Form-I-001 Mobile Crane Form

Form-I-002 Wire Sling Form

Form-I-003 Webbing Sling Form
Form-I-004 Shackle Form
Form-I-005 Chain Block & Level Block Form
Form-I-006 Chain Sling Form
Form-I-007 Forklift Form
Form-I-010A Forklift daily Form
Form-I-021 Manlift Form
Form-I-021A Manlift daily Form
Form-I-022 Gondola form
Form-I-023 Scaffolding Form
Form-I-024 Ladder Form
Form-I-030 Molen concrete manual Form
Form-I-031 Mixer Truck Form
Form-I-031A Mixer Truck Daily Form
Form-I-032 Concrete Pump Form
Form-I-032A Concrete Pump Daily Form
Form-I-040 Pile Driving Form
Form-I-040A Pile Driving Daily Form
Form-I-043 Bulldozer Form
Form-I-043A Bulldozer Daily Form
Form-I-044 Excavator Form
Form-I-044A Excavator Daily Form
Form-I-045 Loadder Form
Form-I-045A Loadder Daily Form
Form-I-046 Grader Form
Form-I-046A Grader Daily Form
Form-I-047 Vibro Roller Form
Form-I-047A Vibro Roller Daily Form
Form-I-048 Power Shovel Form
Form-I-048A Power Shovel Daily Form
Form-I-049 Drag line -clamshell Form
Form-I-049A Drag line -clamshell Daily Form
Form-I-051 Lorry and Common Truck Form
Form-I-051A Lorry and Common Truck Daily Form
Form-I-052 Dump Truck Form
Form-I-052A Dump Truck Daily Form
Form-I-053 Ambulance Form
Form-I-053A Ambulance Daily Form
Form-I-054 Common Vehicle Form
Form-I-054A Common Vehicle Daily Form
Form-I-055 Trailler Truck Form
Form-I-055A Trailler Truck Daily Form
Form-I-060 Compressor, Gen-set, Water jet Form
Form-I-060A Compressor, Gen-set, Water jet Daily Form
Form-I-061 Electrical Panel and Appliance Form
Form-I-062 Welding Machine Form
Form-I-062A Welding Machine Daily Form
Form-I-063 Electric Air Compressor Form
Form-I-064 Chain Saw Form
Form-I-065 Grinding Form
Form-I-066 Hand Drill Form
Form-I-067 Cut-off machine Form
Form-I-068 Electrical Lighting Form
Form-I-069 Electrical Accesories Form
Form-I-070 Welding Trafo Form
Form-I-071 Welding Rod Dryer Form
Form-I-072 Winch Form
Form-I-073 Motor Hoist Form revised
Form-I-081 Safety Harness Form
Form-I-082 Fire Extinguisher Form
Form-I-090 Stamper Form
Form-I-091 Cutting Torch Form
Form-I-092 Manual Hydraulic Form
 Form-I-001

MOBILE CRANE INSPECTION FORM

i-III Project

CRAWLER CRANE TRUCK CRANE TRUCK MOUNTED CRANE ROUGH TERRAIN CRANE ALL TERRAIN
CRANE

:
Company : Police No.
Manufacturer name/ Model : (SILO/ SIA) No .
:
Manufacture year : Certifcate Validity
:
Serial Number : KEUR No.
Tag Number : Validity :

:
Capacity : Date of Inspection
:
Number of partline : Location of Inspection
Hours meter :

Metode
Hasil inspeksi
inspeksi
No Item inspeksi Deskripsi Keterangan
Visual Func. OK Not OK

1 LOWER STRUCTURE
Tidak ada tanda kerusakan mekanis ( retak/
2.1 Chasis bengkok /penyok) dan tidak berkarat ●

- Tekanan angin sesuai dengan rekomendasi

pabirkan
- Tidak sobek atau keretakan pada dinding
2.2 Tires samping ●
- Tidak aus

Tidak ada kebocoran angin pada sistim pengereman,

2.3 Brake ●
dan berfungsi baik

Tidak ada kebocoran angin pada sistim pengereman,

2.4 Parking brake ● ●
dan berfungsi baik

2.5 Steering berfungsi baik dan tidak ada kebocoran oli hidrolis ●

baut lengkap dan tidak kendur, tidak ada tanda

2.6 Under carriage kerusakan mekanis

2.4 Flat bed ( for TMC) Tidak ada kerusakan mekanis ● ●

3 OUTRIGGER

Tidak ada tanda kerusakan mekanis

Outrigger beam (R/L Front, R/L
3.1 mudah digerakkan ( extend/ retract) ● ●
Rear)
lubrication

Outrigger jack cylinder (R/L Front,

3.2 tidak ada goresan dan rembesan oli hodrolis ●
R/L Rear) / aux.

Outrigger shoes (R/L Front, R/L No crack nor mechanical damage ( bent and dent)
3.3 ●
Rear) / aux completed with pin lock

Outrigger Hydraulic hose and

3.4 No leak nor crack ●
connector (R/L Front, R/L Rear, aux)

4 SWING ( TURN TABLE)

4.1 Bolt and nut tidak ada baut yang lepas atau kendur ●

4.2 Hydraulic pump and motor no leak and well function ● ●

4.3 Hydraulic hose and connector no leak and no crack ●

4.4 Swing brake berfungsi baik ● ●

4.5 Swing lock berfungsi baik ● ●

5 PRIME MOVER
no corrosion, crack, and mechanical damage
completed with proper cap
5.1 Fuel tank ●

no water trap change as maintenance schedule

5.2 Fuel filter ●
 Metode
Hasil inspeksi
inspeksi
No Item inspeksi Deskripsi Keterangan
Visual Func. OK Not OK
no leak
5.3 Fuel hose and connector ●

well function
5.4 Fuel indicator ●

changed as maintenance schedule

5.5 Oil filter ●

no leak
5.6 Oil hose and connector ●

well function
5.7 Oil level indicator ●

coolant or water level meet manufacturer

5.8 Radiator recomendation ●

Radiator hose, piping system and no leak nor crack

5.9 ●
conection
Have cover by isolator material ex. rubber, hard
5.10 Battery plastic ●
Mounted properly

Electrical cable and distribution

5.11 insulated conected properly ●
board
well function , Easy for start and stop
5.12 Motor starter for engine start ●

No abnormal noise, no leak, easy for start and off, no

5.13 Main engine spark ● ●

5.14 Exhaust system no mechanical damage ●

5.15 Spark arrestor no mechanical damage ●

6 HYDRAULIC SUPPLY SYSTEM

No corrosion, crack, and mechanical damage
Completed with proper cap
Oil level meet manufacture recomendation
6.1 Oil hydraulic tank ●

well function
6.2 Oil hydraulic level indicator ●

no leak nor crack

6.3 Hose hydraulic supply system ●

no leak nor crack

Well function
6.4 Pump and Selector valve ●

7 Drum and wire rope

- Proper spooling of wire rope
- Proper anchorage
- Drum flange shall extend min 1/2 inch over top
7.1 Load hoist drum ( main) layer of wire rope ● ●
- Smooth movement for lifting and lowering
mechanism

- Proper spooling of wire rope

- Proper anchorage
- Drum flange shall extend min 1/2 inch over top
7.2 Load hoist drum ( Auxilliary) layer of wire rope ● ●
- Smooth movement for lifting and lowering
mechanism

- Proper spooling of wire rope

- Proper anchorage
- Drum flange shall extend min 1/2 inch over top
7.3 Drum boom hoist layer of wire rope ● ●
- Smooth movement for lifting and lowering
mechanism

7.4 Drum brake well function ● ●

7.5 Drum lock Pawl well function ● ●

- The wire rope type and size appropriated with

manufacture
- adequate greasing
- No kinking, crushing, unstranding, birdcaging,
bend severe corroded, and reduction of rope
7.6 Wire rope (main) diameter ●
- No broken wire two randomly in six rope
diameter , or four randomly distributed in 30 rope
diameter.
 Metode
Hasil inspeksi
inspeksi
No Item inspeksi Deskripsi Keterangan
Visual Func. OK Not OK
- The wire rope type and size appropriated with
manufacture
- adequate greasing
- No kinking, crushing, unstranding, birdcaging,
bend severe corroded, and reduction of rope
7.7 Wire rope (Aux.) diameter ●
- No broken wire two randomly in six rope
diameter , or four randomly distributed in 30 rope
diameter.

- The wire rope type and size appropriated with

manufacture
- Adequate greasing
- No kinking, crushing, unstranding, birdcaging,
bend, severe corroded, and reduction of rope
7.8 Wire rope boom hoist diameter ●
- No broken wire six randomly in one lay , or three
broken wire in one strand

- The wire rope type and size appropriated with

manufacture
- adequate greasing
- no crushing, unstranding, birdcaging,
bend severe corroded, and reduction of rope
7.9 wire rope for boom pendant diameter ●
- no more than two broken wires in one lay in
sections beyond end connections or no more
than one broken wire at an end connection

8 BOOM , SHEAVE, A-FRAME

- Retract and extend well function
8.1 Telescopic boom - No mechanical damage ( bent, dent, crack, etc) ● ●

No oil leak
8.2 Boom Lift Cylinder ●

No mechanical damage
8.3 Boom pivot ●

No excessive corrosion nor mechanical damage

( bend, dent, crack, ect) at main cord, lattice member,
8.4 Lattice boom and connection lug in every section of boom ●

No mechanical damage, no slack/ loose, complete

8.5 Joint pin boom with cotter pin ●

No excessive corrosion nor mechanical damage

8.6 Jib or luffing boom ( bend, dent, crack, ect) ●

No excessive corrosion nor mechanical damage

8.7 Boom back stopper ( bend, dent, crack, ect) ●

- No excessive corrosion nor mechanical damage

( bend, dent, crack, ect)
- No in-printing defect
- Smooth and in line, adequate grease at bearing
8.8 Sheave / pulley - Completed with wire rope pin guard ● ●
- No slack nor mechanical damage on center pin

- No excessive corrosion nor mechanical damage

8.9 A-Frame / gantry ●
( bend, dent, crack, ect)

9 COUNTERWEIGHT
- No mechanical damage, proper socket / center
pin / locking device
9.1 Counterweight assy - clear load weight identification ●

No mechanical damage
9.2 Counter weight Lifting lug ●

10 HOOK BLOCK ( Main hoist)

- Name plate : indicated SWL and weight of block
- No mechanical damage on sheave and rever to
10.1 sheave Block asssy 8.8 ● ●

10.2 wedge socket assy Proper installation ●

complete and proper thightening

10.3 tie bolt ●

No mechanical damage and completed with cotter pin

10.4 center pin ●

no slack, adequate grease, and well function

10.5 swivle ● ●

no crack, no excessive corrosion, no indicate welding,

no nick, not twist, and no increase throat opening
10.6 hook body max. 5 % or 6 mm ●
 Metode
Hasil inspeksi
inspeksi
No Item inspeksi Deskripsi Keterangan
Visual Func. OK Not OK
proper self locking hook
10.7 Safety latch ●

11 HOOK BLOCK ( Aux. hoist)

11.1 wedge socket assy Proper installation ●

- No mechanical damage
- pin connection C/W cotter pin
11.2 headache ball or swivle hook assy - no slack, adequate grease, and well function ●
- Name plate : indicated SWL and weight of block

no crack, no excessive corrosion, no indicate welding,

no nick, not twist, and no increase throat opening
11.3 hook body max. 5 % or 6 mm ●

proper self locking hook

11.4 Safety latch ●

12 CABIN
not blurry, not crack
12.1 Wind shield ●

No crack or damage, swing or sliding well function,

12.2 cabin door c/w handle and lock ● ●

Installed properly, no crack or damage

12.3 stair & railing ●

well function
12.4 pedal, operating lever and switch ● ●

Installed properly, good suspension, C/W seat belt

12.5 Operator seat ●

Min. Fire Rating 10 BC

12.6 Portable Fire extinguisher ●

completed and not expired

12.7 First aid kit ●

well function
12.8 whipper ●

13 SAFETY DEVICE AND INDICATOR

13.1 Level indicator well function ●

13.2 Boom angle Indicator well function ●

13.3 Boom length Indicator well function ●

- Indicator of load weight, boom length, working

radius, boom angle, height of lift, reeving, and rated
Load Moment Indicator / Safe load capacity well function as well as safe load limitter.
13.4 - Accuracy measurement for these variable ●
Indicator

13.5 Load chart well function ●

13.6 Boom Hoist Limitter well function ●

13.7 Anti two block ( Main & Aux) well function ●

13.8 Overload warning light and alarm well function ●

13.9 Emergency shut down well function ●

13.10 Drum rotation indicator well function ( by camera or mirror) ●

13.11 Pressure indicator well function ●

13.12 Engine Temperature indicator well function ●

13.13 Hour meter well function ●

14 OPERATING WARNING DEVICE

14.1 Horn well function ●

14.2 Reverse alarm well function ●

14.3 Swing alarm well function ●

 Metode
Hasil inspeksi
inspeksi
No Item inspeksi Deskripsi Keterangan
Visual Func. OK Not OK

14.4 warning lamp on cabin well function ●

14.5 Rotary lamp well function ●

15 MIRROR AND LAMP

15.1 Mirror well function ●

15.2 Front lamp well function ●

15.3 Rear and brake lamp well function ●

15.4 turn signal lamp ( sein) well function ●

15 ACESSORIES
15.1 Safety cone minimum 4 ea
●

15.2 Outrigger mats C/W lifting lug, and appropriated with number of
outrigger ●

Inspection Summary :

Inspection Status :
PASSED

HOLD

REJECTED

Special note from Client

Operator/Subcont Rep. Inspector Contractor Rep. Client

Name and Signature Name and Signature Name and Signature Name and Signature
 Form-I-002

WIRE ROPE INSPECTION

i-III Project
Pre-Hire/ Pre-use / Quarterly

Company : Tag Number format

Date of Inspection Comp. Initial Type unic number

Location of Inspection XXXX WRS XXX

Validity Co
rro
si o
no Ki
Br rh n Da
ok ea k/ ma
e nw t Cr bi ge
W da us rd fit
ir e or m h ca tin
n ag ed ge g Ot
e he
r
Comment
No Tag Number Manufacturer Type WLL Length Serial Number Cert. No Inspection result
(Ton) (m) 3 rd party/ manu. OK Reject Rejection Criteria ASME B30.9)

Inspection Summary & Recommendation :

 Co
rro
si o
no Ki
Br rh n Da
ok ea k/ ma
e nw t Cr bi ge
W da us rd fit
ir e or m h ca tin
n ag ed ge g Ot
e h er
Comment
No Tag Number Manufacturer Type WLL Length Serial Number Cert. No Inspection result
(Ton) (m) 3 rd party/ manu. OK Reject Rejection Criteria ASME B30.9)
Subcont Rep. Inspector Contractor Rep.

Name and Signature Name and Signature Name and Signature

 SYNTHETIC SLING INSPECTION
i-III Project
Pre-Hire/ Pre-use / Quarterly

Company : Tag Number format

Date of Inspection : Comp. Initial Type unic number

Location of Inspection : XXXX WBS XXX

Validity : Bu M
rn an
Ho uf
l (H a ctu
Ab e/s ea re
r na t/ c St r Ta
Cu as g/ he itc g
s io pu m mi
t n ll ica hi ss Ot
l) ng in he
g r

No Tag Number Manufacturer Type WLL Length Serial Number Cert. No Inspection result
(Ton) (m) 3 rd party/ manu. OK Reject Rejection Criteria ASME B30.9)

Inspection Summary & Recommendation :

Subcont Rep. Inspector Contractor Rep.

 Bu M
rn an
Ho uf
(H a ctu
Ab l
e/s ea re
ra na t/ c St r Ta
Cu ssi g/ he itc g
on p ul mi mi
t l ca hi ss Ot
l) ng in h
g er

No Tag Number Manufacturer Type WLL Length Serial Number Cert. No Inspection result
(Ton) (m) 3 rd party/ manu. OK Reject Rejection Criteria ASME B30.9)

Name and Signature Name and Signature Name and Signature

 Form-I-004

Comment
 Form-I-004

SHACKLE INSPECTION
i-III Project
Pre-Hire/ Pre-use / Quarterly

Company : Tag Number format

Date of Inspection : Comp. Initial Type unic number

Location of Inspection : XXXX SC XXX

Validity : be
Th nd ex mi
rea ,t ce ssi
wi ssi He ng
de st, at
dd de ve d m
am nt , co am an
wo rro a u.
ag crac g na Ot
rn e sio e me he
k n r

Comment
No Tag Number Manufacturer Type WLL Size Serial Number Cert. No Inspection result
(Ton) (m) 3 rd party/ manu. OK Reject Rejection Criteria ASME B30.26)

Inspection Summary & Recommendation :

Subcont Rep. Inspector Contractor Rep.

Name and Signature Name and Signature Name and Signature

 Form-I-005

CHAIN BLOCK (CB) & LEVER BLOCK (LB) INSPECTION FORM

Pre-Hire/ Pre-use / Quarterly

Company : Tag Number format :

Date of Inspection : Comp. Initial Type unic number

Location of Inspection : XXXX CB/LB XXX

Validity :

Tag No.

Manufacturer

Serial Number

WLL

Reeving

REJECTION CRITERIA ( Visual ASME 30.16)

1. Load chain
a). No crack, corrosion, twist, bend Yes / No Yes / No Yes / No

b). No cut or indicate unauthorized welding Yes / No Yes / No Yes / No

2. Drive chain

a). No crack, corrosion, twist, bend Yes / No Yes / No Yes / No

b). No cut or indicate unauthorized welding Yes / No Yes / No Yes / No

3. Load Hook

a). No crack, nick, gouges corrosion, twist, bend Yes / No Yes / No Yes / No

b). No cut or indicate unauthorized welding Yes / No Yes / No Yes / No

c). No Safety latch damaged, inability to lock Yes / No Yes / No Yes / No

d). No Increase throat opening Yes / No Yes / No Yes / No

4. Hanger hook

a). No crack, nick, gouges corrosion, twist, bend Yes / No Yes / No Yes / No

b). No cut or indicate unauthorized welding Yes / No Yes / No Yes / No

c). No Safety latch damaged, inability to lock Yes / No Yes / No Yes / No

d). No Increase throat opening Yes / No Yes / No Yes / No

5. Lever

no Bent, cracked, or otherwise damaged Yes / No Yes / No Yes / No

6. Hoist braking system ( function test)

well function Yes / No Yes / No Yes / No

INSPECTION RESULT OK REJECT OK REJECT OK REJECT

Note :
Inspection Summary :

Operator/Subcont Rep. Inspector Contractor Rep.

Name and Signature Name and Signature Name and Signature

 Form No.: Form-I-006

CHAIN SLING Inspection Date :

Location of Inspection :
Company/ Subcontractor :

INSPECTION STANDARD Validty of Inspection :

Seri No. :
(PP/No.50/2012) Type of Inspection : Monthly for High Risk / every 3 Months

INSPECTION METHOD INSPECTION RESULT

No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT Client
1 Link by link of chain No crack ,bent, stretched, heat damage (tidak retak, bengkok, ●
rusak karena panas)
2 Capacity tag Available, readable (tersedia, terbaca) ●

3 Master link or coupling No deformed ●

4 Certicate Valid from authority juridiction (valid, dari pihak yang ●

berwenang)
5 Hook Safety lack work, no bent (pengunci berfungsi, tidak bengkok) ●

6 Chain Not corrosive (tidak berkarat) ●

INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number
 Form No.: Form-I-003
Inspection Date :
FORKLIFT Location of Inspection :
Company/ Subcontractor :
INSPECTION STANDARD Validity of Inspection :
Seri No. :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) Type of Inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government
regulation and PT IP SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No.:
Machine/ Engine No: Certificate (STNK) No.:
Serial/ Plate/ Body No.: Certifcate Validity:
Manufacture/ Year: Validity Vehicle test by Government (KIR):
Lifting Manufacture/ Year: Equip. Operation license (SILO/ SIA) No.:
Equip. Operation license (SILO/SIA)
Capacity:
Validity:
Serial Lifting No: Operator Name:
ID No: FK - ………… Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION USER HSE
Document

1 Maintenance record For the pass year is available ●

2 Daily check list For the pass one month is available ●
3 GoI Certificate valid ●
4 Electrical system
Battery
Wiring
Starter

5 Cooling system ( Radiator)

coolant level
piping and hose
Temperature Indicator

6 Fuel system
Fuel tank
Fuel Filter
Fuel level indicator
piping and hose

7 Lubricant system
oil Filter
piping and hose

8 Engine condition

9 Exhaust
not excessive wear, and not tear on side wall tire ●
10 Wheel tires (ban)

●
10 Wheel brake aan parking brake

11 Hydraulic system
Hydraulic tank
Hydraulic hose and valve
Hydraulic cylinder

12 Cabin
Seat Operator C/W seat belt
Overhead guard (pelindung atas/ atap)

4 Engine oil (oli mesin)
5 Hydraulic oil (oli hidrolic)
6 Radiator
Seat safety belt (sabuk pengaman)
10
is full and free of leaks (penuh,tidak bocor) ●
is full and free of leaks (penuh,tidak bocor) ●
is full and free of leaks (penuh,tidak bocor) ●
is accessible and not damaged, oily, or dirty (mudah ●
dijangkau,tidak rusak/berminyak/kotor)

Engine (mesin) Not leaks and no sparks from the exhaust (tidak bocor, ●
11 tidak ada percikan api dari knalpot)
12 Horn (klakson) Good functiong (berfungsi) ●
Turn signal (bunyi sein) Operates smoothly (berfungsi dengan baik) ● ●
13
Reverves signal (bunyi mundur) Operates smoothly (berfungsi dengan baik) ● ●
14
Lights (head, tail, and warning) Work and are aimed correctly (berfungsi dengan baik) ● ●
15 (lampu : atas, belakang, peringatan)
Gauges and instruments Good functiong (berfungsi) ● ●
16
Steering (kemudi) Smooth and responsive free of excessive play (berfungsi ●
17 dengan baik dan responsif ketika diputar)
Brakes (rem) Good Function (berfungsi baik) ●
18
Fire extinguisher (APAR) is available,not expired,easy for taking (tersedia,tidak ●
19 kadaluarsa, mudah untuk diambil)
First aid xox Available (ada) ●
20
Special Requirement
Not bent, worn, or cracked. Upper limit stops are OK (tidak ● ●
1 Forks and mast (garpu dan tiangnya) bengkok,licin,retak. Maksimum angkat berfungsi)

Load back rest extension (sandaran In place and not bent, cracked, or loose (terletak ● ●
2 ditempatnya, tidak bengkok/ retak/ loose)
beban)
Overhead guard (pelindung atas/ In place and not bent, cracked, or loose (terletak ●
3 atap) ditempatnya, tidak bengkok/ retak/ loose)
4 Forklift body (badan forklift) free from grease, oil (bebas dari grease, oli) ●
In place and readable (pada tempatnya dan terbaca) ●
5 Load rating plate (papan rating beban)

Warning decals (peringatan
6 pemakaian)
7 Lift and lower (atas dan bawah)
8 Tilt (kemiringan)
9 Control levers (presneling)
Parking brake (rem parkir/ rem
10
tangan)
11 Backup alarm (if equipped)
Fire extinguisher (APAR)
12
13 Fuel gas system (bahan bakar gas)
14 Flame arrestor (saringan knalpot)
Operators' manual are present and readable (terdapat ●
manual operasi dan terbaca)
Operates smoothly without excessive drift (berfungsi ●
dengan baik tanpa hambatan)
Operates smoothly without, excessive drift or "chatter" ●
(berfungsi dengan baik tanpa decitan)
Good Function (berfungsi dengan baik) ●
Good Function (berfungsi dengan baik) ●
Good Function (berfungsi dengan baik) ●
is available, not expired, easy for taking (tersedia, tidak ●
kadaluarsa, mudah untuk diambil)
Hose line not crack,leak (slang tidak retak, bocor) ● ●
Regulator tight, work, measured press. Work (regulator ● ●
rapat, berfungsi, pengukuran tekanan berfungsi)
Lpg cage is tight,safety lutch work properly (tempat lpg ● ●
rapat, pengunci berfungsi)
Tight, min. as PT IP standard (rapat, min. sesuai dengan ●
standar PT IP)

INSPECTION STATUS
PASSED
Rear Overhead Cross head
HOLD View Guard
Mirror Lifting
Chain
REJECTED Sign Mas
al k
Lam
p Carriag
SPECIAL NOTE FROM CLIENT: Seat e
Belt
Fork
Fue
l
INSPECTION BY APPROVED BY
Tire Bod Steerin
y Head Lamp g
Name and Signature Name and Signature
Stiker Number

Stiker Number
Stiker Number
 SCAFFOLD INSPECTION FORM SCAFFOLD INSPECTION FORM
1 (Monthly) 1 (Monthly)

Form : F-023 Form : F-023

1 Scaffold No. : 5 Date Erection : 1 Scaffold No. : 5 Date Erection :
2 Category : 6 Erection by : 2 Category : 6 Erection by :
3 Location : 7 PTW No. ( Eretion) : 3 Location : 7 PTW No. ( Eretion) :
4 Section Area / Elevation : 8 Validity Date : 4 Section Area / Elevation : 8 Validity Date :

5 Scaffold Type : 5 Scaffold Type :

Inspector Name Sub-Cont. : / (Sign) Inspector Name Sub-Cont. : / (Sign)
Contractor : / (Sign) Contractor : / (Sign)

Foundation / Ties / Castor Good Poor Foundation / Ties / Castor Good Poor

Sole plate Sole plate

Base Plate Base Plate
Ties Ties
Castor ( Mobile Scaffold) Castor ( Mobile Scaffold)

Structure Scaffold Good Poor Structure Scaffold Good Poor

Standard ( max high 3 x width of base dimension) Standard ( max high 3 x width of base dimension)
Spurs ( cantilever scaffold) Spurs ( cantilever scaffold)
Ledger Ledger
Transom Transom
Long Brace Long Brace
End brace End brace
Plan Brace ( Mobile Scaffold) Plan Brace ( Mobile Scaffold)

Fitting & Connection Good Poor Fitting & Connection Good Poor

Correct Fitting & Connection Correct Fitting & Connection

Fixed Clamp, Swivle clamp, Sleeve coupler, Girder coupler,Inner joint,putlog clamp Fixed Clamp, Swivle clamp, Sleeve coupler, Girder coupler,Inner joint,putlog clamp
Platform Good Poor Platform Good Poor
Putlog Putlog
Boards (min. 2 sheets , max gap 1 ", & proper ties) Boards (min. 2 sheets , max gap 1 ", & proper ties)
Toe board Toe board
Mid Rail Mid Rail
Hand rail ( 90 -110 cm high) Hand rail ( 90 -110 cm high)
Ladder Good Poor Ladder Good Poor
Rung ( 30 cm with anti slip) Rung ( 30 cm with anti slip)
landing platform ( more than 5 m heigh) landing platform ( more than 5 m heigh)
Min Extended 90 cm heigh from platform Min Extended 90 cm heigh from platform

INSPECTION RESULT SAFE / REPAIR INSPECTION RESULT SAFE / REPAIR

 Item to be repair Item to be repair
Finding Description / Recommendation Finding Description / Recommendation

Note Note

Scaffold Category: Scaffold Category:

Heavy Duty ( 675 Kg / Bay) : Transom Spacing 1,2m / ledger spacing 1,8 Heavy Duty ( 675 Kg / Bay) : Transom Spacing 1,2m / ledger spacing 1,8
Medium duty ( 450 Kg /Bay): Transom Spacing 1,8m / ledger spacing 2,4 Medium duty ( 450 Kg /Bay): Transom Spacing 1,8m / ledger spacing 2,4
Light Duty ( 225 Kg / Bay): Transom Spacing 1,8m / ledger spacing 2,4 Light Duty ( 225 Kg / Bay): Transom Spacing 1,8m / ledger spacing 2,4

Type Scaffold: Type Scaffold:

Independent / Single pole / Hung / cantilever/ Mobile Independent / Single pole / Hung / cantilever/ Mobile
 Form No.: Form-I-006

CHAIN SLING Inspection Date :

Location of Inspection :
Company/ Subcontractor :

INSPECTION STANDARD Validty of Inspection :

Seri No. :
(PP/No.50/2012) Type of Inspection : Monthly for High Risk / every 3 Months

INSPECTION METHOD INSPECTION RESULT

No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION HSE USER
1 Link by link of chain No crack ,bent, stretched, heat damage (tidak retak, bengkok, ●
rusak karena panas)
2 Capacity tag Available, readable (tersedia, terbaca) ●

3 Master link or coupling No deformed ●

4 Certicate Valid from authority juridiction (valid, dari pihak yang ●

berwenang)
5 Hook Safety lack work, no bent (pengunci berfungsi, tidak bengkok) ●

6 Chain Not corrosive (tidak berkarat) ●

INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number
 Form-I-081

FULL BODY HARNESS INSPECTION

Pre-Hire/ Pre-use / Quarterly

Company : Tag Number format

Date of Inspection : Comp. Initial Type unic numbunic number

Location of Inspection : XXXX FBH XXX

Validity : Rejection criteria :
1. Excessive Corrosion on carabiner, D-ring, & snap hook

St
W
2. Wear /tear/ loss stitches/ heat damage/ chemical contamination on webbing

sh
it c
eb
harnes or lanyard or shock absorber

oc
hi
b

Sn
in

ka
ng
3. Twist / bent / dent, on D-ring /carabiner/ snaphook

Ca
g

lan

ap
bs
/j
4. Snaphook malfunction

ra
ha

Ot
ya

ho
ah

bi

or
-ri
rn

ne

h
rd
be

ok
i ta
es

ng

er
r

r
n
s
No Tag Number Manufacturer Serial Number Inspection result Comment
Inspection item OK Reject

Inspection Summary & Recommendation :

Prepared/ Inspector Aproved

Name and Signature Name and Signature