FORMS & CHECKLIST No.

GROGOL-HSE-73

“COMMISIONING MOBILE Tgl Penerbitan:

Tgl Persetujuan:
29 Maret 2018
01 Maret 2019

CRANE” No. Revisi: 0

Divisi: HSE Halaman: 1 dari 1

Departemen: HEALTH AND SAFETY ENVIRONMENT(HSE)

HAZARD
No ITEMS / DESCRIPTION GOOD FAIL N/A COMMENT
CODE
1. VISIBILITY
1.1 Strobe Light with Yellow and Blue Color
1.2 Call Sign on 4 Sides of Equipment
1.3 White Color Strip Reflector Around Cabin
2. REQUIREMENT of CABIN
2.1 2 Way Communication Radio
2.2 Operator Seat and Seat Belt
2.3 ROPS / FOPS
2.4 Portable Fire Extinguisher or Fire Suppression System >=100T
2.5 Instrument Panel
2.6 Horn
2.7 Foot Step and Hand Hold
2.8 Front Windshield
2.9 Mirror
3.0 Load and Monitor Control
3. LAMPS and ELECTRICAL ACCESSORIES
3.1 Head Lamps I Rear Lamps I Sign Lamps
3.2 Reverse Alarm
3.3 Swing Body Alarm
3.4 Lock Out and Tag Out Switch
3.5 Battery Isolation Switch
3.6 Emergency Shutdown Push Switch
3.7 Battery and Cable Connection in Good Condition
3.8 SWL Capacity Identification on Telescopic Boom and Block
3.9 Load Chart Identification in Cabin
4.0 Valid Lifting Certification
4. STEERING,BRAKING SYSTEM and UNDERCARIAGE
4.1 Steering Control and Function
4.2 Steering System and Hydraulic Lines
4.3 Steering Wheel Turning Point
4.4 Wheel and Tyres Condition
4.5 Service and Parking Brake
5. ENGINE and OTHERS
5.1 Engine Condition of Leakage
5.2 Engine Usage Meter
5.3 Muffler Pipe Cap
6. IMPLEMENT
6.1 Implement Control and Function
6.2 Wire Rope Condition
6.3 Counter Weight Condition
6.4 Safety Latch for Main and Auxiliary Hook
6.5 Anti Two Block Function
6.6 Over Load Alarm
6.7 Hydraulic Cylinder Condition
6.8 Out Rigger and Base Plate

No Name Occupation and Company Signature No DEVIATION LIST DUE DATE

1 1
2 2
3 3
4 4

Copy 1. HSE Dept HAZARD S = STOP and Repair Immediately

2. Plant Dept H = Repair Immediately in 12 Hours /1 Shift
M = Repair Immediately in max 3 Days
L. = Repair Immediately in max 7 Days
 FORMS & CHECKLIST No. GROGOL-HSE-73

“COMMISIONING MOBILE Tgl Penerbitan:

Tgl Persetujuan:
29 Maret 2018
01 Maret 2019

CRANE” No. Revisi: 0

Divisi: HSE Halaman: 2 dari 1

Departemen: HEALTH AND SAFETY ENVIRONMENT(HSE)

Note/Catatan :

Copy 1. HSE Dept HAZARD S = STOP and Repair Immediately

2. Plant Dept H = Repair Immediately in 12 Hours /1 Shift
M = Repair Immediately in max 3 Days
L. = Repair Immediately in max 7 Days