Hse Questionnaire (Phe Wmo) - 2

PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Document Number KE-HSE-PS- 019 Revision 01
Edition 01
Contractor’s Health, Safety and Revision Date
14 Dec
Environment Management System 2009
Issue Date 30 July 2007 Page 1 of 15
APPENDIX E
PRE-QUALIFICATION
CONTRACTOR’S HSE MANAGEMENT SYSTEM EVALUATION
Company Name : PT SIGMA CAKRAWALA INTERNATIONAL
Work Name : PROVISION OF PHE-5 LQ PLATFORM REFURBISHMENT
PART 1: LEADERSHIP AND COMMITMENT

1.1 HSE Commitment through leadership
a) How are the senior managers personally involved in the HSE management?
Answer:
The senior managers involved in HSE management by create commitment in statement in HSE Policy, site
visit, attend in external & internal HSE meetings.
See attachments
• HSE Policy
• Internal HSE meeting
b) Presenting commitment evidence at all the organization's levels?
Answer:
The commitment is shown in our Management meeting,
see attachment
• Inter Office Memo
• HSE manual document
c)How do you promote positive cultures on HSE issues?
Answer:
We promote a positive culture towards HSE matters by create:
• meetings, see attachment
• banners, see attachment
• put in signs, see attachment
• posters. see attachment
PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
PART 2 : POLICY AND STRATEGY OBJECTIVES

2.1. HSE Policies and Documents
a) Does the company have HSE policy documents?  Yes  No
If yes, please attach.
Answer:
The company has HSE Policy. See attachment
b) Who has the overall and final responsibility for HSE in your organization?
Answer:
The man who has overall and final responsibility for HSE is Director (Chairman of HSE Committee).The
organization chart with personnel highlighted, see attachment, HSE Manual
c)Who is the most senior officer in your organization responsible for the policies being implemented in the
authorized area and the location where the employees work?
Answer:
QHSE Department Manager as the highest responsible in carried out policy at his/her premise or site he/she
is working. The position of QHSE Manager may be found in attachment, SCI-HSEM-01, HSE Manual.
2.2. Availability of Policy Statement for Employees

a) Describe in detail the methods you apply as the source of policy statement for all your employees.
Answer:
The arrangements for advising employees of changes in the policy by:
- Pernyataan Pemahaman”. See attachment
b) What arrangements do you have to inform your employees of changes in policies?
Answer:
- Email, (no attachment)
- bulletin board,
PART 3 : ORGANIZATION, RESPONSIBILITIES, RESOURCES, STANDARDS AND DOCUMENTATION

3.1. Organization – Commitment and Communication
a) How does the management involve in HSE activities, determine the objective and monitoring?
Answer:
The Management attends in regular management meeting to discuss all activities include
b) Do you have safety organization?  Yes  No.

If yes, indicate the organizational chart and job description
Answer:
- see attachment
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HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
3/10
c)How is the structure of your company made to manage and communicate HSE effectively?
Answer:
The company structured to manage and communicate HSE effectively by Management meetings, Safety
talks, Toolbox talks, Bulletin boards. Also see attachment
• Management Meeting,
• Weekly Safety talk,
• Daily Toolbox talk,
d) What provisions does your company draw up for meetings on HSE communication?
Answer:
The company structured to manage and communicate HSE effectively by Management meetings, Safety talks,
Toolbox talks, Bulletin boards. Also see attachment
• Management Meeting, see attachment
• Weekly Safety talk, see attachment
• Daily Toolbox talk, see attachment
3.2. The Capacity and Training for Managers/Supervisors/Senior Field Officers/HSE Advisors
Have managers and supervisors at all levels who will plan, monitor, predict and perform works attended formal
trainings on HSE in accordance with their respective responsibilities in connection with work performance in
accordance with the HSE requirements?
 Yes  No.
If yes, provide the detail. If such training is provided in-house, describe the materials and the duration of the
course
Answer:
Yes. We have records and planning of HSE training for our Manager/Supervisor/Senior Site Staffs/HSE Advisor
3.3. General Capacity and HSE Training

a) What arrangements has your company prepared to ensure that the employees have the basic
knowledge on HSE in the field of industry, and to keep the knowledge up to date?
Answer:
Refer to our HSE policy point 2 we shall update our employee knowledge in HSE matters. Special
arrangement for this, we arrange in “HSE Training procedure”, see attachment
b) What arrangements has your Company prepared to ensure that the employees, including
subcontractors understand your HSE policy and procedures?
Answer:
Refer to attachment, the arrangement is all new employees must join in HSE Induction class and then the
company will send him/her/them to another class or topic.
• Copy of training certificates, see attachment CERTIFICATES AND TRAINING PROGRAM
• Induction program, see attachment
c)What arrangements has your company prepared to ensure that the employees and the new employees
have received instruction and information concerning specific hazards that may arise from a work?
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
What trainings have you provided to ensure that all employees understand the company's conditions?
Answer:
To ensure all new employees and new subcontractor employee have been instructed and have received
information on any specific hazards as company activities by inform all company hazards & risk trough
HSE Induction program, see attachment, HSE Training procedure,
Risk Analysis will refer to JSA procedure as attached. The JSA form for sample of risk analysis, see
attachment
HSE Induction attendance list, see attachment
HSE Training Certificate, see attachment
d) What arrangements has your company prepared to ensure that the present employees' knowledge on
HSE is always up to date? If such training is provided in-house, give the details of the training's
materials.
Answer:
We do HSE Meeting monthly
3.4. Special training
a) How do you identify a location in your operation where special training is required to face potential
hazards? Give the list and detail of the training provided.
Answer:
We have analysis all hazards as company’s nature activities and listed the potential hazard. The list is
attached in our “Hazards & Risk Assessment” procedure. And then we provide training that must be cared
and joined by employees to deal with the potential hazards.
The Hazards list is attached in Hazards & Risks Assessment procedure, see attachment E.5
Refer to documents of SCI-HSEM-01, HSE Manual, part 8, page 9, and SCI-HSE-01, HSE Training
procedure, sub part 5.2, page 5, the training program for each (basic first aid, sea survival, fire fighting,
evacuation drill, etc) will be shown in attachment
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HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
4/10
b) If a certain work involves radioactive, asbestos disposal, chemical substances or other occupational
health hazards, how do you identify, assess and handle the hazards?
Answer:
We refer to documents:
- SCI-HSE-03, Hazards & Risks Assessment procedure
- SCI-HSE-02, Job Safety Analysis,
to identified by its MSDS. From the MSDS got HSE precautions and to be made SOP for the work related
substances. We also always refer to our “Hazardous Substances Handling” procedure. HSE certificates
(PTW) shall be on hand before commencing the work. The work shall be controlled during its doing and
end to end.
- The “Hazardous Substances Handling” procedure, see attachment
- HSE certificate ( sample for form), see attachment
3.5. Employees with HSE Capacity – Additional Training

Does your company employ staff possessing HSE qualification who can provide trainings which are more than just a
basic requirement?
 Yes  No
Answer:
Yes, we have
Which safety qualification format do your staff have? Explain
Answer :
The occupational health, safety and/or environmental to HSE staff is JAMSOSTEK
3.6. Assessment on the conformity of other subcontractors/companies

a) How do you assess :
The HSE capacity
Answer :
We will assess all our subcontractors include its HSE performance. The assessment by using our
“Subcontract by HSE Requirement” procedure.
The procedure, SCI-HSE-05, Subcontract by HSE Requirement is attached
The HSE note of subcontractors and companies you contract?
Answer :
We will assess all our subcontractors include its HSE performance. The assessment by using our
“Subcontract by HSE Requirement” procedure.
The procedure, SCI-HSE-05, Subcontract by HSE Requirement is attached
b) How do you explain that the standards you require are met by your contractors?
Answer:
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
We spell out the standards require our contractors to meet on “Subcontract by HSE Requirement” procedure,
c) How do you ensure that the following standards have been met and checked?
 Training on safety for working employees.
 The recruitment process for employees to work on your projects.
 The employees have comprehended the company's commitment, policies, objectives and standards.
 The plans to have relationship with subcontractors? If any?
Answer:
To ensure them by using bidder’s checklist of “Subcontract by HSE Requirement” procedure
d) Please provide names of major subcontractors, at present, if known.
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
3.7. Standards
a) Do you have HSE Standards?
Answer:
We spell out the HSE performance standards require to be met on our HSE Manual, see attachment SCI-HSEM-
01, HSE Manual,
b) How do ensure that such HSE standards have been implemented?
Answer:
We ensure the standards are met and verified by activities of field supervision, observation and inspection. These
are based on our procedures:
• Best Supervision, see attachment . SCI-HSE-06, and
• HSE Inspection for Equipment, see attachment . SCI-HSE-07.
• Observation card, see attachment
c)How do identify the industrial standards and new HSE regulations that may be applicable to your
activities?
Answer:
We provide Job Safety Analysis (JSA) technique for identification, assessment, control and mitigation of hazards
and effects. SCI-HSE-03 JSA procedure, see attachment
d) Do you have a comprehensive structure to draw up, revise and distribute HSE standards?
Answer:
We have corresponding standards, it can by letters, email
PART 4 : HAZARD AND IMPACT MANAGEMENT

4.1. Hazard and Impact Management
What techniques does your company apply to identify, assess, monitor and minimize hazards and impacts?
Answer:
We provide Job Safety Analysis (JSA) technique for identification, assessment, control
and mitigation of hazards and effects.
The JSA procedure, see attachment E.4. SCI-HSE-02.
And sample of it see attachment
4.2. Exposure to Workers

What system is available to monitor your workers' exposure to chemical substances and physical elements?
Answer:
We use risk assessment system and risk control/JSA (counter measure implemented, and
then do control the implementation by inspection or observation the exposure of our
workforce to chemical or physical agents).
- Sample of risk assessment, see attachment
- Sample of JSA, see attachment
4.3. Potential Hazard Management
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
How do your workers notify others concerning hazards that may arise such as chemical substances, noise,
radiation etc in their works?
Answer:
Workforce advised on potential hazards encountered in the course of their work by
Instruction/Memo, (liat file SOP MSDS, upd). See attachment
4.4. Personal Protective Equipment

a) What arrangements does your company have for the procurement and provision of protective
equipment and work clothes, both the standard ones and those required for special activities?
We have:
- PPE procedure, see attachment E.10. SCI-HSE-08.
- PPE stock records form, see attachment
b) Do you provide Personal Protective Equipment (PPE) which fit your employees? Give list of PPE for
this work scope.
Answer:
yes, we provide PPE for employees.
Employee’s receipt card,
c)Do you provide training concerning the procedure to use PPE ? Explain the training's materials and any
follow up.
Answer:
Yes, we provide PPE training before give them to employees. Content of the training are:
- Main type of PPE
- Function of PPE includes all equipment designed to be worn or held by a person at work to protect against
one or more risks
- PPE as a ‘Last Resort’
- Maintenance.
After the training, we control compliance of PPE usage at field and evaluation and take corrective action, if
needed.
The attendance list of the training us
d)Do you have a program to ensure that PPE is used and maintained?
Answer:
Yes, we have PPE program is impacted and maintained by using a checklist “Kartu
Pengamatan Lapangan” for observation/inspection
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
2009
Environment Management System
PART 4 : HAZARD AND IMPACT MANAGEMENT

4.5. Waste Management
a) What systems are available to identify, classify, minimize and manage wastes?
Answer:
We have a system in:
- HSE Manual, SCI-HSEM-01, page 8, sub part 7.2.
- Waste Management procedure, SCI-HSE-09, page 2 & 3, part 6.
b) Does the system comply with the applicable regulations?
c) Provide us with the total number of incidents that caused damage to the environment in the amount
exceeding USD$ 50,000 in the last 24 months. Please attach the copies of reports submitted to the
government.
Answer:
We have not any experience/record of accident resulting environmental damage in the
amount greater than $50,000.
d) Do you have procedures on waste disposal?  Yes  No
Answer:
We have waste disposal procedure. It is spell out in Waste Management procedure, SCI-HSE-09,
e) Does the system comply with the applicable regulations?
f) Do you have the procedures for reporting oil spills and / or other hazardous materials?
 Yes  No
Answer:
We have procedure for spill reporting in document Controlling to Spill, SCI-HSE-10,
g) Do you have the procedures for cleaning oil spills and / or other hazardous materials?
 Yes  No
Answer:
We have equipment related environmental matters
h) Provide a detail about the equipment you have related to environmental issues.
Answer:
We have equipment related environmental matters, see attachment-4.5e.
i) Who is in charge with coordination of environmental problems and his/her experience?
Answer:
The person in charge who coordinating environment matter is HSE Manager, see
Organization chart in, HSE Manual, SCI-HSEM-01
4.6. Industrial Hygiene
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
2009
a) Do you have programs on industrial hygiene?  Yes  No

If yes, what items are included ?
Answer:
We have an industrial hygiene program. The program are included medical evaluations to employees regularly, first
aid services/clinic/hospital provided at all SIGMA offices. See attachment-3.7.e.1, HSE Manual, SCI-HSEM-01
b) Do you have risk assessment, or similar business, to identify hazards at work places? Explain the process.
Answer:
we have a risk assessment for identifying workplace hazards. See attachment-3.7.e.4,
SCI-HSE-03, Hazards and Risks Assessment and JSA procedure, attachment-3.7.e.3, SCI-HSE-
02.
Sample of risk assessment,
c) If you procure hazardous materials/substances to the work places, please explain the process you will
apply to document and supervise them.
Answer:
We refer to our Hazardous Substances Handling procedure, SCI-HSE-04 in attachment-3.7.e.5. The flow chart
may be met in attachment 4.6.c.
4.7. Drugs and Alcoholic Beverages

Do you have policies on drugs and alcoholic beverages in your organization?
If so, is it included in the entrance test for employees and random checks?
Yes, we have Drugs and Alcohol policy. This policy will include in pre-employment, see attachment-3.7.e1, SCI-
HSEM-01, HSE Manual, page 7, sub part 6.1.
And also shown by document SIGMA Safety Security Rule
PART 5 : PLANNING AND PROCEDURES

5.1. HSE and Operation Manuals
Do you have corporate HSE manual or Operational Manual in conformity with the HSE provisions as
specified in the HSE procedure and safety regulation approved by the company such as the scaffolding for
lifting machine, heavy equipment, pressure vessel or excavation?
 Yes  No
If the answer is Yes, please attach copies of supporting documents.
Answer:
Yes, we have HSE documents to guide working practice in our activities. The document is part of our HSE
system. These are HSE Manual and procedures. See attachment
How do you ensure that the procedures applied by the employees on the field are consistent with your HSE
objectives and policies?
Answer:
We ensure this by implement permit to work system and JSA. See attachment
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
5.2. Equipment Supervision and Maintenance

How do you ensure that the production stations and equipment used in your operational areas, locations or in
other locations by your employees have been registered, certified in accordance with the regulation,
inspected, monitored and properly maintained and under good working condition?
Answer:
Refer to HSE Inspection for Equipment procedure on attachment-3.7.e.8, so all equipment related our activities are
maintenance scheduled and records.
5.3. Transportation Safety Management and Maintenance

What arrangements does your company have to deter vehicle accidents?
Answer:
The arrangement company has for vehicle incident prevention is “Save Traffic” procedure, SCI-HSE-12, see
attachment-
Put posters on visible & right places, see attachment-
Driving safety check list. See attachment-
PART 6 : IMPLEMENTATION AND PERFORMANCE MONITORING

6.1. HSE Management and performance monitoring in Work Activities
a) What arrangements does your company have for supervision and monitoring of HSE performance?
Answer:
The arrangement company has for supervision and monitoring of HSE performance are “Best Supervision”
procedure, “Internal HSE Audit” procedure that can see on attachment-3.7.e7. and 3.7.e14. Result of the
Supervision and audit will be discussed in regular meetings include safety. See attachment-6.1.a. For sample
of heduled (safety talk), speaker, MOM & clear topics
b) What criteria does your company use in assessing performance; give example
Criteria are used in the company :

Percentage ranking
+85% Outstanding Superior Loss Control-All
75 - 85% Good Good Loss Control/Key request
70 - 75% Marginal Needs Some Improvement
60 - 69% Poor Needs Major Improvement
00 - 59% Unacceptable
Example, if in an HSE audit has score 72% so the auditee’s organization in marginal criteria, it means the HSE
performance still need some improvement.
The procedure related with this is “Internal HSE Audit, see attachmen
c) What arrangements does your company have to convey the results and findings from supervision and
monitoring to:
i) Your central management?

Internal Correspondence and Management meeting
ii) Employees in the field?

Safety talk, bulletin boards
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
2009
d) Has your company ever received awards for HSE performance?

 Yes  No
Answer:
Not yet
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
6.2. Safety Program

a) Do you organize safety meetings at your place?
 Yes  No
Explain the frequency, participants and topics.
Answer:
Yes, we organize in-house safety meetings. The meeting is weekly meeting who attended by management for
management meeting and attended by all level for site safety talk meeting. The topic of the meeting is a line with
work activities at that time. Sample of meeting schedule, see attachment
b) Do you organize campaigns to stimulate safe working procedures?

 Yes  No
If yes, give details
We organize campaign to stimulate safe working practice. The campaign will be (see attachments-1):
1.Meetings / socialization
2.Poster
3.Banners
6.3. Incidents/accidents, Remedies, and Notification of Legal Bans

Has your company ever been in a situation where you had to do perform remedies or given notification of legal bans
in the event of an incident/accident by the relevant national agencies, agencies having authority on HSE or other
law enforcement authorities or charged under the HSE law in the last five years ?  Yes  No
If the answer is yes, give the details.
Answer:
NONE
6.4. Records on HSE Performance

a) Do you maintain records on incidents and your HSE performance in the last five years ?
 Yes  No
If yes, mention the following:

 Total number of victims  Restricted Work Day Cases
 Lost Time Injuries  Fatal Accident Rate
 Lost Time Cases  Lost Time Injury Frequency
 Medical Treatment Cases  Total Recordable Incident Rate for each year
Please include your company's definition on the above terms on a separate sheet.
Answer
For records, see attachment-6.
For Definition, see attachment. Incident-Investigation Reporting procedure,
b) How do you document health performance?

Answer:
Typically with item 6.
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
c) How do you document environmental performance?
Answer:
Environmental recorded by using attachment
d) What is the frequency of observation on your HSE performance? By whom?
Answer:
Every end of the project and then 1 a year. See attachment-
6.5. Incident Investigation and Reporting

a) Do you have procedures to investigate, report and follow up on incidents, accidents, or diseases in work
places?
 Yes  No
If yes, please attach.
Answer:
Yes, we have, see attachment-3, Incident and Investigation procedure
b) How is a finding, after being investigated, or relevant incident in other places, is communicated to your
employees?
Answer:
Yes. This is parts of campaign materials. See attachments
c) Is the safety lesson from a near miss reported?

 Yes  No
Answer:
Yes. Sample of the near miss report, see attachment-3, Incident and Investigation procedure.
d) Please provide copies of investigation reports for the last 12 months.
Answer:
No nothing because no incident happened during the periodic time.
PART 7 : AUDIT AND INSPECTION

a) Do you have written policies on HSE audit  Yes  No
Answer:
See attachment-3, SCI-HSE-013, Internal HSE Audit.
b) How do the above policies explain about the auditing standards, including unsafe actions and qualification
for auditors?
Answer:
We will do the audit since this project and recorded.
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PERTAMINA PHE WMO
HSE DEPARTMENT
PROSEDURE
Edition 01
14 Dec
c) Does your company HSE plan include audit schedules?  Yes  No

Which auditing aspects are covered?
Answer:
Yes. The audit activity is one of our program, see attachment-7.
d) How is the auditing effectiveness examined and how does the management report and follow up on the
audit result?
Answer:
We will do for next audit, see answer item 7.b. above.
PART 8 : EMERGENCY RESPONSE PROCEDURE

Do you have emergency response plan?  Yes  No
Provide the list of procedures.
Explain how the emergency preparedness is maintained and the command structure under an emergency situation.
Answer:
Yes, we have. SCI-HSE-015, Emergency and Evacuation Procedure
PART 9 : HSE MANAGEMENT - ADDITIONAL FEATURES

a) Explain the line of your company's business and the extent of your company's participation in organizations
relevant with the industrial, trade and governmental matters.
Answer:
PT SCI participated in KADIN and APTEK
b) Does your company have other features or HSE regulations not included in your response in questionnaire?
Contractor Representative : ________ PSC/TAC Representative : ________
Name/Date : Y Andriyana/14/01/15 Name/Date : ________
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PERTAMINA PHE WMO

Company Name : PT SIGMA CAKRAWALA INTERNATIONAL

Work Name : PROVISION OF PHE-5 LQ PLATFORM REFURBISHMENT

PART 1: LEADERSHIP AND COMMITMENT

b) Presenting commitment evidence at all the organization's levels?

c)How do you promote positive cultures on HSE issues?

PART 2 : POLICY AND STRATEGY OBJECTIVES

2.2. Availability of Policy Statement for Employees

b) What arrangements do you have to inform your employees of changes in policies?

PART 3 : ORGANIZATION, RESPONSIBILITIES, RESOURCES, STANDARDS AND DOCUMENTATION

b) Do you have safety organization?  Yes  No.

3.3. General Capacity and HSE Training

3.5. Employees with HSE Capacity – Additional Training

Which safety qualification format do your staff have? Explain

3.6. Assessment on the conformity of other subcontractors/companies

The HSE note of subcontractors and companies you contract?

d) Please provide names of major subcontractors, at present, if known.

b) How do ensure that such HSE standards have been implemented?

PART 4 : HAZARD AND IMPACT MANAGEMENT

4.2. Exposure to Workers

4.3. Potential Hazard Management

4.4. Personal Protective Equipment

PART 4 : HAZARD AND IMPACT MANAGEMENT

b) Does the system comply with the applicable regulations?

d) Do you have procedures on waste disposal?  Yes  No

e) Does the system comply with the applicable regulations?

i) Who is in charge with coordination of environmental problems and his/her experience?

4.6. Industrial Hygiene

a) Do you have programs on industrial hygiene?  Yes  No

4.7. Drugs and Alcoholic Beverages

PART 5 : PLANNING AND PROCEDURES

5.2. Equipment Supervision and Maintenance

5.3. Transportation Safety Management and Maintenance

PART 6 : IMPLEMENTATION AND PERFORMANCE MONITORING

Criteria are used in the company :

i) Your central management?

ii) Employees in the field?

d) Has your company ever received awards for HSE performance?

6.2. Safety Program

b) Do you organize campaigns to stimulate safe working procedures?

6.3. Incidents/accidents, Remedies, and Notification of Legal Bans

6.4. Records on HSE Performance

If yes, mention the following:

b) How do you document health performance?

c) How do you document environmental performance?

d) What is the frequency of observation on your HSE performance? By whom?

6.5. Incident Investigation and Reporting

c) Is the safety lesson from a near miss reported?

d) Please provide copies of investigation reports for the last 12 months.

PART 7 : AUDIT AND INSPECTION

c) Does your company HSE plan include audit schedules?  Yes  No

PART 8 : EMERGENCY RESPONSE PROCEDURE

Provide the list of procedures.

PART 9 : HSE MANAGEMENT - ADDITIONAL FEATURES

Contractor Representative : ________ PSC/TAC Representative : ________

Name/Date : Y Andriyana/14/01/15 Name/Date : ________

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Contractor Representative : PSC/TAC Representative :