FORMS & CHECKLIST No.

EIM-HSE
Tgl Penerbitan:
“CHECKLIST COMMISIONING” Tgl Persetujuan:
No. Revisi:
Divisi: HSE Halaman: 1 dari 1
Departemen: HEALTH AND SAFETY ENVIRONMENT(HSE)

Kondisi Level
No ITEM PEMERIKSAAN Keterangan
Baik Tidak Keterangan Bahaya
A. VISIBILITY
1 Lampu Rotari
2 Nomor Lambung
3 Papan Nama Unit
B. Dalam Kabin
1 Kotak P3K
2 Kondisi tempat duduk
3 Seat belt
4 APAR
5 Roll Over Protection
6 Fall Over Protection
7 Parking Brake
8 Service Brake
9 Rem darurat
10 Retarder
11 Klakson
12 Fungsi Electrical Gauge
C. Pencahayaan dan lainnya
3.1 Pencahayaan utama (depan,samping,belakang)
3.2 Alarm Mundur
3.3 Steering
3.4 Ban/Track
3.5 Tow Point/penderek
3.6 Tangga pijakan untuk naik
3.7 Handrail
3.8 Spion
3.9 LOTO & isolation battery
4.0 Dokumen lifting yang valid
D. Persyaratan Tambahan
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