PROJECT MANAGEMENT OFFICE

SAFETY AND MAINTENANCE INSPECTION CHECK SHEET : EXCAVATOR

INSPECTION ITEMS

1. GENERAL DATA

1. 1 Tanggal Inspeksi

1. 2 No. Register PMO

1. 3 Brand/Manufactor

1. 4 Year Of Manufactor

1. 5 Type/ Model

1. 6 Rated Capacity

1. 7 Serial number

1. 8 Equipment No./Code

1. 9 No. SILO

1. 10 No. SIO

1. 11 Others…

PROJECT MANAGEMENT OFFICE

2. KABIN CHECK LIST UNIT REMARKS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

2. 1 Kondisi kabin *

2. 2 Ruangan kabin *

2. 3 AC & Tombol *

2. 4 Layar Panel Monitor *

2. 5 Fungsi panel monitor *

2. 6 Kaca Kabin *

2. 7 Kaca Spion *

2. 8 Sabuk Pengaman *

2. 9 Tempat Duduk Operator *

2. 10 Kunci Pintu Kabin *

2. 11 Wiper *

2. 12 tangga / pijakan *

2. 13 Safety Guard Kabin *

2. 14 safety guard body engine *

2. 15 pelindiung bagian bawah *

2. 16 Others…

Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor                     

6. Attached SIO,MANAGEMENT
PROJECT SILO, Certificate, Other related
OFFICE document

CHECK LIST UNIT

3. ENGINE REMARKS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

3. 1 kondisi engine ***

3. 2 Kondisi ruang engine ***

3. 3 Dudukan engine ***

3. 4 Kebocoran engine ***

3. 5 Oli mesin/levell ***

3. 6 Air radiator/level ***

3. 7 Cover ruang engine ***

3. 8 Kunci ruang engine ***

3. 9 Sambungan hose ***

3. 10 Pengikat hose ***

3. 11 Radiator ***

3. 12 Air Radiator ***

3. 13 Penutup Radiator ***

3. 14 Pompa Hydraulic ***

3. 15 Battery ***

3. 16 Air Battery ***

3. 17 Dudukan Battery ***

3. 18 Others….

Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document

PROJECT MANAGEMENT OFFICE

CHECK LIST UNIT

4 TRACK / TIRE REMARKS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

4. 1 Kondisi ban kanan / kiri **

4. 2 kondisi track **

4. 3 Sambungan Track **

4. 4 Pelindung Travel Motor **

4. 5 Baut Travel Motor **

4. 6 Others…

5 BLADE

5. 1 Kondisi Bucket **

5. 2 Kuku Bucket **

5. 3 Pin silinder Bucket **

5. 4 Hose Bucket **

5. 5 Hose silinder bucket **

5. 6 Hose Rotator **

5. 7 Hose Line Pipa **

5. 8 Arm Bucket **

5. 9 Sambungan Arm Bucket

5. 10 Others…

6 Safety Requirement

6. 1 Fire Extinguisher *
6. 2 Peralatan P3K *
6. 3 Lampu Rotary *
6. 4 Alarm Swing/mundur *

6. 5 Klakson *

6. 6 Emergency Brake *
6. 7 Rem Parkir *
6. 8 Lampu Kerja *
6. 9 Others…
                     

Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document

PROJECT MANAGEMENT OFFICE

Equipment is not allowed to be used until Major Items has been closed

Equipment is allowed to be used while Minor Items to be closed

Equipment is allowed to be used, no findings

Inspected by: Checked by: Checke Checked by: Checked by:

Name : Name : Name : Name : Name :

Position : Operator Position : PM/SM Position : Inspector HSE Position : HE Coordinator Position : HSE Manager
Date : Date : Date : Date : Date :

Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document
PROJECT MANAGEMENT OFFICE
SAFETY AND MAINTENANCE INSPECTION CHECK SHEET : EXCAVATOR

INSPECTION ITEMS
1. GENERAL DATA
1. 1Tanggal Insp
1. 2No. Registe
1. 3Brand/Manuf
1. 4Year Of Man
1. 5Type/ Model
1. 6Rated Capac
1. 7Serial numbe
1. 8Equipment N
1. 9No. SILO
1. No. SIO
1. Others…