HSE QUARTER PERFORMANCE RECORD

CONTRACT NUMBER : S44319087A QUARTER : 3

CONTRACTOR NAME : PT. ADIKARI WISESA INDONESIA YEAR : 2021

Maximum for
KPI (Category) Category KPI (Detail) Maximum for Detail Weight Scoring Methodology Remarks Score
Weight

≥10 Peduli card / 35% of Total Card Each Month (10%)

PEDULI CARD 10% 10
<10 Peduli card / 35% of Total Card Each Month (1%)

HSE Town Hall Meeting/ Management Visit ≤1 Meeting/ Quarter and/or Top Management not attend PHE
(Contractor HSE Top Management Talk to All WMO Meeting Invitation (0%)
Input 22% Employees) and Compliance of PHE WMO Meeting 2 Meeting/ Quarter with condition Top Management attend all PHE
6% 6
Invitation (Top Management must attend the WMO Meeting Invitation at that Quarter (2%)
Invitation). This is mandatory and as multiplier for this ≥3 Meeting/ Quarter with condition Top Managemnt attend all PHE
detail, allocated 0% in the event the Contractor Top WMO Meeting Invitation at that Quarter (6%)

PPE/Safety Equipment Distribution List, Monitoring Min-Max Stock,

PPE and Safety Equipment 6% 6
Health, Safety and Environment Control Usage PPE/ Safety Equipment Properly (6%)

As Multiplier for HSE KPI; In the Event of any fatality case in Project,
Fatality HSE Performance must be allocated as 0% and case must be
reported.

Total Recordable Injury Rate (TRIR) Case Including

Output 15% Restrictid Work (RW) Case and Medical Treatment 8% Zero Case/Quarter (8%) 8
(MT) Case - Case Must be reported.

First Aid/ Near Miss/ HIPO/ Incident related to >1 Case and Reported/Quarter (0%)
Property Damage, Marine, Fire/ Explosion, Illness - 7% 1 Case and Reported/Quarter (4%) 7
Case must be reported. Zero Case/Quarter (7%)

>2 Cases/Report at Related Quarter (0%)

2 Cases/Report at Related Quarter (2,5%)

Quality 9% 5
1 Cases/Report at Related Quarter (5%)

Zero Cases/Report at Related Quarter (9%)

>10% Lag Report of Total Report at Related Quarter (0%)

Reporting Perfomance 9% 9
<10% Lag Report of Total Report at Related Quarter (9%)

IFP Administration Compliance (D-2 for the lates

>3 Cases/Quarter (0%)
including SVRC, SBTC, MCU/ Medical Certificate, Sea 3% 3
Survival, COW PA Valid) Zero Case/Quarter (3%)

Operational Efficiency 48%

Response Time 7% Zero Case for Contractor Readiness for follow up user request. (7%) 7

<75% Actual Closed Vs Released (0%)

 Dashboard Perfomance 9% 75%< Actual Closed vs Released < 100% (4%) 9

100% Actual Closed vs Released (9%)

<75% Closed / Quarter (3%)

Measurement Point List (Input to SAP) 9% >75% Closed / Quarter (5%) 9
100% Closed / Quarter (9%)

≤1 Improvement through the application of innovation and

Innovation and Technology Approaches (Reported
technology approaches /Quarter (0%)
and Approved by Contract Holder and OIM/ FSOM/ 2% 0
GOM).
>1 Improvement through the application of innovation and
technology approaches /Quarter (2%)
Zero Case for Pinalty invoicing/Quarter (5%)
Cost 5% Actual Invoicing Release Order 5% 1 - 3 Case Pinalty invoice/ Quarter (2%) 0
>3 Case Pinalty Invoice/Quarter (0%)

Competency Assurance Scheme (Certificate needed as No Available for related Quarter (0%)
5% 0
signed in contract) Available for related Quarter (5%)
People 10%
<2% Turn Over Rate/Quarter (0%)
Staff Turn - Over 5% 5
Zero Turn Over Rate/Quarter (5%)
100%
100% 84
Contractor Representative's PHE WMO Representative's

Director Head of Technical Maintenance Field Operations Manager

PHE WMO PHE WMO

Catatan : penilaian QPR approved via email oleh pak Sapto 02 Desember 2021
 Lampiran 12 Pedoman No. A-005/PHE020/2016-S9 Rev.1
FORM HSE PERFORMANCE

Q3 2021 Predictive Maintenance Services (S44319087A)

Kesesuaian
No HSE Performance Target Realisasi
(%)
I Leading Indikator
1 HSE Meeting 1 3 300%
2 Safety & Intervention Program (Peduli 8 18 225%
Card)
3 Audit/Inspeksi HSE 1 1 100%
4 Emergency Drill N/A N/A
5 Insiden Investigasi 0 0 100%
6 Training HSE 3 3 100%
7 Tindak Lanjut hasil audit/inspeksi/WIP 1 1 100%
8 Jumlah Pekerja yang di Rapid atau Sesuai 9 100%
Swab Test Persyaratan
9 Persentase Pekerja yang Sesuai 9 (100%) 100%
mengumpulkan Formulir Persyaratan
Kewaspadaan COVID-19
10 Persentase daily absensi pekerja 92 91 98,91%
11 Jumlah sosialisasi Penanganan dan 1 1 100%
Pencegahan COVID-19 ke seluruh
Pekerja
12 Jumlah Drill Penanganan dan 1 1 100%
Pencegahan COVID-19
13 Presentase Pelaporan Status COVID- 0 4 0%
19
II Lagging Indikator
1 Jumlah Nearmis <3 0 100%
2 Jumlah First Aid <3 0 100%
3
- Fatality 0 0 100%
- Loss Time 0 0 100%
- Restricted Work Day Case 0 0 100%
- Medical Treatment <3 4 0
4
- Spill 0 0 100%
- Hydrocarbon Release 0 0 100%
- Non Compliance Case 0 0 100%
5 Fire / Explosion 0 0 100%
6 Property Damage 0 0 100%
7 Jumlah Pekerja terkonfirmasi Positif 0 4 0%
COVID-19
8 Jumlah Pekerja yang evakuasi 0 2 0%
COVID-19
Rata-Rata Persentase Kesesuaian 96.95%
 Lampiran 12 Pedoman No. A-005/PHE020/2016-S9 Rev.1

Disetujui

(Tri Aghna Satriya)

Perwakilan Perusahaan Perwakilan Kontraktor
Catatan :

- Jumlah Leading dan Lagging Indikator dapat disesuaikan dengan lingkup pekerjaan
- Target HSE Performance disesuaikan dengan kebutuhan operasi perusahaan
- Pencapaian performance : Diatas Target (>100 %), Sesuai Target (90 – 100 %), Dibawah
Target (<90 %)
 Lampiran 15 Pedoman No. A-005/PHE020/2016-S9 Rev.2

LEMBAR PENILAIAN
WORK IN PROGRESS

Kontraktor : PT. Adikari Wisesa Indonesia

Nama Pekerjaan : Predictive Maintenance Services (S44319087A)
Tanggal : Oktober 2021, Q3 2021
Status (Interim/Final) : Interim

Lingkari nomor yang paling mewakili evaluasi ini didasarkan pada kriteria untuk tujuan Peringkat
terlampir

No A B C D N/A Subtotal Faktor Total

I. PEOPLE - PERSONIL
1 Elemen 1 – Butir 1 0 4 8 12 12
2 Elemen 1 – Butir 2 0 4 8 12 8
3 Elemen 1 – Butir 3 0 4 8 12 12
4 Elemen 1 – Butir 4 0 4 8 12 12
5 Elemen 1 – Butir 5 0 4 8 12 12
6 Elemen 1 – Butir 6 0 4 8 12 12
7 Elemen 1 – Butir 7 0 4 8 12 12
8 Elemen 1 – Butir 8 0 4 8 12 12
9 Elemen 1 – Butir 9 0 4 8 12 12
10 Elemen 1 – Butir 10 0 4 8 12 12
11 Elemen 1 – Butir 11 0 4 8 12 12
12 Elemen 1 – Butir 12 0 4 8 12 12
13 Elemen 1 – Butir 13 0 4 8 12 12
Subtotal 152/13 X1 /13 11.69
II. PLANT- PERALATAN
14 Elemen 2 – Butir 14 0 4 8 12 12
15 Elemen 2 – Butir 15 0 4 8 12 12
16 Elemen 2 – Butir 16 0 4 8 12 12
17 Elemen 2 – Butir 17 0 4 8 12 12
18 Elemen 2 – Butir 18 0 4 8 12 N/A
19 Elemen 2 – Butir 19 0 4 8 12 12
Subtotal 60/5 X2 /5 12
III. PROSES
20 Elemen 3 – Butir 20 0 4 8 12 12
21 Elemen 3 – Butir 21 (*) 0 4 8 12 12
22 Elemen 3 – Butir 22 (*) 0 4 8 12 12
23 Elemen 3 – Butir 23 0 4 8 12 12
24 Elemen 3 – Butir 24 0 4 8 12 12
 Lampiran 15 Pedoman No. A-005/PHE020/2016-S9 Rev.2
25 Elemen 3 – Butir 25 0 4 8 12 12
26 Elemen 3 – Butir 26 0 4 8 12 12
27 Elemen 3 – Butir 27 0 4 8 12 12
28 Elemen 3 – Butir 28 0 4 8 12 12
29 Elemen 3 – Butir 29 0 4 8 12 12
30 Elemen 3 – Butir 30 0 4 8 12 12
31 Elemen 3 – Butir 31 0 4 8 12 12
32 Elemen 3 – Butir 32 0 4 8 12 12
Subtotal 156/13 X3/13 12
. 99.1 %
TOTAL PERSENTASE 100% = 100%

KESIMPULAN

TOTAL PENILAIAN 99.1 %*)

Catatan

• Total penilaian mewakili gambaran pelaksanaan tahapan WIP Kontraktor.

• Pilih N/A jika evaluasi tidak sesuai dengan lingkup pekerjaan
• (*) Bagi AP yang sudah melaksanakan Sistem ijin Kerja Aman (SIKA)
• Jika ada yang harus diperbaiki lanjutkan mengisi form tindak lanjut untuk alat monitoring

Dievaluasi oleh Diverifikasi oleh Disetujui oleh

Pengguna HSE Line Manager

Nama Budi Santoso
Tanggal 29 November 2021

Catatan : penilaian WIP approved via email oleh pak Andi dan pak Sapto 02 Desember 2021
 Lampiran 16 Pedoman No. A-005/PHE020/2016-S9 Rev.1
FORM MONITORING
TINDAK LANJUT TAHAPAN WIP

Kontraktor : PT Adikari Wisesa Indonesia

Nama Pekerjaan : Predictive Maintenance Services (S44319087A)
Tanggal : 19 Oktober 2021, Q3 2021
Status (Interim) : Interim

Tahapan Target Tanggal

No Deskripsi ketidaksesuaian Tindakan perbaikan PIC Status Bukti
(WIP) Penyelesaian Penyelesaian
I. PEOPLE-PERSONIL

II. PLANT-PERALATAN

III. PROSES

IV. HSE PERFORMANCE

Dibuat Oleh

Pengguna (user)