HSE FORM

1 HSE-FF-A.1 JSA and Risk Assessment Form B

2 HSE-FF-B.1 HSE Personal Assessment Form E
3 HSE-FF-B.2 HSE Site Personal Assessment Form E
4 HSE-FF-C.1 PPE Requisition Form D
5 HSE-FF-C.2 PPE Distribution Form D
6 HSE-FF-C.3 PPE Inventory Form D
7 HSE-FF-C.4 PPE Mandatory check list Form A
8 HSE-FF-C.5 Personal Fall Protection / Full Body Harness Check List A
9 HSE-FF-D.2 Hot Work Permit Form D
10 HSE-FF-E.1 Pressure Test Checklist Form D
11 HSE-FF-E.2 Inspection Gas Cylinder-storage & Handling Form D
12 HSE-FF-E.3 Gas Cylinder Storage Inspection Form A
13 HSE-FF-E.4 Gas Cylinder Use of Acyteline & Oksigen Inspection Form A
14 HSE-FF-F.1 Entry Into Confined Space Form D
15 HSE-FF-I.1 Work packing & labelling requirement D
16 HSE-FF-I.2 Chemical Inventory Form D
17 HSE-FF-J.1 List of register sub-contractor form D
18 HSE-FF-J.2 Gate Pass form D
19 HSE-FF-J.3 Left Requisition Form D
20 HSE-FF-J.4 Entry Permit Application Form D
21 HSE-FF-L.1 List of Mechanical Lifting Equipment Form D
22 HSE-FF-L.2 List of Crane Operator / Forklift Driver Form D
23 HSE-FF-L.3 Crane Registration Form D
24 HSE-FF-L.4 Crane Inspection Form D
25 HSE-FF-L.5 Sling/wire rope inspection form D
26 HSE-FF-L.6 Crane position checklist form D
27 HSE-FF-L.7 Crane operation checklist form D
28 HSE-FF-L.8 Rigging Plan Form A
29 HSE-FF-M.1 Heavy vehicle inspection form D
30 HSE-FF-M.2 Light vehicle inspection form C
31 HSE-FF-M.3 Vehicle List for restricted area form D
32 HSE-FF-M.4 Mixer truck inspection form D
33 HSE-FF-M.5 Dump truck inspection form D
34 HSE-FF-M.6 Daily light vehicle inspection D
35 HSE-FF-M.6 Weekly Vehicle Kilometer Driven E
36 HSE-FF-M.7 Monthly Vehicle Kilometer Driven E
37 HSE-FF-M.8 Forklift inspection form A
38 HSE-FF-N.1 List of hand tool and portable power tools form D
39 HSE-FF-O.1 Electrical work permit form D
40 HSE-FF-O.2 Electrical tool inspection form' D
41 HSE-FF-O.3 Grinding Machine form A
42 HSE-FF-P.1 Scaffold inspection form E
43 HSE-FF-Q.1 Permit to excavation form E
44 HSE-FF-S.1 List of machinery and equipment form D
45 HSE-FF-S.2 Genset check list form D
46 HSE-FF-S.3 Air compressor check list form D
47 HSE-FF-S.4 Pump portable checklist form D
48 HSE-FF-S.5 Inspection diesel arc & gas welding and cutting form D
49 HSE-FF-T.1 Fire drill report form D
50 HSE-FF-T.2 Chemical drill report form D
51 HSE-FF-T.3 Drill Observation / feed back form D
52 HSE-FF-T.4 Fire extinguisher checklist form D
53 HSE-FF-U.1 Radiography work permit form D
54 HSE-FF-U.2 Work Sheet Travel of Camera Radiography D
55 HSE-FF-W.1 Working at height form D
56 HSE-FF-Y.1 Accident reporting form A
57 HSE-FF-Y.2 Non-Conformance reporting form A
58 HSE-FF-Y.3 Safety Monthly reporting form D
59 HSE-FF-Y.4 Daily reporting Form D
60 HSE-FF-Y.5 Weekly reporting form D
61 HSE-FF-Y.6 Unsafe Act and Unsafe Condition reporting form B
62 HSE-FF-Y.7 Tool Box Hazard Identification Form D
63 HSE-FF-Y.8 Hazard Assessment Observation Report Form A
64 HSE-FF-Y.9 Work Permit Checklist Form A
65 HSE-FF-Z.1 Sub-contractor HSE Key Performance Indicator K
66 HSE-FF-Z.2. Gap Analysis A
67 HSE-FF-AA/BB/CC.1 Environmental Reporting Form C
68 HSE-FF-AA/BB/CC.2 Bor Soil Form A
69 HSE-FF-EE.1 Attendance Safety Orientation / Induction Form D

Date: 12-08-2010
Prepared by BHS
Reviewed by DG
 PT. REKAYASA INDUSTRI
REKAYASA
ENGINEERING & CONS TRUCTION

MASTERLIST HSE DOCUMENT

No Document Number Document Name Rev page

CORPORATE POLICY
1 4200-PL-12-00 KEBIJAKAN KESELAMATAN, KESEHATAN KERJA DAN LINDUNGAN LINGKUNGAN C 1
2 4200-PL-13 KEBIJAKAN PENERAPAN KESELAMATAN, KESEHATAN KERJA DAN LINDUNGAN H 2
LINGKUNGAN
3 4200-PL-14 HSE POLICY E 3

1 4210-GP-13-01
2 4210-GP-13-02
3 4210-GP-13-03
4 4210-GP-13-04
5 4210-GP-13-05
6 4210-GP-13-06
7 4210-GP-13-07
8 4210-GP-13-08
9 4210-GP-13-10
CORPORATE PROCEDURE
CONTRACTOR SAFETY MANAGEMENT SYSTEM K 4
CONSULTATION AND COMMUNICATION PROCEDURE C 5
EMERGENCY AND EVACUATION PROCEDURE C 6
ACCIDENT INVESTIGATION PROCEDURE A 7
HSE PROCEDURE FOR CONSTRUCTION G 8
HSE EVALUATION PROCEDURE D 9
JSA AND RISK ASSESSMENT PROCEDURE B 10
ACCIDENT AND NON-CONFORMANCE PROCEDURE C 11
WORK PERMIT SYSTEM PROCEDURE A 12
WORK INSTRUCTION

1 4212-WI-13-05-01 Work Instruction for HSE Personal Assessment B 13

2 4212-WI-13-15-02 Work Instruction for PPE B 14
3 4212-WI-13-05-03 Work Instruction Air Emission Management A 15
4 4212-WI-13-05-04 Work Instruction for Hot Work A 16
5 4212-WI-13-05-26 Work Instruction Effluent Management A 17
6 4212-WI-13-05-16 Work Instruction Scaffolding A 18
7 4212-WI-13-05-15 Work Instruction Electrical Safety A 19
8 4212-WI-13-05-05 Work Instruction for Handling and Storage Compressed gas A 20
9 4212-WI-13-05-06 Work Instruction for Entry Into Confined Space A 21
10 4212-WI-13-05-07 Work Instruction for Handling Schedule Waste B 22
11 4212-WI-13-05-08 Work Instruction for Handling Non-Schedule Waste A 23
12 4212-WI-13-05-09 Work Instruction for Chemical and Hazardous Material A 24
13 4212-WI-13-05-10 Work Instruction for Entry Permit At Job Site A 25
14 4212-WI-13-05-11 Work Instruction Housekeeping and Cleanlines A 26
15 4212-WI-13-05-12 Work Instruction Lifting Handling and Storage A 27
16 4212-WI-13-05-13 Work Instruction Lifting A 28
17 4212-WI-13-05-14 Standard Instruction Transportation and Traffic A 29
18 4212-WI-13-05-19 Work Instruction Amonia monitoring A 30
19 4212-WI-13-05-20 Work Instruction Refueling A 31
20 APPENDIX N Work Instruction Handtools and Portable Power Tools D 32
21 APPENDIX Q Standard Instruction Excavation C 33
22 4212-WI-13-05-23 Standard Instruction Demolition A 34
23 APPENDIX S Standard Instruction Machinery and Equipment D 35
24 APPENDIX T Standard Instruction Fire and Chemical Spillage Drill D 36
25 APPENDIX U Standard Instruction Radiography D 37
26 4212-WI-13-05-27 Work Instruction Prohibition of Alcoholic, Drugs and Weapon D 38
27 APPENDIX W Standard Instruction Working At Height D 39
28 APPENDIX X Standard Instruction Lockout / Tagout D 40
29 APPENDIX Z Standard Instruction Working Over Water D 41
30 APPENDIX CC Standard Instruction Noise Management E 42
31 4212-WI-13-05-32 Work Instruction First Aid Management A 43
32 APPENDIX EE Standard Instruction HSE Orientation D 44
33 APPENDIX FF Standard Instruction for HSE Monthly Management Report D 45
34 APPENDIX GG Standard Instruction for Piling Management D 46
35 APPENDIX HH Standard Instruction for Safety Sign Board D 47
36 APPENDIX JJ Standard Instruction for Obedient Level for HSE Regulation A 48
 PT. REKAYASA INDUSTRI
REKAYASA
ENGINEERING & CONS TRUCTION
No Document Number
1 8000-PL-01
1 8001-GP-01-01
2 8001-GP-01-02
3 8001-GP-01-03
4 8001-GP-01-04
5 8001-GP-01-05
6 8001-GP-01-06
7 8001-GP-01-07
8 8001-GP-01-08
9 8001-GP-01-09
10 8001-GP-01-10
1 8001-WI-01-05-01
2 8001-WI-01-05-02
3 8001-WI-01-05-03
4 8001-WI-01-05-04
5 8001-WI-01-05-05
6 8001-WI-01-05-06
7 8001-WI-01-05-07
8 8001-WI-01-05-08
9 8001-WI-01-05-09
10 8001-WI-01-05-10
11 8001-WI-01-05-11
12 8001-WI-01-05-12
13 8001-WI-01-05-13
14 8001-WI-01-05-14
15 8001-WI-01-05-15
16 8001-WI-01-05-16
17 8001-WI-01-05-17
18 8001-WI-01-05-18
19 8001-WI-01-05-19
20 8001-WI-01-05-20
21 8001-WI-01-05-21
22 8001-WI-01-05-22
23 8001-WI-01-05-23
24 8001-WI-01-05-24
25 8001-WI-01-05-25
26 8001-WI-01-05-26
27 8001-WI-01-05-27
28 8001-WI-01-05-28
29 8001-WI-01-05-29
30 8001-WI-01-05-30
31 8001-WI-01-05-31
32 8001-WI-01-05-32
33 8001-WI-01-05-33
34 8001-WI-01-05-34
35 8001-WI-01-05-35
36 8001-WI-01-05-36
37 8001-WI-01-05-37
38 8001-WI-01-05-38
39 8001-WI-01-05-39
40 8001-WI-01-05-40
41 8001-WI-01-05-41
42 8001-WI-01-05-42
43 8001-WI-01-05-43
44 8001-WI-01-05-44
45 8001-WI-01-05-45
46 8001-WI-01-05-46
47 8001-WI-01-05-47
48 8001-WI-01-05-48
49 8001-WI-01-05-49
50 8001-WI-01-05-50
51 8001-WI-01-05-51
52 8001-WI-01-05-52
53 8001-WI-01-05-53
54 8001-WI-01-05-54
55 8001-WI-01-05-55
1 HSE-FF-A.1
2 HSE-FF-B.1
3 HSE-FF-B.2
4 HSE-FF-C.1
5 HSE-FF-C.2
6 HSE-FF-C.3
7 HSE-FF-C.4
8 HSE-FF-C.5
9 HSE-FF-D.2
10 HSE-FF-E.1
MASTERLIST HSE DOCUMENT
Document Name Rev Status
CORPORATE POLICY
KEBIJAKAN PENERAPAN KESELAMATAN, KESEHATAN KERJA DAN LINDUNGAN LINGKUNGAN D sudah di release
CORPORATE PROCEDURE
CONTRACTOR SAFETY MANAGEMENT SYSTEM A sudah di release ke CSU
CONSULTATION AND COMMUNICATION PROCEDURE B sudah di release ke CSU
EMERGENCY AND EVACUATION PROCEDURE B sudah di release ke CSU
ACCIDENT INVESTIGATION PROCEDURE A sudah di release ke CSU
HSE PROCEDURE FOR CONSTRUCTION B sudah di release ke CSU
HSE EVALUATION PROCEDURE A sudah di release ke CSU
JSA AND RISK ASSESSMENT PROCEDURE B sudah di release ke CSU
ACCIDENT AND NON-CONFORMANCE PROCEDURE A sudah di release ke CSU
WORK PERMIT SYSTEM PROCEDURE C sudah di release ke CSU
MANAGEMENT OF CHANGE PROCEDURE 0 sudah di release ke CSU
WORK INSTRUCTION
Work Instruction for HSE Personal Assessment C sudah di release ke CSU
Work Instruction for Hazardous (B3) Waste Management B sudah di release ke CSU
Work Instruction for Personal Protective Equipment B sudah di release ke CSU
Work Instruction for Air Emission Management B sudah di release ke CSU
Work Instruction for Handling and Storage Compressed Gas B sudah di release ke CSU
Work Instruction for Entry Into Confined Space B sudah di release ke CSU
Work Instruction for Handling Schedule Waste B sudah di release ke CSU
Work Instruction for Handling Non-Schedule Waste B sudah di release ke CSU
Work Instruction for Chemical and Hazardous Material B sudah di release ke CSU
Work Instruction for Entry Permit At Job Site B sudah di release ke CSU
Work Instruction for Housekeeping and Cleanlines B sudah di release ke CSU
Work Instruction for Lifting Handling and Storage B sudah di release ke CSU
Work Instruction for Lifting A sudah di release ke CSU
Work Instruction for Transportation and Traffic B sudah di release ke CSU
Work Instruction for Electrical Safety B sudah di release ke CSU
Work Instruction for Scaffolding B sudah di release ke CSU
Work Instruction for Effluent Management B sudah di release ke CSU
Work Instruction for Dust Control B sudah di release ke CSU
Work Instruction for Amonia Monitoring B sudah di release ke CSU
Work Instruction for Refueling B sudah di release ke CSU
Work Instruction Handtools and Portable Power Tools D sudah di release ke CSU
Work Instruction for Excavation B sudah di release ke CSU
Work Instruction for Demolition B sudah di release ke CSU
Work Instruction for Machinery and Equipment B sudah di release ke CSU
Work Instruction for Fire and Chemical Spillage Drill A sudah di release ke CSU
Work Instruction for Radiography B sudah di release ke CSU
Work Instruction for Prohibition of Alcoholic, Drugs and Weapon A sudah di release ke CSU
Work Instruction for Working At Height B sudah di release ke CSU
Work Instruction for Lockout and Tagout B sudah di release ke CSU
Working Instruction for Working Over Water D sudah di release ke CSU
Work Instruction for Noise Management B sudah di release ke CSU
Work Instruction for First Aid Management B sudah di release ke CSU
Work Instruction for HSE Orientation B sudah di release ke CSU
Work Instruction for HSE Monthly Management Report D sudah di release ke CSU
Work Instruction for Piling Management B sudah di release ke CSU
Work Instruction for Safety Sign Board B sudah di release ke CSU
Work Instruction for Obedient Level for HSE Regulation B sudah di release ke CSU
Work Instruction for Hot Tap B sudah di release ke CSU
Work Instruction for Waste management B sudah di release ke CSU
Work Instruction for Spill Response B sudah di release ke CSU
Work Instruction for HidroCarbon Management B sudah di release ke CSU
Work Instruction for Erossion And Sedimentation Management B sudah di release ke CSU
Work Instruction for Clearing and Grubing A sudah di release ke CSU
Work Instruction for Noise Environmental B sudah di release ke CSU
Work Instruction Light Vehicle and Driving A sudah di release ke CSU
Work Instruction Diving Safety 0 sudah di release ke CSU
Work Instruction Fatigue Management 1 sudah di release ke CSU
Work Instruction Sand Blasting A sudah di release ke CSU
Work Instruction Personnel Transfer 0 sudah di release ke CTD
Work Instruction Personal Flotation Devices 0 sudah di release ke CTD
Work Instruction Vessel Emergency Response Team 0 sudah di release ke CTD
Work Instruction Towing Operation 0
Rescue Boat Launching 0
Work Instruction Conducting a Workplace /Health ExposureE Risk Assessment A
Work Instruction Conducting Public Health Risk Assessment A
HSE FORM
JSA and Risk Assessment Form B NEED FOR REVISE
HSE Personal Assessment Form E NEED FOR REVISE
HSE Site Personal Assessment Form E NEED FOR REVISE
PPE Requisition Form D NEED FOR REVISE
PPE Distribution Form D NEED FOR REVISE
PPE Inventory Form D NEED FOR REVISE
PPE Mandatory check list Form A NEED FOR REVISE
Personal Fall Protection / Full Body Harness Check List A NEED FOR REVISE
Hot Work Permit Form D NEED FOR REVISE
Pressure Test Checklist Form D NEED FOR REVISE
No Document Number Document Name Rev Status
11 HSE-FF-E.2 Inspection Gas Cylinder-storage & Handling Form D NEED FOR REVISE
12 HSE-FF-E.3 Gas Cylinder Storage Inspection Form A NEED FOR REVISE
13 HSE-FF-E.4 Gas Cylinder Use of Acyteline & Oksigen Inspection Form A NEED FOR REVISE
14 HSE-FF-F.1 Entry Into Confined Space Form D NEED FOR REVISE
15 HSE-FF-G.1 Waste Identification Checklist A NEED FOR REVISE
16 HSE-FF-G.2 B3 waste subcontractor evaluation A NEED FOR REVISE
17 HSE-FF-G.3 Waste Register A NEED FOR REVISE
18 HSE-FF-G.4 Waste handling inspection A NEED FOR REVISE
19 HSE-FF-G.5 Environmental Inspection checklist A NEED FOR REVISE
20 HSE-FF-G.6 Checklist storage hazaedous material /B3 A NEED FOR REVISE
21 HSE-FF-G.7 MSDS Register A NEED FOR REVISE
22 HSE-FF-I.1 Work packing & labelling requirement D NEED FOR REVISE
23 HSE-FF-I.2 Chemical Inventory Form D NEED FOR REVISE
24 HSE-FF-J.1 List of register sub-contractor form D NEED FOR REVISE
25 HSE-FF-J.2 Gate Pass form D NEED FOR REVISE
26 HSE-FF-J.3 Left Requisition Form D NEED FOR REVISE
27 HSE-FF-J.4 Entry Permit Application Form D NEED FOR REVISE
28 HSE-FF-L.1 List of Mechanical Lifting Equipment Form D NEED FOR REVISE
29 HSE-FF-L.2 List of Crane Operator / Forklift Driver Form D NEED FOR REVISE
30 HSE-FF-L.3 Crane Registration Form D NEED FOR REVISE
31 HSE-FF-L.4 Crane Inspection Form D NEED FOR REVISE
32 HSE-FF-L.5 Sling/wire rope inspection form D NEED FOR REVISE
33 HSE-FF-L.6 Crane position checklist form D NEED FOR REVISE
34 HSE-FF-L.7 Crane operation checklist form D NEED FOR REVISE
35 HSE-FF-L.8 Rigging Plan Form A NEED FOR REVISE
36 HSE-FF-M.1 Heavy vehicle inspection form D NEED FOR REVISE
37 HSE-FF-M.2 Light vehicle inspection form C NEED FOR REVISE
38 HSE-FF-M.3 Vehicle List for restricted area form D NEED FOR REVISE
39 HSE-FF-M.4 Mixer truck inspection form D NEED FOR REVISE
40 HSE-FF-M.5 Dump truck inspection form D NEED FOR REVISE
41 HSE-FF-M.6 Daily light vehicle inspection D NEED FOR REVISE
42 HSE-FF-M.6 Weekly Vehicle Kilometer Driven E NEED FOR REVISE
43 HSE-FF-M.7 Monthly Vehicle Kilometer Driven E NEED FOR REVISE
44 HSE-FF-M.8 Forklift inspection form A NEED FOR REVISE
45 HSE-FF-N.1 List of hand tool and portable power tools form D NEED FOR REVISE
46 HSE-FF-O.1 Electrical work permit form D NEED FOR REVISE
47 HSE-FF-O.2 Electrical tool inspection form' D NEED FOR REVISE
48 HSE-FF-O.3 Grinding Machine form A NEED FOR REVISE
49 HSE-FF-P.1 Scaffold inspection form E NEED FOR REVISE
50 HSE-FF-Q.1 Permit to excavation form E NEED FOR REVISE
51 HSE-FF-S.1 List of machinery and equipment form D NEED FOR REVISE
52 HSE-FF-S.2 Genset check list form D NEED FOR REVISE
53 HSE-FF-S.3 Air compressor check list form D NEED FOR REVISE
54 HSE-FF-S.4 Pump portable checklist form D NEED FOR REVISE
55 HSE-FF-S.5 Inspection diesel arc & gas welding and cutting form D NEED FOR REVISE
56 HSE-FF-T.1 Fire drill report form D NEED FOR REVISE
57 HSE-FF-T.2 Chemical drill report form D NEED FOR REVISE
58 HSE-FF-T.3 Drill Observation / feed back form D NEED FOR REVISE
59 HSE-FF-T.4 Fire extinguisher checklist form D NEED FOR REVISE
60 HSE-FF-U.1 Radiography work permit form D NEED FOR REVISE
61 HSE-FF-U.2 Work Sheet Travel of Camera Radiography D NEED FOR REVISE
62 HSE-FF-W.1 Working at height form D NEED FOR REVISE
63 HSE-FF-Y.1 Accident reporting form A NEED FOR REVISE
64 HSE-FF-Y.2 Non-Conformance reporting form A NEED FOR REVISE
65 HSE-FF-Y.3 Safety Monthly reporting form D NEED FOR REVISE
66 HSE-FF-Y.4 Daily reporting Form D NEED FOR REVISE
67 HSE-FF-Y.5 Weekly reporting form D NEED FOR REVISE
68 HSE-FF-Y.6 Unsafe Act and Unsafe Condition reporting form B NEED FOR REVISE
69 HSE-FF-Y.7 Tool Box Hazard Identification Form D NEED FOR REVISE
70 HSE-FF-Y.8 Hazard Assessment Observation Report Form A NEED FOR REVISE
71 HSE-FF-Y.9 Work Permit Checklist Form A NEED FOR REVISE
72 HSE-FF-Z.1 Sub-contractor HSE Key Performance Indicator K NEED FOR REVISE
73 HSE-FF-Z.2. Gap Analysis A NEED FOR REVISE
74 HSE-FF-AA/BB/CC.1 Environmental Reporting Form C NEED FOR REVISE
75 HSE-FF-AA/BB/CC.2 Bor Soil Form A NEED FOR REVISE
76 HSE-FF-EE.1 Attendance Safety Orientation / Induction Form D NEED FOR REVISE

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