PERTAMINA

ROMP
RDMP Project
Checklist of PTW Verifying & e- COP Reporting Card For Sub-Contractors
Permit Registry No PTW pertorming authority should ill out the table below as per PTW
information daily and provnde it to JO HSE and JO Superintendent)
I1 Date 2 Work Location
tee. 3. Wok Description Pk) 7(S) Ss
4. 0nspector NametoHAR Position $t Comaany SSA Construction WECH HtaneAMI21
By HSE part - The checklist below should be complet Comsary P-sIA
N NA YES NO People (Human error) NJA YES NO
PTW VES
High Potertial Risk (Probability)
1 Procedure NOT followed / NO procedure exists Display properly on Site Falls from height / Drop Ooject
2
Fatigua Verifyng PTW with activity 2 Struck by mcving venicie
3 Change of routine PTW Validation (Valid period, Proper authority.) 3
Struck by meving ooject (Loading. Unload ng
4 Lack of communication
JSA & other required attachment Tragped by something collapsing / overturn
Drugs / alcohol Proper conducted RAof JSA from MS 5 Contact with rotati ng machinary/ Flyrg Cbject
Time / production pressures LOTO - Gas Test - Is olation Implemented 6 Slips, trips, fals on same level with work1ng place
Persorai issues stress 7 Fire Extinguisher 7 Contact with elecuciy elecrcal discharge
Other & Positive 8 Supervision &Training Exposure to fire
Other & Positive
Drowing
10 Asphyxiation
11VProbability of Cther Fata Acciderts

D By Construction part - The checklist below should be completed by the Superintendent in charge of activity.
NO YES
PPE Na NA YES No Work System NA YES NO
Equipmert/ Materiat Na N/A YES NO
Work Envirorment Concition)
Safety Helmet 1 Fazard NOT identity Wrong equioment for the job Ncise
2 Safety Glasses 2 vHazard NOT reported 2 Inadeguate maintenance 2 ightng
3 Safety Shoes 3 vInadequate controls implemented nadequate guarding 3 Vbration
4 Coveral 4 PTW System NOT fallowed Equipment failure 4 Damaged!rstab'e fioor
5 Gioves Other & Positive 5 Materal/ equ'pmert too heay/ awkward Layout / design
Ear Plug 6 Inadequate training pIoVded Dust /iurne

Mask 7 Inadequate L'rence Houstkeep ng sip/ 1np hZ

8 Full Body Harness Inadeqvate FlTgman position, co stume Other & Positive
Other & Positive Other & Positive
 PERTAMINA
NARNS PyAA
SAFETY OBSERVATION CARD RDMO
KARTU OBSERVASI KESELAMATAN
Date& Time/ Tanggal& Waktu :O6-O?-2o23
Location/ Lokasi :Area 46
|Name & Position/ Nama & Posisi
Company/ Perusahaan PT Sh

Type of Observation (Please Thick One)

Jenis Pengamatan (Centang Salah Satu)

SAFETY GOLDEN RULES Violation?

Pelanggoran Terhadap SAFETY GOLDEN RULES?
Yes No

UNSAFE ACT/cONDITION
Kondisi / Prilaku Tidak Aman

SAFE BEHAVIOUR/GOOD PRACTICE

Perilaku/Praktik Kerja Aman
SUGGESTION
Saran

JELASKAN APA YANG ANDA LIHAT

Describe what did you see

faca Sqat
Bowt
|TINDAKAN APA YANG ANDALAKUKAN ATAU KESEPAKATAN YANG ANDA
|BUAT?
Whot Actíon Did You Do or Agreement Made?
|(Berikan saran positif utau menghentikan perliaku/kondisi tidak oman)
(Give Posítiye Suggestion or Stop the Unsafe Action/ Condition)

Mubtchtr
mat G.

WDAKAN REKOMENDASI Action

 PERYAMNA RDMP
SAFETY OBSERVATION CARD
KARTU OBSERVASI KESELAMATAN

Date &Time/ Tanggal &Waktu : 06 22-20Ls

Loation/ Lokasi
Name & Position/ Nama& Posisi
JCommpoyPerusahàan PL

Type of Observation (Please Thick One)

Jenis Pengamatan (Centang Salah Satu)

SAFETY GOLDEN RULES Violation?

Pelanggaran Terhadap SAFETY GOLDEN RULES?
Yes No

UNSAFE ACT/CONDITION
Kondisi / Prilaku Tidak Aman

SAFE BEHAVIOUR/GOOD PRACTICE

Perilaku /Praktik Kerja Aman
SUGGESTION
Saran

JELASKAN APA YANGANDA LIHAT

Describe what did yousee

a Saat babris

TINDAKAN APA YANG ANDALAKUKAN ATAU KESEPAKATAN YANG ANDA

BUAT?
Whot Action Díd You Do or Agreement Made?
(Berikan saranpositif atau menghentikan perllakufkondisi tidak aman)
(Give Positive Suggestion or Stop the Unsafe Action/ Condition)

Ai are Bism

TINDAKAN REKOMENDASI/Recarmmendatlon Action

eresunckaa
 PENTAMNA SAFETY OBSERVATION CARD
KARTU OBSERVASI KESELAMATAN
RDMPJO

lontiov/lokst
NarNe&PosAYNama & Posisi

|Company/ Perusahaan

Type of Observation (Please Thick One)

Jenis Pengamatan (Centang Salah Satu)

SAFETY GOLDEN RULES Violation?

Pelanggoran Terhadap SAFETY GOLDEN RULES? Yes No

UNSAFE ACT/CONDITION
Kondisi/ Prilaku Tidak Aman

SAFE BEHAVIOUR/GOOD PRACTICE

Perilaku/ Praktik Kerja Aman
SUGGESTION
Saran

JELASKAN APA YANG ANDALIHAT

Describe what did you see

|tacisld
TINDAKAN APA YANG ANDA LAKUKAN ATAU
BUAT? KESEPAKATAN YANG ANDA
Whet Action Did You Do or
\(Berikar saran positif atouAgreement Made?
(Gve PGsitive Suggestton ormenghentlkan
Stop the perilakukondisi tidak gmon)
Unsafe Action/ Condition)

TINDAKAN REKOMENDASI /Recommendation Action

 ARINA

SAFETY OBSERVATIONCARD
KARTU OBSERVAS0 KESELAMATAN ROM0
Date & Tìme/ Tanggal & Waktu
Locotion/lokesi
Name Poson/ Nama & Posist
compay/ Perusahaan

Type of Observation (Please Thick One)

Jenis Pengamatan (Centang Salah Satu)

SAFETY GOLDEN RULES Violation?

Pelanggaran Terhadap SAFETY GOLDEN RULES?
Yes No

UNSAFE ACT/CONDITION
Kondisi / Prilaku Tidak Aman

SAFE BEHAVIOUR/GOOD PRACTICE

Perilaku / Praktik Kerja Aman
SUGGESTION
Saran

JELASKAN APA YANG ANDALIHAT

Describe what did you see

KESEPAKATAN YANG ANDA

TINDAKAN APA YANG ANDALAKUKAN ATAU
BUAT?
Whot Action Did You Do or Agreement Made?
perilaku/kondisi tidak aman)
(Berikan saran positif atau menghentikan Action/ Conditior)
Unsafe
(Give Positive Suggestion or Stop the

Aktion
TINDAKAN REKOMENDASI /Recomhendation
 PERTAMINA
SAFETY OBSERVATION CARD
KARTU OBSERVASIKESELAMATAN

& Wakt
: O7770
Dote & Tim/TanRAal
ocatton/ lokasi

ompoNy/Perusahaan

Thick One)
Type of 0bservation (Please
Satu)
Jenis Pengamatan (Centang Salah

SAFETY GOLDEN RULES Violation?

RULES?
Pelanggaran Terhadap SAFETY GOLDEN Yes No

UNSAFE ACT/CONDITION
Kondisi/ Prilaku Tidak Aman

SAFE BEHAVIOUR/GOOD PRACTICE

Perilaku/Praktik Kerja Aman

SUGGESTION
Saran

JELASKAN APAYANG ANDA LIHAT

Describe what did you see

TINDAKAN APA YANG ANDA LAKUKANATAU KESEPAKATAN YANG ANDA

BUAT?
What Action Did You Do or Agreement Made?
\(Berikan saran positif atau menghentikan perilaku/kondisi tidak aman)
|(Give Positive Suggestion or Stop the Unsafe Action/ Condition)

TINDAKAN REKOMENDASI/ Recommendotion Action

 PERTANINA RDMP
SAFETY OBSERVATION CARD
KARTU OBSERVASI KESELAMATAN

Date e Time/ Tanggal & Waktu

JLocation/ Lo kasi
Name & Pos/tion/Nama & Psisi

lcompany/Perusahaan :PI:SSh

Typeof Observation (Please Thick One)

Jenis Pengamatan (Centang Salah Satu)

SAFETY GOLDEN RULES Violation?

Pelanggaran Terhadap SAFETY GOLDEN RULES? Yes No

UNSAFE ACT/CONDITION
Kondisi /Prilaku Tidak Aman

SAFE BEHAVIOUR/GOOD PRACTICE

Perilaku/ Praktik Kerja Aman

SUGGESTION
Saran

JELASKAN APA YANG ANDA LIHAT

Describe what çid yoy

KESEPAKATAN YANG ANDA

7INDAKAN APAYANG ANDA LAKUKANATAU
BUAT?
Made?
What Action Did YouDo or Agreement
perilaku/kondisi tidak aman)
(Berikan saranpositif atau menghentikan Condition)
Unsafe Acton/
\(Give Positive Suggestion or Stop the

TINDAKAN REKOMENDASI/ Recommendation Action

 PATAsLINA
SAFETY OBSERVATION CARD RDMP
KARTUOBSERVASI KESELAMATAN
Date S Thme/ Tangral& Waktu
Loatkon/Lokasi
JNaeS Posko/ Nama & Posisi
Cospony/ Perusahaan

Type of Observation (Please Thick One)

Jenis Pengamatan (Centang Salah Satu)

SAFETY GOLDEN RULES Violation?

Pelanggaran Terhadap SAFETY GOLDEN RULES?
Yes No

UNSAFE ACT/CONDITION
Kondisi / Prilaku Tidak Aman

SAFE BEHAVIOUR/GO0D PRACTICE

Perilaku/ Praktik Kerja Aman
SUGGESTION
Saran

JELASKAN APA YANG ANDA LIHAT

Describe what did you see

TINDAKAN APA YANG ANDALAKUKAN ATAUKESEPAKA TAN YANG ANDA

BUAT?
What Action Did You Do or Agreement Made?
(Berikan saran positif atau menghentikan perilaks/kondisi tidak aman)
|(Give Positive Suggestion or Stop the Unsafe Action/ Condition)

mwea

TINDAKAN REKOMENDASI/Recommendation Action