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SAFETY INSPECTION INSPECTION REPORT

Applies to Tractor/Prime Movers, 6x4 and 6x6
[ ] Pre-mobilization [ ] Semi-annual

Equip No. Type : Model : Brand :

Serial No : Km/Hourmeter
Verified : Service Date : Police No: Owner

Date : Location : :

No Good
Critical

Good
Description to be Checked

N/A
Remarks
?*

Documentation Operator and Equipment

MIGAS / KEMNAKER SILO Certificate
No :
1 (Certification of Inspection (COI) Equipment) Y
Expi Date :
(Match with unit type series)
One-week todays's Pre-use Inspection records (Original copy available on unit, N/A for premobilization inspection)
2 N

Original Manufacture Name Plate with Serial Number (Year of Manufacture)

3 (Name plate is mandatory for premobilization. During periodic inspection, the erial number may be verified through Y
latest inspection record/sticker)
4 Operation Manual Book (Matches unit type, series and in English or Bahasa) N
5 SOP - Standard Operating Procedure equipment (Based on OEM Operation Manual Book) Y
6 Operator/Driver Government Driving License Exp Date : Y
7 Company Operator/Driver Permit Exp Date : Y
8 Driving Permit B3 (KEMENHUB) Exp Date : Y
K3 Licence / SKK-OPA (BNSP-LSP /
9 Exp Date : Y
KEMNAKER)
10 Police Number Plate Front - Rear Exp Date : Y
Surat Lapor Operasi - Traffic Police Document if
11 Exp Date : Y
the police number from non-local

12 STNK - Vehicle Document Exp Date : Y

13 KEUR - Inspection Book Exp Date : Y

14 Nota Pajak - Tax Exp Date : Y

15 B3 Permit (KEMENHUB/KLHK) Exp Date : Y

16 Radioactive Permit (KEMENHUB/BATAN) Exp Date : Y

17 Surat Izin Angkutan Alat Berat (KEMENHUB) Exp Date : Y

18 Company ID Number, Company Logo (Correct size, visible) - minumum size, P x L = 25 x 20 cm Y

19 Yearly Inspection report from qualified inspector Y

Mandatory Safety Inspections and Devices

1 Back-Up Alarm Audible in working condition, 97 Decibles Minimum Y
2 Back-Up Light Adequate Illumination, Function Test Y
3 Horn Controlled, Easily Operated From Inside Operator's Cabin, 97 Decibles Minimum Y
Seat Belts Driver, Swamper, Center Passenger, Good Condition, Properly Mounted with OEM
4 Y
Hi-Tensile Bolts, refer to contract

5 Seats, Cushions Securely Mounted, Ergonomically Good Condition, Not Torn Open or Dilapidated Y

6 Parking Brake Check all system and Function Test Y

7 Brakes Front and Rear Check all system, Properly Adjusted, No Air or Fluid Leaks, and Function Test Y

8 Brake Pedal, Pin & Lock Pin Condition Good condition and preporly installed Y

9 Clutch Pedal, Pin & Lock Pin Condition Good condition and preporly installed Y

10 Acelerator Pedal, Bolt, Pin & Lock Pin Good condition and properly installed Y
Power Steering System Check all system, Steering Linkages No Excess Freeplay, No Loose Ball Joints,
11 Y
Lubricated Properly, No Loose Pins, No Loose Mounting Bolts, and Function Test
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No Good
Critical

Good
Description to be Checked

N/A
Remarks
?*

TIRES and Wheel Condition (No Broken-Missing Lug Nuts, Tread Depth Minimum 3mm or
As per TWI tread Depth , No Recap / Retread / Vulcanized Tires, Tread Mud- Grip (All
Terrain) on rear and front, Correct Rotation (Vulcanized tire not allowed for all vehicles
including heavy vehicles refer to MVS requirement. All tires on same
axle must have same tread, size tired (V-Lug or S-Lug, or U-Lug and Rib-Lug), and single
12 Y
piece rim refer to Peraturan Menteri Perhubungan No. 26 year 2015) except mention on
the contract or additional HES Exhibit.
Suitable Spare Wheel and Tire, Retreads / Vulcanized Tires Are Not Allowed, Recommend
Tread "All-Terrain" Pattern, wheel size the same as those installed on equipment

13 Jack & Lug Wrench Clean, Tidy, Completely Full Y

14 Wheel Nuts Tightening, Ensure all lugs nut was tightening asper Manufacture Recommendation Y
15 Wheel Nuts Marks, Ensure all lugs nut marked with paint for all wheels Y
16 Axle Wheel Bearing Lubrication No Leaks, No MISSING COVERS / CAPS on Grease Type Hubs Y
17 Head Lights-Working Lights-Flood Lights Adequate Illumination, Function Test Y
18 Rear Combination Lights Adequate Illumination, Function Test Y
19 Front Combination Lights Adequate Illumination, Function Test Y
20 All Electrical Wiring Condition, Fuse Block All Splices Insulated, No Bare Wires Y
Side mounted Left and Right or Door mounted Rear View Mirrors, Convex mirror
21 Not Loose, Clear Vision, Unobstructed, Functions Properly (convex mirror refer to contract) Y
Internal Centrally Mounted Rear View Mirrors
22 Not Loose, Clear Unobstructed Vision, Functions Properly Y

23 Back up camera Good function (refer to contract Y

24 Wheel Chocks Two Units, Properly Constructed Y

25 Safety Triangles or Safety ConeTwo Units In Good Condition, Reflective So As Visible at Night Y
Fire Extinguisher
26 Y
Minimum 4kg, Properly Mounted and Accessible. Current Valid Inspection Tag, refer to contract
27 First Aid Kit Clean, Tidy, Completely Full Y
Access Ladder Steps Handrails Securely Mounted, Ergonomic Design, Good Condition, Not Cracked,
28 Not Bent, Not Dilapidated, No Sharp Edges, No Sharp Corners Y

29 Safety Guards All Covers in Place, Not Loose, None Missing, Not Modified, Remain within OEM Specs Y

30 Windshield Wipers and Washer Wiper Blades Not Perished, Test Function Y
Driver Monitoring System (Refer to Contract, perform function test) registered on
CCPM (link to i-JMS)
31 Y
- Premobilization : proper to instal and good function
- Semi Annual : need GPS Data latest from IJMS
32 Revolving Light Function test Y

Body
1 Body Condition Good Paint and General Appearance, No Excess Damage, No Rust Y
2 Mud Flaps Properly Mounted, Not a Falling Hazard to Following Motorists Y
3 Front-Rear Bumper Bar All Rounded Corners, No Sharp Edges, Not Loose, Properly Mounted Y

Cabin and Interior

1 Cabin Interior Condition Clean, No Rubbish, Good Housekeeping Y
Dashboard Indicators
2 Gauges for Fuel, Hours, Kms, Odometer, Temperature, Brake Air Pressure, Hyd Pressure, Alternator, Battery Y
Voltmeter, Battery Charging System, etc, All Operating Properly
3 Wheel Unit Steering Wheel, Steering Column Controls Levers and Switches Test Function Y
4 All Switches and Knobs on Dashboard Test Function Y
5 All Control Linkages and Levers Test Function Y
6 Cabin Tilt and Safey Lockout System Test Function Y
All Window Glass / Windshield Glass Totally Clear, No Film or Stickers Blocking Vision.
7 Y
Units with OEM Window Tint Will Require Approval by Relevant PHR Authorities.
8 Door and Door Locks, Door Handles Left - Right, Outside and Inner, Test Function Y
9 Cabin Air Conditioner Test Function Y

Main Frame and Main Carrier Chassis

1 Main Chassis, Frame Condition Straight, Not Bent, No Cracks, No Uncertified Welding Repairs Y
2 Sub Chassis, Sub Frame Condition Straight, Not Bent, No Cracks, No Uncertified Welding Repairs Y
3 Front and Bumper Bars Straight, Not Bent, No Cracks, No Sharp Edges Y
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No Good
Critical

Good
Description to be Checked

N/A
Remarks
?*

4 Axle Mounts Front and Rear, All U-Bolts Tight, No Cracks Y

5 Suspension System Springs Front / Rear, Straight, Not Bent, No Loose Shackle Pins Y

Underrun protection as appropriate (Regulation of Transp Dept. No 55, 2012, section 90)
Ensure no loose, no crack, no sharp edges, no bent, straight, properly mounted, reflective
sticker attached (If the equipment has Police Number) Ground Clearance cm, if
> 700 mm, need Underrun Protection
6 Y
Measurement of Underrun Protection
- R/H..............cm
- L/H...............cm
- Rear...............cm

General Hydraulics, Fluids, Fuel, Hoses

1 All Fuel Hoses and Lines Properly Secured, No leaks Y
2 All Hydraulic Hoses and Hydraulic Lines Properly Secured, No Leaks Y
3 Hydraulic Tanks Mounts, Leaks, and Filler Cap Properly Secured, No Leaks Y
4 Fuel Tank Mounts, Leaks, and Filler Cap No Leaks, No loose Mounts Y
5 Air Tank No Leaks, No loose Mounts Y
6 Pilot Valves and Hydraulic Cylinders No Leaks Y
7 Hydraulic Pumps and Motors No Leaks, No Excess Noise Y
8 All Controls and Hydraulic Control Valves No Leaks, Test Function Y

Prime Mover 5th Wheel ,

5th Wheel To Be Completely Washed, Inspect Both Jaws for Excess Wear, No Excess Oval Shape, No Excessively
1 Y
Loose Pins / Bushings (5th 4-way not acceptable)

5th Wheel Lock System Test by Using a Pry Bar to Open and Close Jaws Manually, Make Sure Jaws Close Strongly
2 and Positively to a FULL LOCK Position, No Bent Release Lever, Springs on Sliding Lock are NOT Weak Y

Truck to Trailer Air Brake Supply System, Glad Hand Seals No Leaks from Glad Hand Seals
3 Trailer Hose Color Coding is Red Emergency on Left Side and is Yellow or Blue Service on Right Side Check Hose Y
Correct Color and No Leaks, No Lines / Pipes Hanging Loo

Electric Socket supply from Prime Mover to Trailer proper to install, good condition and function, based on OEM
4 Y

Winch
Winch System If Equipped with Winch Must Have Rear Safety Guard Screen Behind Operator, Test
1 function Y

Winch, Winch Wire Rope Terminatiion and Winch Cable Condition

2 Y
Mechanically Spliced Cable, Cable Not Deformed or Bent, No Excess Broken Wire Strands
3 Wire rope certificate, SOP Winch Operation Available on cabin Y

Engine - Transmission - Differentials

1 Engine Clean Appearance, No Leaks, No Defective Mounts, Observe Performance, No Smoke Y
2 Engine Dipstick Easy to read, Oil Level Adequate Y
Battery, Battery Covers, Battery Mounting, Battery Terminals Optional Battery Disconnect Switch, Test
3 Function, No Loose or Corroded Cables-Terminals, Battery Hold-Downs in Place, Clean Battery Box, No Loose Y
Mounts, Battery cover (isolator layer)
4 Starter Motor Test Function, Adequate Cranking Strength, No Bad Noises or Overheating Y
Alternator
5 Y
Observe Charging Function, No Bad Noises or Overheating, No Loose Mounts, No Loose Belts
6 Cooling System Inspect Radiator and Hoses, No Leaks, No Perished Hoses Y
7 V-Belts or Serpentine Belts Not Loose, Not Squealing, Not Cracked Y
PTO and Transmisson, Drive Shafts, Propeller Shafts, U-Joints, Center Carrier Bearing
8 Y
Properly Greased, No Leaks, All Mountings Tight, Nothing Loose
9 Exhaust System Inspect Pipe, Muffler, No leaks, Not Loose Y
10 Automatic Transmission No Leaks, Observe a Function Test of Shifting Sequence Y
11 Main Mechanical Transmission and Auxiliary Transmisson No Leaks, Observe a Function Test Y
12 Clutch No Smoke or Slipping, Observe a Function Test Y
13 Differentials Front and Rear No Leaks, All Mountings Tight, Nothing Loose Y

Servicing and Maintenance

1 Maintenance Schedule - PM and PdM Service Records Available N
Remaining Life Assessment (RLA) (3rd party RLA Engineering Calculation report for unit with 30+ years old)
2 Y
 Page 4 of 4

No Good
Critical

Good
Description to be Checked

N/A
Remarks
?*

Others
Initial Training Equipment For Operator (refer to OEM Operating and Inspection Manual
1 Y
(Evident)
User acceptance document for specified equipment/COC (Certification of Conformance)
2 Y
/COO (Certificate of Origin) (Evident)
Line of Fire Sticker (Drop object, Pinch Point, Power line, under suspended load) is available.
3 N
Prohibited non authorized personel to be on equipment

Comments

GOI Periodic = Periodic item as GOI certification Good = Good condition, able to be operated in
Good = Good Condition
standard all PHR areas
OEM Periodic = Periodic item as OEM Manual No Good = Broken, Malfunction, Repair or
No Good = Broken, Malfunction
Standard Replace
N/A = Not Applicable

Verified by: Reviewed by: Acknowledged by Company : The undersigned hereby accept and agree
that this equipment is "OK" and safe for
operation. Menerima dan Menyetujui bahwa
Alat ini sudah "OK" dan aman untuk
dioperasikan.

SIGNATURE, Date:
Contractor Management Rep. Name