owner /
perusahaan. Pastikan jadwal kedatangan untuk unloading sudah terkordinasi dengan pihak
management perusahaan.
b. Dalam memasuki area harus mengikuti SITE PLAN LOCATION yang telah di tentukan.
c. Titik parkir Trailer dekat area LOKASI unloading site temporary office.
d. Jarak dari pembongkaran (2 kali dari ketinggian site container atau lebar container dari COG
saat manuver) harus di beri barricade untuk menjaga batas aman.
Prepared by PTJ Check’d by PTJ Approved by PTJ Approved by Client/SBI

Syatori Anggis Ega F Hermansyah

Site Spv HSE Officer Site manager