HSE-FORM-A.

05

INSPECTION REPORT (PRE MOB - NEW HIRE - MONTHLY)

ROUGHT TERRAIN CRANE / TRUCK MOBILE CRANE / CRAWLER CRANE

Company / Contractor : SILO :

Equipment Description : SILO Validity :

Manufacture : Location Inspection :

Model / Type : Date of Inspection :

Capacity :
Serial Number : Inspection by :

Engine Number HSE Inspector

Chasis Number

CONDITION CONDITION
DESCRIPTION (URAIAN) COMPONENT
G F P NA G F P NA
STRUCTURE ENGINE
I. BOOM SECTION UPPER, INSERT, LOWER 1 Top Structure
a. Boom Head Kepala boom 2 Radiator, Clean Cone
b. Main Boom Batang Utama 3 Radiator Hose and Clamp
c. Stifener Rangka penguat 4 Oil Leaked
d. Boom Splice Sambungan boom 5 Engine Fuel Leak
e. Stopper Pengunci
f. Boom pivot Engsel bom
II. BOOM EXTENSION & JIB
a. Extension Chord Rangka utama
b. Brace / Lacing Rangka penguat
c. Jib Splice Sambunagn Jib
d. Stopper Pengunci
III. ACTUATING AND TELESCOPIC CYLINDER
a. Hydraulic Cylinder Silinder Hidrolik
b. Hydraulic Arm Lengan Hidrolik
c. Bolting Pembautan
d. Pivot PIN PIN
IV. PLATFORM AND UPPER STRUCTURE
a. Fondation Pondasi
b. Platform floor Lantai
c. Ladder & hand hold Tangga & pegangan
d. Frame - A Rangka - A
e. Control Room/Cabin Ruang kendali/kabin
f. Enginee Room Ruang mesin
g. Counterweight Beban Pengimbang
 CONDITION CONDITION CONDITION
COMPONENT COMPONENT COMPONENT
G F P NA G F P NA G F P NA

ENGINE CABIN OPERATOR & ACCESSORIES TIRE AND UPPER CARRIAGE ASSEMBLY
1 Top Structure 1 Operator Manual Hand Book 1 Front Tire (LH - RH)
2 Radiator, Clean Cone 2 Load Chart and Hand Signal Chat 2 Rear Tire (LH - RH)
3 Radiator Hose and Clamp 3 Electrical Wiring Condition 3 Spare Tire
4 Oil Leaked 4 Door Latch (open & close) 4 Centre Frame
5 Engine Fuel Leak 5 Mirror Side and Spot Mirror 5 Upper Structure
6 Engine Water Leak 6 Seat, Seat Belt Operator/Drive 6 Lower Structure
7 V-Belt Condition 7 Win Shield Glas 7 Carrier Roller
8 Engine Exhaust Gas Leak 8 Glass Window (LH/RH) 8 Left Under Carriage
9 Exhaust Muffler 9 Fuel Indicator 9 Right Under Carriage
10 Spark Arrestor 10 Light Switch 10 Track Adjuster
11 Air Cleaner Indicator Level] 11 Wipper 11 Track Frame
12 Oil Filter 12 Horn / Klakson 12 Track Chain
13 Fuel Filter 13 Gauge Indicator 13 Travel Look
14 Injection Pump 14 Fans or Air Conditioning
15 Enginee Door Looks & Mounting 15 Floor, Railing and Stair
16 Enginee Mounting 16 Adjusment of Clutch
17 Seals 17 Anti - Skid Surface
18 Engine Safety Shutdown 18 Handle Brakes and Function
19 Central Structure 19 Handle of Operator
20 Lower Structure / Sprocket 20 Access Steps & Grap Rails
21 Hourmeter / Odometer CONDITION
COMPONENT
22 Oil Temp Gauges G F P NA

23 Water Temperatur Gauges

SAFETY APPARATUS
24 Load Indicator
25 Level Indicator 1 Fire Extinguisher
CONDITION 2 First Aid Kit
COMPONENT
G F P NA CONDITION 3 Safety Belt (Operator)
COMPONENT
G F P NA 4 Safety Belt (Passanger)
ELECTRIC SYSTEM & BATTERY SYSTEM
5 Triangle Sign
HYDRAULIC SYSTEM
1 Altenator 6 Over Weight Alarm
2 Starter 1 Main Hydraulic & Circuit System 7 Reversing Alarm
3 Head Light (LH - RH) 2 Hydraulic Winch 8 Swing Alarm
4 Signal Light (LH - RH) 3 Electric Switch & Solenoid 9 Air Bag
5 Panel / Gauges 4 Hydraulic Pump 10 Flash Light
6 Wiring / Insulation 5 All Air & Hydraulic Hose 11 Towing Hook
7 Battery and Terminal 6 Hydraulic Valve Hose 12 Radio Communication
8 Battery Water Level 7 Hydraulic Cylinder 13 Marking / Warning Labels
9 Load Meter 8 Hydraulic Winch 14 Reversing Light
10 Wiring Diagram 9 Hydraulic Oil Tank 15 Rotary Light
11 Buzzers / Warning Lamp 10 Whiplock Restrain 16 Anti Two Block
12 Condition of Fuse 11 Hose Clamp 17 Boom Stop
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 INSPECTION REPORT (PRE MOB - NEW HIRE - MONTHLY)
ROUGHT TERRAIN CRANE / TRUCK MOBILE CRANE / CRAWLER CRANE

Manufacture : Serial Number :

CONDITION CONDITION CONDITION

COMPONENT COMPONENT COMPONENT
G F P NA G F P NA G F P NA

HYDRAULIC OUTRIGGER SYSTEM HYDRAULIC BOOM SYSTEM COOLING SYSTEM

1 Outrigger Boxes and Beam 1 Hoist Cylinder Leak 1 Radiator

2 PIN's, Brushing, Bolt and Welds 2 Hoist Slider PIN & Retainer 2 Water Pump / Pompa Air

Outrigger Cylinder and Holding 3 Hoist Cylinder Hose Condition 3 Oil Cooler / Pendingin Oli
3
Valve 4 Boom Pivot PIN 4 Air Cleaner
4 All Stabilizer Pad & Cloats 5 Boom Crack / Damage
6 Sliding Wear Pad Condition CONDITION
5 Stabilizer Cylinder and Holding Valve COMPONENT
7 Tale Cylinder Hose G F P NA

6 Outrigger Front (R/L) Condition 8 Tale Cylinder Leaks

WINCHES SYSTEM
7 Outrigger Rear (R/L) Condition 9 Angel Indicator Condition
8 Vertical Cylinder Leak 10 Boom Sheaves 1 Mounting Bolt
9 Horizontal Cylinder Leak 2 Oil Leaks Gear Box

Hose Vertical Cylinder Leak CONDITION 3 Brake Lining / Adjusment

10
Outrigger Rear (R/L) COMPONENT
G F P NA 4 Brake Oil / Fluid Leaks

Hose Horizontal Cylinder Leak 5 Drum Crack / Damage

11
Outrigger Rear (R/L) BOOM FRAME - TELESCOPIC AND JIB
6 Safety Power Operating
1 Pivot PIN & Brushing Condition 7 Disoderly Rope Winding
CONDITION 2 Sheaves & Guards 8 Oil Level Gear Box
COMPONENT
G F P NA 3 Cable Guide Roller
4 Cable Retaining PINs CONDITION
POWER TRAIN COMPONENT
5 Boom Section (bend, bow, kink) G F P NA

1 Clutch / T. Converter / Coupling

6 Upper Frame Work that Holds Boom MAIN HOST WINCH
2 Transmission Leak
3 Transfer Case 7 Check Boom Leaking Hoist Brake and Brakes Control
1
4 Drive Lines 8 Counter Weight Bolts & PINs System

5 Differential Front 9 Condition of Telescopic 2 Hoist Hydraulic Motor

6 Differential Rear - Front 10 Boom Alignment 3 Operation of Hoist

7 Differential Rear - Rear 11 Auxiliary Boom Head 4 Hoist Hydraulic Circuit Pressure

8 Power Take Off (PTO) 12 Boom Cord Members Condition and Function of Look
5
9 Wheel Hub Oil Leaks 13 Boom Latice Members Hoist

10 Wheel Nut and Locks Area 14 Boom Identification 6 Clutches / Brake Hoist

11 Axle Pivot Condition

12 Front and End Rear Suspension CONDITION CONDITION
COMPONENT COMPONENT
13 Track Pad with Grouse Bar G F P NA G F P NA

14 Bottom Roler and ad PINs

BOOM SUPPORT GROUPS HOOK - WIRE ROPE SYSTEM
15 Top Roller
16 Fluid Clutch 1 Condition Gantry or Mast 1 Lifting 4 Points Wire Rope
17 Torque Converter 2 Boom or Telescopic Stop 2 Lifting 2 Points Wire Rope
18 Reduction Gear Box & Chain 3 Inner Ball 3 Shackle Condition
4 Boom Hoist Reeving 4 Load Binder
CONDITION 5 Boomer Chain and Hook
COMPONENT
G F P NA CONDITION 6 Webbing Sling
COMPONENT
G F P NA 7 Rotation of Hook
LOWER - UPPER STRUCTURE CRANE
8 Safety Latch (Hook)
LIFTING ACCESSORIES
1 Main Frame Condition 9 Rotation of Sheaves
2 "A" Frame Condition 1 Wire Rope Sling 10 Kind in Wire Rope
3 Slew System 2 Certificate Wire Rope Sling 11 Broken Strand Damage of Sling
4 Slew Drive 3 Shackle 12 Corrosion Wire Sling
5 Slew Table Crack 4 Certificate Shackle 13 Wedge Correctly Fitted
6 Slew Motor Leaks 5 Boomer Chain & Hook Condition 14 Rope Clip Fitted to end
 7 Slew Box Oil Level 6 Result Inspection NDT Hook 15 Visual Wire Rope
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INSPECTION REPORT (PRE MOB - NEW HIRE - MONTHLY)

ROUGHT TERRAIN CRANE / TRUCK MOBILE CRANE / CRAWLER CRANE

Equipment Description : Model / Type :

CONDITION CONDITION CONDITION

COMPONENT COMPONENT COMPONENT
G F P NA G F P NA G F P NA

LOWER - UPPER STRUCTURE CRANE

(CONTINUED) LIFTING ACCESSORIES (CONTINUED) SHEAVES, MAIN BLOCK, HOOK & AUXILIARY

8 Slew Brake Operation Rotary 7 Multi Wire Sling 1 Sheaves Check Crack or Good
9 Rotary Connection Leaks 8 Certificated Multi Wire Sling 2 Flanges for Chips
10 Upper house Lock PINs 9 Marking Load Main Hook 3 Groove Sheaves
11 Counter Weight Including PIN 10 SWL Marking Sheaves 4 Side Plate Bolting
12 Gantry 11 Lifting Gears Maintenance Log 5 Side Plate Straight
13 Inner Bail 6 Sheaves PINs Keeper
14 Swivel Assy CONDITION 7 Spacers
COMPONENT
G F P NA 8 Hook and Hook Shanks
CONDITION 9 Hook Swivel and Bearing
COMPONENT BRAKE / SUSPENSION - STERING SYSTEM
G F P NA 10 Safety Lack Functions
1 Steering Cylinder Leak 11 Wear Hook
DOCUMENTS
2 Oil Leak Gear Box 12 Deformation Hook
1 Third Party Certificate 3 Brake Lifting 13 Safety Latches
2 MIGAS / DEPNAKER Certificate 4 Brake Front (LH/RH) 14 Swivel Wear and Lubrication
3 Operator Certificate 5 Brake Rear-Front (LH/RH) 15 Hook Shackle Housing
4 Lifting Gear Certificate 6 Brake Rear-Rear (LH/RH)
5 NDT Result 7 Rear Front Spring (LH/RH) CONDITION
COMPONENT
6 Load Test Certificate 8 Rear Rear Spring (LH/RH) G F P NA

7 Wire Rope Certificate 9 Torque Rod

SAFETY DEVICES (TEST)
8 Manufacture Certificate 10 Parking Brake
9 Equipment Maintenance Log 11 Shock Absorber 1 Reserving Alarm
10 Mechanic N/A Not N/A 12 Steering Pump 2 Overweight Alarm
13 Steering Box (LH/RH) 3 Swing Alarm
CONDITION 14 Tie Rod 4 Angel Alarm
COMPONENT
G F P NA 15 Steering King PIN 5 Anti Two Block
16 Knuckle Bearing 6 Over Hoist Alarm
CONSTRUCTION ACCESSORIES
17 Drag Link 7 Load Indicator
1 Boom Frame 8 Boom Angel Indicator
2 Telescopic 9 Load Rating Chart
3 Track Model 10 Horn Remote
11 Reversing Sensor
12 Main Hook Stop
13 Auxiliary Hook
14 Boom Up Stop
15 Boom Down Stop
16 Electrical Control
17 Control Lever Play
18 Main Brake Operation
19 Emergency Brake Operation
 Initial : Page : 3 of 4

FINDING AND RESULTS INSPECTION REPORT

ROUGHT TERRAIN CRANE / TRUCK MOBILE CRANE / CRAWLER CRANE

Company / Contractor : SILO :

Equipment Description : SILO Validity :

Manufacture : Location Inspection :

Model / Type : Date of Inspection :

Capacity :
Serial Number :
Engine Number :
Chasis Number :

FINDING AND RECOMMENDATION INSPECTION :

INSPECTION RESULT

General Unit Condition : Good Fair Poor

CONCLUTION :

Operator Crane Technician/Mechanical Owner Representative

 Subcontractor Representative HSE Inspector Manager QHSE
Contractor

erland - form inspection lifting ringgingr.xlsx

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