KEMENTERIAN PERHUBUNGAN PT. ARTEFAK ARKINDO – PT. INDULEXCO – PT.

ADHI KARYA (PERSERO) Tbk

DIREKTORAT JENDERAL PERHUBUNGAN UDARA ASIAN DEVELOPMENT BANK PT. TRANS INTRA ASIA, (KSO) DEPARTEMENT GEDUNG

PAKET PEKERJAAN CIVIL WORKS (CW) AIRPORT 2 : WORKS - RECONSTRUCTION OF TERMINAL AND
OTHER BUILDINGS EMERGENCY ASSISTANCE FOR REHABILITATION AND RECONSTRUCTION (EARR)
MUTIARA SIS AL JUFRI AIRPORT IN PALU

DAILY REPORT
HSE INSPECTOR
1. General Information
Information Description
Day Monday
Date 3 Oktober 2022
08.00 – 17.00 WITA (Shift 1)
Time 17.00 – 22.00 WITA (Shift 2)
22.00 – 03.00 WITA (Shift 3)
Project Location Mutiara Sis Al Jufri Airport

PT.ADHIKARYA KARYA (Persero) Tbk DEPARTEMEN GEDUNG

Position Total Position Total Position Total
Project Manager 1 Cost Control 1 Office Boy 1
Project Engineer Manager 1 Quantity Surveyor 2 Security 5
Project Production Manager 2 Drafter 4 Logistik 2
Project Production Manager MEP 1 BIM Modeller 1 DCC 1
Project Finance Manager 1 Scheduler 1 Gudang 1
Project Planner 1 Project Procurement 1 Quality Control 2
TA HSE Sipil 0 Supervisor 8 TA IT 1
TA HSE MEP 0 Surveyor 2 Drafter MEP 1
Tenaga Medis 1 Asisten Surveyor 4 General Affair 1
Petugas Tanggap Darurat/P3K 1 Mekanik 1 Mandor 5
Assisten K3 (Pelaksana 5R) 8 Asisten Mekanik 1 1 Pekerja 151
Safety Man (Pengatur Lalu Lintas) 2 Adm MEP 1 Harian 4
HSE Supervisor 2 Akutansi 1 DSC
Adm. HSE 1 Cost Control 1 PIU
Staff Enviro 1 Kasir 1
Adm. Teknik 1 Driver 1
TOTAL I 230
PT. PRIMA MANDIRI SEJATI (Subcon)
Position Total Position Total Position Total
Sipil 14
TOTAL II 14
PT. INTAN SARANA TEKNIK / IST (Subcon)
Position Total Position Total Position Total
HSE 1 Pekerja Baja 13
TOTAL III 14
CV. Dika Konstruksi (Subcon)
Position Total Position Total Position Total
HSE 1 Pekerja Arsitek 11
TOTAL IV 12
PT Acece Sarana Prima / ASP (Subcon)
Position Total Position Total Position Total
HSE 1 Supervisor 1 Pekerja 24
TOTAL V 26
PT Laju Abadi Sejahtera (Subcon)

1
Position Total Position Total Position Total
Pekerja 9
TOTAL VI 9
PT Adi Teknik (Subcon)
Position Total Position Total Position Total
Pekerja elektrikal 14
TOTAL VII 14
PT Siphonic Flow Mandiri (Subcon)
Position Total Position Total Position Total
Pekerja 3
TOTAL VIII 3
PT Bequem Kreasindo (Subcon)
Position Total Position Total Position Total
Pekerja 1
TOTAL IX 1
PT Media Notifikasi Indonesia (Subcon)
Position Total Position Total Position Total
Pekerja 7
TOTAL X 7
PT Interdesign Cipta Optima (Subcon)
Position Total Position Total Position Total
Pekerja 15
TOTAL XI 15
PT. Anugrah Wijaya Trisna (AWT)
Position Total Position Total Position Total
Pekerja 8
8
TOTAL I + II + III + IV + V + VI + VII + VIII + IX + X + XI 353

2. PERFORMANCE K3L
Cumulative
Required information Unit Amount PT.ADHI Subcon Subcon Subcon Subcon Subcon Subcon Subcon Subcon Subcon Subcon Subcon Total
KARYA Prima Intan Dika Acece Laju Adi Siphonic Beque Media Inter Anugrah
(PERSERO) m design
TBK
Total Workers Person 230 14 14 9 26 9 14 3 1 7 15 8 353
Total Working Hours Hour/ 8/353 1.840 112 112 72 208 72 112 24 8 56 120 64 2824
Person
Near Miss Time 0 0
Accident (Fatality) Time 0 0
Minor Accident Time 0 0
Moderate Accident Time 0 0
Serious Accident Time 0 0
Property Damage Accident Time 0 0
Environmental Pollution Time 0 0
Accident
Lost Time Injuries (LTI) Day 0 0
FR (Frequency Rate) Inciden 0 0
t
SR (Saverity Rate) Day 0 0
Medical Fee (Rp) Rupiah 0 0
Number of Accidents Time 0 0
Number of Safety
0
Inductions Time 0
Performed
Number of Inspection/Patrol Finding 0 0
Findings s
Number of Work Permits Time 0 0
Done

2
3. ISSUED WORK PERMIT

No No Work Permit Type of work Start Date Date of completion The number of
workers

4. K3L ACTIVITIES
1 Sort, Set in order, Shine, Standardize, and Self Discipline (5S)
2 Project Inspection Work

5. K3LK ASPECT

Condition
No ITEM ASPEK K3LK Description
Good Bad
1 Mobil Crane 1 type tadano 80 T
2 Genset 100 KVA
3 Genset 1500 KVA
4 Air Compresor 175 CFM
5 Excavator 
6 Dump Truck
7 Concrete Pump
8 Vibrator Electric
9 Bucket Cor
10 Bucket Material
11 Total Station
12 Theodolite Manual
13 Auto Level
14 Bar Cutter
15 Bar Bender
16 Concrete Mixer 350 Ltr
17 Stamper Plate
18 Tanki Solar 8000 Ltr
19 Scaffolding 
20 Penyiapan RK3K terdiri atas:
a. Pembuatan Dokumen Rencana Keselamatan Konstruksi
b. Pembuatan Manual, Prosedur, Instruksi Kerja, Ijin Kerja

3
 Condition
No ITEM ASPEK K3LK Description
Good Bad
21 Sosialisasi :
a. Induksi K3 (Safety Induction)
b. Pengarahan K3 (Safety briefing)
c. Pertemuan Keselamatan (Safety Talk/ Tool Box Meeting)
Alat Pelindung Kerja (APK) dan Alat Pelindung Diri terdiri
22
(APD) antara Lain :
a. Papan Informasi K3 
23 Alat Pelindung Kerja (APK) :
a. Tali Keselamatan (Life Line)
b. Penahan jatuh (Safety Deck)
24 Alat Pelindung Diri terdiri (APD) :
a. Topi Pelindung (Safety Helmet); 
b. Pelindung Pernafasan dan Mulut (Masker);
c. Sarung Tangan (Safety Gloves);
d. Sepatu Keselamatan (Safety Shoes); 
e. Rompi Keselamatan (Safety Vest); 
25 Asuransi & Perijinan
a. Asuransi (Insurance) 
26 Personil K3 terdiri atas:
a. Ahli K3 Konstruksi (HSS Engineer) 
b. Petugas K3 Konstruksi (HSS Personnel) 
c. Petugas tanggap darurat (Emergency respons personnel) 
d. Petugas P3K (P3K Personnel) 
e. Petugas pengatur lalu lintas(Flagman) 
f. Tenaga paramedis dan/atau kesehatan (Paramedic Personnel) 
27 Fasilitas Sarana Kesehatan dan Penanganan Covid
a. Kotak obat dan P3K (Medicine box and first aid kit )
b. Ruang P3K (Tempat Tidur Pasien, Tabung Oksigen,
Stetoskop, Timbangan Berat Badan) 
c. Penyemprotan Cairan High Disinfektan 
d. Test Anti gen (Covid-19 antigen test)
e. Corona virus testing swab
f. Pengukur Suhu Tubuh
28 Rambu‐Rambu terdiri atas:
a. Rambu Petunjuk; 
b. Rambu Larangan; 
c. Rambu Peringatan; 
d. Rambu Pekerjaan Sementara; 

4
 Condition
No ITEM ASPEK K3LK Description
Good Bad
e. Tongkat Pengatur Lalu Lintas (Warning Lights Stick) ; 
f. Kerucut Lalu Lintas (Traffic Cone) 
g. Lampu putar (Rotary Lamp) 
h. Lampu selang lalu lintas (Traffic hose light) 
i. Alat Pemadam Api Ringan/APAR (Light Fire Extinguisher) 
j. Sirine (Sirens)
k. Bendera K3 (K3 Flag) 
l. Lampu darurat (Emergency Lamp)
29 Pemantauan Lingkungan (Environment Monitoring)
a. Environmental Engineer
b. Environmental Assisten
c. Air Quality & noise Test
d. Water Quality Test
e. Sewa Peralatan (Equipment Rental)
f. Laporan (Reporting) 

6. Documentation K3L

Toolbox meeting PT.Interdesign Cipta Optima

Working hours report 1st shift at 1st security post name Mr. Afandi

5
Working hours report 1st shift at 1st security post name Mr. Firhan

Toolbox meeting PT.Prima Mandiri Sejati

Toolbox meeting PT.Anugrah Wijaya Trisna

Working hours report 2nd shift at 2st security post name Mr.Ferari

6
 Working hours report 2nd shift at 1stsecurity post name Mr.Fikri alamsyah

Working hours report 2nd shift at 1stsecurity post name Mr.Rifai

Traffic condition measurement at Abdulrahman Saleh street

Palu, 3 October 2022

Prepared By. Checked By. Reviewed By.

Moh.Sandy Rizky R.H Miftahul Arifin, ST.MT Musdalifah

An. HSE PT. Adhi Karya (Persero) Tbk. HSE DSC HSE PIU
Departemen Gedung