SBU1 TLD G PR 002 Rev.B Document Control Procedure

PT.
PERUSAHAAN GAS NEGARA

SBU DISTRIBUSI WILAYAH 1 PT. MENARA GADING PUTIH
(Persero) Tbk. JAWA BAGIAN BARAT
PROJECT HSE MANAGEMENT PLAN

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PT. Perusahaan Gas Negara (Persero) Tbk.
(PGN)
PLTG Talang Duku Gas Distribution Project
JHI
0 Approval for Construction Aug 3,10 RMD ALV YA
N
JHI
B Issued for Approval July 14,10 RMD WHY YA
N
JHI
A Issued for Review Jun 28, 10 RMD WHY YA
N
PT. PERUSAHAAN GAS NEGARA

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BY CHKD APVD CHKD APVD

Rev. DESCRIPTION DATE
CONTRACTOR PMC PGN
REVISION HISTORICAL SHEET
Rev No Date Description
A July 14, 10 Issued for Review

B July 26,10 Issued for Approval
0 Aug’ 3,10 Approval for Construction

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TABLE OF CONTENT
1.0 INTRODUCTION....................................................................................................................... 4
2.0 PURPOSE......................................................................................................................... ……. 4
3.0 SCOPE....................................................................................................................................... 4
4.0 DEFINITION............................................................................................................................... 4
5.0 HSE LEGAL AND OTHER REQUIREMENT ............................................................................. 5
6.0 POLICY AND COMMITMENT TO HEALTH, SAFETY AND ENVIRONMENT ..........................6
7.0 PROJECT AIMS AND OBJECTIVES ........................................................................................7
8.0 HSE ORGANIZATION ...............................................................................................................8
9.0 HSE ROLES AND RESPONSIBILITIES....................................................................................9
10.0 HEALTH, SAFETY & ENVIRONMENT PROGRAM ................................................................ 16
11.0 CHECKING AND CORRECTIVE ACTION ..............................................................................23
12.0 ENVIRONMENTAL CONTROL ...............................................................................................25
13.0 REPORTING SYSTEM ........................................................................................................... 26
14.0 SAFE WORK PRACTICE .......................................................................................................27
15.0 ATTACHMENT
- Attachment 1 – MGP Health, Safety and Environment Policy
- Attachment 2 – MGP Drugs and Alcohol Policy
- Attachment 3 – Jobs Safety Analysis Form
- Attachment 4 – Toolbox Talk Form
- Attachment 5 – Dozer Inspection Checklist Form
- Attachment 6 – Crane Inspection Checklist Form
- Attachment 7 – Excavator Inspection Checklist Form
- Attachment 8 – Daily Report Form
- Attachment 9 – Weekly Report Form
- Attachment 10 – Monthly Report Form
- Attachment 11 – Internal Hot Work Permit Form
- Attachment 12 – SOP for Fire cases
- Attachment 13 – SOP for Earthquake Cases
- Attachment 14 – SOP for Civil Unrest / Demonstration
- Attachment 15 – Emergency Tel. List Form
- Attachment 16 – MGP Incident Reporting Form

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1.0 INTRODUCTION
This procedure is to follow a standard method during pipeline construction meeting the
requirement of the project construction and installation works at PT. Perusahaan Gas Negara
(Persero) Tbk. SBU Distribusi Wilayah 1 Jawa Bagian Barat - PLTG Talang Duku Gas
Distribution Project South Sumatera.
2.0 PURPOSE
This Project HSE Management Plan was developed for the PROJECT execution to ensure
the protection of the ‘Safety, Health” for all personnel working on the this PROJECT and to
minimize environmental impacts, and maintain security of MGP’s workplace. The following
plan will be implemented by the ‘MGP PROJECT TEAM’ in conjunction with on going activities
on the site. It is the implementation of Occupational Safety And Health Management System
for a project and provides guidelines on how the project will attain the project and HSE
expected performance.
The Project HSE Management Plan provides the information needed to enable the entire
project team to understand how HSE is managed on the project, and how accountabilities are
set out at various levels of management. It demonstrates that the hazards associated with the
project have been identified, assessed and will be managed. Every individual working on the
PROJECT should use this document for reference and guidance. It can also be used as an
HSE training tool for new members of the Team.
3.0 SCOPE
This document provides an outline of the HSE policies, rules, procedures and activities that
will be followed during the PROJECT. These polices, rules and procedures have been
reviewed and approved for the PLTG Talang Duku Gas Distribution Project.
4.0 DEFINITION
The following words if found elsewhere in this document shall have the meaning as follow:
PGN PT. Perusahaan Gas Negara (Persero) Tbk, the ultimate end
user and owner
PMC

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PT. Erraenersi Konstruksindo selected by PGN as Project

Management Consultancy
MIGAS Indonesian Government Body authorized for issuing permits and

licenses for oil and gas facilities
THIRD PARTY Authorized Inspection Company, who is approved, certified by and

may be appointed to act on behalf of MIGAS
CONTRACTOR PT. Menara Gading Putih ( MGP ) an Engineering, Procurement,
and Construction Company selected by PGN to perform the
Engineering detailed design, procurement, construction, pre-
commisioning, commissioning and trial operation.
PROJECT
PLTG Talang Duku Gas Distribution Project
VENDOR / SUPPLIER Supplier, fabricator and/or original equipment manufacturer awarded a
purchase order by the CONTRACTOR and/or PGN to furnish material or
equipment.
HSE HEALTH SAFETY AND ENVIRONMENT
JSA JOB SAFETY ANALYSIS
PTW PERMIT TO WORK
PPE PERSONAL PROTECTIVE EQUIPMENT
ERT EMERGENCY RESPONSE TEAM

PIC PERSON IN CHARGE
5.0 HSE LEGAL AND OTHER REQUIREMENT
Project management implementation will follow the HSE legal and other related requirements
that written in legal and others requirements list documents and/or these following times but
not limited to :
Local and International Standard References:
 UU No.1 Tahun 1970 regarding General Safety.

 PERMENAKER No. PER.05/MEN/1996 Regarding Health, Safety Management System
 KEPMEN 174 /MEN/1986 and KEPMEN 104/MEN/1986 Regarding Construction Safety.
 ANSI (American National Standard Institute)

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 Indonesian ministry of oil and gas mining regulation (MIGAS) No.300.K/38/M.PE/1997

regarding Pipeline Safety of Oil and Gas.
 Indonesian ministry of oil and gas mining regulation (MIGAS) No. 06.P/0746/M.PE/1991
Regarding Safety inspection of Installation, Equipment and Technique Used in Oil and
Gas Mining Concession and Geothermal Resource.
 ASME (American Society of Mechanical Engineers)
 BSI (British Standards Institute)
 ISO (International Organization for Standardization)
 OHSAS18001: 2007 Occupational Health and Safety Management Systems –
Specification
 OHSAS 18002: 2007 Occupational Health and Safety Management Systems Guideline
implementation
6.0 POLICY AND COMMITMENT TO HEALTH, SAFETY AND ENVIRONMENT
MGP commits to fully comply with PGN and MGP HSE Policy.
MGP has in place a comprehensive HSE program. This program is initiated, supported and
guided by high level documents such as Statement of Policy on Health and Safety and
Protection of the Environment. These policies are implemented throughout all MGP worksites
and maintained that all clients, visitors and subcontractors visiting or working within these sites
are covered by these policies.
The primarily objective of MGP Drug & Alcohol Policy is to maintain a safe, healthy and
productive working environment. Each prospective employee, prior to offer of employment, will
be subject to Medical check up test for the presence of drugs.
The analysis will be conducted by MGP appointed physicians and laboratories. If necessary,
test will be conducted the project Paramedic onsite. Client representative shall be advised
about the test and result shall be submitted.
MGP reserves the right to perform random alcohol and drug testing on any MGP and
subcontractor employees as “Designated Positions” shall be tested.
Drug and alcohol testing may also be performed on any persons when evidence of suspicion
or reasonable cause exists and also in cases of serious accident. If the suspected person is a
PGN/PMC personnel report to his supervisor for PGN’s action any employee or personnel
found in breach of the MGP Drug and Alcohol Policy will be removed from the site project or
company premises as soon as practicable.

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7.0 PROJECT AIMS AND OBJECTIVES
Project Aims:
 To provide a healthy and safe working environment for all personnel working under the
scope of this plan.
 To support and protect the well being of the environment and the communities where we
work.
Project HSE Key Performance Indicator’s (KPI’s):
 100 % participation at personnel Safety Orientation.
 Site personnel to attend tool box and or pre job safety meeting daily.
 Ensure HSE alerts for all serious accident are published within 3 X 24 Hours of the
investigation.
 Action from all audits. Investigation and near misses are resolved timely with 0% overdue.
 HSE Man hours will be recorded and reported in weekly and monthly basis.
Simply stated it is the goals of MGP to conduct its operations with:
 Achieve zero recordable incident and accident
 No Fatalities
 No Lost Time Injuries
 No Medical Treatment Cases
 No Damage to the Environment
Project HSE Objectives:
 To integrate HSE into all aspects of the workplace through the Continuous Improvement
Process.
 To promote communication about HSE as a normal component of all aspects of our work.
 To implement and monitor the Project HSE management Plan throughout the course of the
project.
 To ensure employee placements meet the highest possible physical requirements for their
job allocation.

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 To continue observation and correction of at-risk behavior and condition through the
implementation of Behavior Based Safety Management Process (BBSM).
 To be actively involved in the implementation of Job Safety Analysis (JSA).
 To ensure safety meetings are conducted to permit meaningful communication throughout

the organization.
 To motivate employees to work safely through the implementation of the Employees

Recognition Program.
8.0 HSE ORGANIZATION
At the operation level, the current basic philosophy towards managing construction safety as
applied to any specific project is the emphasis that hazard identification and controls must be
effective through the participation of every employee with the respective supervisory personnel
as the facilitator of such efforts.
The HSE Project site Operations consists of a team of safety officers at site, lead by the Project
HSE Supervisor located also at site. The Project HSE Supervisor reports to the HSE
Coordinator. It is the responsibility of this position to facilitate the development, implementation
and monitoring of the Project HSE Management Plan throughout the life of the project as
defined within the scope of this plan.

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The Project HSE Organization can be described as follows:
Project Manager
Judhi
Project Engineer HSE Engineer

Head Office
Jakarta Yan Ruchyana Alvin Safirie
Project Site Site Construction Mgr HSE Spv

Risman Hilmi Ramadhan
Safety man
TBA
9.0 HSE RESPONSIBILITIES
9.1 General
All personnel are expected to fulfil their HSE responsibilities through actively
participating in the prescribed activities.
The following provides a summary of responsibilities, activities, and HSE support
functions for project groups and individuals.
9.2 Project Manager / Const Mgr
Project Management accepts the HSE philosophy in addition to accepting total

responsibility for implementation of the procedures and policies set fourth in this
Project HSE Management Plan.
Project Management shall familiarize them with this Project HSE Management Plan
in order to ensure adequate site implementation procedures are in place.

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The Project Manager has the delegated responsibility to ensure that the HSE
policies, objectives and activities incorporated in the respective project HSE Plans
are carried out and that related HSE procedures are fully implemented.
He shall continually review the effectiveness of the Project HSE Management Plan,
procedures and those personnel under his control to whom HSE matters have been
assigned.
Specifically:
 Ensure that a Project HSE Management Plan is developed and manage its
implementation across the Project.
 Review and approve project HSE documentation.
 Ensure that Risk Assessments are performed at the earliest practicable

opportunity.
 Ensure that all potential incidents involving injury to persons, damage to property
or the environment are thoroughly considered to propose mitigating measures.
 Ensure that the mitigating measures are followed through to completion.
 Ensure that all personnel are competent to carry out their tasks.
 Attend all projects HSE related meetings where practical, or otherwise appoint a
representative to attend on his behalf.
 Ensure that adequate training of staff to enable them to work in a safe and
healthy manner is forthcoming.
 Promote a high degree of HSE awareness amongst all project personnel.
 Take part in accident / incident investigation when required.
The Project Manager / Construction Mgr are accountable to the client Project
Manager, and have the following responsibilities, accountabilities, and assignments of
activities concerning health, safety and environment management:
Responsibilities Activities
 Champion HSE by providing leadership in  Schedule site visits and audit
implementation of all safety initiatives participation

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 Agree with the strategy and implement the  Review of audit findings and close-
Project HSE Management Plan out reports
 Decide with line managers and HSE dept the  Review incident / hazard reports
necessary resources required to achieve and approval of close-out.
HSE activities and project HSE performance
 Ensure sub-contractor follow our Poject HSE
indicators  Review with safety department
Management PLAN quality and frequency of sub-
contractor HSE activities
 Provide adequate resources for emergency  Require regular safety reviews,
response audits and hazard assessments of
project activities
 Accountable for ongoing development and  Participate in investigations of
implementation of HSE activities and serious or potentially serious
practices incidents and hazard investigations
 Agree with the strategy and implement the  Review overall project HSE
Project HSE Management Plan performance
 Ensuring engineering health and safety  Involvement and attendance at HSE
standards are developed and implemented meetings
 Make available resources to execute HSE  Review and discuss incident/hazard
activities reports
 Monitor incident/hazard reports  Consult with HSE advisors on HSE
promotional concepts
 Provide the necessary resources to ensure  Visit the work site (semester) to
the HSE group can effectively develop and discuss HSE compliance issues
install full health, safety and environmental  To actively encourage and be fully
protection management systems involved with the HSE
issues/matters
9.3 HSE Coordinator / HSE Engineer

The HSE Coordinator or HSE Engineer has the responsibility to Project Manager for
the development and ensuring the implementation of this Project HSE management
Plan.
The HSE Coodinator or HSE Engineer is responsible for assurance of compliance

with applicable regulations and client HSE requirements.

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The HSE Coodinator or HSE Engineer shall work with the appropriate project
manager's to accomplish, the HSE goals and objectives for the project.
HSE Coordinator shall:
 Ensure Project HSE Management Plan is designed to be used friendly and fully
complies with the terms of the contract
 Ensure orientation of Management and Supervision concerning this Project

HSE Management Plan, their responsibilities and compliance with same
 Ensure compliance with all appropriate HSE requirements through routine site
inspections, documenting the same with recommendations to management for
corrective action
 Develop and implement training measures as needed to ensure all personnel

are adequately trained relative to their responsibilities.
 Assist with adequate investigation and analysis of incidents
 Ensure prompt and adequate treatment for injured employees
 Assess the quality of the JSA process to determine its effectiveness.
 Collating safety data for reporting.
The HSE Coordinator or HSE Engineer has the following responsibilities,

accountabilities, and activities concerning HSE management:
 Remain abreast of relevant safety laws,  Regularly contact statutory and industry
standards & codes of practice. bodies in cooperation with the client
 Provide project management with safety  Receipt and circulation of relevant safety
information current to their requirements information
 Ensure safety standards developed for  Safety audits and reviews

the project meet with international best  Develop and implement safety training
practices programs
 Provide project management with  Statistical analysis and injury/damage
feedback on safety performance trends

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 Work with project management on  Project HSE Management Plan and

development of suitable hazard controls procedures development and review
interventions
 Coordinate safety activities  Attendance at senior safety meetings
 Liaise with statutory authorities and  Site visits and liaison with PGN/PMC
industry bodies on safety requirements management, sub-contractor safety
and systems personnel and employees
 Review overall project performance and
Report (Weekly and Monthly)
 Develop emergency response systems
9.4 Site HSE Representative (HSE Supervisor)

The HSE Supervisor has the responsibility to Project Management for the
coordination and implementation of this plan.
The Site HSE Supervisor is responsible for assurance of compliance with
applicable regulations and client safety and health requirements.
A Site HSE Supervisor shall be assigned to all phases of the project.
The Site HSE Supervisor shall work with the appropriate Construction Mgr and the
Corporate HSE Coordinator or HSE Engineer to accomplish the HSE goals and
objectives contained in the Project HSE Management Plan.
Site HSE Supervisor shall:
 Ensure orientation of Management and Supervision concerning this Project HSE

Management Plan, their responsibilities and compliance.
 Ensure compliance with all appropriate HSE requirements through weekly site
inspections, documenting the same with recommendations to Management for
corrective action.
 Develop and implement training measures as needed to ensure all personnel

are adequately trained relative to their HSE responsibilities.
 Assist with adequate investigation and analysis of incidents
 Ensure prompt and adequate treatment for injured employees


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 Assess the quality of the JSA process to determine its effectiveness.
 Collating HSE statistical data for reporting to company and client
 Ensure HSE orientation of all site employees
 Ensure adequacy of necessary personal protective equipment
 Participate in completion of JSAs
 Participate in pre-job HSE meetings
 Attend all Site HSE meetings
 Correct unsafe acts observed
 Comply with the requirements of this Project HSE Management Plan
 Report ALL incidents, regardless of severity, to the line supervisor and Site
Superintendent
 Daily Safety Status shall be reported by HSE Supervisor to HSE Coordnator /

HSE Engineer.
The HSE Representative reports directly to the HSE Coordinator, and administratively to the
Site Superintendent, he has the following responsibilities, accountabilities, and assignments
concerning HSE management:
 Remain abreast of project relevant HSE  Develop contact with supervisors and
laws, codes of practice and standards employees on HSE issues
applicable to the project
 Provide construction and operations  Circulate relevant HSE
management with HSE information information
current to their requirements  Conduct workplace HSE inspections,
audits and reviews
 Ensure project health, safety &  Provide HSE training to personnel
environmental standards meet with  Provide feedback on emergency
international practice requirements and exercises
 Interface with the client's HSE advisors  Provide information and HSE
when required reports for HSE meetings

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 Provide project line-managers with  Assist with the ongoing review and
feedback on HSE performance and development of Project HSE
trends Management Plan Attendance at HSE
meetings
 Work with project line-managers on the  Attendance at HSE meetings
development of suitable hazard controls  Provide feedback on HSE equipment
and interventions suitability and usage
 Ensure that all personnel fully comply  Permit control and review
with, the environmental protection  Provide feedback on incident reporting
requirements and investigations
 Schedule HSE activities  Conduct HSE Induction for new arrivals
& visitors
 Review area HSE performance and  Health / hygiene inspections and
advise line-managers of findings and reviews
potential solutions  Implementation of Emergency
Response system / procedures
9.5 All Project Personnel
All employees shall:
 Participate in JSAs to ensure adequate understanding of the task to be performed.
 Participate in pre-job meetings to ensure adequate understanding of this Project

HSE Management Plan.
 Management Utilize assigned safety equipment as needed.
 Report unsafe conditions to the appropriate supervisor.
 Correct unsafe acts observed.
 Assist with the training/mentoring of co-workers.
 Comply with the requirements of this Project HSE Management Plan.
 Report ALL incidents, regardless of severity, to a supervisor immediately
 Wear their personal protective equipment at all times.
 Take every measure to ensure their safety and of those around them.

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All PLTG Talang Duku Distribution Gas Project personnel are accountable to their
appropriate managers or supervisors, and have the following responsibilities,
accountabilities, and activities concerning HSE.
 STOP any job or activities that they  Proactive on the spot.
believe is un-safe.
 Adhere to all project health, safety and  Report hazardous conditions
environmental protection / management
 Provide HSE improvement
instructions, procedures, guidelines and
suggestions / observations
objectives  Report non-injury / damage
 Report all incidents and hazards to your occurrences / events
supervisor  Remain alert for colleague's
safety
 Wear all Personal Protective Equipment  Conduct task/work assessments
(PPE) and clothing  Participate at HSE meetings
 Advise fellow employees of hazardous  Participate in HSE inspections
situations / conditions
10.0 HSE PROGRAM
10.1 Health Facilities

First-aid Facilities
- First Aid Facilities shall be provided at all MGP offices : Home Office as well as
Project Offices. Where necessary, such as at Construction Site Office.
- First-aider personnel is Safety Representative at site. Injuries treated by fist aider
will only include treatment of minor injuries and redressing.
- Suitable supplies and facilities shall be provided and weekly check perform for
number of first aids item..
- First Aid Facilities provided for all employee, Worker, Visitor and all person who
work at area Activity PLTG Talang Duku Gas Distribution Project.
- Number of personnel and extent of the supplies shall be evaluated on a case by
case basis depending on the nature of the project and project site location with
respect to the nearest available public hospital / clinic
Clinic and Hospital

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- In all cases of serious injury, will be referred to the MGP’s Field Aid or direct to local
clinic or nearest hospital .
- MGP works closely with the clinic and hospital with the paramedics and doctors for
medical services on site.
- Prepared to evacuate transportation accident from the location of the project is
operational car project, also cooperated with the clinic or hospital to borrow an
ambulance if necessary.
- Utilization of doctors and paramedical facilities allocated to all member of
employees, and visitor of PLTG Talang Duku Gas Distribution Project.
10.2 Safety Program

Hazard control was performed under standard hierarchy such as, Elimination,
Substitute, Engineering, Administrative and PPE.
Traffic Management
In these construction activities are on the side of a busy public road, so that at its
construction activities require the handling of hazard with special control.
- use signs to 50 Meters from the end of construction activities going on.
- Safety as a flagman conduct for the guide to be more careful for road users.
- Inspection of Vehicle.
- Implementation of driving the speed limit at site work construction activity.
Job Safety Analysis (JSA)
Hazard Recognation will be conducted for all major work activities for the duration of
the PLTG Talang Duku Gas Distribution Project activities. The main hazard identification
technique to be utilized will be Job Safety Analysis (JSA).
JSA is a systematic review of work practices with the purpose of identifying any hazards
and developing recommendations for safe working procedures.
NOTE:
 JSA to be discussed with all personnel involved with the activity and supervisors to
sign off the JSA after the JSA discussion.

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 Activity with HIGH (residual) risk shall not be performed. It will be redefined or
further control measures put in place to reduce the risk. The control shall be re-
assessed for adequacy prior to starting the job.
 Activity with MEDIUM (residual) risk will only proceed within appropriate
management authorization after consultation with specialist personnel and
assessment team.
Lockout Tagout (LOTO)
The purpose of the lockout/tagout (LOTO) is to prevent personal injury and property
damage due to start up of electrically driven machinery and equipment that is under
repair or upon which maintenance is being performed.
Identify all sources of hazardous energy, movement, or toxic substances. Also locate all
isolation points and disconnects which deactivate the equipment or system.
Physically, isolate, disconnect, or eliminate all hazards by tagging/lockout of circuit

breakers, motor control switches, and removal of fuses, closing and locking of valves,
installation of blinds, etc.
Immobilize and lockout all isolation point and disconnect and try the system to assure
the system is properly disconnected
Tag all isolation points and identify persons installing the tag.
Only the person signing and placing a tag/lock may remove the tag/lock when work
complete.
Fire Protection and Prevention
MGP shall ensure prior to the commencement of any hot work activities that he area
that is or may be effected by the hot work ( e.g. exposed to a fire risk ) shall be free of
all flammable type material ( combustibles, wood, paper, plastic etc., flammable
materials petrol, diesel, paint, thinners or mastic insulation or other flammable insulation
products. )
MGP shall provide at least one fully charged 6 kg Dry Chemical powder fire
extinguisher at the immediate work face of all hot work locations.

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All hot works carried out in elevated areas shall have a fire retardant blanket (Fire
Blanket) strategically placed to ensure the capture of all sparks and or hot metal that
may be produced by the hot work.
MGP shall not allow hot material or sparks to fall or be carried into any other work area
which may affect the safety of other personnel or equipment.
Chemical Handling
Special attention shall be paid on every step of work during chemical cleaning activity.
MSDS shall be available at workplace, thoroughly communicated to all personnel
involved in the tool box meeting prior to start the activity. Personnel shall wear
appropriate PPE’s : clothing, hand gloves, respiratory protection, and other standard
PPE’s.
Waste material shall be properly maintained and disposed off the Site.
Emergency Response
Emergency response procedures are developed for all potential incidents including fire,
explosion, weather disturbances, lightning, etc. This procedure contains details on
communication, fire fighting, medical, evacuation, resumption of operations and other
details as maybe deemed required.
The project team will prepare its own emergency procedure by developing or modifying
the standard procedure, reflecting COMPANY’s requirements and taking the conditions
of the site into consideration.
An emergency communication network showing a list of personnel and parties to be

contacted, available emergency medical services and fire stations with telephone
numbers and addresses, or other addresses for obtaining assistance, will be
established at the construction site.
Work Permit
Risk are inherent part of any work. Risk exist in the work itself and or in the area adjacent
to the work to be carried out. Work permit system is established to control the risks to
manageable level.

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Work permit(s) will have to be prepared for the work(s) to be carried out in Client’s
controlled area, in accordance to Client’s Work Permit procedures : Classification, timing,
approval flow, etc.
Personnel Protective Equipments (PPE)
Personnel Protective Equipments (PPE) shall be provided to every employee relevant

to his or her specific works. Hard hat, safety shoes, safety glasses, hand gloves,
welding goggle, safety harness, face shield, and other equipments relevant to the
specific work shall be sufficiently provided and ready for use by each employee prior to
start working. Control of wearing, maintenance and replacement of equipment shall be
done thoroughly thus each employee will be sufficiently protected while they are
working.
Inspection and Audit
HSE Inspections is conducted at all activities. The result of these inspections, as with the
monthly inspections are recorded on the loss prevention inspection report. Copies of the
inspections report and summary sheet are forwarded to the appropriate Site Manager for
corrective action as necessary.
MGP conducts the HSE audits. The purposes of the audits are:
 Ensuring compliance with MGP and record keeping requirements.

 Reviewing and update training.
 Reviewing claim management and loss prevention control efforts.
 Discerning any potential trends in Safety Violations or injuries that may apply to the
overall project area.
Incident Investigation
All incident resulting in injury, loss, or near misses are investigated and documented.
These investigations are designed to uncover root causes analysis and corrective action.
Housekeeping
MGP shall ensure that all spent blasting material is swept down from all elevated levels
of the Project and collected at grade and removed from the area on a daily basis.

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MGP will not permit spent blasting material to accumulate at the work area or in any
elevated area.
HSE Communication and Socialization
Meetings are held to permit meaningful communications up, down and laterally
throughout the organization and to plan for continuous safety improvement.
1. HSE Communication
- Daily Tool Box Meeting
Line Supervisors are required to hold a safety briefing / tool box meeting for 10 -
15 minutes prior to each shift. This briefing will discuss the activities to be
performed during the shift and any hazards or health and safety implications
that may arise as a result of these activities. No formal minutes are kept for
these meetings. Employees are encouraged to provide feedback on any safety
criteria not considered during the planning phase of the activities.
- Weekly Safety Talk Meeting
Crew safety meetings involve all disciplines at project site and are conducted
every Monday morning by respective Project HSE Coordinator. Topics with local
language shall be prepared. All supervision levels shall attend these meetings
and attendance list may be prepared and signed by participants as evidence to
attend.
- Monthly Employee Site Safety Committee Meeting
Monthly Employee Safety Committee Meetings are held to provide a forum for
communication between employees and management in monthly basis. The
purpose of this committee is to review past accidents/incidents, safety policies,
and procedure and to make recommendations to management on any
necessary changes to the same. Attendees include all employees at site, project
management and client representatives. The site Project Engineer will chairs the
meeting. Minutes are kept of this meeting and distributed through the various
levels of management. Unresolved safety issues are referred to the PMT HSE
Committee.

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2. HSE Socialization
to facilitate the delivery of hazard control required an appropriate approach, so that

the safety messages can be accommodated and conveyed it well.
many ways to socialize the hazard control project. among others, induction, training,
toolbox talk, posters, signboard,
2.0 Training
Information and training required for all employees and supervisors prior to the
start of and during site work, especially to develop the local workers.
MGP shall provide copies of training records or completion certificates for each
employee, documenting date of completion for each training session.
- HSE Induction
The project program for employees and supervisors includes all workers
regardless of number of years worked in construction.
The orientation-induction program will include, but not limited to: Personnel
Identification, Basic HSE Rules, PPE, Emergency Preparedness, COMPANY
HSE Regulation.
- Promotion and Campaign

HSE promotion and campaign programs are considered to be important
alternative in the efforts to building of safety awareness. This program shall be
therefore included in each Project HSE Management Plan, which shall contain
but not limited to the followings :
1. HSE Incentive Awards Programs

2. Posters & banner
HSE promotion and campaign programs is tool of motivation to follow HSE rules.
The programs shall be designed considering the expected results to increase
workers’ consciousness, enthusiasm, and interest in HSE.
The programs shall be established taking account of the size and characteristics of
the projects, client requirement, construction duration, budget, local people attitude,
etc.

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11.0 CHECKING AND CORRECTIVE ACTION
11.1 Performance Measurement and Monitoring: (HSE Performance Tools & Tracking)
MGP’s intention of HSE performance units report and publish as HSE objectives
information both process indicator (leading indicator) and end-result indicator (lagging
indicators). Lagging indicators reflect of HSE output such as Reduced Accident Rate
and Recordable Incident Rate. While leading indicators reflect of HSE process /
activities output such as: Improved Safety Observation Card, Numbers of Safety
Training hours, Number of HSE Improvement Suggestion Card, accomplishment
audit/inspection, number of Closing NC/Incident
Monitoring of HSE performance is necessary to allow management review the HSE
Management System implementation. HSE Performance Targets will be set prior to the
start of the project and progress reported daily at the Weekly Progress Meeting. These
targets will be monitored through the length of the project.
The tracking of HSE performance is necessary to allow management of the HSE Plan.
Measurements of HSE Performance would include, but not limited to safety
observation, numbers of safety audit, injury targets, and completion of
audits/investigations.
HSE Performance Targets will be set prior to the start of the project and progress
reported weekly. These targets will be tracked through the length of the project.
11.2 Accident/incident reporting and investigation
Accident/Incident and Dangerous Occurrence Investigation Analysis. Methodical

investigation and analysis of undesired events that could have or result in harming
employees, damage to property, damage the environment or interrupted work activities,
shall be undertaken according to the accident reporting/investigation procedure.
All MGP personnel shall report the occurrence of all accidents, and near misses
immediately to the project site/field personnel. All incidents will be investigated and
followed up with a report to ensure that reoccurrence of similar incidents is prevented.
An Initial Incident Report from the MGP is required by the end of the shift in which the
incident occurred and will be reviewed at the Daily Meeting.
Completion of the full investigation report is required within twenty-four (24) hours.
Progress on implementing recommendations and corrective actions will be reported to
the Project Owner (As MGP Contract Holder). Corrective steps taken shall be reviewed

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during inspections and audits. Additionally, lessons learned from the incident
investigation shall be reviewed with all affected personnel whose job tasks are relevant
to the incident findings.
START
SERIOUS OR FATAL ACCIDENT FLOW CHART
11.3 Review of HSE Implementation
Inspection
Periodic on-site inspection as warranted will allows HSE personnel and individuals
concerned to observe employees, facilities, equipment tools, materials, surrounding
and works and identify hazard or potential performance problem in order to provide
immediate corrective measure necessary.
Pre-Job Site Inspection Checklist


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The Pre-Job site check-list identify, the list of items which shall be examined to identify
corrective measure. Result of site inspection shall be recorded using MGP-HSE form.
Inspection shall be conducted jointly by HSE & S personnel & Construction personnel.
HSE&S PARTICULARS PRE-JOB SITE INSPECTION CHECKLIST

House Keeping and Fire Waste disposal, cleaning methods, access ways, materials /tools/
Protection equipment storage, extinguisher, alarm, non-smoking areas, response
instructions, emergency exits, sign boards.
Excavation/Trenches Shoring, Barricades, warning sign in place, access ways, work procedures, work
Civil Works practices, work permits.
Personal Protective Gadget Safety helmet, hand gloves, safety footwear, eye protection, hearing
protection, respirator, safety belt.
Confined Space Entry, Work permits, barricades, warning sign in place, access ways, ventilation,
Restricted Area, Hazardous work procedures, work practices, lock out and tag out sign
Work, Lock Out/Tag Out
Electrical Works Breakers switches, fuses, grounding, lock out/tag out, plugs, warning sign,
distribution boards, equipment & tools, work procedures, work permit.
Mechanical Works, Machine guards, lighting levels, emergency shutdown, work space,
Equipment Installation barricades, work permit, work procedures, lock out/tag out, work practices.
Welding and Other Hot Works Hot work permit, work procedure, work practices, equipment & tools,
warning sign, ventilation, hot work protective gadgets.
Scaffolding, Cappers, and Warning sign, walkways, ladders, stairs, bracings, handrail, supports,
Fall Protection safety net, work procedures, work permit.
Rigging, Cranes, Material Work procedure, work permit, work practices, slings, chains blocks,
handling barricades, work space, warning signs, storage methods, handling
methods, operators, work practices.
Others (Including Noise pollution, dust pollution, traffic sign, sanitary facilities, hygiene
Environmental and health) practices, waste management, hazardous material labeling, first aid
facilities, other applicable items not included in above list
12.0 ENVIRONMENTAL CONTROL
CONTRACTOR fully recognized that management of environmental matters during

construction and commissioning work is very important. These responsibilities include the
proper handling of waste materials and environmental protection. (See Doc. Environmental
Management and Monitoring Plan NO. SBU1-TLD-N-CP-001)
Supervisor shall utilize appropriate procedures and protective equipment control measures to
reduce and eliminate all identified sources of significant environment hazards to supervisors.

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13.0 REPORTING SYSTEM

HSE reports will be issued by MGP Site, Checked by Site Manager and Approve by PGN/PMC.
types of reports prepared include daily reports, weekly reports, monthly reports, or reports
Inspection Report and the special case. reporting period are reported in accordance with the
character of the report itself.
- Daily Report
Daily basis report, which makes this report is a safety supervisor field, as the
monitoring of work per day and reported to the safety coordinator or safety
engineer of the site as a daily report.
- Weekly Report
Weekly basis report, Summary daily HSE report from a week before, and
prepared by MGP’s Safety Supervisor, Checked by MGP’s Site Manager, and
Approve by PGN/PMC and reported as a weekly basis.
- Monthly Report
Monthly basis report, summary of monthly activity of project, Prepared by MGP’s
Safety , Checked by MGP’s Site Manager, and Approved by PGN/PMC and
reported as a monthly basis.
- Inspection Report and Special Case Report

Inspection report is case by case report, when conducting inspections or they
have Special case, the report must be made immediately and summary will
included in the daily reports of inspection activities safety supervisor as per case
date, included in the report as a weekly and monthly reports
This report shall contain but not be limited to the following :
- Number of Manpower
- Number of Work hour
- Man hours worked for the period and cumulative hours to date
- Number of Fatality
- Incident / Accident investigation report
- Number of Work Day Lost.
- Number of Lost time injury.

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- Number of Medical Treatment

- Number of First Aid.
- Number of Vehicle Accident
- Number of Property Damage
- Accident Frequency rate.
- Accident Severity rate
- Number Of Induction
- Number Of Toolbox talk.
- Number of drill (HSE Drill)
- Number of HSE Meeting
- Number of Inspection and Audit
- Number of Fire Case.
14.0 SAFE WORK PRACTICE

- Radiography
All radiography work shall be carried out by a licensed radiography persons. All radiation
equipment and radioactive substances shall be stored, handled, transported, or disposed
off as good as it can, so that no person receives an unnecessary dose of radiation.
Radiography equipment shall be inspected monthly by qualified person and the results
shall be recorded and filed for the required period.
In case of a trouble, accident, or loss of radioactive materials, the following provisions shall
be applied:
- When radioactive material is in an abnormal state due to a mechanical fault in the
radiation apparatus, the position of the radioactive materials shall be checked with a
radiation meter, and the position shall be shielded by a lead plate to prevent radiation
from dispersing.
- When a capsule or holder of radioactive material is dropped, the area shall be
designated as a restricted zone, and this zone shall be examine by a radiation meter.
- When radioactive material is scattered from a broken capsule, the contaminated area
shall immediately be declared as a restricted zone.
- Shield plates shall be provided around the scattered radioactive material to prevent
radiation hazards.

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- All workers shall be evacuated immediately from area where hazardous radiation is
anticipated
- Underground Work
when doing underground work, which should be considered are:
a. Check area from the quarry landslide hazard
b. Prepare the work area well
c. Work location large enough for the movement of workers who will do the work
underground
d. If the work are in areas prone to landslides, it was processed to make shoring and
retaining soil erosion should not occur.
e. supervision of the work done during the process is still ongoing until the completion
of
- Welding and Cutting

Welding and cutting shall be controlled by adequate safety measures with particular
reference to:
a. Approved Hot Work Certificate be issued by Plant prior to commencing any welding or
cutting work in areas stipulated by the Permit to Work
b. Only authorized persons shall use welding equipment.
c. Fire Extinguishers and or pressurized fire hose/s or monitor shall be positioned ready for
use.
d. Boxed fire resistance screen must be erected around and below on all elevated or
ground welding work.
e. Areas are well ventilated to prevent any depletion of oxygen in the air.
f. Combustible material shall be removed from the intended work areas.
g. Gas Cylinder Be checked for leaks by means of soapy liquid applied to each joint. This
should be readily available at site
h. Gas Cylinder Be stored vertically, separated and marked ‘EMPTY’ or ‘FULL’
i. Cylinder Be secured vertically during use and transportation. Cylinders shall never be
used in a horizontal position.
j. Be fitted with Flashback Arrestors, being non-return valves designed to prevent an
explosive mix developing in either cylinder

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k. Have leaking cylinders taken out of service immediately, removed outdoors and closely
attended until completely and safely depressurized
- Hydrostatic Test
Before Hydrostatic Test started, the preparation required to support these activity are as
follows :
a. Provide safety sign that related to work activity for high pressure test,
b. Socialization of work activity to local people where activities were carried out, to void
social impact.
c. Take water sample for water that will be use if needed, before water filling started and
dewatering activity begun.
d. Take water sample activity will documented and on file in addition the activities reported
in weekly and monthly report.
e. File the result of water sample.
- Lifting Activity
covers the general requirement and the standard methods of lifting and erection work.
Identified the weight of a load, you need to choose the correct sling to safely lift it. Do not lift
a load if the weight is not marked or cannot be established.
Do not use a chain or sling belt to lift if it does not have a manufacturer's tag. You should
return it to the manufacturer for assessment and retagging.
It might also be necessary to read the SWL from a table in order to choose the correct sling
for a job. The tables and charts section of this resource includes a SWL table for synthetic
slings, which also shows the color codes.
Do Inspection and visual check for lifting equipments and work area before start the activity
for good condition.
15.0 ATTACHEMENTS

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Attachment 1 – MGP HSE POLICY
PROJECT HEALTH AND SAFETY POLICY
PT. MENARA GADING PUTIH shall strive to execute the Project with for most consideration for the
Health and Safety of personnel, protection of assets and the protection of natural environment. We
shall ensure the achievement of the HS objectives set for the project to enhance Project Health,
Safety and Environment standards.
1. Shall respect and comply all applicable law of GOVERNMENT OF INDONESIA pertaining to
“Health, Safety and Environment”.
2. Shall comply EMPLOYER “Health, Safety and Environment” rules and ensure that HSE
requirement are clearly communicated and publish widely to establish a method of monitoring
compliance with policy.
3. To ensure all employees have clear responsibilities with respect to “Health, Safety and
Environment”.
4. To assess the ability of subcontractors in respect to “Health, Safety and Environment” when
selecting and regular monitoring of their performance with respect to HS.
5. To ensure that Risk Assessment and Hazard Identification are carried out for all activity and
mitigation measures are taken before commencement of work.
6. Develop high degree of “Health, Safety and Environment” awareness among all work crew
engaged in project activity.
7. To ensure Personal Protective Equipment are all the time readily available and given to work
crew to protect personnel from injury or ill health.
8. To ensure all equipment mobilized for construction are fit for its purpose and duly tested,
certified, and examined.
9. To ensure line management is accountable for all “Health, Safety and Environment” issues till the
completion of the construction activities.
10. To ensure that all incident / accidents are reported, investigated, monitored, and mitigation
measures are taken to prevent recurrence.
11. PT. MENARA GADING PUTIH has set a challenging targets and objectives and aims for Zero
Accident and Prevention of Lost Time Accident.

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Attachment 2 – MGP Drugs and Alcohol Policy
DRUGS AND ALCOHOL POLICY
Alcohol and drugs are potential safety hazard within the workplace and as such it is forbidden
for any person to possess, or be under the influence of alcohol or non-prescribed drugs, at
anytime or anywhere on the work site. Personnel using prescribed medication shall inform their
work supervisor about the drugs, which they are taking, prior to arrival on site.
It is the policy of PT. MENARA GADING PUTIH to maintain a work environment free from the
influence of alcohol and other drug abuse. Accordingly, PT. MENARA GADING PUTIH prohibits
the consume, use or influence of alcohol and/ or illicit drugs during work hours and PT.
MENARA GADING PUTIH shall take disciplinary action against person discovered in
possession of, or under the influence of alcohol or drugs.

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Attachment 3 – Jobs Safety Analysis Form
JOBS SAFETY ANALYSIS

Date: …… Equipment: Title of Person Analyzed by:
Job Description:
Rev.: ……. …………… Who does job (Supervisor):
…………….
…………… ………………. ………………
JSA Team Work Reviewed by
Location: 1. Dept. Head/Supt.
………………….
……………. …………………
2. MGP HSE Dept.:
………………….
Required PPE:…………… Approved by

PGN/PMC: …………………
Basic Job Steps Potential Hazards Safe Procedure

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Attachment 4 –Toolbox Talk Form
TOOLBOX MEETING
LOCATION :
DATE :
SUPERVISOR :
AGENDA ITEMS
NO DESCRIPTION
ANY OTHER BUSINESS :
ATTENDANCE
NO NAME SIGNATURE
MGP PMC PGN
---------------------------------- ---------------------------------- ----------------------------------


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Attachment 5 – Dozer Inspection Checklist Form
CHECKLIST PEMERIKSAAN DOZER
TANGGAL INSPEKSI : TIM INSPEKSI JABATAN PARAF

TIPE : 1.
NO. SERI : 2.
SERTIFIKAT : 3.
MASA BERLAKU : 4.
KAPASITAS : 5.
LOKASI :
OPERATOR :
SIO / SIM NO. :

MASA BERLAKU :
KONDISI KET
NO DESKRIPSI PERLENGKAPAN TIDAK
BAIK BURUK
ADA
1 ENGINE EMISSION (MESIN DAN EMISI)
2 ELECTRIC SYSTEM (SISTEM KELISTRIKAN)
4 HYDRAULIC SYSTEM (SISTEM HIDROLIK)
5 HOSE (SELANG HYDROLIK)
6 BUCKET(KERANJANG BUCKET )
7 RIPERS TEETH ( GIGI PEMECAH PADA BUCKET)
8 LOCK PIN ( PIN PENGUNCI)
9 REVERS ALARM (ALARM MUNDUR)
10 HORN (KLAKSON)
BRAKE / HAND BRAKE / HYDRAULIC BRAKE (REM / REM TANGAN /REM
11
HIDROLIK)
12 PEDAL FUNCTION (FUNGSI PEDAL DAN TUAS)
13 GAUGES FUCTION (FUNGSI INDIKATOR GAUGE)
14 BREAK LIGHT (LAMPU REM)
15 LIGHT (LAMPU UTAMA)
16 TRACK (RANTE TRACK)
17 BATERY (BATERY POWER)
18 GEARBOX TRACKS
19 CABIN (KABIN)
20 OPERATOR SEAT (KURSI OPERATOR)
21 BLADE (PISAU BUCKET)
22 CUTTING EDGE (SIRIP POTONG )
23 HOUSEKEEPING (KEBERSIHAN DAN PENATAAN
24 FIRE EXTINGUISHER (ALAT PEMADAM API RINGAN)
25 PERSONAL PROTECTIVE EQUIPMENT (ALAT PELINDUNG DIRI)
26 COMMUNICATION EQUIPMENT (PERALATAN KOMUNIKASI)

27 OTHER (LAINNNYA
REKOMENDASI
Diinspeksi Oleh, Disetujui Oleh, Diketahui Oleh,
MENARA GADING PUTIH HSE MGP PGN/PMC


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Attachment 6 –Crane Inspection Checklist Form

CHECKLIST PEMERIKSAAN CRANE

TIPE : 1.
NO. SERI : 2.
SERTIFIKAT CRANE : 3.
MASA BERLAKU : 4.
KAPASITAS : 5.
LOKASI : OPERATOR :
SIO / SIM NO. :
MASA BERLAKU :
KONDISI KET
BAIK BURUK
ADA
3 CABLE / WIRE SLING (KABEL SLING)
5 BOOM
6 BOOM HOIST (KATROL BOOM)
ANTI TWO
7
BLOCK
8 PLAY JIB
9 LOAD ANGLE INDICATOR (INDIKATOR SUDUT BOOM)
10 LIMIT SWITCH (INDIKATOR PEMBATAS)
11 LIMIT SWITCH ALARM (ALARM INDIKATOR PEMBATAS)
12 HOOK (PENGAIT)
13 MAIN AND AUXILIARY HOIST (KATROL INTI DAN PENDUKUNG)
14 WIRE CLIP (PENJEPIT KAWAT)

15 DRUM
16 DRUM BREAK
17 SWING (PUTARAN / ROTASI)
18 SWING ALARM (ALARM ROTASI)
19 REVERSING ALARM (ALARM MUNDUR)
20 HORN (KLAKSON)
BRAKE / HAND BRAKE / HYDRAULIC BRAKE (REM / REM TANGAN /REM
21
HIDROLIK)
24 LIGHT SIGNAL ( L / R ) (LAMPU SEN L / R)
25 OUT RIGGER
26 TIRES / CRAWLER (BAN / CRAWLER)
27 GEARBOX TRACKS
28 LOAD CHART (DIAGRAM BEBAN)
29 CABIN (KABIN)
31 AIR CONDITIONER
32 WIPER
33 MIRROR (KACA SPION)
34 WINDOW GLASS (KACA JENDELA)
35 SPARE OF TIRE (BAN CADANGAN)
36 HOUSEKEEPING (KEBERSIHAN DAN PENATAAN)

OTHER
40
(LAINNNYA)
REKOMENDASI


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Attachment 7 –Excavator Inspection Checklist Form
CHECKLIST PEMERIKSAAN EXCAVATOR

TIPE : 1.
NO. SERI : 2.
SERTIFIKAT : 3.
MASA BERLAKU : 4.
KAPASITAS : 5.
LOKASI : OPERATOR :
SIO / SIM NO. :
MASA BERLAKU :
KONDISI KET
BAIK BURUK
ADA
5 BOOM ARM
6 HOSE (SELANG HYDROLIK)
7 BUCKET(KERANJANG BUCKET )
8 TEETH ( GIGI PADA BUCKET)
9 LOCK PIN ( PIN PENGUNCI)
10 SWING (PUTARAN / ROTASI)
11 SWING ALARM (ALARM ROTASI)
12 REVERS ALARM (ALARM MUNDUR)
13 HORN (KLAKSON)
14 BRAKE / HAND BRAKE / HYDRAULIC BRAKE (REM / REM TANGAN /REM HIDROLIK)

17 TRACK (RANTE TRACK)
18 BATERY (BATERY POWER)
19 GEARBOX TRACKS
20 LOAD CHART (DIAGRAM BEBAN)
21 CABIN (KABIN)
23 AIR CONDITIONER
24 WIPER
25 MIRROR (KACA SPION)
26 WINDOW GLASS (KACA JENDELA)
27 SPARE OF TIRE (BAN CADANGAN)
28 HOUSEKEEPING (KEBERSIHAN DAN PENATAAN)

OTHER
32
(LAINNNYA)
REKOMENDASI
Attachment 8 –Daily Report Form


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LAPORAN HARIAN HSE
HARI / TANGGAL :
ARE / LOKASI :
KEGIATAN :
INFORMASI KEGIATAN
TENAGA KERJA PERALATAN YANG DIGUNAKAN

NO LOKASI
PENGAWAS /
PEKERJA JENIS JUMLAH JENIS JUMLAH
MANDOR
KINERJA HSE CATATAN CUACA
NO PENJELASAN TIDAK YA KETERANGAN WAKTU KONDISI WAKTU KONDISI
1 Briefing sebelum kerja 07.00-08.00 19.00-20.00
2 Alat Pelindung Diri 08.00-09.00 20.00-21.00
3 Perlengkapan P3K 09.00-10.00 21.00-22.00
4 Alat Pemadam Api Ringan 10.00-11.00 22.00-23.00
5 Kasus Fatality 11.00-12.00 23.00-24.00
6 Kasus Perawatan Medis 12.00-13.00 00.00-01.00
7 Kasus First Aid 13.00-14.00 01.00-02.00
8 Kasus Nearmiss 14.00-15.00 02.00-03.00
9 Kasus Kebakaran 15.00-16.00 03.00-04.00
10 Kasus Property Damage 16.00-17.00 04.00-05.00
11 Kasus Kerusakan Lingkungan 17.00-18.00 05.00-06.00
12 Masalah lingkungan 18.00-19.00 06.00-07.00

KONDISI CUACA
13 Temuan Bahaya (Cantumkan dalam kolom catatan)
Dari :
14 Jam kerja sampai : CR : Cerah GR : Gerimis
15 Lainnya MD : Mendung HL : Hujan Lebat
CATATAN DAN REKOMENDASI
Attachment 9 – HSE Weekly Report Form


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Week Number: From: To:
CONTRACTOR NAME PHASE :
PERSONEL
MGP SUBCONTRACTOR GROSS
DESCRIPTION Last Week This Week Total Last Week This Week Total TOTAL
Manpower 0 0 0 0 0 0 0
Manhours 0 0 0 0 0 0 0
No. of Fatality 0 0 0 0 0 0 0
Work day Lost 0 0 0 0 0 0 0
Medical Treatment 0 0 0 0 0 0 0
First Aid Cases (FAC) 0 0 0 0 0 0 0
Motor Vehicle Accident (MVA) 0 0 0 0 0 0 0

Property Damage (PD) 0 0 0 0 0 0 0
Accident Frequency Rate 0 0 0
Accident Severity Rate 0 0 0
0 0 0 0 0 0 0
Fire Cases 0 0 0 0 0 0 0
Near Miss 0 0 0 0 0 0 0
Environmental Damage 0 0 0 0 0 0 0
SUMMARY OF ACCIDENT AND INCIDENT/NEAR MISS
H S E INSPECTION / AUDIT
SUBJECT / COMMENTS
Safety Induction :
ToolBox Talk :
Training / Drill :
HSE Meeting :
Prepared by, Checked by, Approved by,
MGP - HSE MGP – Site Manager PGN / PMC


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Attachment 10 – HSE Monthly Report Form
MONTHLY HSE STATISTIC REPORT

SBU DISTRIBUSI WILAYAH 1 JAWA BAGIAN BARAT
Month :
PERSONEL
MGP SUBCONTRACTOR GROSS
DESCRIPTION Last Month This Month Total Last Month This Month Total TOTAL
Manpower 0 0 0 0 0 0 0
Manhours 0 0 0 0 0 0 0
No. of Fatality 0 0 0 0 0 0 0
Work day Lost 0 0 0 0 0 0 0
Medical Treatment 0 0 0 0 0 0 0
Lost Time Injury (LTI) 0 0 0 0 0 0 0
Incident / Accident 0 0 0 0 0 0 0
Motor Vehicle Accident (MVA) 0 0 0 0 0 0 0
Property Damage (PD) 0 0 0 0 0 0 0
Accident Frequency Rate 0 0 0
Accident Severity Rate 0 0 0
First Aid Cases (FAC) 0 0 0 0 0 0 0

Fire Cases 0 0 0 0 0 0 0
Near Miss 0 0 0 0 0 0 0
Environmental Damage 0 0 0 0 0 0 0
SUMMARY OF ACCIDENT AND INCIDENT/NEAR MISS
H S E INSPECTION / AUDIT
SUBJECT / COMMENTS
Safety Induction :
ToolBox Talk :
Training / Drill :
HSE Meeting :
Prepared By, Checked by, Approved by,
MGP - HSE MGP - Site Manger PGN / PMC
Legend : LTI : Lost Time Injury, MTI : Medical Treatment Injury, FAC : First Aid Case, MVC : Motor Vehicle Case

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Attachment 11 – Internal Hot Work Permit Form
SURAT IJIN KERJA PANAS

Dari : Tanggal ……. / …….. / ……… Jam …… : …….
Sampai : Tanggal ……. / …….. / ……... Jam …… : …….
Lokasi : ………………………………………………………
Pekerjaan: ………………………………………………………………..
Hasil
No. Daftar Periksa Catatan
Ya Tidak
A
1 Gorong-gorong, saluran pembuangan air dekat tempat kerja sudah
ditutup / di blok
2 Material mudah terbakar sudah dipindahkan dari tempat kerja.
3 APAR sudah tersedia.
4 Penjaga kebakaran stand by.
5 Peralatan pengelasan sudah di arde / grounding
6 Apakah ijin tempat kerja ditanggulangi
7 Apakah mesin diesel, compressor udara sudah ditempatkan pada tempat
yang aman.
8 Apakah penempatan tabung gas sudah tersedia dengan posisi yang aman.
B Apakah telah dilakukan:

1 Inspeksi listrik dan Isolasi listrik
2 Isolasi utilitas lain
C Apakah arah angin sudah diperhitungkan.

Diperlukan uji gas.
INSTRUKSI KHUSUS:
Pakaian Pelindung dan Peralatan

Gas Test Gas Mudah terbakar Gas Beracun Gas Pengikat oksigen
Keselamatan yang diperlukan
Nama
Waktu
Tanda Tangan
Note:
Sudah dilakukan pemeriksaan dilapangan dan dinyanyatakan bahwa pekerjaan sudah bisa dilanjutkan.
JABATAN TANGGAL NAMA TTD CATATAN
Diminta
Foreman
oleh:
Diperiksa
Supervisor
oleh:
HSE
supervisor
Disetujui HSE
oleh: koordinator
Site

Document No. Rev.
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SBU1-TLD-N-CP-002 0
Manager
PMC / PGN

Document No. Rev.
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SBU1-TLD-N-CP-002 0
Attachment 12 – Fire
SOP for
1. Fire Prevention
1. Any inflammable or combustible material shall be removed from near and below the firework
location, or shielded with non- combustible materials, if removing infeasible.
2. Fire Extinguishers suitable for the work operations shall be furnished near the firework,
electrical equipment, engine-driven equipment, refueling location, etc.
3. Fire prevention equipment shall be inspected periodically.
4. Prior to commencing work at locations anticipated inflammable or volatile gas leakage, any gas
leakage shall be checked using a proper gas detector.
5. A fire watchman shall be allocated at the firework location when required.
6. Possibility of any remaining fire at the work location shall be reconfirmed after finishing the
work.
2. Fire Safety
Fire safety is an important part of daily routine. During an emergency, proper action saves lives.
For your safety, please familiarize yourself with these basic steps, which pertain to employee.
1. If you discover a fire or smell smoke, sound the fire alarm. Know the location of the fires
station. Do not panic, if fire is major, warn people to begin evacuation from affected area to
Emergency Assembly Area as designated, and call Fire Brigade immediately and follow the
emergency and evacuation procedure.
2. If fire is minor, try to put out the fire with fire extinguisher.
3. Upon hearing a a fire alarm signal, immediately begin evacuation. Use the nearest safe exit.
4. Leave the location of fire and assemble in area established.
5. Know the location of all exits from the fire location.
Evacuation routes are posted in all prominent places. However, all employees should be
familiarized with all exits the work places/office in order that the nearest safe exit will be
properly chosen in an emergency.

Document No. Rev.
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Attachment 13 – Earthquake
SOP - EARTHQUAKE
1. If you are outside - move to an open area away from any buildings.
2. If you are inside a building - take shelter under tables, desks or in doorways. Stay away from
windows, shelving, and large free standing furniture.
3. After the earthquake, look for any injured persons in your area, if necessary.
4. If safe to do so, leave the building as soon as possible.
1. Evacuation Procedures
The building should be evacuated when the evacuation siren sounds for longer than 30
seconds.
All occupants should:
 Cease all activities.
 Leave the building immediately by the fire/emergency exits, or as directed by a

Squad Member. Squad Members will be wearing orange hats. SHE Supervisor
will be wearing a white hat. The attached floor plans indicate exits to be used by
staff in each zone.
 Leave personal possessions behind.
 Do not lock doors.
 Do not use the lift or circulation stairwell.
 Proceed to the designated assembly area on the northern side of the building.
 Keep clear of building entrances.
 Follow the direction of safety staff and do not re enter until directed.

Document No. Rev.
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SBU1-TLD-N-CP-002 0
Attachment 14 – Civil Unrest/Demonstration
SOP Civil Unrest / Demonstration
Any employee observing any sign of a demonstration shall immediately report the situation to the
Security Chief. The most obvious sign of a demonstration is a group of people moving toward the PGN
Talang Duku Gas Distribution Project.
It is MGP’s policy that the employees are not expected to take any action to stop the demonstrators.
Report the situation and let security take care of it. Security’s responsibility is to protect personnel first
and then protect property/facilities.
Upon hearing the alarm or any sign of it, all employee should stop working, secure their work
areas/equipment (lock equipment, room and building) and go to the muster point area. After all
personnel are accounted for, personnel shall wait for further instruction from the MGP HSE Supervisor.
All vehicles should be parked as near to the Office as feasible and secure.

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Attachment 15 – Emergency Telephone List
EMERGENCY TELEPHONE LIST

1. In Case of Emergency
SUMMON THE PROPER PEOPLE IMMEDIATELY
Police Department: ____________________ Telephone: ____________

Fire Department: ______________________ Telephone: ____________
Ambulance: __________________________ Telephone: ____________
__________________________ Telephone: ____________
Hospital _____________________________
Address: ____________________________ Telephone: ____________
Physicians
Name: ______________________________ Telephone: ____________
Address: ____________________________ Telephone: ____________
PGN / PMC:
1. ____________________________________ Office Phone: ____________
Home Phone: ____________
2. ____________________________________ Office Phone: ____________
Home Phone: ____________
3. ____________________________________ Office Phone: ____________
Home Phone: ____________
4. ____________________________________ Office Phone: ____________
Home Office: ____________
MGP Personnel:
1. ____________________________________ Office Phone: ____________
Home Phone: ____________
2. ____________________________________ Office Phone: ____________
Home Phone: ____________
3. ____________________________________ Office Phone: ____________
Home Phone: ____________
4. ____________________________________ Office Phone: ____________
Home Office: ____________

Document No. Rev.
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SBU1-TLD-N-CP-002 0
Attachment 16 - MGP Incident Reporting Form
MGP Accident / Incident Reporting form
Type of Report: _ On The Job _ Off The Job
Report No: _ English Version _ Indonesian Version
Status of Injured Person _ Employee

_ Contractor _ Direct contractor to MGP
_ Sub-contractor to
_ Visitor / Guest
_ None
Company of Injured Person _ PT. Menara Gading Putih

_ Other :
General Information
1. Brief Description of Incident:
2. Incident Location:
3. Facilities:
4. Activity: _ Stringing _ Joint Coating

_ Welding _ Holiday Test
_ Tie-In _ Road Crossing
_ Lowe-In _ Landing & Un-landing
_ Back filling _ Clearing / Grading
_ Radiography
_ Other:
5. Department
6. Date of Report (MM/DD/YYYY)
7. Date of Incident / Injury or (MM/DD/YYYY)

Diagnosis of Occupational Illness
8. Time of Incident / Injury (HH:MM)
9. Place of Incident / Injury


Document No. Rev.
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SBU1-TLD-N-CP-002 0
Injured Person
10. Name of Injured Person:
11. ID Number:
12. Job Title:
13. Nationality:
14. Gender _ Female _ Male
15. Date of Birth (MM/DD/YYYY)
16. Date of Employment (MM/DD/YYYY)
17. Time worked as Present Position (experience) year(s) month(s)
18. Time worked on shift-rotation before accident day(s) hour(s)
19. IP’s Supervisor
Incident / Injury Information

20. Description of Incident
(Actual)
21. What could have

happened (Potential)
22. Witness No Name Company

1
2
3
23. Date Employer Notified
24. Treatment Given at Site _ None _ First Aid

Describe Medication
25. Sent to Doctor _ Yes _ No

Doctor Name
Home address and
phone no

Document No. Rev.
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SBU1-TLD-N-CP-002 0
26. Sent to Hospital _ Yes _ No

Doctor Name
Home address and
phone no
27. Describe Treatment at

Hospital
28. Day Away from Work _ Yes _ No _ To be advised

Date Began (MM/DD/YYYY)
Date Returned (MM/DD/YYYY)
29. Restricted Workday _ Yes _ No _ To be advised

Date Began (MM/DD/YYYY)
Date Returned (MM/DD/YYYY)
Weather at Time of Incident

30. Visibility _ Clear _ Dusk _ Raining
_ Cloudy _ Foggy _ N/A
31. Wind _ Calm (<5 _ Moderate ( 5-15 _ Rough ( >15 knots)

knots) knots)
32. Current state / wave _ Calm (<5 _ Moderate ( 5-15 _ Rough ( >15 knots)
knots) knots)
Incident Classification
_ Near Miss
_ Personnel _ Asset _ Environmental

_ First Aid Case _ Property Damage _ Spill / Bbls
Leak
_ Medical Treatment Case _ Fire _ Emission / Discharge
_ Restricted Workday Case _ Natural Cause Est. Amount Ton / m3
_ Lost Workday Case _ Production Interruption /
Loss
_ Death / Fatality Hours Bbls/mmcf
_ Environmentally Infectious
Disease
_ Financial Loss
Est. Cost US$
_ Motor Vehicle

Document No. Rev.
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SBU1-TLD-N-CP-002 0
_ Responsible Vehicle Case _ Non-Responsible Vehicle

Case
Vehicle: _ Company owned _ Non Company owned

Type:
_ Hit vehicle in front _ Hit pedestrian _ Being passed _ Hit & Run
_ Hit by vehicle behind _ Roll Over _ Ran off road _ Other
_ Backed into _ Sideswipe _ Hit animal
_ Hit stationary object _ Passing _ Fell asleep
Road Condition:
_ Paved _ Unpaved _ Off road
Speed when incident occurred: Km /hrs
_ Non-Tab

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PT.

PERUSAHAAN GAS NEGARA

PROJECT HSE MANAGEMENT PLAN

PT. Perusahaan Gas Negara (Persero) Tbk.

PLTG Talang Duku Gas Distribution Project

PROJECT HSE MANAGEMENT PLAN

BY CHKD APVD CHKD APVD

REVISION HISTORICAL SHEET

Rev No Date Description

A July 14, 10 Issued for Review

PROJECT HSE MANAGEMENT PLAN

PROJECT HSE MANAGEMENT PLAN

PROJECT HSE MANAGEMENT PLAN

PT. Erraenersi Konstruksindo selected by PGN as Project

MIGAS Indonesian Government Body authorized for issuing permits and

THIRD PARTY Authorized Inspection Company, who is approved, certified by and

HSE HEALTH SAFETY AND ENVIRONMENT

JSA JOB SAFETY ANALYSIS

PTW PERMIT TO WORK

PPE PERSONAL PROTECTIVE EQUIPMENT

ERT EMERGENCY RESPONSE TEAM

5.0 HSE LEGAL AND OTHER REQUIREMENT

Local and International Standard References:

 UU No.1 Tahun 1970 regarding General Safety.

PROJECT HSE MANAGEMENT PLAN

 Indonesian ministry of oil and gas mining regulation (MIGAS) No.300.K/38/M.PE/1997

6.0 POLICY AND COMMITMENT TO HEALTH, SAFETY AND ENVIRONMENT

PROJECT HSE MANAGEMENT PLAN

7.0 PROJECT AIMS AND OBJECTIVES

Project HSE Key Performance Indicator’s (KPI’s):

 100 % participation at personnel Safety Orientation.

Simply stated it is the goals of MGP to conduct its operations with:

 Achieve zero recordable incident and accident

 No Lost Time Injuries

 No Medical Treatment Cases

 No Damage to the Environment

Project HSE Objectives:

PROJECT HSE MANAGEMENT PLAN

 To be actively involved in the implementation of Job Safety Analysis (JSA).

 To ensure safety meetings are conducted to permit meaningful communication throughout

 To motivate employees to work safely through the implementation of the Employees

8.0 HSE ORGANIZATION

PROJECT HSE MANAGEMENT PLAN

The Project HSE Organization can be described as follows:

Project Engineer HSE Engineer

Project Site Site Construction Mgr HSE Spv

9.0 HSE RESPONSIBILITIES

9.2 Project Manager / Const Mgr

Project Management accepts the HSE philosophy in addition to accepting total

PROJECT HSE MANAGEMENT PLAN

 Review and approve project HSE documentation.

 Ensure that Risk Assessments are performed at the earliest practicable

 Ensure that the mitigating measures are followed through to completion.

 Promote a high degree of HSE awareness amongst all project personnel.

 Take part in accident / incident investigation when required.

PROJECT HSE MANAGEMENT PLAN

9.3 HSE Coordinator / HSE Engineer

The HSE Coodinator or HSE Engineer is responsible for assurance of compliance