Construction SV Checklists 18 Aug 2022 REV

TEP Self Verification Record Sheet Rev.
Date / Tanggal: Purpose

Location / Lokasi: The purpose of this Self
Activity / Aktivitas: Verification is to ensure that Work
Activity at the TEP Tangguh Site is
Permit Number / Nomer Permit: executed in line with the Barrier
Name of Verifier / Pemeriksa: Management and Access Control
Persons Interviewed / Orang yang Procedure and associated relevant
Diwawancarai: documentation under the CSTS
Sub-Contractor / Subkontraktor: Management System
Doc. Compliance
Barrier Management Comments / Remarks
Reference YES / NO / NA
Does the task / activity was barricading using the right barricade tape following
TEP specific soft barrier identification such as : Lifting, Scaffolding,
1 Commissioning, Start up etc.?
Apakah aktivitas sudah diberi barikade yang tepat sesuai TEP seperti : Lifting,
scaffolding, Commissioning, Start up, dll.?
Are all the soft barricades completed with proper safety sign with the Warning
word when its been erected?
2
Sudahkah semua soft barikade dilengkapi dengan safety sign yang jelas ketika semua
didirikan?
Does hard barrier for the excavation made of scaffolding or sturdy materials and have the
warning signed available on the barricade?
3
Apakah hard barikade untuk excavation terbuat dari scaffolding dan sudah dilengkapi
dengan tanda bahaya?
Are the barrier installed completed with information of the responsible person of
the activities and include how to contact?
4
Apakah pembatas sudah dilengkapi dengan informasi orang yang bertanggung jawab dan
termasuk bagaimana cara menghubungi?
Does the barrier still in use as protection for activty and completely in good
condition?
5
Apakah pembatas masih dipakai sebagai proteksi untuk aktivitas dan dalam kondisi yang
baik?
Do the workers have a complete WAH checklist when they install barriers for
working at high activity?
6
Sudahkah pekerja melengkapi checklist WAH ketika mereka memasang pembatas untuk
aktivitas bekerja di ketinggian?
Is there an alternative access route provided for the barrier that is installed
blocking public access?
7
Apakah ada rute akses alternatif yang disediakan untuk pembatas yang sudah dipasang
untuk menutup jalur umum?
Are there available segregations between pedesterian and mobile / moving

vehicles using jersie barrier or any means of segregation?
8
Apakah tersedia pemisah di antara jalur pejalan kaki dan orang berlalu lalang /
pergerakan kendaraan yang menggunakan pembatas jersie atau ?
Are the hard barricades that erected as Fall prevention completed with Toe
board, mid rail and top rails and the height around : 950 mm made of scaffolding tube?
9 Apakah hard barikade yang didirikan untuk mencegah benda jatuh dilengkapi dengan Toe
board, mid rail dan top rails dan dalam ketinggian sekitar : 950 mm terbuat dari
scaffolding tube?
Does radiography barricade complete with safety signs? And are barricade tape provided
with warning light during night shift?
10
Apakah barikade radiography dilengkapi dengan safety sign? Dan pita barikade
dilengkapi dengan warning light pada saat shift malam?
Does safety sign that attached on the barricade details describe about : detail
on any hazards, owner of the barrier, date and time erected, contact of the
owner? And available in 2 languange ( Bahasa indonesia and English ).
11
Apakah tanda keselamatan tertempel di barikade dan menjelaskan : detil dari bahaya,
pemilik barier, tanggal dan waktu didirikan, kontak pemilik? Dan tersedia di 2 bahasa
( Bahasa Indonesia dan Bahasa Inggris )
Was the barricade erected on all sides around the existing hazards?
12
Apakah barikade didirikan di semua area berbahaya?
# Saipem Classification - General Use

Doc. Compliance
Barrier Management Comments / Remarks
Does the barricade NOT blocking emergency equipment, such as plant fire
extinguishers, safety showers, etc.? If block do they have permition to the
13 project management and ERT Team ?
Apakah barikade TIDAK menghalangi peralatan darurat, seperti APAR, safety showers
dll.? Seandainya terhalang apakah ada izin dari project management dan tim ERT?
Is barrier size adequately protect the hazardous zone?

14
Sudah memadai kah ukuran pembatas untuk melindungi dari zona bahaya?
Are the area that being barricade provided with sufficient ilumination for vicibility to
15 acceptable during darkess hours.
Apakah area yang sudah diberi barikade sudah disediakan tanda ketika keadaan gelap?
Are drop zones clearly defined, personnel are outside barriers during lifting?
16
Apakah drop zone sudah jelas diterapkan, personil harus diluar pembatas selama lifting?
Percentage of Implementaion #DIV/0!
RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
1
2
3
4
5

TEP Se
Date / Tanggal:
Location / Lokasi:
Activity / Aktivitas:
Permit Number / Nomer Permit:
Name of Verifier / Pemeriksa:

Persons Interviewed / Orang yang
Diwawancarai:
Sub-Contractor / Subkontraktor:
Created Openings
1 Are created openings identified and entered in the created op
Has the task planning process reviewed whether a creating o

2 required, and have other options for completing the task witho
opening been considered?

Does the permit and method statement require that the creati
3
present for the shortest possible time?
Are barriers, guardrails and signage in place to restrict acces

4
openings?
Are fall protection devices specified in the permit and being u

5
are exposed to the created opening?
Where required, are attendants actively managing access an

6
workers are being exposed to the created opening?
Have the risks and control measures required been effectivel

7
crew?
8 Is a hatch management process in place to reduce created o
9 Is there a process to communicate this work to the next shift w
Are locations beneath open created openings barricaded to m

10
dropped objects?

Where appropriate, is edge protection in place to reduce the
11
into the created opening?
Are SIMOPS agreed between any work crews that need to in

12
created opening?
Is the created opening 'hard covered' when worker access is

13
clearly labeled?
Do employees understand that they have the authority and ex

14
unsafe work?
15 Has the work crew received positive feedback on raising conc
Did the risk assessment or pre-job discussion include any les

16
incidents from similar work?
Are emergency response plans robust in terms of equipment

17
including rescue, recovery and the ability to treat casualties?
Do rescue plans and preparations include adequate provision

18
potential for suspension trauma where emergency response

Is the rescue team aware of the activity, and available while w
19
performed?
Is there STARRT card/ECOW PERMIT for the activity, proper

20
to the crew?

NO ACTION
1
2
3
4
5

TEP Self Verification Recor
Created Openings
tified and entered in the created opening register?
cess reviewed whether a creating opening is actually

ptions for completing the task without creating an

od statement require that the creating opening is
ssible time?
d signage in place to restrict access to the created
specified in the permit and being used correctly when workers

d opening?
dants actively managing access and egress when

d to the created opening?
measures required been effectively communicated to the work
ocess in place to reduce created openings on vessels?
municate this work to the next shift where applicable?
n created openings barricaded to minimise the impact of

e protection in place to reduce the risk of objects being kicked
een any work crews that need to interact through the
d covered' when worker access is not required and is the cover
that they have the authority and expectation to stop
d positive feedback on raising concerns?
pre-job discussion include any lessons from past

?
plans robust in terms of equipment and personnel,

and the ability to treat casualties?
arations include adequate provision to reduce the

auma where emergency response may be delayed?

of the activity, and available while work is being
OW PERMIT for the activity, properly filled and communicated

RECOMMEND
ACTION

ion Record Sheet
Purpose
The purpose of this Self Verification is to ensure th

Activity at the TEP Tangguh Site is executed in line
Created Opening Procedure and associated rele
documentation under the CSTS Management Sy
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose
e purpose of this Self Verification is to ensure that Work

vity at the TEP Tangguh Site is executed in line with the
Created Opening Procedure and associated relevant
documentation under the CSTS Management System
Comments / Remarks

Percentage of Implementaion
MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Se
Date / Tanggal:
Location / Lokasi:

Diwawancarai:
Excavation Safety
Does the permit or authorization adequately describe the task

1 contain all mandatory information such as signatures, dates,
used?
Does the JSA adequately describe the task being carried out
2
hazards and controls?

Has SIMOPS been assessed, including the potential for overh
3
all relevant parties notified?
4 Was a toolbox talk held with the workforce prior to the work s
5 Did the TBT describe the job and reflect the work being carrie
Was the work location scanned by competent personnel usin

6 equipment to identify any underground infrastructure such as
optic, or electrical cables and mark on the drawing work pack
7 Were underground utilities identified, marked and isolated wh
Has hand digging or hydro-excavation been conducted near u

8
obstructions prior to conducting mechanical excavation?
Are barriers and signs installed to keep vehicles and equipme

9 distance from the edge? (Heavy equipment should not be allo
meters (5 ft) of the excavation edge).
Are materials such as pipe spools, excavated soil, etc. placed

10 meter (3ft) from the edge of the excavation? (Objects that cou
excavation should be properly “chocked”).

Does the excavation area have proper bracing and shoring, a
11
competent person each shift and after rain?
Are there adequate visibility measures for excavations, openi

12
low light conditions?
Are barriers provided around excavation areas, and are clear

13 posted? Do the barriers provide fall prevention where excava
hazard?
Do workers understand that they are not permitted inside the

14
any machine digging operation?
Has a competent person conducted an atmospheric test insid

15
area where applicable?
Are generators and other CO emitting equipment situated so

16
do not enter confined space excavations?
17 Is an adequate dewatering system in place, where applicable
18 Do workers know what to do in an emergency situation?

Have the emergency responders been notified of work tasks
19
response events for entry into excavations?
Are excavation walls made sloped, shored according to soil ty

20
available?
Excavation entry daily checklist properly filled and available a

21
excavation?

22
to the crew?

NO ACTION
1
2
3
4
5

Excavation Safety
zation adequately describe the task being carried out? Does it

mation such as signatures, dates, location, equipment being
describe the task being carried out? Does it identify the relevant

sed, including the potential for overhead power lines and have
?
th the workforce prior to the work starting?
ob and reflect the work being carried out?
nned by competent personnel using relevant scanning

underground infrastructure such as fire line, water pipe, fiber
nd mark on the drawing work pack?
identified, marked and isolated where appropriate?
-excavation been conducted near underground

cting mechanical excavation?
alled to keep vehicles and equipment a safe work

Heavy equipment should not be allowed within 1.5
tion edge).
spools, excavated soil, etc. placed a minimum of 1

of the excavation? (Objects that could roll into the
erly “chocked”).

have proper bracing and shoring, and is it inspected by a
ift and after rain?
y measures for excavations, openings or obstructions including
nd excavation areas, and are clear warning signs

ovide fall prevention where excavations present fall
at they are not permitted inside the excavation during

ation?
onducted an atmospheric test inside the excavation
CO emitting equipment situated so that the emissions

e excavations?
system in place, where applicable?
do in an emergency situation?

onders been notified of work tasks and potential
nto excavations?
e sloped, shored according to soil type? If not, trench box
cklist properly filled and available at the entrance to

RECOMMEND
ACTION

ion Record Sheet
Purpose

Ground Disturbance, Earthworks, Excavation Proce
associated relevant documentation under the C
Management System
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose

und Disturbance, Earthworks, Excavation Procedure and
associated relevant documentation under the CSTS
Management System
Comments / Remarks

MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Se
Date / Tanggal:
Location / Lokasi:

Diwawancarai:
Electrical Safety
Is there a validated permit available adequately describing th

1
containing all manadatory signatures, dates, location, equipm
Is there a validated JSA avaialble adequately describing the t

2
identifes the relevant hazards and controls to carry out the wo

Are other supplementary certificates referenced in the above
3
available for review? ( approved Isolation Certificate and Mar
Was a STARRT/ECOW PERMIT meeting held with the workf

4 starting and
completed filled reflecting the activity?
5 Do the personnel working at Electrical system have adequate
6 Do equipment have the fitting temporary earths in an approve
7 Do the personnel in-charge working in system utilize the non-
Is LOTO implementation available during the work in order to

8
start-up able to occur?
Are adequate information to the person carrying out the work

9
conductor involved, associated electrical system and the fore
10 Are the barriers properly installed and appropriate warning sig

Are the one man standby outside the loops available to provid
11
an emergency?
Is the Standby person equipped with proper isolation tools in

12
fast intervention in case any incident happens?
Are the portable electric tools equipped with double insulation

13
grounded type?
14 Are all cable and plug and socket connector in good condition
Is the Generator maintained on daily basis? - Evidence of pla

15
appear
16 Are generators fully earthed via rods or structural steel?
Is cable management in-place? - the cable are routed in a pro

17
Mechanical protection
18 Is equipment tagging valid as per colour code?

19 Is correct PPE being used while working on electrical equipm

20
to the crew?
NO ACTION
1
2
3

4
5

Electrical Safety
available adequately describing the task being carried out

signatures, dates, location, equipment being used etc?
vaialble adequately describing the task being carried out which

rds and controls to carry out the work safely?

ertificates referenced in the above documents
roved Isolation Certificate and Marked up Drawing )
ERMIT meeting held with the workforce prior to the work
the activity?
at Electrical system have adequate competency?
ing temporary earths in an approved manner?
e working in system utilize the non-conductive ladder?
vailable during the work in order to avoid unexpected
o the person carrying out the work regarding electrical

ated electrical system and the foreseeable risks?
nstalled and appropriate warning signs as well?

outside the loops available to provide assistance in the event of
ipped with proper isolation tools in order to have a

ny incident happens?
ols equipped with double insulation or three wire
socket connector in good condition?
ed on daily basis? - Evidence of planned maintenance shall
d via rods or structural steel?
ace? - the cable are routed in a proper way, Insulated S-Hook /
as per colour code?

while working on electrical equipment ?
RECOMMEND
ACTION

ion Record Sheet
Purpose

Electrical Safety Procedure and associated rele
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose

Electrical Safety Procedure and associated relevant
Comments / Remarks

MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP S
Date / Tanggal:
Location / Lokasi:

Diwawancarai:
Process, Plan or Procedure to be Verified

Drop Object Prevention Procedure (TEP-930-PRC-HS-B

Is there a validated permit available adequately describing th
containing all mandatory signatures, dates, location, equipme
(Grating/Handrail Removal & Open Hole Work Permit )
Apakah permit yang divalidasi tersedia dan menjelaskan den
1 tugas yang sedang dilakukan yang berisi semua tanda tanga
lokasi, peralatan yang digunakan.(Grating/Pemindahan hand
lubang)
No. Reference :
(………………………………………………………………………
Is there a validated JSA avaialble adequately describing the t

which identifes the relevant hazards and controls to carry out
( SCAFFOLDING, and other Task that required working at he
Apakah JSA yang divalidasi tersedia secara memadai mengg
2 sedang dilakukan yang mengidentifikasi bahaya dan kontrol y
melaksanakan pekerjaan dengan aman? (Perancah, dan pek
dibutuhkan untuk pekerjaan ketinggian)
No. Reference : (……………………………………………………
…………..)
Is there a validated Method Statement available which adequ

being carried out?
3
Apakah Method Statement yang divalidasi tersedia yang cuku
mengenai pekerjaan?

Are all other supplementary certificates referenced in the abo
for review? E.g Lifting plan, MSDS, Gas Check, Rescue Plan
Clearance, etc( ISOLATION CERTIFICATE , LINE DIAGRAM
reviewed )
4
Apakah semua sertifikat tambahan lainnya dirujuk dalam dok
untuk ditinjau? Seperti renacana pengangkatan, MSDS, Gasc
penyelamatan, Izin pekerjaan underground ( Sertifikat isolasi
direview )
Has SIMOPS been assessed, and all relevant parties notified

regarding work at height shall be attached in work permit pac
5
Apakah SIMOPS telah dinilai, dan semua pihak terkait diberit
mengenai bekerja di ketinggian harus dilampirkan kedalam p
Was a STARRT/ECOW PERMIT conversation held with the w

work starting?
1
Apakah diskusi STARRT/ECOW PERMIT diadakan dengan p
pekerjaan dimulai?
Was the Drop Object Checklist filled out prior to commence a
the procedure?
1 Sebelum memulai pekerjaan apakah telah diisi daftar periksa
pencegahan benda jatuh?
Does worker carrying Small materials, hand tools or documen

prevent the drop object such as Back pack, tools bags, etc?
2 Apakah pekerja membawa peralatan kerja kecil, Document d
menggunakan tempat khusus, task punggung atau apapun u
benda jatuh?

Were container to bring the materials, tools and documents fu
inspected and free from any sign of damage or torn?
3
Apakah tempat peralatan, document telah diperiksa sebelum
tempat alat) bebas dari tanda-tanda kerusakan atau robekan
Is there any designated lifting area completed with hard barric

and manufactured canvas bags (with SWL marked), rope 16
4 Apakah telah tersedia tempat untuk menaikan dan menurunk
lengkap dengan hard barikade, tanda peringatan dan tas can
angkat yang jelas) serta menggunakan katrol standard dan ta
Has the Drop Zone been set up below the working at height a
signed and size was sufficient to allocate the potential bounce
5
Apakah lokasi dibawah area kerja ketinggian telah dibarikade
peringatan dan ukuran yang mencukupi menampung potensi
Are tool lanyards used on all tools to secure them?

6
Apakah semua peralatan menggunakan lanyard untuk menga
Are all opening on platforms, around Pipe penetration betwee

closed/protected to prevent the materials or tools falling throu
7 semua bukaan pada platform, bukaan modifikasi untuk pipa a
dilantai kerja telah dilengkapi dengan pelat/papan kaki untuk
terjatuh?

Have the grating or any structure being secured utilizing sling
before shifting, cutting or modified to prevent becoming a falli
8 Grating, atau lantai kerja ataupun bagian structure telah diika
ataupun sling sebelum dipindahkan, digeser ataupun diangka
terjatuh?
Were material on scaffold platforms or grating secured and se

9
material di atas scaffolding atau grating diamankan atau disim
Are material at the excavations stored witin 1 m of the excava

material that has the probability of rolling into the excavation b
10
Apakah material yang berada di dekat pinggir galian dalam ja
yang punya kemungkinan untuk bergulir ke dalam galian sud
Are the welding or any other working area on grating covered

from falling to the below levels?
11
Apakah pekerjaan pengelasan atau pekerjaan lainnya di atas
mencegah benda kecil jatuh ke bawah?
22
Do workers that acend and decend ladders and staircases ca

bags/backpacks/tool belts?
12
Apakah pekerja yang menaiki dan menuruni tangga dan anak
peralatan dengan aman di tas/tas punggung/tool belts?

NO ACTION
1
2
3
4
5

TEP Self Verification Re
ss, Plan or Procedure to be Verified

ntion Procedure (TEP-930-PRC-HS-BP4-0019_B01)

mit available adequately describing the task being carried out
y signatures, dates, location, equipment being used etc?
oval & Open Hole Work Permit )
validasi tersedia dan menjelaskan dengan cukup mengenai
kukan yang berisi semua tanda tangan yang wajib, tanggal,
digunakan.(Grating/Pemindahan handrail/ Ijin kerja membuka
……………………………………………………….…..)
A avaialble adequately describing the task being carried out

vant hazards and controls to carry out the work safely?
other Task that required working at height )
idasi tersedia secara memadai menggambarkan tugas yang
mengidentifikasi bahaya dan kontrol yang relevan untuk
an dengan aman? (Perancah, dan pekerjaan lainnya yang
jaan ketinggian)
…………………………………………………………………...
hod Statement available which adequately reflects the task
ment yang divalidasi tersedia yang cukup untuk menjelaskan

ntary certificates referenced in the above documents available
plan, MSDS, Gas Check, Rescue Plan, Underground
TION CERTIFICATE , LINE DIAGRAM UPDATED AND
t tambahan lainnya dirujuk dalam dokumen di atas tersedia

renacana pengangkatan, MSDS, Gascheck, Rencana
erjaan underground ( Sertifikat isolasi, diagram terbaru dan
essed, and all relevant parties notified? ( SIMOPS MATRIx

ht shall be attached in work permit pack )
dinilai, dan semua pihak terkait diberitahu? (SIMOPS MATRIX
tinggian harus dilampirkan kedalam permit)
W PERMIT conversation held with the workforce prior to the
T/ECOW PERMIT diadakan dengan pekerja sebelum
hecklist filled out prior to commence activity as per mandate on
erjaan apakah telah diisi daftar periksa/checklist untuk

uh?
mall materials, hand tools or documents using safe means to

such as Back pack, tools bags, etc?
awa peralatan kerja kecil, Document dan material
khusus, task punggung atau apapun untuk mencegah terjadinya

the materials, tools and documents fully closed, handles
m any sign of damage or torn?
an, document telah diperiksa sebelum digunakan (pegangan
tanda-tanda kerusakan atau robekan?
lifting area completed with hard barricade, signed, gin wheel

vas bags (with SWL marked), rope 16 mm?
empat untuk menaikan dan menurunkan barang/ materials,
arikade, tanda peringatan dan tas canvas (dengan kapasitas
a menggunakan katrol standard dan tali yang sesui 16 mm?
n set up below the working at height area completed with the

fficient to allocate the potential bounce area?
area kerja ketinggian telah dibarikade lengkap dengan tanda
yang mencukupi menampung potensi besaran area jatuh?
on all tools to secure them?

an menggunakan lanyard untuk mengamankan mereka?
orms, around Pipe penetration between scaffold boards

vent the materials or tools falling through the opening? Apakah
atform, bukaan modifikasi untuk pipa atau lubang apapun
ngkapi dengan pelat/papan kaki untuk mencegah benda

structure being secured utilizing sling, wire or any other tools
or modified to prevent becoming a falling object? Apakah lantai
a ataupun bagian structure telah diikat dengan kawat, tali
dipindahkan, digeser ataupun diangkat untuk mencegah
old platforms or grating secured and securely stored? Apakah

ding atau grating diamankan atau disimpan ditempat aman?
avations stored witin 1 m of the excavation edge and are

obability of rolling into the excavation being chocked?
berada di dekat pinggir galian dalam jarak 1 m dan material
an untuk bergulir ke dalam galian sudah dihalang?
other working area on grating covered to prevent small objects

w levels?
gelasan atau pekerjaan lainnya di atas grating ditutup untuk
jatuh ke bawah?
and decend ladders and staircases carry tools in secured

elts?
menaiki dan menuruni tangga dan anak tangga membawa
n di tas/tas punggung/tool belts?

RECO
ACTION

ication Record Sheet
Purpose
The purpose of this Self Verification is to ensure tha

the TEP Tangguh Site is executed in line with the
Prevention Procedure and associated relevant docu
the CSTS Management System
Doc.
Reference

CoW Procedure 5.6
CoW Procedure 5.3.1
CoW Procedure 6.1

CoW Procedure 6.1
SIMOP Procedure 4.2
CoW Procedure 5.3.2
5. Apendix 1.
5.1

5.1
5.1 & WAH Procedure

5.6.1
5.2
5.2
5.2

WAH Procedure 5.7
5.3
5.4

RECOMMENDATION

ord Sheet
Purpose
e of this Self Verification is to ensure that Work Activity at

Tangguh Site is executed in line with the Drop Object
Procedure and associated relevant documentation under
Comments / Remarks

ENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Se
Date / Tanggal:
Location / Lokasi:

Diwawancarai:
Scaffolding and Ladder Safety
Is the inspection tag system in place and clearly visible on sc

1
including correct inspection dates?
2 Is the scaffolding inspected by a competent personnel and ar

Is the scaffold being used in accordance with the “designed fo
3
shown on the "Scafftag"?
The scaffolding platform is provided with handrails, toe board

4
secured deck?
Stored scaffold materials are neatly stowed where they are un

5
not block access ways?
6 Is decking material appropriate, in good condition, and free fr
Are self-closing swing gates that open inward or an equivalen

7
ladder access points?
8 Is the maximum climb height between platforms at or below 6
9 Has special attention been given to eliminating vertical scaffo
Have scaffold ladders been installed at 90 degrees to the pla

10
accessed? (Up to 135 degrees allowed but not desirable)

Is the ladder access suitable, free from obstructions, secured
11
angle?
Have ladders been placed on secure footing and extend beyo

12
by a minimum of 1m (3ft)?
is fall protection in place where the height of climb is above 3

13
inclined ladders and cages on vertical ladders is preferred ov
Are platform ladders used in place of extension or straight lad

14
work?
Are all temporary ladder climb heights limited to 6m (20ft) or l

15 use of an extension ladder is the only means of access to com
9m (30ft) ladders are allowed but not desirable.)
Do the extension ladders, A-frame ladders and other adjustab

16
locking mechanisms fully engaged while in use?
Is fall protection used when performing work at heights over 2

17
(Complete handrail on platform ladder or PPE)
Did the risk assessment or pre-job discussion include any les

18
incidents from similar work?

19
to the crew?

NO ACTION
1
2
3
4
5

caffolding and Ladder Safety
m in place and clearly visible on scaffold/ladders

n dates?
d by a competent personnel and are records available?

in accordance with the “designed for use” criteria
provided with handrails, toe boards and a fully
are neatly stowed where they are unlikely to fall and do
riate, in good condition, and free from defects/debris
es that open inward or an equivalent barrier used at
ght between platforms at or below 6m (20ft)?
given to eliminating vertical scaffold ladders?
n installed at 90 degrees to the platform deck being

rees allowed but not desirable)

ble, free from obstructions, secured and at a 75 degree
on secure footing and extend beyond work platform
here the height of climb is above 3m (10ft)? (Guardrails on

s on vertical ladders is preferred over PPE.)
in place of extension or straight ladders to perform
imb heights limited to 6m (20ft) or less? (When the

is the only means of access to complete the work,
wed but not desirable.)
A-frame ladders and other adjustable ladders have

engaged while in use?
n performing work at heights over 2m (6ft)?

form ladder or PPE)
pre-job discussion include any lessons from past

?


RECOMMEND
ACTION

ion Record Sheet
Purpose

Scaffolding Procedure and associated relevant docum
under the CSTS Management System
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose

olding Procedure and associated relevant documentation
under the CSTS Management System
Comments / Remarks

MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Se
Date / Tanggal:
Location / Lokasi:

Diwawancarai:
Risk Assessment
1 Is there a clear description of the overall task provided?
2 Is the task broken into logical steps in the correct sequence?

3 Are all credible hazards clearly identified and described?
4 Is there a manageable number of controls prescribed?
Have sufficient engineering or physical controls been prescrib

5
not over-reliant on people to manage risks during execution)
For controls that rely on people doing something to mitigate th

6 potential and consequence of someone making a mistake rec
managed?
Did the lead talk through the task for the day, emphasizing th
7
personal and process safety hazards?
8 Was the TBT focused, brief and to the point, taking 5-10 mins
Was the team engaged and involved in the TBT? Did the lead
9
questions to encourage participation?
Did the lead check understanding in the group - people were

10
actions, hazards and controls?

Did the group agree hold points in the task to check status an
11
safe to continue the task?
Did the lead reinforce expectations to slow, pause or stop wh

12
changes?

NO ACTION
1
2
3
4
5

Risk Assessment
of the overall task provided?
cal steps in the correct sequence?

early identified and described?
mber of controls prescribed?
g or physical controls been prescribed? (i.e. the task is

to manage risks during execution)
eople doing something to mitigate the risks, is the

e of someone making a mistake recognized and
he task for the day, emphasizing the controls for

ty hazards?
f and to the point, taking 5-10 mins?
d involved in the TBT? Did the lead ask open

rticipation?
tanding in the group - people were clear on their

ols?

points in the task to check status and make sure it was
ectations to slow, pause or stop when something

RECOMMEND
ACTION

ion Record Sheet
Purpose

Risk Assessment Procedure and associated rele
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose

Risk Assessment Procedure and associated relevant
Comments / Remarks

MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Se
Date / Tanggal:
Location / Lokasi:

Diwawancarai:
STARRT Card/ECOW PERMIT
1 STARRT card/ECOW PERMIT to be conducted and complete
2 Leaders explained clearly the workscope and methods

3 STARRT card/ECOW PERMIT /JSA identify all critiacl risks a
4 Leaders well conversant on Method Statement and Job Safet
Anyone or member of group can talk and comprehend, feel c

5
proceed with interactive
Leaders to ensure that work must stop if they encounter prob

6
doubts or find new hazard in worksite
7 Leaders discussed actions in case of emergency situation?
8 All workers involved attended STARRT card/ECOW PERMIT
9 Workers who joint later (if any) are briefed on STARRT card/E

NO ACTION
1
2
3
4
5

STARRT Card/ECOW PERMIT
RMIT to be conducted and completed at the worksite
the workscope and methods

RMIT /JSA identify all critiacl risks associated wth the tasks ?
n Method Statement and Job Safety Analysis (JSA)
up can talk and comprehend, feel comfortable to
rk must stop if they encounter problems, experience

in worksite
in case of emergency situation?
ded STARRT card/ECOW PERMIT meeting
any) are briefed on STARRT card/ECOW PERMIT ?

RECOMMEND
ACTION

ion Record Sheet
Purpose

Control of Work Procedure and associated rele
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose

Control of Work Procedure and associated relevant
Comments / Remarks

MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Se
Date / Tanggal:
Location / Lokasi:

Diwawancarai:
Temporary Pipe Support, Pipe Fit Up & Welding at
Does the pipe to be fit up on the temporary support already s

1
standard temporary support?
Is the stopper are installed on the pipe to prevent uncontrolle

2 fit up on the temporary support? Is the size of stopper are sui
diameter of pipe?

Is the SWL of the temporary support are suitable for pipe, che
3
calculation and design or from manufacture
4 Is the area adequately barricaded,signs posted and covering
For irregular spools, are minimum three point temporary supp

5
ensure the pipe are safely supported.
For using tripod jack up support, is the tripod jack up are not d
6
soft ground? using proper steel mat or on the concrete floor?
Has a pipe fitter crew member are aware on the requirement

7
the temporary pipe support adjustment and reposition?
Is the pipe fitter crew are aware on the requirement for ensure
8 are left in the safe condition when leaving it for coffe break or
ask them how they do that to ensure it is in safe condition
Is there any regular check on the condition of the long term te

9
support to ensure the condition and integrity are still safe?
10 Are barriers effective at all times? E.g no unauthorised entry

Is there any competent person (Lifting team) involved in dete
11
and placement of temporary support installations?

NO ACTION
1
2
3
4
5

upport, Pipe Fit Up & Welding at Ground Level
on the temporary support already settled down using

rt?
on the pipe to prevent uncontrolled movement during

pport? Is the size of stopper are suitable compare with

ry support are suitable for pipe, check on engineering
rom manufacture
ricaded,signs posted and covering working area?
inimum three point temporary support are installed to

supported.
pport, is the tripod jack up are not directly touch to the

steel mat or on the concrete floor?
mber are aware on the requirement only rigger can do

t adjustment and reposition?
ware on the requirement for ensure their working area

n when leaving it for coffe break or end of the shift ?
to ensure it is in safe condition
on the condition of the long term temporary pipe

dition and integrity are still safe?
times? E.g no unauthorised entry

rson (Lifting team) involved in determining the use
ry support installations?

RECOMMEND
ACTION

ion Record Sheet
Purpose

xxxxx Procedure and associated relevant documenta
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose

Comments / Remarks

MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Self Verification Record Sheet Rev.0

Location / Lokasi:
Permit Number / Nomer Permit: The purpose of this Self Verification is to ensure that Work Activity
at the TEP Tangguh Site is executed in line with the Compressed
Gas Cylinder Procedure and associated relevant documentation
Persons Interviewed / Orang yang under the CSTS Management System
Diwawancarai:
Process, Plan or Procedure to be Verified Doc. Compliance

Comments / Remarks
COMPRESSED GAS CYLINDER Procedure (TEP-930-PRC-HS-BP4-0015) Reference YES / NO / NA
Has the cylinder received with the good labelled, Colour Coding, Valid
relevant certification? Issued by Ministry Manpower of Republic Indonesia or
any certain valid conformity certificate (Appendix 2 and 3)
Tabung bertekanan dilengkapi dengan Label, Kode warna dan sertifikat yang
1
masih berlaku? Sertifikat yang dikeluarkan oleh Kementrian Ketenagakerjaan 5.1
Indonesia ( appendix 2 & 3 )
Are there seperations between Compresses Gas cylinder with combustible or

flammable materials (at least 6 meter away) or have 1,5 Meter seperated wall
that could witstand 1 hours fire? And Safety signed display : NO SMOKING &
NO NAKED FLAME.
2 5.4
Apakah tabung bertekanan dipisahkan dengan jarak 6 meter dengan bahan
mudah terbakar, mudah meledak atau 1,5 meter tembok pemisah tahan api 1
jam. dan tersedia tanda peringatan : DILARANG MEROKOK DAN MEMBUAT
API.
Are there protection roof / shed to avoid Compressed Gas Cylinder being
exposed directly to the Sun or any heat source, and is there good ventilation
as well?
3 5.4
Apakah tersedia atap pelindung untuk menghidari tabung gas terpapar
langsung dengan sinar matari atau sumber panas dan mempunyai sirkulasi
udara yang baik?
Is a fire extinguisher (20 KG) available in a storage area?

4 5.4
Apakah alat pemadam api ringan (20 Kg) tersedia di gudang.
Are Compressed Gas Cylinder Valve cap / Protection attached, tightly

screwed down, in upright position during operation, storage and transport?
(Secured inside cage / Frame or using chain during storage or transportation)
5 5.4
Apakah penutup katup tabung gas terpasang, kuat dan terkunci dalam posisi
tegak selama penyimpanan dan pemindahan ? (Pastikan gas disimpan di
dalam keranjang dan terikat selama transportasi)
Does compressed gas cylinder frame attach with proper lifting lugs,
Inspected, color coded and SWL display / Marked?
6 5.1
Apakah keranjang dari tabung gas terpasang titik angkat, dan sudah
diinspeksi, diberikan kode warna dan SWL tersedia?
Is there a designated person to handle the storage area of compress Gas

Cylinder?
7 5.5
Apakah tersedia pekerja yang ditugaskan untuk mengurus gudang
penyimpanan tabung gas bertekanan ?
Is there any means to test leaking at every possible connection at the

Compress Gas Cylinder? (Soap Solution)
8 5.7
Apakah tersedia cara untuk mengecek kebocoran gas pada setiap
sambungan tabung gas? (Cairan sabun)
Are the hose and connection following manufactured standard? Is a whip

check available between connection/fitting?
9 5.7
Apakah selang gas dan sambungan gas merupakan buatan pabrik? Apakah
penahan sambungan tersedia (Whip checks)?
Are Flashback Arrestor (FA) available? - FA to prevent the explosion occuring

and shall be fitted at the torch and at the gauges connection.
10 5.8
Apakah Flashback Arrestor (FA) terpasang? Di dua sisi: tabung dan alat
potongnya ?
Are the Pressure regulator maintained with valid certification and manufacture
instruction? - Provide valid certificate on-site.
11 5.9
Apakah regulator tekanan terpasang dan mempunyai sertifikat dan petunjuk
dari pabrikan? (Sertifikat yang sah di lokasi kerja)
Are all empty Cylinder segregated and clearly signed to identify?

12 Apakah semua tabung kosong dipisahkan dan terpasang penanda yang 5.3
jelas?
Are the Compress Gas Cylinder free from electrical circuit or electrical
cables? (Every Compress Gas Cylinder shall free from any electrical circuit)
13 5.3
Apakah tabung gas terbebas dari jaringan listrik atau kabel listrik? (tabung
gas tidak boleh menyatu dengan kabel listrik )
Is the Checklist for Compressed Gas Cylinder storage and handling

available?
14 - Seeking on-site and validate Appendix 1
Apakah tersedia daftar periksa/check list untuk tabung bertekanan di gudang
tabung gas?
Are Compressed Gas Cylinder cages loaded/unloaded and transported

15
properly? Are they properly fixed during trasnportation?

RECOMMENDATION
1
2
3
4
5

TEP Se
Date / Tanggal:
Location / Lokasi:

Diwawancarai:
Painting Coating
1 Is the permit/STAART card correct? Has everyone signed?
2 Are the blaster / painter competent to perform the task?

3 Does everyone understand their R&R’s?
4 Has the hazards and risks been assessed and communicated
5 There is eye wash station at work location?
6 Are workers use the correct tools for the job?
Are all equipment and tools (Blasting hose, Compressor, Pain

7
hose, Airless hose) in good condition?
8 Are all hose connection secured (whip check available, etc) ?
Explosive atmosphere special regulations - blast cleaning and

equipment shall be earthed (grounded). In hazardous areas,
9 shall be used for cleaning purposes and flameproof equipmen
compulsory. In confined space area, the lighting shall be used
light.

Paint Mixing Tray. Mechanical Agitator for mixing more than 5
10
in good condition.
Housekeeping at area are in good standard, free from slip, tri

11
suitable barriers and signs in place
12 Deadman valve is working properly on the blasting gun
13 Warning signs and barriers in place
Correct segregation for hazardouz material and waste. Dedic

14
available.
15 Fire extinguisher available near paint mixing area
Worker use a correct PPE for the job (Respirator, Apron, face
16
google, helmet & gloves right for task) and in good condition

NO ACTION
1
2
3
4
5

Painting Coating
d correct? Has everyone signed?
mpetent to perform the task?

d their R&R’s?
been assessed and communicated?
at work location?
ct tools for the job?
s (Blasting hose, Compressor, Paint pump, Air spray

d condition?
cured (whip check available, etc) ?
cial regulations - blast cleaning and spray-painting

d (grounded). In hazardous areas, non-spark tools
purposes and flameproof equipment shall be
pace area, the lighting shall be used explosion proof

nical Agitator for mixing more than 5L is available and
in good standard, free from slip, trip hazards and

in place
properly on the blasting gun
s in place
zardouz material and waste. Dedicated trash bin
near paint mixing area
for the job (Respirator, Apron, face shield, safety

ght for task) and in good condition

RECOMMEND
ACTION

ion Record Sheet
Purpose

xxxxx Procedure and associated relevant documenta
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose

Comments / Remarks

MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Self Verification Record Sheet Rev.0

Location / Lokasi:
Permit Number / Nomer Permit: The purpose of this Self Verification is to ensure that Work
Activity at the TEP Tangguh Site is executed in line with the
xxxxx Procedure and associated relevant documentation under
Persons Interviewed / Orang yang the CSTS Management System
Diwawancarai:
Doc. Compliance
Insulation Comments / Remarks
1 Is the permit/STARRT card correct? Has everyone signed?
Is everyone is qualified as per tradesman level, e.g Matal fabricator, Wintech opr,
2
Band saw opr, etc.
3 Are Injection PIF Operator competent to perform the task?
4 Are the supervisors/inspectors competent to perform task?
5 Are the hazards and risks controllable?
6 Correct tools for the job
All Equipment & Tools (Wintech Unit, Band saw, Injection, etc) In good condition
7
and stored with adequate weather protection (eg. Shelter, container, etc)
8 All pressurized connection secured (whip check available, etc)
Pressurized equipment certified giving the maximum safe working pressure and
9
have routine inspection
Housekeeping at area to good standard, free from slip, trip hazards and suitable
10
barriers and signs in place.
Cover area is sufficient for cutting macine Activity (to minimize contamination to
11
other working area)
Correct segregation for hazardous material & waste. Dedicated trash bin
12
available.
13 Fire Extinguisher available near working area
14 CSTS area supervision is assigned
15 Subcontractor supervision/inspector is assigned
Worker use a correct PPE for the job (Respirator, Apron, face shield, safety
16
google, helmet & gloves right for task) and PPE in good order
RECOMMENDATION
1
2
3
4
5

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TEP Self Verification Record Sheet Rev.

Date / Tanggal: Purpose

Are there available segregations between pedesterian and mobile / moving

# Saipem Classification - General Use

Is barrier size adequately protect the hazardous zone?

Percentage of Implementaion #DIV/0!

# Saipem Classification - General Use

Permit Number / Nomer Permit:

Name of Verifier / Pemeriksa:

1 Are created openings identified and entered in the created op

Has the task planning process reviewed whether a creating o

# Saipem Classification - General Use

Are barriers, guardrails and signage in place to restrict acces

Are fall protection devices specified in the permit and being u

Where required, are attendants actively managing access an

Have the risks and control measures required been effectivel

8 Is a hatch management process in place to reduce created o

9 Is there a process to communicate this work to the next shift w

Are locations beneath open created openings barricaded to m

# Saipem Classification - General Use

Are SIMOPS agreed between any work crews that need to in

Is the created opening 'hard covered' when worker access is

Do employees understand that they have the authority and ex

15 Has the work crew received positive feedback on raising conc

Did the risk assessment or pre-job discussion include any les

Are emergency response plans robust in terms of equipment

Do rescue plans and preparations include adequate provision

# Saipem Classification - General Use

Is there STARRT card/ECOW PERMIT for the activity, proper

# Saipem Classification - General Use

# Saipem Classification - General Use

tified and entered in the created opening register?

cess reviewed whether a creating opening is actually

# Saipem Classification - General Use

d signage in place to restrict access to the created

specified in the permit and being used correctly when workers

dants actively managing access and egress when

measures required been effectively communicated to the work

ocess in place to reduce created openings on vessels?

municate this work to the next shift where applicable?

n created openings barricaded to minimise the impact of

# Saipem Classification - General Use

een any work crews that need to interact through the

d covered' when worker access is not required and is the cover

that they have the authority and expectation to stop

d positive feedback on raising concerns?

pre-job discussion include any lessons from past

plans robust in terms of equipment and personnel,

arations include adequate provision to reduce the

# Saipem Classification - General Use

OW PERMIT for the activity, properly filled and communicated

# Saipem Classification - General Use

# Saipem Classification - General Use

The purpose of this Self Verification is to ensure th

# Saipem Classification - General Use

# Saipem Classification - General Use

e purpose of this Self Verification is to ensure that Work

# Saipem Classification - General Use

# Saipem Classification - General Use

# Saipem Classification - General Use

# Saipem Classification - General Use

Permit Number / Nomer Permit:

Name of Verifier / Pemeriksa: