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JASA PERANCANGAN, PENGADAAN LUTION P wxaunaces | “DAN KONSTRUKSI PEMBANGUNAN | DSTISO:2"° PIPA GAS SENIPAH - BALIKPAPAN ‘SAFETY INSPECTION CHECK LIST PGAS -HSSE EXCAVATOR Rev (Form No. 02) Project/ Ste Seni pa i iz Date of Inspection WW ho [ty ‘SIN of equipment 7 regsratonnumer__| 08/6SSS1 Company Row Location ofinspection | WS AO~ No DESCRIPTION Good | FAIR | POOR | N/A | REMARKS 7_| Operator certificate (S10) — — 2_| Third party certificate (iting point) | _ 3 | Wiper - 4_| SWL Marked on the acm (fuze foriftng) - Swing Alarm “7_[ ESD. system lic system and hose condition [3 Tunings 10 | Spark Arrestor (fuse within interface oreo) [a tty tnt counter weigh 42 | Cabin condition 73 | Battery connection and protective cover 14 | Engine and fuel system (leaks) 45 | Tires / track condition 16 | Maintenance log book & P2H 17 | insulation of exnaust pipe 18 | Electrical cable connection, isolation 19 [Fireextingusher 20_| First aid kt 21 | Colour coae 22 | sito Depnaker ‘Comment: ERK EK KKK KK Sr, Pak Tobe pRvon pl rin” linspected by PGAS (HSE & Authorized Person) ‘Acknowledge by: PTG - HSE Name = (Layer Name: Beare Name Feu AL [ Position: Se Postion fy Position = San aye sen? YP Sea 0 a y A PERTAMINA skkmigas HULU MAHAKAM ae Expédteur: POVOSF - Crane Austor oe POIOSFIINS — BPN Dale: August 26, 2023 ‘Référoncé No : POIOSFINS/EXCIYS/2023-605 Recitn No. of Pages : page + 10 attachments ‘Object PT. PERTAGAS HITACHI EXCAVATOR (ACM-EXC-08) RE-AUDIT Subject Réterencé_: Tintin Waya, email date : Thu 8/24/2023 7.04 AM "Memo No. PO/OSF/INS/EXC/TP/2023-527 daie: August 08, 2023. Re-Audit of excavator owned PT. PERTAGAS have been performed on August 25, 2023 at Workshop PT ‘ACM KP 7 Pemedas - Senipah Area, the purpose of audit isto ensure that equipment which willbe used is. complying with PERTANINA Hulu Mahakam Regulation and scope of aut are: 1, Review documents 2. Physical visual inspection 3. Function test ‘Audit Findings 4. None ‘CONCLUSION and RECOMMENDATION Based on pre hire audit resul, the excavator with serial number HCMOCDF2HO0065551 is Acceptable to be sed in PERTAMINA Hulu Mahakam premises with recommendations: 4.None [A solid color code rectangular BLUE (RAL-£012) is to be applied tothe liting equipment which Acceptable to 'be used, and rectangular RED ~ (RAL. 9020) is to be applied to iting equipment which not Acceptable, ‘This MEMO is valid until February 01, 2024, Reged Acsnowedge by NAH Mujito Abdul neon v Rahman neon Yayan Satria Mujto Abdul Rahman ‘Note; DISNAKER Testimony inspection and Safety Examination No. 16376/XX2022 valid until Sept 01, 2024 + Excavator (Certificate of Inspection) by PT LD Servis No.LDS-EXC-1360-ACM vaild unt Sept 24, 2029. + User responsible to kept all certificate Crane and iting gears is valid for purpose. + There is any change to crane condition major or ciical component) the crane subject to re-audit a & A PERTAMINA skkmigas HULU MAHAKAM AUDIT RESULT & RECOMMENDATIONS We summarize result of the audit and corrective action to be performed as follows: AUDIT RESULT & RECOMMENDATIONS (soo attached chocklist fr dai) A. CATEGORY-1 NON-CONFORMITIES: "Non-conformities listed below are the reason forthe excavator not fi for use No FINDING ‘RECOMMENDATION None None CATEGORY-2 Potential serious non-conformities listed below must be rectified within 28 days FINDING ‘RECOMMENDATION 1 None None CATEGORY This finding has been noied on previous memo and should be rected in due date, No FINDING RECOMMENDATION None None CCatogory 1 (ho excavator must rot bo usec, Re-audt shal be performed afer recitation o category frecmmendations (rbofce use n PHM Category 2 (must be recite within 26 days). For in sone aud o-audt shal be perormed ater 28 dys. Reciiction of category 2 toms may noed more then 28 days for r-aut andthe excavatr can tapered. at recommenced by tho sudo, when spare pars avabity wail be more than 28 days Category 3 (shoul be rected in ue tine), Re-aust shal be performed as requied, ronal after 6 month x ge &* PERTAMINA skkmigas HULU MAHAKAM 1. TAG/D&S/N +_ACM EX 08 / HCMDCDF2H00065551, 2. TYPE / MODEL 1 5G Series Excavator 1 2X210F 3. CAPACITY / SWL 2 Ton 4. MANUFACTURER 5. YEAR OF BUILT 6 Boom/Arm Length 7 8 9. ‘Max working height ‘Max working dept ‘Max working reach 10. Bucket size 11. MAIN ENGINE OR MOTOR DATA © MANUFACTURER © TYPE / MODEL + SERIAL No ‘© _ ENGINE START SYSTEM 12. MAIN HOISTING © MAIN HOIST WINCH MOTOR + MANUFACTURER ~ TYPE / MODEL = SERIAL No + MAIN HOIST HOOK BLOCK ‘CAPACITY - No. OF SHEAVE © MAIN HOIST LINE ~ DIAMETER - TOTAL REEVING/PART LINE - DATE OF INSTALLATION 13. AUXILAIARY HOISTING ‘AUXILIARY HOIST WINCH MOTOR - MANUFACTURER + TYPE / MODEL = SERIAL No + AUXILIARY HOIST HOOK BLOCK = CAPACITY -_ DATE OF LAST INSTALLATION © AUXILIARY HOIST LINE = DIAMETER = SWL 14. BOOM HOISTING (IF APPLICABLE) = BOOM HOIST WINCH MOTOR - MANUFACTURER + TYPE / MODEL = SERIAL No © BOOM HOIST LINE = DIAMETER + TOTAL REEVING/PART LINE DATE OF LAST INSTALLATION a ge A= PERTAMINA skkmigas HULU MAHAKAM. Operaing manual em manvcier alarms, ot. 2. Manufacture lod chart ‘dato - : 3. Excavator operation og book & se inspection Se ee a Adora : 5 For Excavaior a,_Bargeessel dock sural svengih clouaion NP NAP NAP '5__Mafenance manval fom manufacturer Raataok Preventive Maintenance ecard as per manuladurer mantenance manual and company standard a. 6 monty ‘aria 2 : >. 12monhiy and Adalidak : 3 c. Major ainenanoe (whenever appicabie) ‘rT : 5 7. Certificate and nspecion Report form 3% party nspcion | sara - - company wth holding SKUP™* ‘a 6montly {Thorough visual nspecbon of comple exanvaior and allits associated Ling Equipmentincluding | Ada a wie rope. NOT on excavator Pad oye Reale ‘wailable 5 _12montiy i, monty nepedton ‘Adak é 5 NDT or rack detection of sul boom ‘Adora : - Functon test offe check swing boom maton Bre. |_ paar 7 . a e A PERTAMINA skkmigas HULU MAHAKAM FINDINGS a)_Fuel 5 Al intake ©) Exhaust ')_Belvtensionor 0 ERRRE) | RREEE| | 8 RE Fue! For hydraulic iype angie sariar system check or any hydraulic ol leak Running Test ')_Any exsessive noise, vibralion or smoke 'b) Check Oil cooler sysiom & temperature for any ‘anomal {@]_ Check engine ESD push bution 1) Check Insiruments/Gaus ©) Check Fuel leaks. ‘Visual check of ‘system for: ') Linemoses. »b) oil cooler ©) Cylinder valves: 0) reservoir €) hydraulic oi £) hydraulic ollFiter Running Test '2) During engine running, check main hydraulic and distribution system (Min hydraulic pump, hydraulic hose and connection) for anomalies 'B) Check hydraulic cooking system (i any) is function f gi ager ‘Visual check for bol tightness and lis general condition ‘a. Tum table and bot be ‘Gear box ‘c_ubricant int d. LockBrake Function Test Slew 'a)_ Slew smooth moverneni, speed and brake ’b) Swing imit functional and set properly as per actual Condition on sites egeeee |/2) 2 if .Y & A PERTAMINA Siemiaas. HULU MAHAKAM BOOM ‘)_Boom Visual condition )_Gylinders/Rods condition ©) Hoses\LinesFitings ins/Locks ee2e —s_ )_ Hydraulic Cylinders condition Function Test Boom ‘@) Boom basic movement boom up/down) (upldown, smooth movement, speed and brake) ‘check for anomalies DIPPER ARM ‘a) Dipper Visual condition )_Cylinders/Rods condition ‘c) Hoses/LinesiFittings ‘d)_Pins/Locks. ‘e) Hydraulic Cylinders Function Test Dipper 1) Dipper basic movement boom upidown) (up/down, smooth movement, speed and brake) ¥ check for anomalies Visual Check of | a Make sure the bucket is the right size and type ‘a) Bucket TeethiCutting edge ’b) Bucket Pin ‘¢)_Bucket bushing vu [—d) Pad eyes on e) Hydraulic Cylinders Function Test Bucket ‘a) Bucket basic movement (up/down, smooth movement.) check for anomalies pcs Hydraulic oy < E PERERRE &

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