LSR SV Form Checklists 18 Aug 2022 REV

TEP Se
Date:
Location:
Task / Activity :
Permit Number :
Name of Verifiers :
Persons Interviewed or Supervisor:
Sub-Contractor:
Bypassing Safety Controls
Do I see evidence of equipment such as fire suppression, det

electrical systems clearly identified & well maintained?Apaka
1
peralatan seperti pemadam kebakaran, deteksi, kontrol tekan
diidentifikasi dengan jelas & terpelihara dengan baik?
# Saipem Classification - General Use

Are personnel aware of the safety critical equipment that is pr
2 location and understand its use?Apakah personel mengetahu
keselamatan yang ada di lokasi kerja mereka dan memaham
Do I observe unauthorised override/ bypass of safety critical s

limit switches, alarm cancelled etc.?Apakah saya mengamati
3
sah dari sistem kritis keselamatan, mis. menonaktifkan sakela
dll.?
Are any safety critical systems that have been disabled/ overr
measures clearly communicated to personnel during appropr
4 talk?Apakah ada sistem kritis keselamatan yang telah dinona
pengendalian alternatif dikomunikasikan dengan jelas kepada
tepat, mis. pembicaraan kotak alat?
Ask personnel what procedure/s should be employed if safety

5 be isolated Tanyakan kepada personel prosedur apa yang ha
kritis keselamatan perlu diisolasi
Ask the supervisor to explain what alternative control measur

critical system is isolated to allow work to be performed. Mint
6
menjelaskan tindakan pengendalian alternatif apa yang akan
keselamatan diisolasi untuk memungkinkan pekerjaan dilaku
Are safety critical systems inspected, tested & recorded in co

7 operating procedures?Apakah sistem kritis keselamatan dipe
dengan prosedur operasi standar?

Are system overrides authorised & recorded in appropriate do
8
penggantian sistem diotorisasi & dicatat dalam dokumentasi
Are there records of Safety Critical Equipment being bypasse

9
Peralatan Kritis Keselamatan yang dilewati?
10
11
12
13
14
15

16
17
18
19
20
21
22
23

NO ACTION
1
2
3
4
5

TEP Self Verification Recor
Bypassing Safety Controls
pment such as fire suppression, detection, pressure controls,

dentified & well maintained?Apakah saya melihat bukti
m kebakaran, deteksi, kontrol tekanan, sistem kelistrikan yang
& terpelihara dengan baik?

e safety critical equipment that is present within their work
s use?Apakah personel mengetahui peralatan kritis
okasi kerja mereka dan memahami penggunaannya?
override/ bypass of safety critical systems, e.g. disabling of

elled etc.?Apakah saya mengamati override/bypass yang tidak
amatan, mis. menonaktifkan sakelar batas, alarm dibatalkan,
ems that have been disabled/ overridden & alternative control

icated to personnel during appropriate moments, e.g. tool-box
itis keselamatan yang telah dinonaktifkan/diganti & tindakan
omunikasikan dengan jelas kepada personel pada saat yang
otak alat?
dure/s should be employed if safety critical equipment needs to

ada personel prosedur apa yang harus digunakan jika peralatan
solasi
ain what alternative control measures will be provided if a safety

o allow work to be performed. Minta penyelia untuk
gendalian alternatif apa yang akan diberikan jika sistem kritis
k memungkinkan pekerjaan dilakukan.
inspected, tested & recorded in compliance with standard

kah sistem kritis keselamatan diperiksa, diuji & dicatat sesuai
standar?

orised & recorded in appropriate documentation?Apakah
sasi & dicatat dalam dokumentasi yang sesuai?
y Critical Equipment being bypassed? Apakah ada catatan

an yang dilewati?

RECOMMEND
ACTION

ion Record Sheet
Purpose
The purpose of this Self Verification is to ensure th

Activity at the TEP Tangguh Site is executed in line w
executed in line with the Greenfield Construction C
Work/TEP-930-PRC-HS-BP4-0002 Procedure and a
relevant documentation under the CSTS Managemen
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose
e purpose of this Self Verification is to ensure that Work

ity at the TEP Tangguh Site is executed in line with the is
cuted in line with the Greenfield Construction Control of
k/TEP-930-PRC-HS-BP4-0002 Procedure and associated
ant documentation under the CSTS Management System
Comments / Remarks

Percentage of Implementaion
MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

TEP Self Verification Record Sheet Rev.0
Date: Purpose
Location:
Task / Activity : The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at theTEP Tangguh Site is executed in line with the
Confined Space Entry/TEP-930-PRC-HS-BP4-0016 Procedure
Name of Verifiers : and associated relevant documentation under the CSTS
Persons Interviewed or Supervisor: Management System
Sub-Contractor:
Doc. Compliance
Confined Space Entry Comments / Remarks
Reference YES / NO / NA
Have considerations been given to the possibility of eliminating the need for
1 confined space entry?Apakah pertimbangan telah diberikan untuk kemungkinan
menghilangkan kebutuhan untuk masuk ruang terbatas?
Have the necessary permits, entry certificate(s) and isolation documents been
2 completed and posted at the worksite?Apakah izin, sertifikat masuk, dan dokumen isolasi
yang diperlukan telah dilengkapi dan dipasang di tempat kerja?
is the Isolaction Control Certificate approved by Isolated Authority, designated by

3 Commissioning Manager?Apakah Sertifikat Kontrol Isolasi disetujui oleh Otoritas
Terisolasi, yang ditunjuk oleh Manajer Komisioning?
4 Has a risk assessment been completed? Apakah penilaian risiko telah selesai?
Are all personnel involved in the task aware of the hazards and controls? Apakah semua
5
personel yang terlibat dalam tugas sadar akan bahaya dan pengendaliannya?
Has the Responsible Person (RP) been designated and identified on the permit? Apakah
6
Penanggung Jawab (RP) telah ditunjuk dan diidentifikasi dalam izin?
Are all persons involved in the confined space entry competent and trained? Apakah
7
semua orang yang terlibat dalam entri ruang terbatas kompeten dan terlatih?
Have suitable atmospheric tests been conducted, verified and repeated as

required? These may include O2, LEL, H2S, etc. Apakah pengujian atmosfer yang sesuai
8
telah dilakukan, diverifikasi, dan diulangi jika diperlukan? Ini mungkin termasuk O2, LEL,
H2S, dll.
Where required, have the neceesary checks on the breathing apparatus been
9 conducted and is it being used? Jika diperlukan, apakah pemeriksaan yang diperlukan
pada alat bantu pernapasan telah dilakukan dan apakah alat tersebut digunakan?
Have the employee obtained authorization to enter the confined space? Sudahkah
10
karyawan memperoleh otorisasi untuk memasuki ruang terbatas?
Is there an attendant assigned, continually on-station and in communication

11 while personnel are in the confined space? Apakah ada petugas yang ditugaskan, terus-
menerus di stasiun dan berkomunikasi saat personel berada di ruang terbatas?
Has clear communication been established between the entrants and attendant, and
between the attendant and rescue personnel? This may be voice contact, radio, pre-
12 arranged signals, whistles etc. Apakah komunikasi yang jelas telah terjalin antara
pendatang dan petugas, dan antara petugas dan petugas penyelamat? Ini mungkin
kontak suara, radio, sinyal yang telah diatur sebelumnya, peluit, dll.
Have barriers and signage been put in place to prevent unauthorized entry? Apakah
13 penghalang dan tanda telah dipasang untuk mencegah masuknya orang yang tidak
berwenang?
Is a rescue plan in place and responders notified and available? Apakah ada rencana
14
penyelamatan dan responden diberitahu dan tersedia?
Have SIMOPS issues that may conflict with this work been considered? Apakah masalah
15
SIMOPS yang mungkin bertentangan dengan pekerjaan ini telah dipertimbangkan?
Is change management (MOC) used to manage any scope or permit changes? Apakah
16 manajemen perubahan (MOC) digunakan untuk mengelola ruang lingkup atau
mengizinkan perubahan?
Do employees understand that they have the authority and expectation to stop activity if
feel unsafe or find unsafe condition? Apakah karyawan memahami bahwa mereka
17
memiliki wewenang dan harapan untuk menghentikan aktivitas jika merasa tidak aman
atau menemukan kondisi tidak aman?
Did the risk assessment or pre-job discussion include any lessons from past
18 incidents from similar work? Apakah penilaian risiko atau diskusi pra-pekerjaan
memasukkan pelajaran dari kecelakaan kerja serupa?
Has the work crew received positive feedback on raising concerns and
information on what is being done related to concerns raised? Apakah kru kerja menerima
19
umpan balik positif dalam menyampaikan kekhawatiran dan informasi tentang apa yang
sedang dilakukan terkait dengan masalah yang diangkat?
Is there STARRT card/ECOW PERMIT for the activity, properly filled and communicated
20 to the crew? Apakah ada kartu STARRT/ECOW PERMIT untuk kegiatan tersebut, diisi
dengan benar dan dikomunikasikan kepada kru?
Percentage of Implementaion #DIV/0!
RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
1
2
3
4
5

Date: Purpose
Location:
Task / Activity / aktivitas

The purpose of this Self Verification is to ensure that Work
Permit Number / Nomor Permit Activity at the TEP Tangguh Site is executed in line with the
Name of Verifiers / Pemeriksa Working at Height Procedure and associated relevant
documentation under the CSTS Management System.
Sub-Contractor:
Process, Plan or Procedure to be Verified Doc. Compliance

Comments / Remarks
WORKING AT HEIGHT Procedure (TEP-930-PRC-HS-BP4-0047_B04) Reference YES / NO / NA
DOCUMENTS/ADMINISTRATION /POLICY/ PROCEDURE
Is there a validated permit available adequately describing the task being carried
out containing all manadatory signatures, dates, location, equipment being used
etc? (Grating/Handrail Removal & Open Hole Work Permit)
Apakah permit yang divalidasi tersedia dan menjelaskan dengan cukup mengenai
CoW
1 tugas yang sedang dilakukan yang berisi semua tanda tangan yang wajib,
Procedure
tanggal, lokasi, peralatan yang digunakan.(Grating/Pemindahan handrail/ Ijin
kerja membuka lubang)
No. Reference :
(………………………………………………………………………………….…..)
Is there a validated JSA avaialble adequately describing the task being carried
out which identifes the relevant hazards and controls to carry out the work safely?
( SCAFFOLDING, and other Task that required working at height )
Apakah JSA yang divalidasi tersedia secara memadai menggambarkan tugas
CoW
2 yang sedang dilakukan yang mengidentifikasi bahaya dan kontrol yang relevan
Procedure
untuk melaksanakan pekerjaan dengan aman? (Perancah, dan pekerjaan lainnya
yang dibutuhkan untuk pekerjaan ketinggian)
No. Reference : (………………………………………………………………………...
…………..)
Is there a validated Method Statement available which adequately reflects the

task being carried out? CoW
3
Apakah Method Statement yang divalidasi tersedia yang cukup untuk Procedure
menjelaskan mengenai pekerjaan?
Are all other supplementary certificates referenced in the above documents

available for review? E.g Lifting plan, MSDS, Gas Check, Rescue Plan,
Underground Clearance, etc( ISOLATION CERTIFICATE , LINE DIAGRAM
4
UPDATED AND reviewed ) CoW
Apakah semua sertifikat tambahan lainnya dirujuk dalam dokumen di atas Procedure
tersedia untuk ditinjau? Seperti renacana pengangkatan, MSDS, Gascheck,
Rencana penyelamatan, Izin pekerjaan underground ( Sertifikat isolasi, diagram
terbaru dan direview )
Has SIMOPS been assessed, and all relevant parties notified? ( SIMOPS
MATRIx regarding work at height shall be attached in work permit pack ) CoW
5
Apakah SIMOPS telah dinilai, dan semua pihak terkait diberitahu? (SIMOPS Procedure
MATRIX mengenai bekerja di ketinggian harus dilampirkan kedalam permit)
Pre Start Communication to the Workers (Sometimes referred to as the TBT)
Was a STARRT/ECOW PERMIT meeting held with the workforce prior to the
work starting? CoW
1
Apakah diskusi STARRT/ECOW PERMIT diadakan dengan pekerja sebelum Procedure
pekerjaan dimulai?
Has the STARRT Card/ECOW PERMIT been signed by all relevant personel?
(Workers/Supervision) CoW
2
Apakah Kartu STARRT/ECOW PERMIT telah ditandatangani oleh semua Procedure
personel yang relevan? (Pekerja/Pengawasan)
Has the STARRT Card/ECOW PERMIT been filled correctly and verified all
requirement in place? CoW
3
Sudahkah Kartu STARRT/ECOW PERMIT diisi dengan benar dan diverifikasi Procedure
semua persyaratan?
Does the Description of the STARRT/ECOW PERMIT adequately reflect the work
being carried out? CoW
4
Apakah Deskripsi STARRT/ECOW PERMIT cukup mencerminkan pekerjaan Procedure
yang dilakukan?
Do the Hazards and Controls identified on the STARRT/ECOW PERMIT sheet

adequately reflect the task? CoW
5
Apakah Bahaya dan Kontrol yang diidentifikasi pada lembar STARRT/ECOW Procedure
PERMIT cukup mencerminkan tugas?
Has the person who held the STARRT/ECOW PERMIT meeting received
training? CoW
6
Apakah orang yang mengadakan pertemuan STARRT/ECOW PERMIT menerima Procedure
pelatihan?
Are at least 2 members of the work force able to identify at least 50% of the
hazards and controls on the STARRT sheet/ECOW PERMIT? (Not counting the
7
Supv) when INDEPENDANTLY questioned? CoW
Apakah setidaknya 2 anggota angkatan kerja dapat mengidentifikasi setidaknya Procedure
50% dari bahaya dan kontrol pada lembar STARRT/ECOW PERMIT (Tidak
termasuk Supv) ketika dipertanyakan secara INDEPENDEN?
WORK EXECUTION - WORKING AT HEIGHT
#Saipem Classification - General Use

Have all workers who are involved in the working at height task attended working
at height training? (If possible check their training passport)
1 5.1.1.
Sudahkah semua pekerja yang terlibat dalam tugas ketinggian bekerja
menghadiri pelatihan ketinggian? (Jika mungkin periksa paspor pelatihan mereka)
Are worker wearing full body harnesses when they work at height (higher than 1.8
meter) and tied off when they were exposed to the fall through an opening?
2 Apakah pekerja mengenakan full body harness ketika mereka bekerja di 5.4
ketinggian (lebih tinggi dari 1,8 meter) dan terikat ketika ada resiko jatuh melalui
celah?
Has the personal fall arrest system follow the project requirement (twin tail
lanyard, shock absorber,double latch self- locking snap hooks, or webbing made
of synthetic fiber) are they inspected and color coded as per project procedure?
3 Apakah personal fall arrest system sesuai dengan persyaratan proyek (twin tail 5.4.4
lanyard, shock absorber, double latch self-locking snap hooks, atau webbing
made of synthetic fiber), apakah diinspeksi dan dikode warna sesuai dengan
prosedur proyek?
Are any anchor points available on the working plaform to be hooked in case of
people falling? (It should not sharp edges, and it should be above the waist
4 height) 5.4.4
Apakah anchor points tersedia diatas platform untuk dikaitkan bila ada orang
terjatuh? (Seharusnya tidak tajam, dan harus di atas ketinggian pinggang)
Do workers NOT tie off to the line of fire, gas lines, instrument lines, or any pipe
work less than 3 inches in diameter?
5 5.5.6
Apakah pekerja TIDAK mengikat harness ke jalur berbahaya, jalur gas, jalur
instrumen, atau pipa apa pun yang berdiameter kurang dari 3 inci?
Are temporary platforms, been inspected regurally by competent person and

inspection tag being displayed at the main entry?
6 5.1.3
Apakah platform sementara, telah diperiksa secara berkala oleh orang yang
kompeten dan tanda inspeksi ditampilkan di jalur masuk utama?
Are temporary platforms, such as scaffolding platform, mobile scaffolding platform

prevented to move during work at height?
7 5.3.1
Apakah platform sementara, seperti platform perancah, platform perancah seluler
dicegah untuk bergerak saat bekerja di ketinggian?
Are all the opening covered or protected by scaffolding barrier and are the
warning signs displayed to minimize people to fall or accidentally enter the
opening?
8 5.7
Apakah semua bukaan tertutup atau dilindungi oleh penghalang perancah dan
apakah tanda peringatan ditampilkan untuk meminimalkan orang jatuh atau tidak
sengaja memasuki bukaan?
Are areas below where working at height are conducted barricaded when it is
required, such as scaffolding task, welding, cutting, or lifting?
9 5.8
Apakah area di bawah pekerjaan di ketinggian dibarikade saat diperlukan, seperti
pekerjaan perancah, pengelasan, pemotongan, atau pengangkatan?
Have portable ladder/step ladder been inspected and color coded?

10 5.3.6
Sudahkah tangga portabel/anak tangga diperiksa dan diberi kode warna?
Are portable ladders placed at not slippery surface (with anti slips), with correct
angle 75 degree, secured the top and the bottom, and 1m of the ladder being
protruded for 1m? (If a ladder is 4 meter long, it should be protruded for 1 meter
11
above the platform( 4:1 )) Appendix 3
Apakah tangga portabel ditempatkan pada permukaan yang tidak licin (dengan Ladder safety
anti slip), dengan sudut 75 derajat, diamankan bagian atas dan bawah, dan
tangga menonjol diatas sepanjang 1 m? (Jika sebuah tangga memiliki panjang 4
meter, itu harus menonjol sejauh 1 meter di atas platform (4: 1))
Do workers follow the 3 points contact rule when they are using ladders?
Appendix 3
12 Apakah pekerja mengikuti aturan 3 titik kontak ketika mereka menggunakan
Step-ladder
tangga?
Do workers carry documents and equipment with back pack or tool bag instead of
carrying by hands?
13 5.6.1
Apakah pekerja membawa dokumen dan peralatan dengan tas punggung atau
tas alat daripada membawa dengan tangan?
Are all equipment, which are less than 5 kg, attached with manufactured tools
lanyards when working at height? (for tools weight 5 kg shall be 4 mm certified
wire use as tools lanyard )
14 5.5.3
Apakah semua peralatan, yang kurang dari 5 kg, terpasang dengan alat lanyard
yang diproduksi saat bekerja pada ketinggian? (untuk alat berat 5 kg harus
menggunakan kawat bersertifikat 4 mm sebagai alat lanyard)
Are tool bags for lifting/hoisting attached SWL and rope with diameter 12 -15 mm
and proper safe knot for manual hoisting? And are the areas below barricaded for
exclusive zone/dropped zone?
15 5.6.1.
Apakah tas peralatan untuk mengangkat tercantum SWL dan tali terpasang
dengan diameter 12 -15 mm dan simpul aman untuk pengangkat manual? Dan
apakah area di bawah ini dibarikade untuk zona eksklusif/zona benda jatuh?
Are all opening, such as grating and handrail removal, or penetration, barricaded
with hard barricades with scaffolding tubular and wrapped with red and white tape
and safety sign in Bahasa and English?
16 Apakah semua bukaan, seperti pemindahan grating dan membuka handrail, atau 5.7
penetration, dibarikade dengan hard baricade dengan tubular perancah dan
dibungkus dengan pita merah putih dan tanda keselamatan dalam Bahasa dan
Bahasa Inggris?
Saipem Classification - General Use

#
Are cables, hoses, and leads elevated above 1.8 meter with proper cable hangers
to minimize tripping and tangling hazards, and blocking access?
17 Apakah kabel, selang, dan timah dinaikkan di atas 1,8 meter dengan gantungan 5.3.1.
kabel yang tepat untuk meminimalkan bahaya tersandung dan tersangkut, dan
memblokir akses?
Are there any sparks or slug catcher (containment) below the hot work area? (or
if possible the area below the hot work shall be barricaded with red and white
tape)?
18 5.5.2
Apakah ada percikan api atau slug catcher (penampung) di bawah area
pekerjaan panas? (atau jika mungkin area di bawah pekerjaan panas harus
dibarikade dengan pita merah dan putih)?
Are materials or waste kept/stored in designated area to avoid being kicked down
or becoming potential drop object?
19 5.7
Apakah bahan atau sampah disimpan di tempat khusus untuk menghindari
tertendang atau menjadi potensi benda terjatuh?
Are tool bags or boxes available to store any small materials, which are carried
during working at height? (bolt, nuts, nails, wrench, or such materials that could
drop through small opening)
20 5.6.2
Apakah tas peralatan atau kotak alat tersedia untuk menyimpan bahan kecil,
yang dibawa selama bekerja di ketinggian? (baut, mur, paku, kunci pas, atau
bahan semacam itu yang bisa jatuh melalui celah kecil)
Are Mobile Elevating Works Platform (MEWP) carrying oversize loads that could
be an obstruction or potential dropping object inside the basket?
21 Apakah Mobile Elevating Works Platform (MEWP) membawa muatan yang terlalu 5.3.5.
besar yang bisa menjadi penghalang atau benda menjatuhkan potensial di dalam
keranjang?
Are MEWP equiped with fall prevention, such as guard rail with mid rail and toe
boards, anti slip floor, or anchor points?
22 5.3.5.
Apakah MEWP dilengkapi dengan pencegahan jatuh, seperti handrail dengan rel
tengah dan toe board, lantai anti slip, atau titik angkur?
Is banksman/flagman to assist the movement of the MEWP?

23 5.3.5.
Apakah bankman/flagman membantu gerakan MEWP?
EMERGENCY PREPAREDNESS/WORKER PROTECTION
Is all emergency equipment identified and required for the specific task avaialble,
in cetification and ready for use? e.g Spill Kit, Fire extinguisher, Eye Wash, First
Aid Kit, Stretcher etc (Tripod, Gottcha rescue kits, etc) Actual Check
1
Apakah semua peralatan darurat diidentifikasi dan diperlukan untuk tugas khusus on-site
yang tersedia, dalam sertifikasi dan siap digunakan? Contoh Spill Kit, Fire
extinguisher, Eye Wash, First Aid Kit, Stretcher dan sebagainya.
Have persons received adeqaute training or familiarisation in the use of any

specificed emergency equipment or duties for the task. E.g. Designated First
2
Aider, Firewatcher. Emergency Auxilary team . Actual Check
Sudahkah personel menerima pelatihan atau pengenalan yang memadai tentang on-site
penggunaan peralatan darurat atau tugas tertentu untuk tugas tersebut? Seperti
First aider yang ditunjuk, firewatcher, tim darurat tambahan
Do workers know what to do in the event of an emergency? - Ask at 2 members

of the team (1) how to raise the alarm/notify emergency (2) the emergency
contact number, (3) where their muster point is. Put "Yes" only if the all of the
answers are correct) Actual Check
3
Apakah pekerja tahu apa yang harus dilakukan jika terjadi keadaan darurat? - on-site
Tanyakan pada 2 anggota tim (1) bagaimana cara meningkatkan alarm /
memberitahukan darurat (2) nomor kontak darurat, (3) di mana titik keramaian
mereka. Masukkan "Ya" hanya jika semua jawaban sudah benar)
Is all PPE stated on the Permit or JSA being worn? Worn correctly? and in good
condition
Actual Check
4 Apakah semua APD yang tercantum pada Izin atau JSA dikenakan? Apakah
on-site
benar? Dan dalam kondisi baik (Pekerja dapat menjelaskan dan menunjukkan
cara memakai dan menggunakan seluruh tubuh dengan benar)

RECOMMENDATION
1
2
3
4
5

#
Updated 02 May 2021
Date: Purpose
Location:
Task / Activity / aktivitas The purpose of this Self Verification is to ensure that Work
Permit Number / Nomor Permit Activity at the TEP Tangguh Site is executed in line with the
Name of Verifiers / Pemeriksa Contractor Control of Work for Greenfield and associated
Persons Interviewed or Supervisor: relevant documentation under the CSTS Management System
Sub-Contractor:
Process, Plan or Procedure to be Verified
Doc. Compliance
CONTRACTOR CONTROL of WORK for GREENFIELD Comments / Remarks
(TEP-930-PRC-HS-BP4-0002_B07)
DOCUMENTS/ADMINISTRATION /POLICY/ PROCEDURE
Is there a validated permit available adequately describing the task being

carried out containing all mandatory signatures, dates, location, equipment
being used etc?
1 Apakah permit yang divalidasi tersedia dan menjelaskan dengan cukup Section 3.1
mengenai tugas yang sedang dilakukan yang berisi semua tanda tangan yang
wajib, tanggal, lokasi, peralatan yang digunakan.
No. Reference : (……………………………………………………………...….)
Is there a validated JSA available adequately describing the task being carried
out which identifes the relevant hazards and controls to carry out the work
safely?
Section 8.2
2 Apakah JSA yang divalidasi tersedia secara memadai menggambarkan tugas
Appendix 4
yang sedang dilakukan yang mengidentifikasi bahaya dan kontrol yang
relevan untuk melaksanakan pekerjaan dengan aman?
No. Reference : (……………………………………………………………...)
Is there a validated Method Statement available which adequately reflects the

task being carried out?
3 Apakah Method Statement yang divalidasi tersedia yang cukup untuk
Section 8.2
menjelaskan mengenai pekerjaan?
Are all other supplementary certificates referenced in the above documents

available for review? E.g Lifting plan, MSDS, Gas Check, Rescue Plan,
Underground Clearance, etc
4 Apakah semua sertifikat tambahan lainnya dirujuk dalam dokumen di atas
Section 8.2
tersedia untuk ditinjau? Seperti renacana pengangkatan, MSDS, gas check,
Rencana penyelamatan, Izin pekerjaan underground
Has SIMOPS been assessed, and all relevant parties notified? (SIMOPS
MATRIX)
5 Apakah SIMOPS telah dinilai, dan semua pihak terkait diberitahu? (SIMOPS
Section 4.5
MATRIX)
Are Daily Works/SIMOPs board available and displayed visually for today
activities?
6 Apakah papan pekerjaan harian/SIMOP tersedia dan menampilkan aktivitas
Section 4.5
hari ini?
Does low risk activity use Generic Risk Assessment (GRA) instead of Permit
to Work?
7 Apakah aktifitas resiko rendah menggunakan Generic Risk Assessment
Section 3.1
(GRA) ketimbang menggunakan Permit to Work?
Are the high risk activities mention in Section 6 CoW Procedure use Permit to
Work? Section 3.1
8 Apakah aktifitas resiko tinggi seperti yang disebutkan pada Section 6 CoW Section 6
Procedure menggunakan Permit to Work?
Is there STARRT card/ECOW PERMIT for the activity, properly filled and
9 communicated to the crew?
Section 5.3
Are at least 2 members of the work force able to identify at least 50% of the
hazards and controls on the STARRT sheet/ECOW PERMIT (Not counting the
Supv) when INDEPENDANTLY questioned?
10 Apakah setidaknya 2 anggota angkatan kerja dapat mengidentifikasi
setidaknya 50% dari bahaya dan kontrol pada lembar STARRT/ECOW
PERMIT (Tidak termasuk Supv) ketika dipertanyakan secara INDEPENDEN?
Has The Permit to Work been reviewed, and signed by Area Issuing Authority
(AIA) and Operating Authority (OA)?
11 Sudahkah Surat Ijin Kerja direview, dan ditanda tangani oleh Area Issuing Section 8.3
Authority (AIA) dan Operating Authority (OA)?
Has the high-risk permit been showed on the mimic board in the PTW Office?
12 Apakah ijin kerja yang berisiko tinggi sudau ditampilkan di mimic board di Section 4.5
PTW Office?
For High Risk activity. Has the subcontractor work pack document been
completed during check? such as?
a. PTW
a. Method Statement
b. JSA
c. STARRT Card
13 d. All required supplementary documents (checklist, MSAS, ERP, isolation Section 8.2
Certificate, etc etc)
Untuk aktifitas risiko tinggi. Apakah dokumen paket kerja subkontraktor sudah
lengkap pada saat diperiksa? Seperti: MOS, JSA, STARRT Card, dokumen
lainnya yag dibutuhkan

#
For medium risk activity. Are the required document already completed such
as:
a. JSA
b. Approved Method Statement or construction procedure
c. STARRT Card /ECOW PERMIT
Untuk pekerjaan risiko menengah. Apakah dokumen yang dibutuhkan sudah
14 lengkap, seperti: Section 7
a. JSA
b. MOS atau prosedur konstruksi yang sudah disetujui
c. STARRT Card /ECOW PERMIT
For low risk activity the permit is not required. Are the required document
already completed such as:
a. An approved generic risk assessment
b. STARRT Card/ECOW PERMIT
c. Approval Procedures
Untuk pekerjaan risiko rendah ijin kerja tidak dibutuhkan. Apakah dokumen
15 yang dibutuhkan sudah lengkap, seperti:
Section 7
a. GRA yang sudah disetujui
b. STARRT Card/ECOW PERMIT
c. Prosedur yang sudah disetujui
Does the copy of Permit to Work available at the Site PTW Offices and the
original available at workplace?
16 Apakah copy Permit to Work disimpan di Site Permit Offices dan aslinya Section 8.4
tersedia di lokasi kerja?
Has STARRT CARD/ECOW PERMIT Meeting been conducted In the specific

work location, which is the task will be executed and lead by Permit Holder
(PH) or Supv. from subcontractor?
17 Sudahkah pertemuan Kartu STARRT/ECOW PERMIT dilakukan di lokasi Section 5.3
dimana pekerjaan akan dijalankan dan dipimpin oleh Permit Holder (PH) dan
Subcontractor supervisor?
Are Permit Holder (PH) able to explain what task will be carried out and what
the requirement is to conduct the work in safe manner?
18 Apakah Permit Holder (PH) menjelaskan tentang pekerjaan yang akan Section 4.2
dilaksanakan dan persyaratan kerja amannya?
Have Permit Holder (PH) and Operating Authority (OA) visited the work
location prior to sign or renew the Permit to work as per Procedure
19 requirement? Section 4.2
Sudahkah Permit Holder (PH) dan Operating Authority (OA) memeriksa lokasi
kerja sebelum menandatangani sesuai dengan persyaratan ?
Is Permit to Work, which is being used on site, still valid as per Control of
Work procedure? (Check the validity when was the 1st date that PTW was
verified)
- 14 days for Cold work;
- 7 days for Hot Work, Confined Space Entry, and Excavation Permit;
- 1 shift for Radiography and Create Opening.
20 Apakah Permit to Work, yang digunakan di lokasi, masih valid sesuai
Section 8.5
prosedure Control of Work? (periksa validitas kapan hari pertama PTW
diverifikasi?)
- 14 hari untuk Pekerjaan Dingin;
- 7 hari untuk Pkerjaan Panas, Ruang Terbatas, dan Ijin Penggalian;
- 1 shift untuk Radiografi dan Create Opening.
Has the hot work inside the confined space been completed with a hot work
permit and attached to a confined space entry permit? (if any)
21 Apakah kerja panas di dalam ruang terbatas sudah dilengkapai dengan ijin Section 3.2
kerja panas tambahan dan dilampirkan di ijin kerja masuk ruang terbatas?
RECOMMENDATION
1
2
3
4
5

#
TEP Se
Date:
Location:
Task / Activity :
Permit Number :
Name of Verifiers :
Sub-Contractor:
Safe Mechanical Lifting
1 Has a risk assessment been completed? Apakah penilaian ris
2 Is there a lifting plan in place? Apakah ada perencanaan pen

Are all controls implemented where required? Apakah semua
3
jika diperlukan?
Do all workers fully understand the lifting operation and contr

4 applicable for the lift? Apakah semua pekerja sepenuhnya me
pengangkatan dan tindakan pengendalian yang berlaku untu
Are all personnel involved in the lifting operations competent

5
personel yang terlibat dalam operasi pengangkatan kompete
Has SIMOPs been considered before beginning this type of o

6
telah dipertimbangkan sebelum memulai jenis operasi ini?
Has a pre-use inspection of the lifting equipment and load be

7
pemeriksaan pra-penggunaan peralatan pengangkat dan beb
Are the lifting accessories tagged or marked/color coded (to p

8 indicator of certification status)? Apakah aksesori pengangka
tanda/kode warna (untuk memberikan indikator visual status
9 Is the lifting equipment free from defects? Apakah alat penga
10 Is the safe working load marked? Apakah beban kerja aman

Where required, do lifting equipment certifications match the
11 serial number? Jika diperlukan, apakah sertifikasi alat pengan
unik/nomor seri?
Is the lift area controlled and is everyone clear of the load? A

12
semua orang bebas dari beban?
Are signalling methods and communication agreed and clear

13 banksman and crane operator? Apakah metode pensinyalan
dan jelas antara petugas bank dan operator derek?
Do frontline employees only operate equipment that they are

14 karyawan garis depan hanya mengoperasikan peralatan?bah
syarat untuk digunakan?
Have exclusion zones been established and obeyed? Apakah

15
ditetapkan dan dipatuhi?
Are frontline employees aware of the hazards and never walk

16 suspended load? Apakah karyawan garis depan sadar akan
berjalan di bawah beban yang ditangguhkan?
Is change management (MOC) used to manage any scope o

17 manajemen perubahan (MOC) digunakan untuk mengelola?r
perubahan?
Are Contractor SV or BP Oversight checks completed to conf

18 conducted as per process? Apakah pemeriksaan Pengawasa
telah selesai untuk memastikan bahwa pekerjaan telahdilaku

Do employees understand that they have the authority and ex
unsafe work? Can they give an example of when this happen
19
Pengawasan SV atau BP Kontraktor telah selesai untuk mem
telahdilakukan sesuai proses?
Did the risk assessment or pre-job discussion include any les
20 incidents from similar work? Apakah penilaian risiko atau disk
memasukkan pelajaran dari masa lalu?insiden dari pekerjaan
Is there STARRT card/ECOW PERMIT for the activity, proper

21 to the crew? Apakah ada kartu STARRT/ECOW PERMIT unt
benardiisi dan dikomunikasikan kepada kru?

NO ACTION
1
2
3
4
5

Safe Mechanical Lifting
en completed? Apakah penilaian risiko telah selesai?
ce? Apakah ada perencanaan pengangkatan?

ed where required? Apakah semua kontrol diimplementasikan
tand the lifting operation and control measures

kah semua pekerja sepenuhnya memahami operasi
n pengendalian yang berlaku untuk lift?
in the lifting operations competent and trained Apakah semua

m operasi pengangkatan kompeten dan terlatih?
ered before beginning this type of operation? Apakah SIMOP

elum memulai jenis operasi ini?
of the lifting equipment and load been carried out? Apakah

aan peralatan pengangkat dan beban telah dilakukan?
tagged or marked/color coded (to provide a visual

atus)? Apakah aksesori pengangkat diberi tag atau diberi
memberikan indikator visual status sertifikasi)?
e from defects? Apakah alat pengangkat bebas dari cacat?
arked? Apakah beban kerja aman ditandai?

equipment certifications match the unique number /
ukan, apakah sertifikasi alat pengangkat cocok dengan nomor
nd is everyone clear of the load? Apakah area lift terkontrol dan

eban?
d communication agreed and clear between the

ator? Apakah metode pensinyalan dan komunikasi disepakati
ank dan operator derek?
ly operate equipment that they are qualified to use? Apakah

ya mengoperasikan peralatan?bahwa mereka memenuhi
n established and obeyed? Apakah zona eksklusi telah
ware of the hazards and never walk under a

karyawan garis depan sadar akan bahaya dan tidak pernah
ang ditangguhkan?
MOC) used to manage any scope or permit changes? Apakah

OC) digunakan untuk mengelola?ruang lingkup atau izin
Oversight checks completed to confirm that work is

? Apakah pemeriksaan Pengawasan SV atau BP Kontraktor
stikan bahwa pekerjaan telahdilakukan sesuai proses?

that they have the authority and expectation to stop
e an example of when this happened? Apakah pemeriksaan
Kontraktor telah selesai untuk memastikan bahwa pekerjaan
es?
pre-job discussion include any lessons from past
? Apakah penilaian risiko atau diskusi pra-pekerjaan
ri masa lalu?insiden dari pekerjaan serupa?
OW PERMIT for the activity, properly filled and communicated

kartu STARRT/ECOW PERMIT untuk aktivitas, dengan
sikan kepada kru?

RECOMMEND
ACTION

ion Record Sheet
Purpose

Activity at the TEP Tangguh Site is executed in line
Lifting Procedure/TEP-930-PRC-HS-BP4-0032 Proce
associated relevant documentation under the C
Management System
Doc.
Reference

RECOMMENDATION

cord Sheet
Purpose

vity at the TEP Tangguh Site is executed in line with the
g Procedure/TEP-930-PRC-HS-BP4-0032 Procedure and
associated relevant documentation under the CSTS
Management System
Comments / Remarks

MMENDATION
RESPONSIBLE PERSON

Rev.0
Compliance
YES / NO / NA

#DIV/0!
TARGET DATE

Date: Purpose
Location:
Permit Number : Activity at the TEP Tangguh Site is executed in line with the
Greenfield Construction Control of Work/TEP-930-PRC-HS-
Name of Verifiers : BP4-0002 Procedure and associated relevant documentation
Persons Interviewed or Supervisor: under the CSTS Management System
Sub-Contractor:
Doc. Compliance
Line of Fire Comments / Remarks
Do I see evidence of equipment properly guarded/protected? Apakah saya melihat bukti peralatan
1
dengan benardijaga/dilindungi?
Are risk areas clearly defined and barriers and signs in use to warn personnel of dangers? Apakah
2 area risiko didefinisikan dengan jelas dan hambatan dantanda-tanda yang digunakan untuk
memperingatkan personel tentang bahaya?
Are pedestrian corridors available to allow safe passage of personnel around their work location?
3 Apakah koridor pejalan kaki tersedia untuk memungkinkan keamanan?lintas personel di sekitar
lokasi kerja mereka?
Do I see evidence of the use of drops protection equipment, e.g. tool lanyards, tool bags etc.?
4
Apakah saya melihat bukti penggunaan perlindungan tetes?peralatan, mis. alat lanyard, tas alat dll?
Do I see evidence of collective drops protection measures, e.g. netting, toe-boards etc.? Apakah
5
saya melihat bukti perlindungan tetes kolektif?langkah-langkah, misalnya jaring, papan kaki dll.?
Do I see evidence of work being planned to avoid the risk of dropped objects occurring? Apakah
6
saya melihat bukti pekerjaan yang direncanakan untuk dihindari?risiko benda jatuh terjadi?
Do I see evidence of work planned to avoid the risk of accidental contact with overhead power lines?
7 Apakah saya melihat bukti pekerjaan yang direncanakan untuk menghindaririsiko kontak yang tidak
disengaja dengan saluran listrik di atas kepala?
Are plant & equipment operators observant of overhead risks that could negatively impact on safety?
8 Apakah operator pabrik & peralatan memperhatikanrisiko overhead yang dapat berdampak negatif
pada keselamatan?
Are plant & equipment operators observant of overhead risks that could negatively impact on safety?
9 Apakah operator pabrik & peralatan memperhatikan risiko overhead yang dapat berdampak negatif
pada keselamatan?
Potential pathways of energy release within their working environment, e.g. pneumatic, hydraulic,
stored energy under tension, trapped between etc.? Jalur potensial pelepasan energi di dalam
10
lingkungan kerja, mis. pneumatik, hidrolik, energi yang tersimpan di bawah tegangan, terjebak di
antara dll?
Are personnel observant of vehicle movements & ensure that they remain visible to drivers &
11 equipment operators? Apakah personel memperhatikan pergerakan kendaraan?& memastikan
bahwa mereka tetap terlihat oleh pengemudi & operator peralatan?
Ask personnel to describe examples of locations/activities which may present the risk of a line of fire
incident occurring if not managed effectively. Mintalah personel untuk menjelaskan contoh
12
lokasi/kegiatan yang dapat menimbulkan risiko rangkaian kejadian kebakaran terjadi jika tidak
dikelola secara efektif.
Is there STARRT card/ECOW PERMIT for the activity, properly filled and communicated to the crew?
13 Apakah ada kartu STARRT/ECOW PERMIT untuk aktivitas, dengan benardiisi dan dikomunikasikan
kepada kru?

RECOMMENDATION
1
2
3
4
5

Date: Purpose
Location:
Task / Activity :
The purpose of this Self Verification is to ensure that Work
Permit Number : Activity at TEP Tangguh Site is executed in line with the Hot
Name of Verifiers : Work/TEP-930-PRC-HS-BP4-0026 Procedure and associated
relevant documentation under the CSTS Management System
Sub-Contractor:
Doc. Compliance
Hot Work Comments / Remarks
Does the risk assessment address all risks and controls relevant to the activity?
1 Apakah penilaian risiko menangani semua risiko danpengendalian yang relevan dengan
aktivitas?
If the PTW requires a gas test or gas monitoring, has this been completed/ in place and
recorded?
2
.Jika PTW memerlukan uji gas atau pemantauan gas, apakah ini sudah selesai/
dalamtempat dan dicatat?
Has a Fire Watch been appointed and do they know their duties?
3
Apakah Fire Watch telah ditunjuk dan apakah mereka tahutugas mereka?
Has authorization been obtained prior to commencing hot work?

4
Apakah otorisasi telah diperoleh sebelummemulai pekerjaan panas?
Is a daily, pre-use, visual inspection conducted of tools and equipment?

5
Apakah inspeksi visual harian, pra-penggunaan, dilakukan?dari alat dan perlengkapan?
Are flashback arrestors in all oxygen and fuel gas lines.

6
Apakah penangkal kilas balik di semua oksigen dan bahan bakarsaluran gas.
Where required, are workers properly using controls for metal fumes? I.e. masks,
forced ventilation, etc.
7
Jika diperlukan, apakah pekerja menggunakan kontrol asap logam dengan benar? Yaitu.
topeng,ventilasi paksa, dll.
Is adequate lighting in place?

8
Apakah pencahayaan yang memadai tersedia?
Has the area been cleared of combustible/flammable materials?

9
Apakah area tersebut telah dibersihkan dari bahan yang mudah terbakar/terbakar?
Are the correct fire extinguishers available in close proximity to the hot work activity?
10
Apakah alat pemadam kebakaran yang benar tersedia di dekat tempat kerja panas?
Have the welding cables, fuel gas lines and electrical cables been run to avoid damage
and slips, trips and falls?
11
Apakah kabel las, saluran bahan bakar gas dan kabel listrik telah dijalankan untuk
menghindarikerusakan dan terpeleset, tersandung dan jatuh?
Has the correct PPE been identified and used?

12
Apakah APD yang benar telah diidentifikasi dan digunakan?
Are barriers and/or warning signage in place?

13
Apakah ada pembatas dan/atau rambu peringatan?
Is habitat used where required and according to requirements?

14
Apakah habitat digunakan jika diperlukan dan sesuai dengan persyaratan?
Has body positioning to undertake the task been reviewed / considered?

15
Apakah posisi tubuh untuk melakukan tugas telahditinjau / dipertimbangkan?
If Hot Work is being performed at height, has protection been provided to prevent dropped
objects, sparks and hot metal?
16
Jika Pekerjaan Panas dilakukan di ketinggian, apakah perlindungan telah diberikan untuk
mencegah benda jatuh, percikan api, dan logam panas?
If there is a requirement for tool lanyards and barriers, are these in use?
17
Jika ada persyaratan untuk lanyard dan penghalang alat, apakah ini digunakan?
Have all sources of ignition been identified and controlled?

18
Apakah semua sumber penyulutan telah diidentifikasi dandikendalikan?
Has gas testing been completed prior to starting hot work in a hazardous area?
19 Apakah pengujian gas telah diselesaikan sebelum memulai pekerjaan panas di area
berbahaya?

Is there continuous gas monitoring in place, where required?
20
Apakah ada pemantauan gas terus menerus, jika diperlukan?
Do employees understand that they have the authority and expectation to stop unsafe
work? Can they give an example of when this happened?
21 Apakah karyawan memahami bahwa mereka memiliki wewenang dan harapan untuk
menghentikan pekerjaan yang tidak aman? Bisakah mereka memberi contoh kapan ini
terjadi?
Did the risk assessment or pre-job discussion include any lessons from past incidents
from similar work?
22
Apakah penilaian risiko atau diskusi pra-pekerjaan mencakup pelajaran dari insiden masa
lalu dari pekerjaan serupa?
to the crew?
23
Apakah ada kartu STARRT/ECOW PERMIT untuk kegiatan tersebut, diisi dengan benar
dan dikomunikasikan kepada kru?

RECOMMENDATION
1
2
3
4
5

Date: Purpose
Location:
Permit Number : Activity at the TEP Tangguh Site is executed in line with the
Energy Isolation/TEP-930-PRC-HS-BP4-0021 Procedure and
Name of Verifiers : associated relevant documentation under the CSTS
Persons Interviewed or Supervisor: Management System
Sub-Contractor:
Doc. Compliance
Energy Isolation Comments / Remarks
Are isolation controls managed by a responsible person (RP)?

1
Apakah kontrol isolasi dikelola oleh orang yang bertanggung jawab (RP)?
Are permits and isolation plans accessible to the workforce?

2
Apakah izin dan rencana isolasi dapat diakses oleh tenaga kerja?
Is the responsible person performing the isolations documented on the permit?

3
Apakah orang yang bertanggung jawab melakukan isolasi didokumentasikan pada izin?
Does the RP(s) have the required training and competency to perform the task?
4 Apakah RP memiliki pelatihan dan kompetensi yang diperlukan untuk melakukan tugas
tersebut?
Was a risk assessments completed for the job?

5
Apakah penilaian risiko telah diselesaikan untuk pekerjaan itu?
Are isolation points labelled to show: Permit Number, Device Number, Lock Number and
Isolation Position?
6
Apakah titik isolasi diberi label untuk menunjukkan: Nomor Izin, Nomor Perangkat, Nomor
Kunci, dan Posisi Isolasi?
Have applied isolations been effectively secured (e.g., locks, chains, wire locks)?
7 Apakah isolasi yang diterapkan telah diamankan secara efektif(misalnya, kunci, rantai,
kunci kawat)?
Did the responsible party sign the Permit for application or removal of each isolation
control?
8
Apakah penanggung jawab menandatangani Izin untuk penerapan atau penghapusan
setiap kontrol isolasi?
Was a test carried out to ensure the isolation is effective (in confirming a zero energy
state)?
9
Apakah tes dilakukan untuk memastikan isolasi efektif (dalam mengkonfirmasi keadaan
energi nol)?
Is there a process to communicate this work to the next shift where applicable?
10
Apakah ada proses untuk mengomunikasikan pekerjaan ini ke shift berikutnya jika ada?
Have SIMOPS issues have been considered and addressed in the risk assessment?
11
Apakah masalah SIMOPS telah dipertimbangkan dan ditangani dalam penilaian risiko?
Have all energy sources been identified?

12
Apakah semua sumber energi telah diidentifikasi?
13
Have hazardous energy sources been isolated, locked, and tagged ?
Apakah sumber energi berbahaya telah diisolasi, dikunci, dan diberi tag?
Have lessons learnt from similar tasks been incoporated into this activity?
14
Apakah pelajaran yang dipetik dari tugas serupa telah dimasukkan ke dalam kegiatan ini?
Do employees understand that they have the authority and expectation to stop unsafe
work? Can they give an example of when this happened?
15 Apakah karyawan memahami bahwa mereka memiliki wewenang dan harapan untuk
menghentikan pekerjaan yang tidak aman? Bisakah mereka memberi contoh kapan ini
terjadi?
Isolation Authority (IA) is approved by Letter of Designation?

16
Otoritas Isolasi (IA) disetujui oleh Surat Penunjukan?
to the crew?
17
Apakah ada kartu STARRT /ECOW PERMITuntuk kegiatan tersebut, diisi dengan benar
dan dikomunikasikan kepada kru?

RECOMMENDATION
1
2
3
4
5

#
TEP Se
Date:
Location:
Task / Activity :
Permit Number :
Name of Verifiers :
Sub-Contractor:
driving Safety
Observe vehicle operations. Are personnel using seat belts p

1 Perhatikan pengoperasian kendaraan. Apakah personel yang
pengaman disediakan dengan benar?
Look for instances of personnel intervening when seat belts a
2 Cari contoh personel yang melakukan intervensi ketika sabuk
dengan benar.
Do I see evidence of practices used to bypass the correct use

belt is permanently fastened but not worn, allowing user to sit
secured.
3
Apakah saya melihat bukti praktik yang digunakan untuk men
sabuk pengaman yang benar? Misalnya. sabuk pengaman di
tidak dipakai, memungkinkan pengguna untuk duduk di atas
Does the driver remind the passengers to fasten their seat be

4 Apakah pengemudi mengingatkan penumpang untuk memas
sebelum berangkat?
Do I see evidence of drivers using cell phones while manoeu

5 Apakah saya melihat bukti pengemudi menggunakan ponsel
kendaraan?
Are speed limits displayed in the work location & observed by

6
Apakah batas kecepatan ditampilkan di lokasi kerja & diperha
Do drivers demonstrate a cautious attitude to driving operatio

7
Apakah pengemudi menunjukkan sikap hati-hati terhadap op
Do drivers use hands-free phone functions while driving?
8
Apakah pengemudi menggunakan fungsi telepon handsfree s
Do I see evidence of intervention if drivers violate the rule?

9
Apakah saya melihat bukti intervensi jika pengemudi melangg
Does the driver comply with conditions of the plan?

10
Apakah pengemudi mematuhi ketentuan rencana?
Do I find evidence of random screening/testing facilities? Are

correct equipment to perform the task?
11
Apakah saya menemukan bukti fasilitas penyaringan/penguji
dilengkapi dengan peralatan yang benar untuk melakukan tug
Ask personnel to describe the potential negative consequenc

of failing to use a seat belt while travelling inside a moving ve
12 Minta personel untuk menjelaskan potensi konsekuensi nega
akibat kegagalan menggunakan sabuk pengaman saat beper
yang bergerak.
NO ACTION
1
2
3
4
5
driving Safety
s. Are personnel using seat belts provided correctly?

kendaraan. Apakah personel yang menggunakan sabuk
gan benar?
onnel intervening when seat belts are not used correctly.
melakukan intervensi ketika sabuk pengaman tidak digunakan
ices used to bypass the correct use of the seat belt? E.g. seat
ed but not worn, allowing user to sit on top without being
praktik yang digunakan untuk mengabaikan penggunaan

nar? Misalnya. sabuk pengaman diikat secara permanen tetapi
an pengguna untuk duduk di atas tanpa diamankan.
passengers to fasten their seat belts prior to departing?

ngatkan penumpang untuk memasang sabuk pengaman
rs using cell phones while manoeuvring vehicles?

pengemudi menggunakan ponsel saat melakukan manuver
in the work location & observed by drivers?

ditampilkan di lokasi kerja & diperhatikan oleh pengemudi?
cautious attitude to driving operations?

njukkan sikap hati-hati terhadap operasi mengemudi?
phone functions while driving?
gunakan fungsi telepon handsfree saat mengemudi?
vention if drivers violate the rule?

intervensi jika pengemudi melanggar aturan?
h conditions of the plan?

tuhi ketentuan rencana?
om screening/testing facilities? Are they equipped with the

rm the task?
bukti fasilitas penyaringan/pengujian acak? Apakah mereka
an yang benar untuk melakukan tugas?
the potential negative consequences that may occur as a result

while travelling inside a moving vehicle.
elaskan potensi konsekuensi negatif yang mungkin terjadi
nakan sabuk pengaman saat bepergian di dalam kendaraan
RECOMMEND
ACTION
ion Record Sheet
Purpose

Activity at the TEP Tangguh Site is executed in line
Transportation Safety/TEP-930-PRS-HS-BP4-0003 P
and associated relevant documentation under the
Management System
Doc.
Reference
RECOMMENDATION
cord Sheet
Purpose

vity at the TEP Tangguh Site is executed in line with the
sportation Safety/TEP-930-PRS-HS-BP4-0003 Procedure
nd associated relevant documentation under the CSTS
Management System
Comments / Remarks
MMENDATION
RESPONSIBLE PERSON
Rev.0
Compliance
YES / NO / NA
#DIV/0!
TARGET DATE

LSR SV Form Checklists 18 Aug 2022 REV

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LSR SV Form Checklists 18 Aug 2022 REV

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TEP Se

Persons Interviewed or Supervisor:

Bypassing Safety Controls

Do I see evidence of equipment such as fire suppression, det

# Saipem Classification - General Use

Do I observe unauthorised override/ bypass of safety critical s

Ask personnel what procedure/s should be employed if safety

Ask the supervisor to explain what alternative control measur

Are safety critical systems inspected, tested & recorded in co

# Saipem Classification - General Use

Are there records of Safety Critical Equipment being bypasse

# Saipem Classification - General Use

# Saipem Classification - General Use

# Saipem Classification - General Use

Bypassing Safety Controls

pment such as fire suppression, detection, pressure controls,

# Saipem Classification - General Use

override/ bypass of safety critical systems, e.g. disabling of

ems that have been disabled/ overridden & alternative control

dure/s should be employed if safety critical equipment needs to

ain what alternative control measures will be provided if a safety

inspected, tested & recorded in compliance with standard

# Saipem Classification - General Use

y Critical Equipment being bypassed? Apakah ada catatan

# Saipem Classification - General Use

# Saipem Classification - General Use

The purpose of this Self Verification is to ensure th

# Saipem Classification - General Use

# Saipem Classification - General Use

e purpose of this Self Verification is to ensure that Work

# Saipem Classification - General Use

# Saipem Classification - General Use

# Saipem Classification - General Use

# Saipem Classification - General Use

is the Isolaction Control Certificate approved by Isolated Authority, designated by

Have suitable atmospheric tests been conducted, verified and repeated as

Is there an attendant assigned, continually on-station and in communication

Percentage of Implementaion #DIV/0!

# Saipem Classification - General Use

Task / Activity / aktivitas

Process, Plan or Procedure to be Verified Doc. Compliance

DOCUMENTS/ADMINISTRATION /POLICY/ PROCEDURE

Is there a validated Method Statement available which adequately reflects the

Are all other supplementary certificates referenced in the above documents

Pre Start Communication to the Workers (Sometimes referred to as the TBT)

Do the Hazards and Controls identified on the STARRT/ECOW PERMIT sheet

WORK EXECUTION - WORKING AT HEIGHT

#Saipem Classification - General Use

Are temporary platforms, been inspected regurally by competent person and

Are temporary platforms, such as scaffolding platform, mobile scaffolding platform

Have portable ladder/step ladder been inspected and color coded?

Saipem Classification - General Use

Is banksman/flagman to assist the movement of the MEWP?

EMERGENCY PREPAREDNESS/WORKER PROTECTION

Have persons received adeqaute training or familiarisation in the use of any

Do workers know what to do in the event of an emergency? - Ask at 2 members

Percentage of Implementaion #DIV/0!

Saipem Classification - General Use