Document title: Revision : 00

HSE Procedure
Document no.: Page:
HSE/FORM-25 1 of 1

SCAFFOLDING INSPECTION CHECKLIST

DAFTAR PEMERIKSAAN PERANCAH
Date of Inspection
:
TanggalPemeriksaan
Project
:
Proyek
Location
:
Lokasi

Items to Check Goo Reject-

No NA
(Poin-poin yang diperiksa) d ed
Has warning signs stating “Scaffold Unsafe for Use” been fixed in prominent locations before
inspection and approval of the scaffold used?
1
(Adakah tanda peringatan “Scaffold Unsafe for Use” di gunakan di lokasi akses sebelum inspeksi
dan penglulusan perancah?)
Has the scaffold been inspected in the daily basis by the Scaffold Supervisor/Foreman?
2
(Sudahkah perancah dicek setiap hari oleh Supervisor/mandor perancah?)

Is the surrounding area or in the vicinity of the scaffold bases and sole plates water logged?
3
(Adakah areal sekitar atau lokasi perancah sole plate atau base plate di banjiri dengan air?)

Are the scaffold components and fittings showing signs of deterioration such as rusting?
4 (Adakah kondisi komponen atau fittings perancah jelek atau tidak aman untuk digunakan seperti
berkarat?)
Are the sole plates, base plate and foot ties in good condition and in its original position?
5 (Adakah sole plate, base plate dan foot tie perancah dalam kondisi aman dan berada di lokasi
aslinya?)
Are the standards plumbs as observed from base level?
6
(Adakah tiang penyangga / standards tegak dari bawah hingga ke atas?)
Are the ledgers and transoms horizontal as observed?
7
(Adakah ledgers dan transoms perancah dalam posisi mendatar sewaktu pengecekan?)
Are all the bracings and fittings tight and complete?
8
(Adakah bracing dan fitting perancah ketat dan dipasang pada semua pengcantuman perancah?)
Is the ladder access and ladders giving access easy to climb?
9
(Adakah akses perancah dan tangga perancah senang untuk d gunakan?)
Are all working platforms completely decked out and toe boards fitted?
10 (Adakah panggung kerja perancah tertutup dengan rapi dan papan pembatas dibangunkan dengan
aman?)
Are guard rails fitted at the correct height and location?
11
(Adakahrelpengaman di pasangpadaketinggianstandardanlokasi yang aman?)
Are the working platforms, access ways and landings cleared of any obstructions, loose objects and
tripping hazards?
12
(Adakahpanggungkerja, aksesjalandantempatturun / naikaksesbebasdaribenturan, benda yang
mudahjatuhatauresikotersandung?)
Does the working platform feel solid to walk on?
13
(Adakah pengguna merasa panggung kerja perancah memlentur sewaktu berjalan di atasnya?)
Are materials, stored on the platform, dispersed so as not to cause a concentration of load in excess
of that permitted?
14
(Adakah material yang di letakkan di atas panggung kerja di sebarkan berat bebannya untuk
menghidari dari melebihi faktor beban selamat (SWL)?)
Has the scaffold been used only for its intended purposes, e.g. it has not been used to stabilize
structural members?
15
(Adakah perancah yang di bangunkan di gunakan berlainan dari tujuannya? Contoh: Adakah
perancah itu di gunakan untuk menyangga struktur?)
Are you satisfied that the scaffold is safe for its intended purposes?
16 (Adakah anda merasa puas baik perancah yang diperiksa dalam keadaan aman dan sesuai dengan
kegunaannya?)
Please indicate √ For Good, Rejected, and NA(Silahkan beri tanda√ untuk Baik, Ditolak danTidak Berlaku)
*Note / Catatan: Good (Baik) Rejected (Ditolak) NA: Not Applicable (Tidak Berlaku)

Inspected by / Diperiksaoleh Acknowledged by Diketahuioleh HSE/ Site Supervisor

Name (Nama) : Name (Nama) :

Position (Jabatan) : Position (Jabatan) :
Sign (TandaTangan) : Sign (TandaTangan) :