ALSTOM Grid EHS - HSV checklist and report （lndonesian language）

• Prepared by

HIERARCHICAL SAFETY VISIT

• Name of site

• Type of site

  industrial

  Field / construction

  office
• Area visited
  Address

• Conducted on

  Date

• USE CHECKLIST?

  Use

GENERAL CONDITIONS

• Is the site tidy and clean? Apakah site bersih dan teratur?

  Yes

  No

  N/A

• Are material and scrap properly stored? Apakah material dan sisa sisa material tersimpan dengan baik ?

  Yes

  No

  N/A

• Is EHS information properly posted ? Apakah info EHS terpampang dengan baik?

  Yes

  No

  N/A

• Have you done your EHS induction ? Apakah anda mendapat EHS induksi?

  Yes

  No

  N/A

• Explain why

PERSONAL PROTECTIVE EQUIPMENT

• Safety boots? Sepatu safety?

  Safe

  At Risk

  N/A

• Ear protection? Pelindung telinga?

  Safe

  At Risk

  N/A

• High visibility vest or straps? Rompi Hi-vi?

  Safe

  At Risk

  N/A

• Safety glasses, face shield? Kacamata pelindung, pelindung wajah?

  Safe

  At Risk

  N/A

• No gloves for rotating hand tools? Tidak menggunakan sarung tangan untuk hand tools yang berputar?

  Safe

  At Risk

  N/A

• Respiratory protection? Perlindungan penapasan?

  Safe

  At Risk

  N/A

• Fire resistant garments? Pakaian tahan api?

  Safe

  At Risk

  N/A

* CONFINED SPACES

• Applicable ? Teraplikasi?

  Yes

  No

  N/A

• Are competency & training checked? Apakah kompetensi dan training di cek?

  Yes

  No

  N/A

• Air test done? Test udara dilakukan?

  Yes

  No

  N/A

• Was the permit delivered? Apakah ijin kerja dilaksanakan?

  Yes

  No

  N/A

• Are confined spaces clearly identified? Apakah ruang terbatas teridentifikasi dengan jelas?

  Yes

  No

  N/A

• Is there a keeper dedicated to the confined space? Apakah ada penjaga khusus untuk ruang terbatas?

  Yes

  No

  N/A

• Emergency Arrangements checked ? Apakah pengaturan keadaan darurat di cek?

  Yes

  No

  N/A

* LOCK OUT TAG OUT

• Applicable? Teraplikasi?

  Yes

  No

  N/A

• LOTO procedure available? Prosedur LOTO tersedia?

  Yes

  No

  N/A

• One lock̀, one key, one person? Satu gembok,satu kunci,satu orang?

  Yes

  No

  N/A

• Are employees trained to LOTO? Apakah semua pekerja sudah di training LOTO?

  Yes

  No

  N/A

• Absence of residual Energy is checked before work? Apakah sisa energy sudah di cek sebelum memulai perkerjaan?

  Yes

  No

  N/A

• Is LOTO done on all energized equipment? Apakah LOTO dilaksanakan untuk semua peralatan yang bertegangan?

  Yes

  No

  N/A

* ELECTRICAL SAFETY

• Applicable? Teraplikasi?

  Yes

  No

  N/A

• Are competency & training checked? Apakah kompetensi dan training di cek?

  Yes

  No

  N/A

• Is equipment dead prior to work? Apakah semua peralatan bebas tegangan sebelum memulai pekerjaan?

  Yes

  No

  N/A

• Are electrical panels tagged? Apakah semua panel listrik di tagged/ditandai?

  Yes

  No

  N/A

• Is there work live on Voltage? Apakah bekerja di tegangan listrik dilarang?

  Yes

  No

  N/A

• Are appropriate tools available? Apakah peralatan yang memadai tersedia?

  Yes

  No

  N/A

• Are safe working distance respected? Apakah jarak bekerja yang aman di patuhi?

  Yes

  No

  N/A

• Are appropriate PPE available? Apakah PPE yang memadai tersedia?

  Yes

  No

  N/A

* MACHINE SAFETY

• Applicable? Teraplikasi?

  Yes

  No

  N/A

• Are competency and training checked? Apakah kompetensi dan training di cek?

  Yes

  No

  N/A

• Are all guards in place & checked? Apakah semua pelindung berfungsi dan di cek?

  Yes

  No

  N/A

• Are electric tools inspected & conform? Apakah semua perkakas listrik diperiksa dan memenuhi syarat?

  Yes

  No

  N/A

• Are equipment unplugged when changing tools? Apakah semua peralatan dilepas dari sumber listrik saat melakukan pergantian parts?

  Yes

  No

  N/A

• Are extension cords protected or suspended? Apakah kabel extension terlindungi atau tergantung?

  Yes

  No

  N/A

* WORKING AT HEIGHT

• Applicable? Teraplikasi?

  Yes

  No

  N/A

• Are competency & training checked? Apakah kompetensi dan training di cek?

  Yes

  No

  N/A

• Lifting equipments inspected? Apakah semua peralatan untuk bekerja diketinggian diperiksa?

  Yes

  No

  N/A

• Fall arrest equipments inspected? Alat penahan jatuh di periska?

  Yes

  No

  N/A

• Scaffolds inspected and tagged? Scaffolding diperiksa dan di label/tagged?

  Yes

  No

  N/A

• Temporary floor/roof openings protected? Lantai sementara atau bukaan atap di proteksi?

  Yes

  No

  N/A

• Ladders attached and secured? Tanggan terikat dengan baik?

  Yes

  No

  N/A

• Full body harness & chinstrap worn? Full body harness dan pengikat dagu digunakan?

  Yes

  No

  N/A

• Fall arrest equipments listed on a register? Alat penahan jatuh ter registrasi dalam list perlatan?

  Yes

  No

  N/A

• Was the permit delivered? Apakah ijin kerja dilaksanakan?

  Yes

  No

  N/A

* EXCAVATION AND TRENCHES

• Applicable? Teraplikasi?

  Yes

  No

  N/A

• Permit delivered for excavation > or = 1,2 meters? Ijin kerja dilakukan untuk penggalian > atau = 1,2 meters?

  Yes

  No

  N/A

• Are all excavations inspected daily? Apakah semua penggalian di inspeksi setiap hari?

  Yes

  No

  N/A

• Rigid barriers less than 1,5 from edges for excavation > or = 1,2 meters? Penahan keras/rigid barrier terpasang kurang dari 1.5m dari tepi galian yg dalamnya > atau = 1.2 meter?

  Yes

  No

  N/A

• Slopes according to construction code? Kemiringan galian sesuai dengan norma konstruksi?

  Yes

  No

  N/A

• Trenches identified and protected? Parit teridentifikasi dan diproteksi?

  Yes

  No

  N/A

• Vehicle parking 3 meters from hedge? Kendaraan diparkir 3 meter dari tepi galian?

  Yes

  No

  N/A

• Protective system against fall of the excavation? System proteksi dari keruntuhan galian (shoring)?

  Yes

  No

  N/A

• Excavated material > or = 1 meter from hedge? Tumpukan galian >= 1 meter dari tepi galian?

  Yes

  No

  N/A

• Ladders or exits every 15 meters? Tangga atau jalan keluar tersedia di setiap 15 meter?

  Yes

  No

  N/A

* LIFTING OPERATIONS

• Applicable? Teraplikasi?

  Yes

  No

  N/A

• Lifting permit to work issued? Ijin pekerjaan pengangkatan dilakukan/tersedia?

  Yes

  No

  N/A

• Lifting plan available? Rencana pengangkatan tersedia?

  Yes

  No

  N/A

• Are competency and training checked ? Respected? Apakah kompetensi dan training di cek?dan diterapkan dengan baik?

  Yes

  No

  N/A

• Are lifting equipment in register? Apakah peralatan pengangkatan ter registrasi/terdaftar secara formal?

  Yes

  No

  N/A

• Safety zone established under the lifting area? Daerah aman ditetapkan dibawah daerah pengangkatan?

  Yes

  No

  N/A

• Are lifting equipment inspected and conform? Apakah peralatan pengangkatan diperiksa dan memenuhi syarat?

  Yes

  No

  N/A

* VEHICULE MOVEMENTS

• Applicable? Teraplikasi?

  Yes

  No

  N/A

• Are vehicules tidy and clean? Apakah kendaraan dalam keadaan rapid an bersih?

  Yes

  No

  N/A

• Is traffic signing properly installed? Apakah rambu lalu lintas terpasang dengan baik dan benar?

  Yes

  No

  N/A

• Parking Area & rules established? Tempat parkir dan peraturan ditentukan?

  Yes

  No

  N/A

• Are competency and training checked ? Respected? Apakah kompetensi dan training di cek?dan dilakukan dengan baik dan benar?

  Yes

  No

  N/A

• Forklifts with fork lowered, boom tilted back and seat belt fastened? Forklift dengan garpu dibawah, boom condong kebelakang dan seat belt digunakan?

  Yes

  No

  N/A

• Circulation of mobile equipment and pedestrians seperated and clearly signalized? Pergerakan kendaraan dan pejalan kaki terpisah dengan jelas dan dengan rambu2?

  Yes

  No

  N/A

• Is a safe distance of 2 meters respected between pedestrians and vehicles? Apakah jarak aman 2 meter benar diterapkan antara pejalan kaki dan kendaraan?

  Yes

  No

  N/A

ENVIRONMENT

• Applicable? Teraplikasi?

  Yes

  No

  N/A

• Are MSDS available? Apakah MSDS tersedia?

  Yes

  No

  N/A

• Are flammable segregated from oxidizing material? Apakah material mudah terbakar terpisah dari material yang meng oksidasi?

  Yes

  No

  N/A

• Are compressed gases secured? Apakah gas bertekanan dalam keadaan aman?

  Yes

  No

  N/A

• Are compressed gases stored in designated area? Apakah gas bertekanan disimpan di tempat yang telah ditentukan?

  Yes

  No

  N/A

• Is oil store in designated area? Apakah oil disimpan ditempat yang ditentukan?

  Yes

  No

  N/A

FIRST AID, EMERGENCY AND ENVIRONMENT PREPAREDNESS

• First aid kit available and inspected? Alat P3K tersedia dan di periksa?

  Yes

  No

  N/A

• Is evacuation plan & gathering point communicated ? Apakah rencana evakuasi dan tempat berkumpul di komunikasikan?

  Yes

  No

  N/A

• Is First aiders list posted ? Apakah petugas P3K terpampang?

  Yes

  No

  N/A

• As there and inspected fire extinguisher? Apakah ada inspeksi untuk tabung pemadam kebakaran?

  Yes

  No

  N/A

• Are spill kits available and inspected? Apakah alat penampung tumpahan dan di periksa?

  Yes

  No

  N/A

SAFETY OBSERVATION REPORT

• Positive observations

• Add media

  Media

• Aspects to improve or Deviations

• Add media

  Media

• Action and person in charge

• Date of completion

  Date

• Satisfaction level of the visit (very poor; 10 excellent)

• Signature

  Sign