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SAFETY INSPECTION REPORT

Applies to Truck Crane (Lattice Boom & Telescopic Boom)
[ ] Pre-mobilization [ ] Re-Inspection

No Contract :

Equip. No. : Type : Model : Brand :

Serial No. : Km/Hourmeter : Service Date : BM Plate No :

Capacity : Date : Location : Owner :

Req

Critical ?*

No Good
Description to be Checked Remarks

Lattice

Telscp
Boom

Boom
Good

N/A
A - Documentation Operator and Equipment :

1 MIGAS / KEMNAKER SILO Certificate (Certificationof Inspection (COI) Equipment) No: Y Y Y

(Matches UnitType-Series) Expire date :

2 One-week to Today’s Pre-Trip Inspection and Pre-use Inspection records (Original copy available on unit, N/A for pre- N Y Y
mobilization inspection)

3 Original Manufacture Name Plate with Serial Number (Year of manufacture)(Nameplate is mandatory for pre-mobilization. Y Y Y
During periodic inspection, the serialnumber may be verified through latest inspection record/sticker)

4 Operation Manual Book ( Matches Unit Type, Series and In bahasa ) N Y Y

5 SOP - Standard Operating Procedure equipment ( Based on OEM Operation Manual Book ) Y Y Y
6 Company Operator/Driver Permit Expire date : Y Y Y
7 SIO / SKK-OPA (BNSP-LSP / KEMNAKER) Expire date : Y Y Y

8 CLOVER (Lifting Operator Permit -CPI) including BP's Cranes (it's requirement shall Expire date : Y Y Y
not inhibit equipment Pre-mobilization safety Inspection process)

9 Company ID Number, Company Logo (Correct Size, Visible) Minimum Size, P x L = 25 x 20 cm Y Y Y

Yearly inspection report from qualified inspector (Inspector/s shall check yearly inspection result of block, sheaves, pins,
10 bushings,main nut, hooks & etc.). Yearly inspection shall be performed by Qualified GOI Crane Y Y Y
Inspector assigned by equipment owner/user. Company’s Inspector mayrecommend equipment owner/user to conduct NDT
based on assessment result.

B - Mandatory Safety Inspections and Devices & ( Motor Vehicle Safety )

1 Back-Up Alarm ( Easy to Hear, 97 Decibles Minimum ) Y Y Y
2 Back-Up Light ( Adequate Illumination, Function Test ) Y Y Y
3 Horn ( Coontrolled, Easily Operated From Inside Operator's Cabin, Easy to Hear ) Y Y Y
4 Swing System (Function test, must be smooth and controlled) Y Y Y
5 Swing Brake (Must be positive action, witness a function test) Y Y Y
5 Original Factory Load Chart (Visible, affixed to cabin wall), Load Chart shall be in Bahasa or English Y Y Y
6 Swing Alarm (audible in working condition) N Y Y
7 Swing Lights (Flashing okay, easy to see) N Y N
8 Swing Operating Brake ~ Automatic Hydraulic (Must be positive action, witness a function test) Y Y Y
9 Boom Lock (Must be positive action, witness a function test) Y Y N
10 Swing Lock (Must be positive action, witness a function test) Y Y Y

11 Original Factory Load Chart (Visible, affixed to cabin wall), Load Chart shall be in Bahasa or English Y Y Y

12 Boom Angle Indicator (Affixed to boom and functioning properly) Y Y Y

13 Level Gauge (Bubble indicator and functioning properly) Y Y Y

14 Boom Hoist Automatic Limit Switch (Boom Kick Out) (Witness a function test, must shut off boom hoist control at maximum - Y Y N
range 780- 820)

15 Outdoor Alarm (load limiter alarm) and Light device (In good condition and properlyinstalled) - as Manufacture Standard N Y Y

16 Boom Backstop System (Witness a function test, must shut off boom hoist control) Y Y N

17 Safety Pawls for Hoist Drums (Function test, easily engaged / disengaged by Operator) - Or similar Protection Function. Y Y Y

18 Anti-Two Block Alarm (Test its function alarm and must Shut Off) Y Y Y
19 Emergency Shutdown (In good condition and properly installed) -(Engine Stop) Y Y Y

20 Operator's Electronic Operational Aids (Refer to OSHA 29 CFR Part 1926.1416(e)(4)(i) Cranes and Derricks - page 48151 for Y Y Y
load weighing and similar devices)
21 Positive-free-fall lockout system (Witness a function test) as manufactured standard Y Y Y
22 Positive-free-fall lockout system (Witness a function test) as manufactured standard Y Y Y

23 Gantry (No Fatigue Cracks) Gantry Sheaves, Pins, Bushings (In good condition, adequate lubrication, sheaves no flat spots) Y Y N

24 Safety Latch in Hook Block and Headache Ball (Not bent, positive closing action) Y Y Y

Block, Sheaves, Pins, Bushings, Main Nut, Hooks, Above Swivel Bearing (Good condition, swivel bearing assays good
25 condition, not loose, properly lubricated, sheaves no flat spots, locked in place by proper and safe split cotter pin, Y Y Y
painted with a highly visible, block weigh and block capacity must be marking. Can’t become undone).

Main and Auxiliary Hoist Cable (Rope socket ends swaged, no hand spliced ends, socket ends not deformed or bent, wire rope
26 cable not deformed, not bent, no kinks, not crushed, no excess of broken wire strands or refer to IBU L&R Standard - Wire Y Y Y
rope discard criteria)

27 Telescopic Boom including Jib (Fully extend all telescopic boom section and boom down, look for fatigue cracks, Y N Y
excessive bending, excessive twisting, excessive kinking, bent, dent, excess wear on sliding surfaces)

28 Lattice Boom Sections, including Jib (Boom down for inspection examine for cracks, bent chords, bent lacings, dents, N Y N
corrosion)

29 Boom Pendants (Pin condition is good, pins held by proper and safe split cotter pins, rope sockets not deformed or bent, no Y Y N
excess of broken wire strands, refers to IBU – L&R Standard - Wire rope discard criteria)

Boom Hoist Cable Condition (Rope socket ends swaged, no hand spliced ends, socket ends not deformed or bent,
30 wire rope cable not deformed, not bent, no kinks, not crushed, no excess of broken wire strands - refers to IBU – L&R Y Y N
Standard - Wire rope discard criteria)

31 Boom Mount Connecting PINS (All must be secured by proper and safe split cotter pins) Y Y N

32 Hoisting and Lowering Brakes (Automatic brake system or manual brake, free-fall lockout) function test, all brake Y Y Y
actions smooth and controlled, and witness and record performance test)
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Critical ?*

No Good
Description to be Checked Remarks

Lattice

Telscp
Boom

Boom
Good

N/A
33 Carrier Power Steering Systems (Function test, smooth and controlled, easy maneuvering) Y Y Y

34 Carrier Steering Box, Steering Linkages (No excess free play, no loose ball joints, lubricated properly, no worn-out pins, no Y Y Y
loose mounting bolts, function test)

35 Carrier Axle Wheel Bearing Lubrication (Oil-hubs to be properly filled and no leaks, no missing covers / caps on grease type Y Y Y
hubs)

TIRES and Wheel Condition (No Broken-Missing Lug Nuts, Tread Depth Minimum 3mm or As per TWI tread Depth , No Recap
/ Retread / Vulcanized Tires, Tread MudGrip (All Terrain) on rear and front, Correct Rotation (Vulcanized tire not allowed
for all vehicles including heavy vehicles refer to IBU-MVS requirement. All tires on same axle must have same tread, size tired
36 (V-Lug or S-Lug, or U-Lug and Rib-Lug), and single piece rim refer to Peraturan Menteri Perhubungan No. 26 year 2015) Y Y Y
except mention on the contract or additional HES Exhibit.
Suitable Spare Wheel and Tire, Retreads/Vulcanized Tires Are Not Allowed, Recommend Tread "All-Terrain" Pattern, wheel
size the same as those installed on equipment

37 Seat Belts for Operator (Good condition, retractable properly, mounted with OEM hi-tensile bolts) Y Y Y
38 Seats, Cushions (Securely mounted, ergonomically good condition, not torn open or dilapidated) N Y Y
39 Carrier Parking Brake System (Function test) Y Y Y
40 Carrier Brakes Front and Rear (Properly adjusted, no air or fluid leaks, test function) Y Y Y
41 Truck Service Air / Hydraulic Brakes Front and Rear (Properly adjusted, no air or fluid leaks, test function) Y Y Y
42 Brake Pedal, Pin & Lock Pin Condition (In good condition and properly installed) Y Y Y
43 Clutch Pedal, Pin & Lock Pin Condition (In good condition and properly installed) Y Y Y
44 Accelerator Pedal, Bolt, Pin & Lock Pin (In good condition and properly installed) Y Y Y
45 Head Lights (Adequate illumination, function test) Y Y Y
46 Anti-Lighting/Sun Visor (In good condition and properly installed) if required refer to JHA N Y Y

47 Working Lights-Flood Lights (Adequate illumination, function test -must be two spots: 1. light leads to the load 2. light leads Y Y Y
to the top of the boom)
48 Front and Rear Combination Lights (Adequate illumination, function test) as Manufacture Standard Y Y Y
49 Electrical Wiring Condition, Fuse Block (All splices insulated, no bare wires) Y Y Y
50 Battery Disconnect Switch (No loose wires or battery cable connections, function test) as Manufacture Standard Y Y Y

51 Amber Rotary Light (Adequate illumination, function test) -if the type of equipment is not mandatory to be installed by GOI, N Y Y
GOI Permit is required (becomes critical if stated in the Contract)

52 All Window Glass / Windshield Glass (Totally clear, no film or stickers blocking vision. units with OEM window tint will Y Y Y
require approval by relevant CPI authorities).
53 Windshield Wipers and Washer (Wiper blades not perished, test function) Y Y Y
54 Door and Door Locks, Door Handles, Outside and Inner (Test function) Y Y Y

55 Side mounted Left and Right or Door mounted Rear View Mirrors (Not loose clear unobstructed vision, functions properly) Y Y Y

56 Wheeled Chocks (Two units, properly constructed) Y Y Y

57 Safety Triangles (Two units are in good condition, reflective so as visible at night) Y Y Y
58 Fire Extinguisher (Minimum 4kg, current and valid inspection tag, properly mounted and accessible). Y Y Y
59 First Aid Kit (Clean, tidy, completely full) - as per GOI Regulation PP No. 55 Year 2012 Y Y Y

60 Access Ladder Steps Handrails (Securely mounted, ergonomic design, good condition, not cracked, not bent, not dilapidated, N Y Y
no sharp edges, no sharp corners).
61 Safety Guards and Covers (All in place, not loose, none missing, not modified, remain within OEM Specs). Y Y Y

Turn table (Slewing Bearing, Roll Bearing Pointed, Path, Connection Bolt & Nut)(Must use only genuine OEM supplied
hardware, good condition, straight, not bent, no cracks, no uncertified welding repairs, properly secured with straight bolts,
62 no loose mountings, bolt or nut has been marked) - By Visual Inspection and document Y Y Y
maintenance record.
Yearly Inspection shall be performed by Qualified GOI Crane Inspector assigned by equipment owner/user. Company’s
Inspector may recommend equipment owner/user to conduct NDT based on assessment result.

63 Roller Circle Face (Lubricated, not loose, no loose mounting bolts) Y Y Y

Driver Monitoring System (Refer to CPI Contract, perform function test)registered on CCPM (link to i-JMS)
64 (Perform function test, confirmation that there are no signs of tampering include seals, connections, plugs, etc.) N/A if not Y Y Y
required by contract

Underrun protection as appropriate (Regulation of Transp Dept. No 55,

2012, section 90) Ensure no loose, no crack, no sharp edges, no bent, straight, properly mounted, reflective sticker attached
(if the equipment has police number)
65 Ground Clearance: cm, if > 700 mm, need Underrun Protection Measurement of Underrun Protection Y Y Y
- R/H: cm
- L/H: cm
- Rear: cm

C - Body
1 Body Condition ( Good Paint and General Appearance, No Excess Damage, No Rust ) N Y Y

D - Crane Cabin and Carrier Cabin Interior

1 Cabin Interior ( Good Condition, Clean, No Rubbish, Good Housekeeping ) N Y Y

Dashboard Indicators, Engine EMS (Electronic Monitoring System)

2 ( Gauges for Fuel, Hours, Kms, Odometer, Temperature, Brake Air Pressure, Hyd Pressure, Alternator, Battery Voltmeter, Y Y Y
Battery Charging System, etc, All Operating Properly )

3 Combination Switch, Light Switch, Switches, Knobs (Test Function ) Y Y Y

4 Cabin Air Conditioner and Fan ( Test Function ) - refer to contract N Y Y
5 Control Linkages and Levers ( Test Function, Complete with marking & Labeling ) Y Y Y

E - Main Frame and Main Carrier Chassis (Check 3rd party inspection result of Carrier/chassis, thru thickness, NDT, Straightening (deflection or deformation of chassis) inspection results)
1 Main Chassis, Frame ( Good Condition, Straight, Not Bent, No Cracks, No Uncertified Welding Repairs ) Y Y Y
2 Sub Chassis, Sub Frame ( Good Condition, Straight, Not Bent, No Cracks, No Uncertified Welding Repairs ) Y Y Y
3 Carrier Springs, Suspension System (Front / Rear, Straight, Not Bent, No Loose Pins) Y Y Y
4 Carrier Axle Mounts, Front and Rear (All U-Bolts Tight, No Cracks) Y Y Y
5 Carrier Outrigger Extension and Retraction Cylinders (Test function, no leaks, no loose mountings) Y Y Y
6 Truck Outrigger Extension and Retraction Cylinders (Test function, no leaks, no loose mountings) Y Y Y

7 Y Y Y Area = (0.65 x (Crane Mass + Total Load to be

Carrier Outrigger PADS (Proper and safe, no cracks, no excess distortion, no loose mountings) refer to load calculation (JHA)
lifted))/ (MaxPermissible ground pressure (Pmax) or Barring Capacity)
8 Carrier Outrigger Remote Control System Levers (No loose mountings, loose pins, test function) Y Y Y
9 Electrical Wiring Condition, Fuse Block (All splices properly insulated, no bare wires) Y Y Y
10 Swing Bearing (Swivel) (Clean condition, lubricated, not loose, no loose mounting bolts) Y Y Y
11 Counterweight Mountings (All holding bolts / pins are safe, tight, no loose mountings) Y Y Y
12 Front / Rear Bumper Bars (Rounded corners, no sharp edges, not loose, properly mounted) N Y Y

F - Crane Hydraulics, General Hydraulics, Fluids, Fuel, Hoses

1 All Fuel Hoses and Lines ( Properly Secured, No leaks ) Y Y Y
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Critical ?*

No Good
Description to be Checked Remarks

Lattice

Telscp
Boom

Boom
Good

N/A
2 All Hydraulic Hoses and Hydraulic Lines ( Properly Secured, No Leaks ) Y Y Y
3 Hydraulic Tank(s) ( Tight Mounts, No Leaks, Filler Cap Properly Secured, Complete with marking) Y Y Y
4 Fuel Tank(s) ( Tight Mounts, No Leaks, Filler Cap Properly Secured, Complete with marking) Y Y Y
5 Air Tank(s) ( No Leaks, No loose Mounts, Complete with marking) Y Y Y
6 Hydraulic Pilot Valves ( No Leaks ) Y Y Y
7 Hydraulic Pumps and Motors (No leaks, no excess noise) Y Y Y
8 All Controls and Hydraulic Control Valves ( No Leaks, Test Function, Complete with marking) Y Y Y

9 Hydraulic Cylinders ( Any Leaks or Excessively Worn Pins/Bushings, All Pins Properly Secured with Split Cotter Pins and/or Y Y Y
Bolted End Plates )

10 Remote Control System Levers for Outriggers ( No Loose Mountings, Loose Pins, Test Function, Complete with marking & Y Y Y
Labeling)

G - Engine(s) - Transmission(s)
1 Upper Engine (Clean appearance, no leaks, no defective mounts, observe performance, no smoke) Y Y N
2 Lower Engine (Clean appearance, no leaks, no defective mounts, observe performance, no smoke) Y Y Y
3 Engine Dipstick ( Easy to read, Oil Level Adequate ) Y Y Y

Battery, Battery Covers, Battery Mounting, Battery Terminals (Optional battery disconnect switch, test function, no loose or
4 corrodedcables-terminals, battery hold-downs in place, clean battery box and noloose mounts ) - Critical for Equipment Y Y Y
Electrical Control

5 Starter Motor ( Test Function, Adequate Cranking Strength, No Bad Noises or Overheating ) Y Y Y
6 Alternator ( Observe Charging Function, No Bad Noises or Overheating, No Loose Mounts, No Loose Belts ) Y Y Y
7 Cooling System ( Inspect Radiator and Hoses, No Leaks, No Perished Hoses ) Y Y Y
8 V-Belts or Serpentine Belts ( Not Loose, Not Squealing, Not Cracked ) Y Y Y
9 Exhaust System ( Check Pipe and Muffler, No leaks, Not Loose ) Y Y Y
10 Transmission and Auxiliary Transmisson ( No Leaks, Observe a Function Test ) Y Y Y

11 PTO and Transmisson, Drive Shafts, Propeller Shafts, U-Joints, Center Carrier Bearing Y Y Y
( Properly Greased, No Leaks, All Mountings Tight, Nothing Loose )

12 Clutch ( No Smoke or Slipping, Observe a Function Test ) Y Y Y

13 Carrier Differentials Front and Rear ( No Leaks, All Mountings Tight, Nothing Loose ) Y Y Y

H - Remote Operator's Console

1 Control Linkages and Levers (Test Function, Complete with marking & Labeling) Y Y Y
2 Emergency Shutdown (Good condition and properly installed) - (Engine Stop) Y Y Y

I - Servicing and Maintenance

1 Maintenance Schedule - PM and PdM N Y Y

(Service records available frequent inspection & periodic inspection)

2 Remaining Life Assessment (RLA) (3rdparty RLA Engineering Calculation report for crane unit with 30+ years old) Y Y Y

J - Others
1 Microphone (In good condition and properly installed) - Refer to manufacture N Y Y
2 Initial training equipment for operator(refer to OEM Operating and Inspection Manual ( Evident ) Y Y Y

3 User acceptance document for specified crane/COC (Certification of Conformance)/COO (Certificate of Origin) (Evident) N Y Y Only On boarding

4 Wind Speed Indicator (In good condition and properly installed) - Refer to High lifting > 40-meter height Y Y Y

Function and Performance Test

Load Weighing Device - Load Moment Indicator + Load Meter, Load Moment Limiter with Display (Static Lift Test)

Initial Weight (source : OEM reference or Third Party Read Weight (source load meter or loadmoment limiter with display) Percentage of Deviation (if there isdeviation shall refer to OEM recommendation)
Certificationor scaled weight)

Ton Ton %

Load Moment Limiter ( Dynamic Lift Test)

Initial Weight (source : OEM reference or Third Party Load Pick UpWorking Radius and Capacity Load SetWorking Radius and Capacity
Certificationor scaled weight)

Ton Meter Ton Meter Ton

Performance Test at 100% of the crane's capacity as per OEM Load Chart (Static Lift Test)

Initial Weight (source : OEM reference or Third Party Boom Lenght Boom Angle Working Radius Crane Capacity onLoad Chart
Certificationor scaled weight)

Ton Meter Ton Meter Ton

Time Duration : Minutes

Wire Rope Elongation Outrigger Cylinder Condition Hoist BrakesCondition OtherConsideration

(note : identify outrigger cylinderbecomes shorter) ( note : identifybrakes slipping ) ( note : Inspectorjustification )

GOI Periodic = Periodic item as GOI certification standard Good = Good Condition Y = Required as per manufacture
OEM Periodic = Periodic item as OEM Manual standard No Good = Broken, Malfunction N = Not Required as per manufacture
No Good = Broken, Malfunction
Comments

The undersigned hereby accept and agree that this equipment is

Verified by: Reviewed by Acknowledged by CPI "OK" and safe for operation.

SIGNATURE, Date :
Contractor's Name
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SAFETY INSPECTION REPORT

Applies to Truck Crane (Lattice Boom & Telescopic Boom)
[ ] Pre-mobilization [ ] Re-Inspection
No Contract :

Equip. No. : Type : Model : Brand :

Serial No. : Km/Hourmeter : Service Date : BM Plate No :

Capacity : Date : Location : Owner :

Fact Finding

Not Aplicable
Inspection

Inspection
Posiible
Finding Group Fact Finding Descriptions
Critical

Other

A. Documentation Operator and Equipment : 0 0 0 10

B. Mandatory Safety Inspections and Devices 0 0 0 65
C. Body 0 0 0 1
D. Crane Cabin and Carrier Cabin Interior 0 0 0 5
E. Main Frame and Main Carrier Chassis 0 0 0 12
F. Crane Hydraulics, General Hydraulics, Fluids, Fuel, Hoses 0 0 0 10
G Engine(s) - Transmission(s) 0 0 0 13
H. Remote Operator's Console 0 0 0 2
I. Servicing and Maintenance 0 0 0 2
J Other 0 0 0 4
TOTAL 0 0 0 124

TOTAL FINDING 0