Title Page
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Inspected by
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Employee ID SAP
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Job Title
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Inspection Date
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Name Site Project or EI Building
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Location
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ID Project or Building
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Department
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Supervisor or Site Safety Responsible
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Using Subcontractor
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Subcontractor Company
1. GENERAL
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1.1 TBT & Morning Briefing meeting held regularly (TBT dan Morning briefing dilakukan secara regular)
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When last TBT/Morning Briefing conduct (Kapan TBT terakhir dilakukan)
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Topic from last TBT (Topik yang disampaikan ketika TBT terakhir)
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TBT Lead by (TBT dipimpin oleh)
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1.2 Workplace safe (huge debris , sharp , falling object)
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Specific area that hazards exist (Area lokasi spesifik bahaya)
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1.3 Workplace sufficient lighting (inside / outside shaft) (Area kerja pencahayaan memadai
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Specific area that hazards exist (Area lokasi spesifik bahaya)
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1.4 All workers must have and bring Safety and Technical Passport (Semua pekerja wajib memiliki dan membawa Safety/Teknikal Passport
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All workers have and bring S&T Passport? (Semua pekerja memiliki dan membawa S&T Passport)
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1.5 Chemicals (Diesel,lubricant,hydraulic oil,thinners etc) labelled & in upright position away from drainage (Bahan kimia diberi label dan berada pada posisi jauh dari drainase.
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1.6 All Power tools is inspected and certified (Semua peralatan power tools diinspeksi dan tersertifikasi)
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1.7 No hazards of Electrical during activity (Tidak terdapat paparan bahaya kelistrikan)
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Details of hazards
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1.8 No Exposure of Rotating Parts (Tidak terdapat paparan bahaya benda bergerak)
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Detail of rotating part hazards (Detil bahaya benda bergerak)
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1.9 PPE is in place and good usage (APD tersedia dan digunakan dengan baik)
2. FALL PROTECTION (NO GO)<br>
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2.1 Workers working at height , wearing safety harness attached to lifeline or tested anchor Point (Pekerja bekerja di ketinggian, menggunakan FBH dikaitkan pada lifeline atau TITIK angkur yang telah diuji)
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All worker who expose falling hazard protected by fall protection system? (Apakah semua pekerja yang terpapr bahaya jatuh terlindungi system perlindungan jatuh?)
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2.2 Full Body Harness is in Good Condition (and used) (FBH digunakan dan dalam kondisi baik)
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All of FBH is in a good condition? (Semua FBH dalam kondisi baik?)
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All workers using FBH properly? (Semua pekerja menggunakan FBH dengan baik?)
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2.3 Anchor Point is Load Tested (TITIK angkur sudah dilakukan pengujian)
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All anchor already tested? (Semua angkur sudah dites?)
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2.4 Lifeline is installed safely (Lifeline dipasang dan digunakan dengan aman)
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Explain the hazards condition
3. SAFE HOISTWAY ACCESS (NO GO)
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3.1 Emergency Stop in Pit is working well
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3.2 Emergency Stop on the Car top is working well
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3.3 Door Switch is working properly
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3.3 Door Stopper is used properly
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3.4 The Worker follow the SHA accordingly
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3.5 Workers work safely at car top
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3.6 Pit dry & no damp
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3.7 Counterwight protection provided
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3.8 Lift Buzzer is working well in the pit
4. HOISTWAY PROTECTION (NO GO)<br>
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4.1 Safety Barricade in good condition
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4.2 Scaffolding safe & validated
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4.3 Car top barriers in good condition
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4.4 Top Work Platform installed accordingly
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4.5 Safe access and clear of hazard on Landing
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4.6 Materials kept away from floor edge or shaft opening
5. LOTO AND JUMPER (NO GO)<br>
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5.1 LOTO Kit is available on site for authorized person only
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5.2 Tag Information is align with the personnel
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5.3 JUMPER is available on site for authorized person only
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5.4 LOTO/JUMPER process in place
6. HOISTING AND RIGGING (NO GO)<br>
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6.1 Lifting Plan is established
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6.2 Hoisting Hook is Load Tested
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6.3 All Lifting Gears is Certified and Valid
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6.4 False car correctly installed and checked regularly
7. ESCALATOR
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7.1 Barricade provided at upper & lower entrances
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7.2 Workers work safely
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7.3 No sharp edges and live wire
Result and Recommendation
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Stop work
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Number of Stop Work
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Stop Work No Go
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Required Sanction
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Name employee who required sanction
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Recommendation
Sign Off
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Sign off Safety Auditor or Safety Inspector