WEEKLY HEALTH & SAFETY PLANT & EQUIPMENT INSPECTION

Project Name : Inspector Name's :

Date :

Location :

The following is to be used as a guide by the team to perform the safety inspection. Observation should be noted on the attached observation sheet. Upon completion of the inspection each category should be rated as
scoring system:
0 = Unacceptable ( 25 to 59% ) SCORING DESCRIPTION
SCORING
SYSTEM

1 = Poor ( 60 to 74% )
2 = Fair ( 75 to 84% )
3 = Acceptable ( 85 to 94 % )
4 = Good ( 95 to 100% )
No.
0 = Potential for serious injury / major damage to equipment 3 = General compliance with legal & site safety requirements
1 = Personnel or equipment may be exposed to hazard 4 = Compliance substantial but not 100% of company requirements
2 = Potential for an incident to occur if not addressed
COMPLIANCE
ITEM OBSERVATIONS & COMMENTS
ACHIEVED

No. Of Facilities Observed: Actual Possible

1.0 PERSONAL PROTECTIVE EQUIPMENT / APD

Is PPE sign available

1 4
Apakah sign APD tersedia

Hard hats/Helmet worn and maintained as required

2 4
Alat pelindung kepala digunakandan dan dipelihara

Hearing protection worn as required

2 4
Alat pelindung telinga digunakan saat diperlukan

Eyes protection required and worn in a proper manner

3 4
Alat pelindung mata digunakandengan benar

Proper foot protection worn for job performed

4 4
Alat pelindung kaki digunakan sesuai pekerjaan

Face Shield or goggles worn as required

5 4
Pelindung wajah digunakan saat diperlukan

Others, respirators, gloves, chemical resistant garments

6 4
Pelindung pernafasan, sarung tangan dan pakaian untuk zat kimia digunakan

Barricades, and or rebar caps installed and maintained

7 4
Penghalang dan penutup benda runcing terpasang
0 32

0%

2.0 FALL PROTECTION / PELINDUNG JATUH

Body harness are inspected prior to use and recorded

1 4
Body harness diperiksa dan di catat sebelum digunakan

Body harness required and worn in a proper manner

2 4
Body harness digunakan dengan benar saat bekerja

Landyard are adequately secured to suitable anchorage

3 4
Landyard dikaitkan ke posisi dengan benar

Static lines, rat lines installed and capable of supporting force

4 4
Tali Statik , Dasar Tali dipasang dan mampu menahan beban dengan cukup kuat

Fall protection equipment is used only for all protection

5 4
Alat pelindung jatuh digunakan hanya untuk pelindung jatuh

Fall protection maintained and has current inspection

6 4
Pelindung jatuh dirawat dan diinspeksi secara rutin
0 24

0%

3.0 FIRE PROTECTION / PENCEGAH KEBAKARAN

Flammable stored properly

1 4
Material mudah terbakar disimpan dengan aman

Are MSDS available and published?

2 4
Adakah MSDS tersedia dan di publikasikan?

Oxygen and combustibles separated

3 4
Oksigen dan material mudah meledak dipisahkan

Containers labeled as to content

4 4
Tempat bahan-bahan kimia telah dilengkapi dengan label

Fire extinguisher properly located and inspected

5 4
Pemadam api tersedia di lokasi kerja dan telah di inspeksi

Flash arrestor installed

6 4
Flash back arrestor terpasang

Compressed gas cylinders properly maintained

7 4
Tabung gas bertekanan telah tersimpan dengan aman

Containment of hot work and welding screens as required

8 4
Welding screen tersedia ketika pekerjaan panas (welding, cutting, grinding)

Regulator gauges properly attached and maintained

9 4
Regulator terpasang dan terawat
0 36

0%

4.0 POLICY, OBJECTIVE & TARGET, MEASURE CONTROLL & WORK METHOD

Work Permit completed before start work

1 4
Ijin bekerja sudah lengkap sebelum melakukan pekerjaan

Personnel are complying with permit / procedure requirements

2 4
Personal menyetujui adanya permit / prosedur yang sudah ditetapkan

Is there tool box meeting and pre-shift briefing conducted regularly?

3 4
Apakah tool box meeting dan pengarahan kerja diselenggarakan secara teratur?

Is there pre-shift briefing conducted prior working?

4 4
Apakah ada pengarahan singkat yang dilaksanakan dipergantian jam kerja?

Is there Hazard observation assessments being performed prior working?

5 4
Apakah penilaian pengamatan bahaya dilakukan selama bekerja?

IMS_112 QSHE WEEKLY HEALTH SAFETY PLANT EQUIPMENT INSPECTION

The following is to be used as a guide by the team to perform the safety inspection. Observation should be noted on the attached observation sheet. Upon completion of the inspection each category should be rated as
scoring system:
0 = Unacceptable ( 25 to 59% ) SCORING DESCRIPTION
SCORING
SYSTEM
1 = Poor ( 60 to 74% )
2 = Fair ( 75 to 84% ) 0 = Potential for serious injury / major damage to equipment 3 = General compliance with legal & site safety requirements
3 = Acceptable ( 85 to 94 % ) 1 = Personnel or equipment may be exposed to hazard 4 = Compliance substantial but not 100% of company requirements
4 = Good ( 95 to 100% ) 2 = Potential for an incident to occur if not addressed
COMPLIANCE
No. ITEM OBSERVATIONS & COMMENTS
ACHIEVED

No. Of Facilities Observed: Actual Possible

Is there JSEA provided for certain work activity and supervisors have JSEA's in the field?
6 4
Apakah JSEA tersedia pada aktifitas pekerjaan dan supervisor memiliki JSEA?

Is a JSEA completed by employees involved and communicated?

7 4
JSEA dibuat oleh karyawan yang terlibat dan bahas bersama?

Do supervisors complete JSEA Verification ?

8 4
Apakah supervisor melengkapi verifikasi JSEA ?

Are policies posted in the public area of the office?

9 4
Apakah kebijakan HSE terpampang ditempat umum dalam area kantor?

Are the employee know about Company HSE Policy?

10 4
Apakah karyawan mengetahui tentang kebijaksanaan HSE perusahaan?

Are the operators following safety procedures on operating his equipment?

11 4
Apakah operator sudah mengikuti prosedur keselamatan pada saat bekerja?

Is there rule of parked and access way already following?

12 4
Apakahn peraturan parkir dan akses jalan sudah diikuti?

Is there spotter procedure already following?

13 4
Apakah prosedur spotter sudah diikuti?

Are inspections of the site conducted & recorded?

14 4
Apakah inspeksi dilaksanakan dan dicatat?

Competence employee for task available

15 4
Karyawan kompeten untuk aktivitas pekerjaan sudah ada

Barricades are installed surrounding area

16 4
Barikade tersedia di sekitar lingkup area

Personal danger tags & Padlock/LOTO correctly fitted out and in place
17 4
Label bahaya & Padlock terpasang dengan benar

Have all the plans been tested?

18 4
Apakah semua perencanaan sudah dites?

Are objectives and targets displayed on notice boards?

19 4
Apakah sasaran dan target ditunjukkan pada papan pengumuman?
0 76

0%

5.0 HAZARDOUS & TOXIC / BAHAN BERBAHAYA DAN BERACUN

Have all waste correctly maintain

1 4
Apakah limbah (oli, grease, majun, battery, scrap metal filter,etc) dikeloka dengan benar

Is there any waste bin available and maintained

2 4
Apakah tempat penampungan tersedia dan dirawat

Is there B3 storage always be empty

3 4
Apakah tempat penampungan B3 selalu dikosongkan
0 12

0%

6.0 LIFTING EQUIPMENT / PEKERJAAN ALAT ANGKAT

Is the operator competent and has a simper , SIO

1 4
Apakah crane operator berkompeten dan memiliki Simper, SIO

Have Understanding about SWL ( safety weight lifting )

2 4
Apakah barang yang di angkat dilengkapi dengan tag line

Is the rigger competent

3 4
Apakah rigger berkompetent

Is there lifting work appropriate with SWL?

4 4
Apakah barang yang di angkat sesuai dengan SWL alat angkat?

Is there crane swing area is free from electrical hazard

5 4
Apakah area swing untuk crane bebas dari bahaya listrik

the outrigger be in heavy ground

6 4
Apakah outrigger berada di permukaan yang padat

Is there communication available between operator and rigger

7 4
Apakah alat komunikasi tersedia antara operator crane dan rigger
0 28

0%

7.0 GENERAL CONDITION / KONDISI UMUM

Is there any safety sign at workshop area available?

1 4
Apakah ada papan tanda aman tersedia diworkshop?

Is there safe distance already following?

2 4
Apakah jarak aman sudah diikuti?

Is there resting place clean and tidy?

3 4
Apakah tempat istirahat bersih dan rapi/teratur?

Is there adequate lighting available in certain position?

4 4
Apakah penerangan ada dan cukup memadai pada positi yang tepat?

Is there first aid kit available at workshop area?

5 4
Apakah kotak P3 tersedia di area workshop?

Is there eye wash station available ?

6 4
Apakah tempat pembasuh mata tersedia ?

0 24

0%

IMS_112 QSHE WEEKLY HEALTH SAFETY PLANT EQUIPMENT INSPECTION

The following is to be used as a guide by the team to perform the safety inspection. Observation should be noted on the attached observation sheet. Upon completion of the inspection each category should be rated as
scoring system:
0 = Unacceptable ( 25 to 59% ) SCORING DESCRIPTION
SCORING
SYSTEM
1 = Poor ( 60 to 74% )
2 = Fair ( 75 to 84% ) 0 = Potential for serious injury / major damage to equipment 3 = General compliance with legal & site safety requirements
3 = Acceptable ( 85 to 94 % ) 1 = Personnel or equipment may be exposed to hazard 4 = Compliance substantial but not 100% of company requirements
4 = Good ( 95 to 100% ) 2 = Potential for an incident to occur if not addressed
COMPLIANCE
No. ITEM OBSERVATIONS & COMMENTS
ACHIEVED

No. Of Facilities Observed: Actual Possible

8.0 HOUSEKEEPING & ENVIRONMENT / KEBERSIHAN

Project work areas are clean and free of access trash & debris
1 4
Area kerja bersih dan bebas dari sampah dan puing

Walkways and passageways clear

2 4
Gang dan jalan masuk bebas dari halangan

Material or equipment properly stored

3 4
Material atau peralatan disimpan dengan baik

Electrical cord, hoses, welding leads, etc elevated to prevent trip hazard
4 4
Sambungan kabel, kabel las di atur dengan baik untuk menghindari bahaya tersandung

Scrap metal free of protruding nails or other puncture hazard

5 4
Sampah logam bebas dari bahaya tertusuk/terpukul

Trash receptacles are provide for work areas and water kegs
6 4
Tempat sampah tersedia ditempat kerja dan berlabel

Barricades, and or rebar caps installed and maintained

7 4
Barikade atau penutup rebar dipasang dan terpelihara

Wash pad is free from muds

8 4
Wash pad bebas dari lumpur

0 32

0%

9.0 ADDITIONAL SUGGESTION / TAMBAHAN

1 4

2 4

3 4

4 4

5 4

0 20

0%

NO PICTURES FINDING NOTES PIC

5
IMS_112 QSHE WEEKLY HEALTH SAFETY PLANT EQUIPMENT INSPECTION
The following is to be used as a guide by the team to perform the safety inspection. Observation should be noted on the attached observation sheet. Upon completion of the inspection each category should be rated as
scoring system:
0 = Unacceptable ( 25 to 59% ) SCORING DESCRIPTION
SCORING
SYSTEM
1 = Poor ( 60 to 74% )
2 = Fair ( 75 to 84% ) 0 = Potential for serious injury / major damage to equipment 3 = General compliance with legal & site safety requirements
3 = Acceptable ( 85 to 94 % ) 1 = Personnel or equipment may be exposed to hazard 4 = Compliance substantial but not 100% of company requirements
4 = Good ( 95 to 100% ) 2 = Potential for an incident to occur if not addressed
COMPLIANCE
No. ITEM OBSERVATIONS & COMMENTS
ACHIEVED

No. Of Facilities Observed: Actual Possible

5

General Comments

Conducted by Acknowladge by

Safety Supv , Officer & Mechanic Supv Plant Manager

IMS_112 QSHE WEEKLY HEALTH SAFETY PLANT EQUIPMENT INSPECTION

 HEALTH & SAFETY PREPARATION AND LABORATORY INSPECTION
Project Name :
Date :
Location :

The following is to be used as a guide by the team to perform the safety inspection. Observation should be noted on the attached observation sheet. Upon completion of the inspection each category should be rated
as scoring system:
0 = Unacceptable ( 25 to 59% ) SCORING DESCRIPTION
SCORING
SYSTEM

1 = Poor ( 60 to 74% )
2 = Fair ( 75 to 84% ) 0 = Potential for serious injury / major damage to equipment 3 = General compliance with legal & site safety requirements
3 = Acceptable ( 85 to 94 % ) 1 = Personnel or equipment may be exposed to hazard 4 = Compliance substantial but not 100% of company requirements
4 = Good ( 95 to 100% ) 2 = Potential for an incident to occur if not addressed
COMPLIANCE
No. ITEM OBSERVATIONS & COMMENTS
ACHIEVED
No. Of Facilities Observed: Actual Possible
1.0 PREPARATION & LAB FACILITY
Is there resting place clean and tidy?
1 4
Apakah tempat istirahat bersih dan rapi/teratur?
Is there adequate lighting available in certain position?
2 4
Apakah penerangan ada dan cukup memadai pada posisi yang tepat?
Is there rubbish bin provided?
2 4
Apakah tempat sampah tersedia ?
Is there parking area provided?
3 4
Apakah disediakan tempat parkir?
Is the parking area level & parking sign provided?
4 4
Apakah area parkir datar & rambu parkir tersedia?
Is the toilet available & clean ?
5 4
Apakah toilet tersedia dan bersih ?
0 24
0%
2.0 PERSONAL PROTECTIVE EQUIPMENT / APD
Is PPE sign available
1 4
Apakah sign APD tersedia
Hard hats/Helmet worn and maintained as required
2 4
Alat pelindung kepala digunakandan dan dipelihara
Eyes protection required and worn in a proper manner
3 4
Alat pelindung mata digunakan dengan benar
Proper foot protection worn for job performed
4 4
Alat pelindung kaki digunakan sesuai pekerjaan

Others, respirators, gloves, chemical resistant garments as required

5 4
Pelindung pernafasan, sarung tangan dan pakaian untuk zat kimia digunakan saat diperlukan

Hearing protection worn as required

6 4
Alat pelindung telinga digunakan saat diperlukan
Face Shield or goggles worn as required
7 4
Pelindung wajah digunakan saat diperlukan
0 28
0%
3.0 EMERGENCY SYSTEM / SISTEM KEDARURATAN
Flammable stored properly
1 4
Material mudah terbakar disimpan dengan aman
Compressed gas cylinders properly maintained
2 4
Tabung gas bertekanan telah tersimpan dengan aman
Is there first aid box available?
3 4
Apakah kotak P3K tersedia ?
Fire extinguisher properly located and inspected?
4 4
Pemadam api tersedia di lokasi kerja dan telah di inspeksi?
Regulator gauges properly attached and maintained?
5 4
Regulator terpasang dan terawat?
Is there eye wash station available ?
6 4
Apakah tempat pembasuh mata tersedia ?
Fire extinguisher properly located and inspected?
7 4
Pemadam api tersedia di lokasi kerja dan telah di inspeksi?
Evacuation routes are available and unobstructed?
8 4
Jalur evakuasi tersedia dan tidak terhalang?
Sign evacuation routes posted and clearly?
9 4
Sign jalur evakuasi terpasang dan jelas?
Muster point properly located?
10 4
Tempat titik kumpul tersedia di lokasi?
0 40
0%
4.0 POLICY, OBJECTIVE & TARGET, MEASURE CONTROLL & WORK METHOD
Is there tool box meeting and pre-shift briefing conducted regularly?
1 4
Apakah tool box meeting dan pengarahan kerja diselenggarakan secara teratur?
Is there pre-shift briefing conducted prior working?
2 4
Apakah ada pengarahan singkat yang dilaksanakan dipergantian jam kerja?
Is there Hazard observation assessments being performed prior working?
3 4
Apakah penilaian pengamatan bahaya dilakukan selama bekerja?
Is there SOP, JSEA or Work Instructions provided for certain work activity and supervisors have
SOP, JSEA or Work Instructions in the field?
4 4
Apakah SOP, JSEA atau IK tersedia pada aktifitas pekerjaan dan supervisor memiliki SOP, JSEA
atau IK?
Is a JSEA completed by employees involved and communicated?
5 4
JSEA dibuat oleh karyawan yang terlibat dan dibahas bersama?
Are Mining Safety policies posted in the public area of the office?
4
6 Apakah kebijakan KP terpampang ditempat umum dalam area kantor?
 Are the employee know about Company Mining Safety Policy?
7 4
Apakah karyawan mengetahui tentang kebijaksanaan KP perusahaan?
Are the operators following safety procedures on operating his equipment?
8 4
Apakah operator sudah mengikuti prosedur keselamatan pada saat bekerja?
Is there rule of parked and access way already following?
9 4
Apakah peraturan parkir dan akses jalan sudah diikuti?
Is there spotter procedure already following?
10 4
Apakah prosedur spotter sudah diikuti?
Are inspections of the site conducted & recorded?
11 4
Apakah inspeksi dilaksanakan dan dicatat?
Competence employee for task available
12 4
Karyawan kompeten untuk aktivitas pekerjaan sudah ada
Barricades are installed surrounding area
13 4
Barikade tersedia di sekitar lingkup area
Have all the plans been tested?
14 4
Apakah semua perencanaan sudah dites?
Are pre-start check of the site conducted & recorded?
15 4
Apakah P2H dilaksanakan dan dicatat?
0 60
0%
5.0 HAZARDOUS & TOXIC / BAHAN BERBAHAYA DAN BERACUN

Have all waste correctly maintain

1 4
Apakah limbah (oli, grease, majun, battery, scrap metal filter,etc) dikeloka dengan benar

Is there any waste bin available and maintained

2 4
Apakah tempat penampungan tersedia dan dirawat
Is there B3 storage always be empty
3 4
Apakah tempat penampungan B3 selalu dikosongkan
Are MSDS available and published?
4 4
Adakah MSDS tersedia dan di publikasikan?
Containers labeled as to content?
5 4
Tempat bahan-bahan kimia telah dilengkapi dengan label?
0 20
0%
6.0 HOUSEKEEPING & ENVIRONMENT / KEBERSIHAN
Project work areas are clean and free of access trash & debris
1 4
Area kerja bersih dan bebas dari sampah dan puing
Walkways and passageways clear
2 4
Gang dan jalan masuk bebas dari halangan
Material or equipment properly stored
3 4
Material atau peralatan disimpan dengan baik
Scrap metal free of protruding nails or other puncture hazard
4 4
Sampah logam bebas dari bahaya tertusuk/terpukul
Trash receptacles are provide for work areas and water kegs
5 4
Tempat sampah tersedia ditempat kerja dan berlabel
0 20
0%
7.0 ADDITIONAL SUGGESTION / TAMBAHAN
1
2
3
4
5
0 0
0%

NO PICTURES FINDING NOTES PIC

General Comments

Conducted by, Checked by, Approved by,

1 Sign:
2 Sign:
3 Sign:
4 Sign:
5 Sign:
Inspection Representative SHQ Head Dept. Laboratory Head Dept. Chief Technical of Mine (KTT)

Originator : Document No. :

Frans Nico Rory HM-FRM-SHQ-085(00) - Health & Safety Preparation & Laboratory Inspection
Revision Description : Expire Date : Department : Document Type :
Issue Revision Date
First Issue Dec 31st, 2025 SHQ Form