MINE MAINTENANCE DEPARTMENT

Commissioning Inspection Form (Heavy Equipment)

Commissioning Inspection Form (Heavy Equipment)
Doc No: CDC-MMN-000-F399 Version: 1.1 Page: 1 of 7
Approval Date: 11/20/2023 Review Cycle: 3 Years Author: Supt. - Maintenance Planning
Document Classification: For Internal Purpose Approval: Manager - Maintenance

Revision History
Version Date Summary Changes
1.1 Nov 20, 2023 Change to the current template

Reference/associated documents
Document Number Document Title or Information Source Location

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THIS DOCUMENT IS UNCONTROLLED OUTSIDE DOCUMENT CONTROL SYSTEM
MINE MAINTENANCE DEPARTMENT
Commissioning Inspection Form (Heavy Equipment)
Commissioning Inspection Form (Heavy Equipment)
Doc No: CDC-MMN-000-F399 Version: 1.1 Page: 2 of 7
Approval Date: 11/20/2023 Review Cycle: 3 Years Author: Supt. - Maintenance Planning
Document Classification: For Internal Purpose Approval: Manager - Maintenance

MACHINE INFORMATION

MACHINE DETAIL: EQR017899

Machine No : EX01
Machine Type : Sany Hydraulic Excavator
Machine Model : SY75C
Machine SN : SY007CEQ338K8
Machine Arr :

Engine Model : ISUZU 4JG1-NABGB-03-C2

Engine SN : 4JG1-649240
Engine Arr. No :

Front Suspension RH :
Front Suspension LH :

Rear Suspension RH :
Rear Suspension LH :

Turbocharger RH :
Turbocharger LH :

Transmission Pump SN :
Transmission Pump Arr. :

Transmission SN :
Transmission Arr :

Starter Motor SN :
Starter Motor Arr :

Body Dump SN-(OHT/ADT only) :

Date of Commissioning : 13 Juli 2024

COMMISIONING INSPECTION FORM

HEAVY EQUIPMENT

DOKUMEN INI TIDAK DIKENDALIKAN DI LUAR SISTEM KONTROL DOKUMEN

THIS DOCUMENT IS UNCONTROLLED OUTSIDE DOCUMENT CONTROL SYSTEM
MINE MAINTENANCE DEPARTMENT
Commissioning Inspection Form (Heavy Equipment)
Commissioning Inspection Form (Heavy Equipment)
Doc No: CDC-MMN-000-F399 Version: 1.1 Page: 3 of 7
Approval Date: 11/20/2023 Review Cycle: 3 Years Author: Supt. - Maintenance Planning
Document Classification: For Internal Purpose Approval: Manager - Maintenance

Company: PT Lintech Duta Pratama Equipment Type: Sany Hydraulic Excavator

Equipment No: EXC01 Date Inspection: 13 Juli 2024

HOURS METER: 46

DOKUMEN INI TIDAK DIKENDALIKAN DI LUAR SISTEM KONTROL DOKUMEN

THIS DOCUMENT IS UNCONTROLLED OUTSIDE DOCUMENT CONTROL SYSTEM
MINE MAINTENANCE DEPARTMENT
Commissioning Inspection Form (Heavy Equipment)
Commissioning Inspection Form (Heavy Equipment)
Doc No: CDC-MMN-000-F399 Version: 1.1 Page: 4 of 7
Approval Date: 11/20/2023 Review Cycle: 3 Years Author: Supt. - Maintenance Planning
Document Classification: For Internal Purpose Approval: Manager - Maintenance

N/
Ref. Item Comment Pass Fail
A
A. CRITICAL ITEMS (check throughout inspection)
1.  Visibility
Rotary light /Flashing light orange or blue as per Pit
1.1 √
Traffic Rules
1.2 Asset numbers on both sides/front/rear clearly visible. √

2.  In the cabin
2.1 Radio communication (Two way) Hand Held √
2.2 Seat condition manufacturers standard √
2.3 Seat belt installed properly in good working order √
ROPS manufactures/international standard (not applicable
2.4 √
for excavators)
2.5 FOPS manufactures/international standard √
2.6 Fire extinguishers fully charged and mounted properly. √
2.7 Fire Suppression – Charged and Operational √
2.8 Air Conditioner - Operational √
2.9 All electrical gauges working √
2.10 Horn - Operation √
2.11 Fully enclosed canopy for Coal Mining √
2.12 Fatigue warning for haul trucks – if applicable √
2.13 Front wiper & windshield washer - Operation √
2.14 Safety Pin lock/cable for dump body (for Haul truck only) √
2.15 First Aid Kit √
2.16 Cab Door Locks & Window Functional √
2.17 Noise test < 85 dB in the cabin, if > 85 dB √
2.18 Install Jigsaw / GPS (Optional) √

3.  Mechanical/Electrical
3.1 All work lamps (head, tail, brake, reverse) √
3.2 Reversing alarm/movement alarm √
Tyres & Rims/Mounting hardware in good condition and
3.3 Track √
secure.
3.4 Tow point if fitted must be to Macmahon Standard. √
3.5 Access system & steps in good condition √
3.6 General mechanical condition/All fluid levels correct √
3.7 Ground level engine shutdown - Operational √

DOKUMEN INI TIDAK DIKENDALIKAN DI LUAR SISTEM KONTROL DOKUMEN

THIS DOCUMENT IS UNCONTROLLED OUTSIDE DOCUMENT CONTROL SYSTEM
 MINE MAINTENANCE DEPARTMENT
Commissioning Inspection Form (Heavy Equipment)
Commissioning Inspection Form (Heavy Equipment)
Doc No: CDC-MMN-000-F399 Version: 1.1 Page: 5 of 7
Approval Date: 11/20/2023 Review Cycle: 3 Years Author: Supt. - Maintenance Planning
Document Classification: For Internal Purpose Approval: Manager - Maintenance

3.8 Handrails, safety chain & bar √

3.9 Front spill guard for Haul Truck √
3.10 Rear view mirrors – Clear and undamaged √
3.11 Blade/Ripper Functions(Dozer & Grader) - Operation Bucket & Blade √
3.12 Isolation lock out & battery isolation switch √
Check for loose or missing items. (Guards,Covers,
3.13 √
Steps,etc)
3.14 Steering Operation- Standard and Emergency √
3.15 Parking brake - Check Operation as per OEM Standard √
3.16 Service brake - Check Operation √
3.17 Emergency brake – Check Operation √
3.18 Retarder (c/w lamp) - if applicable – Check Operation √
Dump Body Function – ADT/OHT – Cycle time for
3.19 √
Raise/Lower – OEM Specification
3.20 Check for Fault Alarms/Codes active √
3.21 Record Machine Hours at completion of Commissioning 46 √
If new machine, has OEM Commissioning report been
3.22 √
supplied?

Comments :

AMAN UNTUK BEROPERASI DILINGKUNGAN KERJA BATU HIJAU

B. COMMISSIONING TEAM :

Inspector / Supervisor Name : Aster Tuelah / 23002271 Signature:

Manager / Superintendent Name : I Nengah Sukriadi / 23000051 Signature:

Safety Supervisor / Officer Name : ______________________ Signature: _____________________

DOKUMEN INI TIDAK DIKENDALIKAN DI LUAR SISTEM KONTROL DOKUMEN

THIS DOCUMENT IS UNCONTROLLED OUTSIDE DOCUMENT CONTROL SYSTEM
MINE MAINTENANCE DEPARTMENT
Commissioning Inspection Form (Heavy Equipment)
Commissioning Inspection Form (Heavy Equipment)
Doc No: CDC-MMN-000-F399 Version: 1.1 Page: 6 of 7
Approval Date: 11/20/2023 Review Cycle: 3 Years Author: Supt. - Maintenance Planning
Document Classification: For Internal Purpose Approval: Manager - Maintenance

DOKUMEN INI TIDAK DIKENDALIKAN DI LUAR SISTEM KONTROL DOKUMEN

THIS DOCUMENT IS UNCONTROLLED OUTSIDE DOCUMENT CONTROL SYSTEM