PROJECT SAFETY PLAN

Customer Name :
Project Name :
Project Code :
Project Location :
Project Schedule : until
Max Worker Activity : Worker

Plan
No Description
Yes No
1 Safety Officer Organization
2 Safety Emergency Procedure and Organized Rescue Tim Safety regulation and Procedure
1 House Keeping
3 2 Trafic Control and Transportation
3 Fire Prevention Precaution and Fire Fighting Equipment 4 Working in Confined Space
5 Excavation
6 Hot Working (welding, cutting operation & Equip.) 7 Electrical Equipment
8 Crane
9 Hoist
10 Other Lifting ( Takle/Jimpole)
11 Manual Lifting ( L Jack, H Pallet) 12 Scaffolding and work Flat Form 13 Ladders
14 Powers tool
15 Hand tools and Portables power Driven tolls 16 Hazardous Substance
17 Working at Height
18 Structural Steel Erection
19 Floor and Wall Opening & Stair ways 20 Lighting
21 Protection Againt Damage Material Clotching & Equipment Safety Devices
1 Working clutches
2 Safety Helmet
3 Clutching and Equipment Safety Devices 4 Safety Belt / Full Body Harness
5 Hand Gloves Cotton / Leather 6 Masker
7 Earning Protection
8 ID Card
Insurance / jamsostek Lock Out Safety System
1 Card Note
2 Key Procedure Document record
1 Accident Report ( if any ) 2 Safety Activity
3 Safety Box meeting 4 Toolbox meeting
5 Safety Schedule

5
6

7
Remarks
EII-HSE-FRM-04 - R(0) page : 1 of 17
 WEEKLY HSE PERFORMANCE REPORT

Contractor name: PT. Encona Inti Industri Contract No. : Work Area:
Decsription of work:
Reporting Period from
t
o

DAY Mon Tue Wed Thu Fri Sat Sun Total Project
DATE This week Todate
Number of Personnel
Expat
Staff
Non-Staff
Number of Man Hours
Illness
Number of Light Vehicles
KMs Drive n
Number of Heavy Vehicles
KMs Drive n
Number of Equipment
Operating Hours
Notes:
Light vehicles: Sedan, minibus, pick-up, ect.
Heavy vehicles: Dump truck, crane truck, semitrailer, ect.
No. of personnel to include all Managers, Supervisors, and Crafts.
Work Related Incident/Accident Report

This Week Last Week Cumulative

Fatality 0 0 0
Lost Work Day Case(s) 0 0 0
Restricted Work Day Case(s) 0 0 0
Medical Treatment Case(s) 0 0 0
First Aid Case (s) 0 0 0
Near Misses Incident 0 0 0
Fire Incident 0 0 0
Oil Spill Case 0 0 0
Hazard Identification Report 0 0 0
Motor Vehi cle Crashes 0 0 0
Equipment Incident (EI) 0 0 0

ORIENTATION/TRAINING AND MEETING PROGRAM

This Week Last Week Cumulative

Orientation 0 0 0
DDC 0 0 0
FSWP 0 0 0
Incident Investigation 0 0 0
JSA Training 0 0 0
First Aid Training 0 0 0
Fire Training 0 0 0
BBS Training 0 0 0
Others Training 0 0 0
Tailgate Meeting 0 0 0
Weekly Meeting 0 0 0
Monthly Meeting 0 0 0

Remarks:

……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..

Prepared by ; Reviewed by ; Approved by ;

( ) ( ) (
E REPORT

Contract No. : Work Area:

Remarks:
Injury Formula
Nos of Incident X 200,000 Total hours
MVC Formula
Nos of MVC X 1,000,000
Miles Driven
Equipment Incident Formula
Nos of EI X 100,000
Operating Hours

Approved by ;
( )
EII-HSE-FRM-08-R(0)
EII-HSE-FRM-03-R(1)
EII-HSE-FRM-07 - R(1) hal. : 4 dari 17
 RISK ASSESSMENT

Divisi : Proyek :
 RISK ASSESSMENT

Lokasi Pekerjaan : Tgl. Penilaian :

 Tingkat Rsk dpt
No Kegiatan Identifikasi Bahaya Akibat Peluang Resiko ditoleransi
(Y/N)
1
 Tingkat Rsk dpt
Pengendalian Resiko Akibat Peluang Resiko ditoleransi
(Y/N)
Peluang Akibat Tingkat Resiko Penjelasan Score
1 2 3 4 5
A E E E E H E = Extreme Risk H A = Hampir pasti terjadi/almost certain B = A=1
B E E H H H = High Risk Cendrung untuk terjadi B=2
M = Moderate Risk L C = Mungkin dapat terjadi C=3
C E H H M M = Low Risk D = Kecil kemungkinan terjadi E = Jarang D=4
D E H M M L terjadi/rare E=5
E H H M L L
 Akibat Score Tingkat Resiko

5 = Tidak ada cidera, kerugian materi kecil L= 18 - 25

4 = Cidera ringan / P3K, kerugian materi sedang M= 13 - 18
3 = Hilang hari kerja, kerugian cukup besar H= 6 - 12
2 = Cacat, kerugian materi besar E= 1 - 5
1 = Kematian, kerugian materi sangat besar
Disusun Oleh : Diperiksa Oleh : Disetujui oleh :
Risk Rate : Severity of harm x Likelihood of occurrence
Keparahan dari bahaya x kemungkinan terjadi
EII-HSE-FRM-23 - R(1) Page 5 of 17
Nama Proyek :
No. Proyek :
Daerah Pemantauan : KONSTRUKSI
Periode :
RENCANA PEMANTAUAN LINGKUNGAN
Area Pemantauan Pemantauan terhadap Bentuk Fisik Sumber Dampak
upaya pengelolaan
Jenis Dampak Periode Pelaksana
Pemantauan Pemantauan
Prepared by :
EII-EMS-FRM-01
ENVIRONMENTAL SITE INSPECTION CHECK LIST
Project :
Site Location :
Construction stage/status during inspection : Inpection Date :
Inpection Time :
Weather :
Note : This form is designed for general use and may not be exhaustive.Modifications and additions may be necessary to suit individual projects and to address specific
environmental issues and associated mitigation measures.
 Implemented?
Yes No*
Inspection Items N/A

1. Air Pollution Control

1.1. Are the construction sites watered to

minimize dust generated?
1.2. Are stockpiles of dusty materials (size with
more than 20 bags cement) covered or watered?

1.3. Cement debagging process undertaken in

sheltered areas
1.4. Are all vehicles carrying dusty loads
covered/watered over prior to leaving the site?

1.5. Are demolition work areas watered? (e.g.

trimming activities by using breaker)
1.6. Are dusty roads paved and/or sprayed with
water?
1.7. Are dust controlled during percussive
drilling or rock breaking?
1.8. Are plant and equipment well maintained?
(any black smoke observed, please indicate the
plant/equipment and location)

1.9. Is dark smoke controlled from plant ?

1.10. Are there enclosures around the main dust-
generating activities ?
1.11. Hoarding (not <2.4m) provided along
boundaries and properly maintained (any damage
/ opening observed, please indicate the location).

1.12. Are speed control measures applied? (e.g.

speed limit sign)
1.13. Others (please specify)

2. Water Pollution Control

2.1. Are water discharge licenses valid?
2.2. Are conditions of the license compiled with?
(check the monitoring records and observe
physically)

2.3. Are wastewater treatment system being

used and properly maintained on site? (e.g.
desilting tank)

2.4. Are there any wastewater discharged to the

stormdrains? Is the wastewater being treated?

2.5. Are measures provided to properly direct

effluent to silt removal facilities? (e.g. provide
earth bunds / U-channels)
2.6. Are u-channels and manholes free of silt
and sediment?
2.7. Are sedimentation traps and tanks free of
silt and sediment?
2.8. Are all manholes on-site covered and
sealed?
 Remarks

(i.e. specify location, good practices, problem observed, possible cause of nonconformity
and/or proposed corrective/preventative actions)
EII-EMS-FRM-03 7 of 17
 Implemented?
Yes No*
Inspection Items N/A

2.9. Are sandbags/earth bund adopted to

prevent washing away of sand/silt and
wastewater to drains, catchpit, public road and
footpath?
2.10. Are vehicles and plants cleaned before
leaving the site?
2.11. Are wheel washing facilities well maintained
to prevent overflow, flooding sediment?

2.12. Is sand and silt settled out in wheel washing

bay and removed?
2.13. Is the public road/area around the site
entrance and site hoarding kept clean and free of
muddy water?
2.14. Is domestic water directed to septic tanks or
chemical toilets?
2.15. Others (please specify)

3. Noise Control
3.1. Is the CNP (Construction Noise
Permit) valid for work during restricted hours?
3.2. Are copies of the valid Construction Noise
Permits posted at site entrance/exit?
3.3. Do air compressors and generators operate
with doors closed?
3.4. Is idle plant/equipment turned off or
throttled down?
3.5. Do air compressors and hand-held
breakers have valid noise emission labels (NEL)?

3.6. Any noise mitigation measures

adopted (e.g. use noise barrier / enclosure)?
3.7. Are silenced equipments utilized?
3.8. Others (please specify)

4. Waste Management
4.1. Is the site kept clean and tidy? (e.g.
litter free, good housekeeping)
4.2. Are separate chutes used for inert and non-
inert wastes?
4.3. Are separated labelled containers / areas
provided for facilitating recycling and waste
segregation?

4.4. Are construction wastes / recyclable wastes

and general refuse removed off site regularly?

4.5. Are construction wastes collected

and disposed of properly by licensed collectors?
4.6. Are chemical wastes, if any, collected and
disposed of properly by licensed collectors?

4.7. Does chemical waste producer license

covers all major chemical wastes produced on
site?

4.8. Are chemical wastes properly stored and

labelled?
4.9. Are oil drums and plants/equipments
provided with drip trays?
4.10. Are drip trays free of oil and water?
4.11. Is there any oil spillage? Clean-up the
contaminated soil immediately?
4.12. Is litter, foam or other objectionable
matters in nearby water drain/sewer cleaned?
4.13. Are asbestos wastes handled by registered
professionals?
4.14. Others (please specify)
 Remarks

(i.e. specify location, good practices, problem observed, possible cause of nonconformity
and/or proposed corrective/preventative actions)
EII-EMS-FRM-03 8 of 17
 Implemented?
Yes No*
Inspection Items N/A

5. Storage of Chemicals and Dangerous

Goods (DG)
5.1. Are chemicals stored and labelled properly?

5.2. Does storage of DG comply with license

conditions (include types and quantities if DG
store is available, check the DG store license)?

5.3. Are proper measures to control oil spillage

during maintenance or to control other chemicals
spillage? (e.g. provide drip trays)

5.4. Are spill kits / sand / saw dust used for

absorbing chemical spillage readily accessible?

5.5. Others (please specify)

6. Protection of Flora, Fauna and Historical

Heritage
6.1. Are disturbance to terrestrial flora
minimized (e.g. plants to be preserved)?
6.2. Are disturbance to terrestrial fauna
minimized (if rare species identified)?
6.3. Any historical heritage exists on site? If yes,
ensure appropriate measures taken to preserve it

6.4. Others (please specify)

7. Resource Conservation
7.1. Is water recycled wherever possible for dust
suppression?
7.2. Is water pipe leakage and wastage
prevented?
7.3. Are diesel-powered plants and equipments
shut off while not in use to reduce excessive use?

7.4. Are energy conservation practices

adopted?
7.5. Are metal or other alternatives used to
minimize the use of timber?
7.6. Are materials stored in good
condition to prevent deterioration and
wastage (e.g. covered, separated)?

7.7. Are pesticides used under the requirement

of Agriculture, Fishers and Conservation
Department?
7.8. Others (please specify)

8. Emergency Preparedness and Response

8.1. Are fire extinguishers / fighting facilities

properly maintained and not expired? Escape not
blocked / obstructed?
8.2. Are accidents and incidents
reported and reviewed, and corrective &
preventive actions identified and
recorded?
8.3. Others (please specify)
 Remarks

(i.e. specify location, good practices, problem observed, possible cause of nonconformity
and/or proposed corrective/preventative actions)
*Any “No” recorded represents the potential breach of regulation or improvement needed and details of nonconformity (NC) shall be recorded in the Remarks.
* Report NC in the following forms. Each NC should make reference into the checklist as coded. Th
 Signature of Site Inspector : Date :
Reviewed by Project Manager : Date :

EII-EMS-FRM-03
9 of 17
IDENTIFIKASI , PENGENDALIAN DAN PEMA
LINGKUNGAN
Status / Revisi :
Diajukan oleh Konfirmasi Disyahkan oleh

HSE Project Manager

LOKASI
:
PENANGGUNG JAWAB
:
TANGGAL EVALUASI
:
No. Rec :
 Aktifitas -Produk Jasa
Jenis
Aspek

PROBABILITY
Kemungkinan
Lingkungan
NO SEVERITY

Penaggung
Jenis dampak

No. Aspek
lingkungan Tingkat Keparahan
Rutin-Non

Jawab
Spesific
Rutin

1 2 3 4 5 6 7 8
9

Luas Waktu
B3 Penyebar Pemuliha n
an
 SKOR TINGKAT
PERATURAN ASPEK NOMOR ACTION NOMOR
SEVERITY INISIAL

PEMENUHAN
Perundang-undangan PENTING PLAN PEMANTAUAN

PERATURAN
PENTING
gkat Keparahan

9 10 11 12 13 14 15 16

Sumber
SVRT

Daya Alam
Keterangan Warna:
: Data INPUT (Dapat Dirubah)
: Hasil (Tidak Dirubah)
EII-EMS-FRM-05 - R(0)
 SAFETY MEETING

Project : Present :
Subject : 1.                                    /                   4.                                     /                   
Date : 2.                                    /                   5.                                     /                   
3.                                    /                   6.                                     /                   
Venue :
MATTERS DISCUSSED
SAFETY:
QUALITY :
RESULTI/PLANING/PROBLEM/OTHER :
ETY MEETING

esent :
                                 /                   
                                 /                   
                                 /                   

ACTION DUE DATE

EII-HSE-FRM-02 - R(0) page : 11 of 17
 TOOLBOX MEETING
Daily

Code Proyek 1-C12-01-1-046 Day / Date

Loka si Proyek HOLCIM Cilacap Speaker
Own er HOLCIM Cilacap
-. Pemakaian APD yang sesuai dengan jenis pekerjaan
-. Sosialisasi Job Safety Analysis (JSA)
-. Konsentrasi pada saat bekerja & selalu waspada terhadap sekitaran Lokasi Kerja
-. Selalu waspada dan perhatikan langkah didalam lokasi kerja

Topic

No Name Company Division Signature No Name Company Division Signature

1 26
2 27
3 28
4 29
5 30
6 31
7 32
8 33
9 34
10 35
11 36
12 37
13 38
14 39
15 40
16 41
17 42
18 43
19 44
20 45
21 46
22 47
23 48
24 49
25 50
 Prepared by: Acknowledge by:
(                                            ) Mengetahui oleh :
Safety ( Rahmat .NE ) Site Manager
EII-HSE-FRM-01 - R(0) page : 12 of 17
 HSE INVESTIGATION RECORD
Proyek :
Project

NO NAMA / NAME JENIS KEJADIAN / INCIDENT DEPARTEMEN /

TYPE DEPARTEMENT

Investigasi / Investigation : DENAH LOKASI KEJADIAN
(Cantumkan nama saksi bila perlu) Location Incident Lay out
Penyebab :
Cause of
Tindakan Koreksi :
Corrective Action
Tindakan Pencegahan :
Precaution
Tindakan / Action
Pertolongan pertama / First Aid
Tindakan lanjutan / Continuation Action
(                                    ) (                                     ) (                                   )
Staff HSE Project Manager
EII-HSE-FRM-05-R(0) hal. : 13 dari 17
INCIDENT STATEMENT
LAPORAN KEJADIAN
Kronologi Kejadian - Chronology Incident
Pernyataan dari Saksi  : Tanda T
Statement of Witness Sig

Pernyataan dari Pelaku  :
Statement of Pri

Pernyataan dari Pelaku  :
Statement of the
EII-HSE-FRM-05-R(0) hal. : 14 dari 17
 PROBLEM IDENTIFICATION AND C
( PICA )
PICA No.
Date of PICA
Periodical Analysis
No Activity Problem Caused of Problem
NTIFICATION AND CORRECTIVE ACTION
( PICA )
Approved by Prepared by
1.                                 2                                   

Initiative Corrective Action PIC Due date Remark

EII-HSE-FRM-21- R(0)
Project Name :
No. Project :
Location :
Day / Date :

EMERGENCY DRILL REPORT

-. Fires, explosions ;
-. Chemical Spillage or leakage ;
-. Accidents as a result of equipment failure

Type of Emergency Drill

Department / Section

Starting Time
Completion Time
Number of participants
(name list attached)
Participation Rate
Name of Fire Officer

Suggestion Items

Action Plan
Prepared by : Approved by :
EII-HSE-FRM-22 - R(0) 16 of 17
 HSE INVESTIGATION RECORD
Proyek : CIL Dome pelletizer Truk Bullding
Project
NO NAMA / NAME JENIS KEJADIAN /
DEPARTEMEN / DEPARTEMENT

INCIDENT TYPE
1 material beam property damage
bracing, rafter

Investigasi / Investigation : DENAH LOKASI KEJADIAN
(Cantumkan nama saksi bila perlu) Location Incident Lay out
Tidak ada korban
Penyebab :
Cause of
Crew crane pada hr kamis jam 07.35 mema nasi
mesin crane dan bersih-bersih kabin
 crew crane tidak mengetahui kalau stick up
boom tersenggol. Karena begitu istirahat
tahu-tahu mesin mati.Setelah di lihat keatas boom crane menggenai beam bracing shg rafter no 4
Tindakan Koreksi : s/d no 7melengkung di akibatkan oleh keteledaron crew crane .
Corrective Action
Di pastikan orang yang berkompenten untuk melakukan aktifitas di kabin crane tersebut.
Tindakan Pencegahan :
Precaution
Safety dan Supervisor memastikan crew crane yang berkompenten untuk melakukan aktifitas di kabin crane .
Tindakan / Action
Pertolongan pertama / First Aid
Tindakan lanjutan / Continuation Action
Di perlukanya inspection secara berkala dan dlm pelaksanaan pekerjaan selalu mengikuti prosedur keselamatan kerja
perkakas alat angkat dan angkut.
(                                    ) (                                                             )
Staff HSE Site manager
STIGATION RECORD
lding

ARTEMEN / DEPARTEMENT

construction

DENAH LOKASI KEJADIAN
ocation Incident Lay out
ak mengetahui kalau stick up
ggol. Karena begitu istirahat
as boom crane menggenai beam bracing shg rafter no 4
gkung di akibatkan oleh keteledaron crew crane .
orrective Action
n untuk melakukan aktifitas di kabin crane tersebut.
 Pencegahan :
Precaution
ang berkompenten untuk melakukan aktifitas di kabin crane .
ndakan / Action
gan pertama / First Aid
jutan / Continuation Action
aksanaan pekerjaan selalu mengikuti prosedur keselamatan kerja
alat angkat dan angkut.
(                                                             )
Site manager