Site-Specific HSE Plan

Site-Specific HSE Plan
Jl. Raya Jepara - Kudus, Tegelon, Pelang, Kec. Mayong,

Revisions: 0 Jepara Regency, Central Java 59465
Introduction
Objective:
The PLTS project located at Parkland World Jepara has a high commitment to PT ACE E&C's K3L policy by
controlling and monitoring K3L through the implementation of K3L
procedures & standards.
Scope: Developing an K3 program to support employee work health and safety . Compile, supervise and
maintain documents related to the company's K3. Prepare K3
performance reports in the company. Identify various problems that
are predicted to be potential dangers for employees, carry out
prevention and handling of potential dangers in the work environment.
Applicable Rules, Regulations, Standards:

1- Health
It is ensured that employees who work at PWJ are in good health, and before activities start we
always warm up, by means of gymnastics or stretching before TBM starts, and after TBM we as HSE
always carry out blood and heart checks every day to ensure workers are in good health..
2- Housekeeping
We as HSE ensure that each work area is clean, and we require all foremen before work and after
work to clean their respective work areas.
3- Smoke
We here as the HSE team prohibit all employees from smoking while working, because we have
prepared a shelter for smoking which is equipped with an ashtray, fire extinguisher and 3 colored
trash boxes.
1. Red B3 Waste / Hazardous & Toxic Materials .
2. an organic yellow color.
3. Organic green color.
4- Alcohol and drugs
DO NOT abuse alcohol and illegal drugs or use, possess, distribute or trade illegally. The Company
will not employ personnel who are Users, or have a current record of using illegal drugs or have
abused drugs. Any Employee found to be violating the Company's Illicit Drug Policy WILL BE
IMMEDIATELY TERMINATED.
K3L Reference Images and Documents
Description :
1- Ensure that the K3 Project Plan has been prepared in accordance with standards and sent to
interested parties.
2- Ensure that all heavy equipment and equipment used has valid certification.
3- Ensure protection of 3rd parties and the surrounding environment is planned safely.
4- Ensure that all heavy equipment is operated by operators who have an SIO (Operating License) and
are still valid.
5- In dangerous conditions must be able to stop work.
6- Carry out inspections of heavy equipment and equipment every time it is used and carry out
routine K3 inspections.
7- Make periodic reports on K3 Performance and report them to the authorities and interested
parties.
8- Building operations must have at least 1 General K3 Expert.
Page 1/ 17 Template #TE0113 - Revision date: June 25, 2020


Site-Specific
Specific HSE Plan
Description :
1. Use PPE that is clean and meets standards.

2. Regularly check the helmet and its suspension. Fastens with the chin strap and there's the company
name on the front of the helmet, the K3 logo on the back, the safety induction logo on the front and a
competency sticker on the left
eft side.
3. Regularly check all PPE used and inspect it before use. Helmets that have been crushed by material
and safety belts/body safety belts that have withstood the weight of a fall or are in abnormal
condition must be replaced after inspection (use the checklist).
4. Safety belts and body safety belts must be checked before each use, ensuring that there is no damage
to the strap hooks, connection straps, etc. Helmets that have been crushed by material and safety
belts/body safety belts that have withstood the weight of a fall or are in an abnormal condition must
be replaced after inspection (use the checklist)
5. All project workers must wear reflective vests, safety shoes or shoes with steel toe protectors, safety
glasses and gloves.
6. All workers and people entering
tering the project must use identity cards.
7. Make a notebook of the PPE usage period and prepare replacement PPE when it expires.
8. Other PPE should be used according to the type of work and potential hazards.
9. Violation of the use of PPE (not used or not according
acco to standards).
1. PERSONAL PROTECTIVE EQUIPMENT REQUIREMENTS

Head protector
1. The project helmet must be ANSI Z.89.1-2014

Z.89.1 2014 standard or at least SNI standard.
2. Check the condition of the helmet at least once every 2 weeks, replace it if it is defective or
damaged.
Foot protector
1. . Safety shoes must be ANSI Z.41-1999

Z.41 standard or at least SNI 7079-2009
2009 standard.
2. Check the condition of your shoes at least once every 2 weeks, replace them if they are damaged or
damaged.

Site-Specific
Specific HSE Plan
Eye Protection
1. All workers and people entering the project must wear eye protection.
2. Check the condition of the glasses at least once every 2 weeks, replace them if they are defective or
damaged.
Protector face
1. Work that specifically endangers the worker's face (welding, cutting, grinding, etc.) must use face
protection according to the standard.
2. Welding and cutting work with both welding transformers and cutting welding must use a welding
mask.
3. Work on grinders and other rotating portable tools (snail
(snail machines, shovels, etc.) in open areas
must use a face shield combined with a helmet (fig. 2), while work in work workshops can use a
regular face shield.
4. Check PPE before use, do not use damaged PPE.
Fall Protection From Height
1. Workers who work above 1.8 meters are required to wear a Full Body Harness.
2. Check Full Body Harness before use.

Site-Specific
Specific HSE Plan
Hand Protector
1. All workers must use gloves according to the SNI-06-0652-2015

SNI standard.
2. Workers should generally wear cotton gloves min. 8 threads (fig. 1)..
3. Rougher work, such as ironwork, steel, formwork, handling steel rope, wire, etc., must use
combination gloves (fig. 2).
4. Welding, cutting and grinding work must use leather gloves (fig. 3).
5. Work with chemicals and toxic substances requires the use of chemical-resistant
resistant gloves (vinyl, PVC,
nitrile, etc.) (fig. 4).
6. Electrical technicians must wear electrically resistant gloves min. 5KV (fig. 5).
7. Check the condition of the gloves every time they are used, replace them if they are damaged or
damaged.
Ear protector
1 2
1. If working at noise levels above 85 dB for exposure for 8 hours, you must use ear protection (ear
plugs or ear muffs).
2. Ear plugs are plugs that are inserted into the ear canal.
3. Ear plugs (fig. 1) must be made of rubber or soft plastic and must be able to reduce noise by X-85
X
dB (X is the noise intensity received by the worker).
4. Earmuffs (fig. 2) are covers for the entire ear that can reduce noise by 35-45
35 45 dB.
5. . Check ear plugs or earmuffs before use, make sure they are cleanclean and put them back in the box
after use after cleaning.

Site-Specific
Specific HSE Plan
2. CONCEPT IN THE WORK AREA
1. Concise
Concise is separating everything that is necessary and removing what is not necessary from the
workplace. Knowing which items not to use, which to keep, and how to store them so they can
be easily accessed can prove to be very useful for a company. The way to do this is by listing
the various types of items you own, classifying them according to their type and use, marking
certain items, thenn placing the items in their proper place.
2. Neat
Neatness means placing things in their place so that they do not appear scattered in the
workplace, which could endanger the safety of workers. Neat is applying the principle of kaizen
which is continuous improvement.
3. Rehearsal
Cleanliness is cleaning the place, equipment and work clothes used. With this principle, it is
hoped that we will be able to create a clean and comfortable work environment.
4. Treat
Care is carrying out maintenance so that what was achieved
achieved in the three previous stages can be
maintained. Maintenance is not limited to the products produced but also maintenance of the
equipment used in carrying out the production process.
5. Diligent
Diligence is the creation of employees' personal habits to maintain and improve what has been
achieved. Diligence is related to punctuality of work, accuracy in fulfilling customer requests,
accuracy in achieving targets to be achieved. Once achieved, it is maintained so that conducive
working conditions can be maintained.
m

Site-Specific
Specific HSE Plan
Site identification
Site name: Parkland world Jepara
Full address: Jl. Raya Jepara - Kudus, Tegelon, Pelang, Kec. Mayong, Jepara Regency, Central Java 59465
Indonesian country
EPC / O&M Contractor: Total Energy
Total Affiliates: 2
Company name: Ace Engineering & Construction
Name and details of contact person: Chu Tae Sik(-)
Sik(
Location owner/operator: Kim sang kug

Company name: Ace Engineering & Construction
Name and contact person details: Kim sang Kug (082129881000)
Short description of the
he site: Installation of PLTS
Brief description of the work: Installation of PLTS
Job location within the site: Finish Good&Canteen
Planned mobilization date: June 5, 2023
Planned duration of work: 24 weeks

Construction / O&M Team
On-Site Management Representative:

Name: Mr Kim Sangkug Telephone: 082129881000
Main responsibilities: Project Manager
HSE Team:
1. Position: HSE MANAGER (HO) Name: Maruf Asroi Telephone: 08111907910
Main responsibility:
• Audit and carry out work planning, implementation and supervision.
• Provide standard regulations in each work procedure.
• Become a liaison for company information with HSE at the project location and in the work
unit.
• Recruit prospective employees in the health, safety and environment division who meet their
qualifications.
• Responsible for the smooth implementation of the project from the HSE aspect.
• Responsible for work safety and security at the project location and his subordinates such as
safety officers, safety supervisors, safety engineers, safety admins, safety men.
2. Position: HSE Coordinator (PWJ) Name: M Romdon A Telephone: 081312229768

• Oversee health, safety and environmental management for the company
3. Position: HSE Supervisor Name: Anugerah Anasta Susila Telephone: 081231996599
• Ensure that all workers are aware of the importance of wearing Personal Protective
Equipment.
• Ensure, check and carry out monthly inspections regarding the suitability and availability of
PPE and work safety equipment such as APAR, P3K, etc.
• Ensure that safety signs at the work site are installed properly.
• Providing training to workers such as using APAR, First Aid, Emergency Response, etc.
• Monitor that the SOP is implemented properly by all employees.
• Create a program to minimize B3 waste so that it is accommodated well.
• Providing B3 waste storage for each work unit.
• Routine inspection of the impacts and hazards of the work carried out.
• Implement and create a HSE Meeting program every month.
• Organize and lead emergency simulations every month so that when an actual emergency
occurs, it can be anticipated.
• Obtain monthly reports regarding the inspection.
• Hold daily briefings and instructions to HSE Officers, Man / Staff.
• Reprimand and impose sanctions on workers who violate established occupational safety and
health (K3) regulations.
• Coordinating safe work permits / work permits has been implemented in each work unit,
especially contractors.
• Can solve problems, investigate, audit and provide input for something that is not safe.

4. Position: HSE Officer Name: Nanang Suwandi Telephone: 081316041678

• Identify and map potential hazards that are likely to occur in the work environment.
• Create and maintain documents related to K3.
• Create an idea related to the K3 program.
• Evaluate the possibility or chance of an accident incident that could occur
• Become a liaison between government regulations and company policies.
List of subcontractors:
Company Responsible for this site
Scope of work
Name Address Name Telephone
Golden
Fatmawati,
BLOK J16~17
COMPLEX, Jl.
RS. Fatmawati
Raya No.6,
ACE Energy RT.8/RW.6,
Mr Song 081281683844 PLTS
Services Gandaria Sel.,
Kec. Cilandak,
South Jakarta
City, Special
Capital Region
of Jakarta
12420
Estimated number of workers planned simultaneously on site: 65
List of competent persons:

The evaluation has determined that the persons identified below are knowledgeable about the systems,
equipment, conditions and procedures, proper use, inspection, manufacturer's recommendations and
instructions, and maintenance for the activities specified below. Therefore, such person has been
designated as a “Competent Person” and delegated responsibility and authority to coordinate the activities
and operations covered by such designation.
Activity Name of Competent Person

Fall Protection Anasta Susila (Tata) Award
Scaffolding Anasta Susila (Tata) Award
Electricity Rahman/Rizky

Emergency action plan

Name of employee trained in First Aid/CPR: Anugerah Anasta Susila
How to contact them: All HSE Team
First aid box location: In the PWJ Canteen
Ambulance telephone number: 081328330838
Approximately. response time to arrive at location: 2 minutes
Fire Department telephone number: 0291592113
Approximate response time to arrive at location: 2-5 minutes
Police telephone number: 0291755724
Approximately. response time to arrive at location: 7 minutes
Hospital: Name: PKU Muhammadiyah Mayong Hospital
Address: Jl. Mayong Pawnshop No.12, Gloge, Mayong Lor, Kec. Mayong, Jepara Regency,
Central Java 59465
Telephone number: 02914256500/02914248300
Emergency procedures / Actions to be taken if an accident occurs:
1. Still Calm
2. Call the emergency telephone number.
Gathering point in case of evacuation: Next to the PWJ canteen location
Evacuation procedures:
1. Immediately leave the building with instructions from the emergency evacuation team or follow
the direction of the evacuation route/exit sign, do not return for any reason.
2. Gather in a safe area (muster point) that has been determined, remain gathered while waiting for
further instructions, the emergency response team supervisor, assisted by their respective
superiors, records the number of employees, including those who are missing and injured, then
reports it to the coordinator.
Procedures for other types of risks:
EMERGENCY EVACUATION FOR AN EARTHQUAKE:
1. The Floor Emergency Response Officer notifies the Building Emergency Response Officer and the
Electrical Emergency Response Officer.
2. Floor Emergency Response Officers collect the crowd (building occupants).
3. Building Emergency Response Officers report an earthquake to:
a. Jepara Regency Fire and Disaster Management Service.
b. Health Service Officer.
If you experience an emergency, then:
1. IMMEDIATELY : Stop work and leave the building when you know/hear there is a danger signal or
when you are asked to do so.
2. AVOID : Panic.
3. FOLLOW : Instruct and cooperate with those responsible for the emergency.
4. TURN OFF : All work equipment, especially electricity and close desk drawers.
5. DON'T : Delay leaving the building immediately by searching for personal items and/or other
people.
Site-Specific
Specific HSE Plan
6. GO : To an open area far enough

nough away from buildings and do not get in the way of personnel and
their equipment.
7. DO NOT : Re-enter
enter the building until there are instructions from superiors, officers or other
authorities regarding this matter.
Jobsite setup
Location of site office: PWJ factory
Location of emergency action plan posting:
posting PWJ Clinic
Location of fire extinguisher(s):: Any work area
Location of sanitary facilities:: Implement the 5Rs
Location of lunch facilities:: Exit the work area
Location of clock room: 11:30
Type of drinking water supply and location: Warehouse and work area
How is shade provided and location : Stock in warehouse
Location of the smoking area:PWJ
PWJ Shelter
Will any of your work be in close proximity to the public or employees of an existing facility? Yes
Will you be using any flammable/combustible liquids?
liquids Yes
Will you use flammable/combustible liquids? Yes
If Yes, where will these be stored?
At warehouse area
What fire prevention precautions will be taken for the flammable material storage?
storage
We always
lways store flammable materials separately from other materials
What spill prevention measures will be taken?
A special place was created, and a sign was made so that not just anyone would enter
Describe electrical supply: PLN
Site-Specific
Specific HSE Plan
List of waste containers and their content:

content 3, Red, Yellow, Green
Location of waste containers:
Safety training, awareness, risk assessment

Safety trainings records shall be made available upon request and shall meet applicable training
requirements for all employees.
Worksite induction will be given to each new comer on site, upon arrival and before engaging in any work
activity, by with HSE
Toolbox safety talks will be conducted:
conducted
Frequency: Daily Time: 5-15 minutes By Who: HSE Supervisor
List of specific method statement (including job hazard analysis) required: (fill list as per initial assessment,
and then complete as new activities appear)
Must be completed
Activity Complete
before work begins
Site Preparation 07/07/23 08/05/23
Mobilization to site 05/08/23 07/24/23
Scaffolding Assembling 11/07/23 07/19/23
Stake out 07/17/23 09/15/23
Guardrail 07/15/23 09/15/23
Foundation casting 07/29/23 05/09/23
Installation of mounting structures 08/31/23 01/10/23
Installation of pv module 10/05/23 10/13/23
Installation cable tray 10/05/23 10/22/23
Installation of dc cable 12/10/23 10/15/23
Describe how method statements / JHA will be communicated to involved workers:

Through Safety Induction and Tool box Meeting

Site-Specific
Specific HSE Plan
Describe the work permit process for the site:
Who can approve the

Permission type Permit validity
permission
Excavation permit HSE PWJ 3 days
Hot work permit HSE PWJ 3 days
Limited space permits HSE PWJ 3 days
Crane lifting plan HSE PWJ 3 days
LOTO permission HSE PWJ 3 days
Location coordination
HSE PWJ 3 days
permit
Work at height - roof

Will work be performed on any roof areas?
areas ☐ Yes
If Yes, describe your fall protection plan: (Include pictures if necessary)
All sides of the roof use hard barricade.
Access to the roof:
new temporary scaffolding
Engineering control:
temporary guardrail
PPE:
Type:
☐ Fall protection
☐ Fall arrest (Explain how you will administer fall arrest with pictures)
List of items:
☐ existing life path ☐ temporary life path ☐ new life path
☐ existing anchor point ☐ temporary anchor point ☐ new anchor point
☐ self-retracting rescue rope ☐ double rope with shock absorber ☐ rope + grab rope
☐ others (explain):-
Rescue plan description:
If suspended by safety rope: LIFE LINE

Site-Specific
Specific HSE Plan
If someone is injured on the roof: Immediately take them downstairs, and immediately take them to the
PWJ clinic
Other possible scenarios:-
Comment:

Site-Specific
Specific HSE Plan
Excavation / trenching
Will you perform excavations, trenches, holes?☐
holes? No
If yes, how deep are they?
Have any workers entered the excavation/trench? ☐ No
Hot work
Will you do hot work (cutting, welding…)? ☐ Yes
Explain safety controls for hot work on site: Wear PPE according to the type, and always monitor workers,
whether they are safe or not, if not, they must
must stop temporarily.
Traffic
Is the work site muddy/slippery or is it likely to be muddy/slippery? ☐☐ No
Does the work site have a sloping area (except the rooftop)? ☐ Yes
Is the work location close to public or private road traffic areas? ☐ Yes
Is the work location close to pedestrian traffic areas? ☐ Yes
Based on the answers to the questions above, create a map of safe routes for vehicles and pedestrians and
directions for their use.
Pedestrian paths are red, vehicle paths are green, as in the map below:
Weather
List and explain organizational controls that must be taken when dealing with severe weather, including
site zoning and a list of permitted/prohibited activities.
When it rains, the work is above k
Height must be temporarily stopped.

Other
List and explain other location specific controls, attach any useful documents:-

Site-Specific
Specific HSE Plan
Personal protective equipment (PPE)

List of PPE required at all times on the job site:
Full length trousers
Shirts with a sleeve length of at least four (4) inches
Safety shoes
Helmet
Safety glasses and gloves (must be worn immediately if required by the task)
Areas where high visibility vests must be worn (earthwork areas involving moving equipment, public roads.
Is there any other PPE required (noise, vibration,

vibration, chemicals, dust/fume/gas, height, etc.)? ☐ Yes
If Yes, explain:
Any work that involves grinding or drilling and so on which creates noise, the worker must wear ear plugs.
Approvals
Version: Prepared by Approved by

Date
when Name + signature Name + signature
A 10-30-2023
M Romdon A
B 11-04-2023
Nanang Suwandi

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Site-Specific HSE Plan

Jl. Raya Jepara - Kudus, Tegelon, Pelang, Kec. Mayong,

Applicable Rules, Regulations, Standards:

Page 1/ 17 Template #TE0113 - Revision date: June 25, 2020

Page 2/ 17 Template #TE0113 - Revision date: June 25, 2020

1. Use PPE that is clean and meets standards.

1. PERSONAL PROTECTIVE EQUIPMENT REQUIREMENTS

1. The project helmet must be ANSI Z.89.1-2014

1. . Safety shoes must be ANSI Z.41-1999

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Fall Protection From Height

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1. All workers must use gloves according to the SNI-06-0652-2015

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2. CONCEPT IN THE WORK AREA

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EPC / O&M Contractor: Total Energy

Location owner/operator: Kim sang kug

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Construction / O&M Team

On-Site Management Representative:

2. Position: HSE Coordinator (PWJ) Name: M Romdon A Telephone: 081312229768

Page 8/ 17 Template #TE0113 - Revision date: June 25, 2020

4. Position: HSE Officer Name: Nanang Suwandi Telephone: 081316041678

Estimated number of workers planned simultaneously on site: 65

List of competent persons:

Activity Name of Competent Person

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Emergency action plan

If you experience an emergency, then:

6. GO : To an open area far enough

List of waste containers and their content:

Safety training, awareness, risk assessment

Describe how method statements / JHA will be communicated to involved workers:

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Describe the work permit process for the site:

Who can approve the

Work at height - roof

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Personal protective equipment (PPE)

Is there any other PPE required (noise, vibration,

Version: Prepared by Approved by

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