Contractor Safety, Health and Environment Management Systems

Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

SECTION 1 – LEADERSHIP AND COMMITMENT

SECTION 1 – Komitment dan Kepemimpinan
1. Commitment to HSE through leadership
Komitment terhadap K3LL dalam kepemimpinan
a) How are senior managers personally involved in HSE management ?
Bagaimanakah secara pribadi manajer-manajer senior terlibat dalam pengelolaan K3LL?
(harap dijelaskan)

Lampirkan: Kegiatan Kunjungan kelapangan

Answer: The Managing Director accepts the overall responsibility of the policy. The managing director delegates
his responsibility to the technical director who delegates to Head of Departments and the Supervisors in ensuring
that the policy, together with the Safety and Health procedural requirements and instruction are read and
understood by all employees as well as conductors and their associates.

b) Provide evidence of commitment at all levels of the organization ?

Berikan bukti komitmen pada semua jenjang organisasi?

Lampirkan : HSE MOM and participants list

Answer: Please see our HSE Management Meeting

c) How do you promote a positive culture towards HSE matters?

Bagaimanakah anda mempromosikan budaya positif melalui masalah K3LL?
(berikan penjelasan)

Lampirkan: HSE meeting, posters, awards, etc.

Answer: By distribution all HSE manual, HSE policies, HSE procedure and HSE issues
By training to all employees
Demonstrated on the wall
Communicate with HSE office in the field

SECTION 2: POLICY AND STRATEGIC OBJECTIVES

SECTION 2: Kebijakan dan Strategi Objektif
2.1. HSE Policy & Documents
a) Does your company have an HSE policy document? Yes No. If Yes, please attach.
Apakah perusahaan anda mempunyai dokumen tertulis mengenai kebijakan K3LL? Jika Ya, lampirkan.

Lampirkan : HSE Policy

Answer:
Yes, there are PT. Promatcon Tepatguna HSE Policy, Drugs and Alcohol Policy, PPE Policy, STOP Policy.
And also Company Rules.

1
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

b) Who has overall and final responsibility for HSE in your organization?
Siapakah yang mempunyai tanggung jawab akhir dan menyeluruh untuk K3LL dalam organisasi anda?

Lampirkan: Struktur Organisasi HSE

Answer:
All personnel have a responsibility for HSE. However overall and final responsibility for HSE are
managing Director and / or Technical Director. And if the Managing director / Technical Director is not
on office, they delegate to HSE Steering Committee Coordinator.

c) Who is the most senior person in the organization responsible for this policy being carried out at the
premises and on site where his employees are working?
Siapakah pejabat yang paling senior dalam organisasi yang bertanggung jawab untuk pelaksanaan
kebijakan ini di areal perusahaan dan tempat dimana karyawan bekerja?

Lampirkan: Struktur Organisasi Perusahaan

Answer:
Please see our attachment

2.2. Availability of Policy Statements to Employees

a) Itemize the methods by which you have drawn your policy statement to the attention of all your employees
?
Sebutkan metode-metode yang anda pergunakan untuk menarik perhatian semua karyawan anda
terhadap pernyataan tertulis mengenai kebijakan perusahaan anda?

Lampirkan : Bukti sosialisasi HSE Policy

Answer:
a. By implementing inspection for site HSE implementation
b. Poster, booklet
c. Safety talk
d. Induction for new employee
e. HSE Board

b) What are your arrangements for advising employees of changes in the policy?
Pengaturan apakah yang anda lakukan untuk memberitahukan karyawan mengenai perubahan-perubahan
kebijakan?

Lampirkan : Bukti sosialisasi HSE Policy

Answer:
The changes will be distributed by email and signed off by all employees. Please see our previous answer

2
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

SECTION 3: ORGANIZATION, RESPONSIBILITY, RESOURCES, STANDARDS AND

DOCUMENTATION
SECTION 3: ORGANISASI, TANGGUNG JAWAB, SUMBER DAYA, STANDAR DAN
DOKUMENTASI
3.1. Organizations – Commitment and Communication
a) How is management involved in HSE activities, objective setting and monitoring?
Bagaimanakah manajemen terlibat dalam kegiatan K3LL, dalam penetapan sasaran dan pemantauan?

Lampirkan: HSE objectives, MOM HSE, etc.

Answer:
Senior managers and staff are all personally involved in achieving, developing and improving HSE-MS.
He is given the authority and responsibility to ensure that the requirements of the HSE are implemented
and maintained.

b) Do you have a safety organization? Yes No.

If Yes, please provide an organization chart and a description of responsibilities.
Apakah anda memiliki organisasi keselamatan kerja? Jika Ya, berikan Bagan Organisasi dan uraian
tanggung jawabnya.

Lampirkan : Bagan Organisasi (ref 2.1.c)

Answer: Yes. Please see attachment

c) How is your company structured to manage and communicate HSE effectively?

Bagaimanakah perusahaan anda mengelola dan mengkomunikasikan masalah K3LL secara efektif?
(berikan penjelasan)

Lampirkan : Group meeting with clear topic and speaker. Attendants list

Answer:
By established HSE management system, distributed to all manager. Manager conduct safety manner to
supervisor and crew. And All manager give input related to HSE to HSE manager.

Manage

Top SPV

Employe

HSE

3
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

d) What provision does your company make for HSE communication meeting?
Ketentuan apa yang dibuat oleh perusahaan anda untuk pertemuan komunikasi K3LL?

Lampirkan : Prosedur Komunikasi

Answer:
Please see our Prosedur Komunikasi, Partisipasi dan Konsultasi No. 02/018/OHS/2007

3.2. Competence and Training of Manager/Supervisors/Senior Site Staff/HSE Advisor

Have the managers and supervisors at all levels that will plan, monitor, oversee and carry out the work
received formal HSE training in their responsibilities with respect to conducting work to HSE requirements?
Apakah para manajer dan pengawas di semua tingkat yang akan merencanakan, memantau, memperkirakan
dan melaksanakan pekerjaan sudah menerima pelatihan K3LL sesuai tanggung jawab mereka dalam kaitannya
dengan pelaksanaan pekerjaan sesuai dengan persyaratan-persyaratan K3LL?

If Yes please give details. Where the training is given in-house please describe the content and duration of
courses.
Jika sudah, berikan rincian. Jika Pelatihan diberikan in-house, jelaskan materi dan lamanya kursus.
(Gunakan lembar tambahan)

Yes/Sudah No/Belum
Lampirkan: Training Certificate, dan Training Need Analysis (TNA)

Answer:
Yes, Training is given to Managers, Supervisor (Field team leader) by external training and in house
training. Example PPE training (in-house training), Bosiet training (external training). (Please see
attachment PT. Promatcon Tepatguna Training Matrix)

3.3. Competence and General HSE Training/Kemampuan dan Pelatihan K3LL Umum

a) What arrangements does your company have to ensure employees have knowledge of basic industrial HSE,
and to keep this knowledge up to date?
Pengaturan apa yang telah dibuat perusahaan anda untuk memastikan bahwa karyawan mempunyai
pengetahuan tentang K3LL dasar dalam industri, dan untuk menjaga agar pengetahuan tersebut selalu
tidak ketinggalan perubahan?

Lampirkan : ref 3.2

Answer:
Giving HSE training to all employees regularly. Their knowledge is up-dated on a regular basis by
regular meetings, seminars and training. In addition, a start of fieldwork all field teams are given a
safety briefing / safety induction meeting on site

b) What arrangements does your company have to ensure new employees, including sub contractors, also
have knowledge of your HSE policies and practices?
Pengaturan apa yang telah dibuat perusahaan anda untuk memastikan bahwa karyawan, termasuk
subkontraktor, juga memahami kebijakan dan tata cara K3LL anda?

Lampirkan : training certificate & Induction prg.

4
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

Answer:
All new employees and subcontractor employees are given HSE induction meeting/ HSE training before
they start to the fieldwork. Their knowledge is up-dated on a regular basis by regular meetings / safety
induction meeting on site. And all employees and subcontractor’s employees have a copy all HSE policies
and signed off when they read the policies.

Before go the site they have a copy of HSE document, there is : PT. Promatcon Tepatguna HSE
Implementation Scheme for each project

c) What arrangements does your company have to ensure new employees and new subcontractor employee
have been instructed and have received information on any specific hazards arising out of the nature of the
activities? What training do you provide to ensure that all employees are aware of company requirements?
Pengaturan apa saja yang telah dibuat perusahaan anda untuk memastikan bahwa karyawan dan
karyawan subkontraktor yang baru telah diberi dan menerima informasi mengenai bahaya khusus yang
timbul dari sifat pekerjaan? Pelatihan apa yang telah anda berikan untuk memastikan bahwa semua
karyawan mengetahui semua persyaratan-persyaratan Perusahaan?

Lampirkan: Risk analisis, HSE induction & training certificate or attendance list.

Answer:
We give Safety Induction for new employees and subcontractor.
We conduct daily toolbox meeting, work permit for special job, and of course HIRARC every new process
established. Please see our attachement

d) What arrangements does your company have to ensure existing staff HSE knowledge is up to date? If
training is provided in-house please give details of content!
Pengaturan apa yang telah dibuat perusahaan anda untuk memastikan bahwa pengetahuan K3LL
karyawan yang sekarang selalu up to date? Jika pelatihan dilakukan in-house berikan rincian materi
pelatihan!

Lampirkan: TNA, trg schedules, HSE handbook, Observation/audit system (STOP&ASA)

Answer: We give the existing staff Re-Induction training and conduct HSE handbook

3.4. Specialized Training/Pelatihan Khusus

a) How have you identified areas of your company’s operations where specialized training is required to deal
with potential hazards? Please itemize and provide details of training given?.......
Bagaimana anda telah mengidentifikasi lokasi dalam operasi anda dimana pelatihan khusus diperlukan
untuk menghadapi bahaya yang mungkin teerjadi? Berikan daftar dan rincian dari pelatihaan yang
diberikan?

Lampirkan : Hazards list and Training program for each – first aid, fire fighting, evacuation drill

Answer:
Directors and senior managers have >10 years experience operations. And they have identified
potential hazards that are generally common. However PT. Promatcon Tepatguna prepared
Emergency Response Procedure) to ensure all employees are aware of onsite work risk and guide all
employees on do the safety jobs.
5
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

Specialised training to deal with potential hazards includes:

- First Aid training
- PPE Training
- Fire drill training
- Emergency Response Training (Earthquake, Medecav, Flood and Fires)

b) If the specialized work involves radioactive, asbestos removal, chemical or other occupational health
hazards, how are the hazards identified, assessed and controlled?
Jika suatu pekerjaan khusus melibatkan radioaktif, pembuangan asbes, bahan kimia atau bahaya
kesehatan kerja lainnya, bagaimana bahaya tersebut diidentifikasi, dinilai dan diatasi?

Lampirkan : procedures and implementation records (samples), HSE certificates

Answer:
We use very professional subcontractor or qualified staff if doing jobs above. Initially, we conduct JSA to
make sure the job execute on the right path.

3.5. HSE Qualified Staff – Additional Training/Karyawan yang mempunyai kemampuan K3LL –
Pelatihan Tambahan
Does you company employ any staffs that possess HSE qualifications that aim to provide training in
more than the basic requirements?
Yes/Ya No/Tidak
What format of safety qualifications does your staff have? Describe!

Apakah perusahaan anda mempekerjakan staf yang memiliki qualifikasi K3LL yang ditujukan untuk
memberikan pelatihan yang lebih dari sekedar persyaratan dasar?
Format kualifikasi keselamatan apa yang dipunyai oleh staff anda? Jelaskan!

Lampirkan: Certificate, Training program and attendance list.

Answer:
For ensure every employee have basic requirement we have HSE manager, whom give several in house
training. If we need to provide special training, we send employee to certified provider.

3.6. Assessment of Suitability of Subcontractors / Other Companies

a) How do you assess/Bagaimana anda menilai:

HSE competence / Kemampuan K3LL

HSE record of the subcontractors and companies with whom you place contract?
Catatan K3LL subcontractor dan perusahaan-perusahaan yang anda kontrak?

Lampirkan: copy halaman contract yang menunjukkan HSE statement.

Answer :
Please see our Prosedur Subkontraktor No. 02/020/OHS/2007

b) Where do you spell out the standards you require your contractors to meet?
Dimana anda menjelaskan standar yang anda tuntut agar dipenuhi oleh kontraktor anda?

6
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

Lampirkan: copy halaman contract yang menunjukkan HSE statement dan sanksinya.

Answer:
We speel out in the Work Order

c) How do you ensure these standards are met and verified?

• Safety training for employee working.
• Recruiting process for employee working for your work.
• Employees understand the company, commitments, policy, objective & standard.
• Interface plan with sub-contractor? If any?
Bagaimana anda memastikan standar-standar di bawah ini telah dipenuhi dan diperiksa?
• Pelatihan keselamatan bagi karyawan yang bekerja
• Proses penerimaan karyawan yang kan bekerja untuk proyek anda
• Karyawan memahami komitmen, kebijakan, tujuan dan standar perusahaan
• Rencana berhubungan dengan sub-kontraktor? Kalau ada

Lampirkan: halaman contract atau memo or MOM (PJA?)

Answer:
We ensure from HSE questionnaire and evidence attachment. If we think inadequate, we will interview
the HSE Manager and several subcontractor’s worker.

d) Please provide the names of major sub-contractor, if known, at this time!

Berikan nama-nama subkontraktor utama, pada saat ini, kalau diketahui!

Answer:
PT. Maju Bersama. Others, please see our attachment.

3.7. Standards/Standar
a) Where do you spell out the HSE performance standards you require to be met?
Di mana anda menjelaskan standar yang anda tuntut agar dipenuhi?

Lampirkan: hal yg menjelaskan standar (ref pages dari manual)

Answer:
We refer Occupational Health Safety Assessment System and Permennakertrans 05/96 as HSE
regulatory or industrial standards that our company refers to for the intended service.

b) How do you ensure these are met and verified?

Bagaimana caranya anda memastikan standar-standar ini dipenuhi dan diperiksa?

Lampirkan: observasi, Inspection yang dilakukan, etc.

Answer:
Top Management of PT. Promatcon Tepatguna delegated to the HSE Steering Committee whom
responsible for ensure that all HSE activities within PT. Promatcon Tepatguna are carried out the
requirements, rules, and procedures provide in HSE Manual and its associated HSE Procedures and HSE
Plans by implementing HSE Inspection, Audit and Management Review.

c) How do you identify new industry or regulatory standards that may be applicable to your
activities?
Bagaimana anda mengenali standar-standar industri dan aturan baru yang mungkin berlaku
bagi aktivitas anda?
7
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

Lampirkan: sources or list

Answer:
We updating our regulatory compliance list every six month. Propose to management to comply to our
workplace

d) Is there an overall structure for producing, updating and disseminating standards?

Adakah struktur menyeluruh untuk membuat, memperbaruhi dan menyebarkan standar?

Lampirkan: email, receipt

Answer:
We have procedure for controlling the revision of document and the changes made for all PT. Promatcon
Tepatguna, it is change control procedure that implemented change request form. Please see our
Prosedur No. 02/017/OHS/2007

e) List your HSE procedures manuals. Please submit current copies

Buatlah daftar prosedur/panduan K3LL anda. Sertakan copy yang terbaru!

Lampirkan: HSE Manual/prosedur yang ada

Answer:
Please see attachment

SECTI ON 4: HAZAR DS AND EFFECT M ANAGEM ENT

SECTI ON 4: P ENGELOLAAN BAHAYA DAN DAM P AK
4.1. Hazards and Effect Management ? Penanganan Bahaya dan Dampak
What techniques are used within your company for the identification, assessment, control and
mitigation of hazards and effects?
Teknik apa yang anda gunakan dalam perusahaan anda untuk mengidentifikasi, menilai, mengawasi
dan mengurangi bahaya dan dampak?

Lampirkan: samples Risk Analisis? Procedures (ref pages)

Answer:
We use HIRARC, Please see our attachment

4.2. Exposures of the Workforce

What systems are in place to monitor the exposure of your workforce to chemical or physical agents?
Sistim apa yang ada untuk memantau paparan pekerja anda terhadap bahan kimia atau unsur-unsur
fisik?

Lampirkan: Inspection Samples, Risk Assessment?

Answer:
We conduct environment inspection annually

8
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

4.3. Handling of Potential Hazards

How is your workforce advised on potential hazards, e.g. chemicals, noise, radiation, etc.,
encountered in the course of their work?
Bagaimana pekerja anda diberitahu mengenai bahaya yang mungkin timbul seperti bahan kimia,
kebisingan, radiasi, dsb, dalam pekerjaan mereka?

Lampirkan : Memo, related MOM

Answer: We give them knowledge through safety talk, PPE. Conducting JSA before execute job.
Provide MSDS when handling. And only authorized certified personnel who could do these jobs

4.4. Personnel Protective Equipment

a) What arrangements does your company have for provision and distribution of protective
equipment and clothing, both standards issue, and that required for specialized activities?
Pengaturan apa yang dimiliki perusahaan anda untuk pengadaan dan pemberian alat
pelindung dan pakaian kerja, baik yang standar maupun yang diperlukan untuk kegiatan-
kegiatan khusus?

Lampirkan: PPE Procedure, PPE Stock Records and maintenance

Answer:
We have a procedure of Personal Protective Equipment (PPE). All employees must be use Personal
protective equipment shall be provided and worn where:
- Hazards cannot be otherwise prevented or suitably controlled, e.g. by engineering or
administration controls, total enclosure, substitution.
- Complete protection is essential, e.g. in some occupational environments with uncertain levels of
hazards, or
- Legislation required it.

The provision and use of personal protective equipment does not reduce or replace the need for proper
accident prevention measures, such as engineering or administrative controls, to be undertaken.
Specification of such preventive measures must always be fully explored before consideration of issue of
personal protective equipment.

b) Do you provide appropriate personal protective equipment (PPE) for your employees? Please
provide a listing of the PPE for the scope of this work.
Apakah anda mennyediakan PPE yang sesuai untuk karyawan anda? Berikan daftar PPE untuk
lingkup kerja ini.

Lampirkan: employee,s receipt

Answer:
Yes, please see attachment

c) Do you provide training on how to use PPE? Explain the content of the training and any
follow up?
Apakah anda memberikan pelatihan mengenai cara menggunakan PPE? Jelaskan materi
pelatihan dan setiap tindak lanjutnya.

Lampirkan: attendant list

9
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

Answer:
Yes, through safety talk. Follow up by conduct PPE inspection

d) Do you have a program to ensure that PPE is impacted and maintained

Apakah anda mempunyai program untuk memastikan bahwa PPE digunakan dan dijaga?

Lampirkan: Observation cards / inspection report

Answer:
We conduct impacted PPE Inspection, we ensure the stockist. We ensure every workforce maintain the
PPE by sign the statement letter. Every safety talk we remind every worker to use PPE. We communicate
to find best PPE to wear at the workplace

4.5. Waste Management / Penanganan Limbah

a) What systems are place for identification, classification, minimization and management of
waste?
Sistim apa yang ada untuk identifikasi, klasifikasi, pengurangan dan penaganan limbah?

Lampirkan: Ref pages of Manuals or procedures

Answer:
Please see our Prosedur Pemantauan Lingkungan No. 02/008/OHS/2007

b) Please provide the number of accidents resulting in environmental damage in the amount
greater than $50,000 for the last 24 months. Attach copies of any governmental reports
submitted!
Berikan jumlah kecelakaan yang menyebabkan kerusakan lingkungan dalam jumlah yang
melebihi $ 50,000 untuk 24 bulan terakhir.

Lampirkan: copy laporan yang dikirim ke pemerintah!

Answer: NONE

c) Do you have procedures for waste disposal? Yes / Ya No / Tidak

Apakah anda mempunyai prosedur pembuangan limbah?

Lampirkan : 4.5a

Answer:
Yes, please see our Prosedur Pemantauan Lingkungan No. 02/008/OHS/2007

d) Do you have procedures for spill reporting? Yes / Ya No / Tidak

Apakah anda mempunyai prosedur pelaporan tumpahan minyak?

Lampirkan : prosedur pelaporan

Answer:
Yes, please see attachment. In fact, we don’t have any spill because we collect used oil and sell it to
collector

10
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

e) Please provide details at any of your equipment related to environmental matters.

Berikan rincian mengenai peralatan anda yang berkaitan dengan masalah lingkungan!

Lampirkan: related equipment list.

Answer: Desiccant for collecting dust form sandblast room, collect chemical vapour from painting job.
Paper garbage storage, waste storage, and other equipment related to office environmental matter

f) Who is the person in charge for coordinating environment matter and what is his experience?
Siapa orang yang berwenang untuk mengkoordinasi masalah lingkungan dan bagaimana
dengan pengalamannya?

Lampirkan: Organization Chart & Experience records?

Answer:
HSE Manager with the help from Environmental Lab, actually we have Environment Engineer on site

4.6. Industrial Hygiene/Kesehatan Industri

a) Do you have an industrial hygiene program? Yes / Ya No / Tidak
If yes, what are included in the program?
Apakah anda mempunyai program kesehatan industri?
Jika ada, apa saja yang termasuk di dalamnya?

Lampirkan: Medical check-up, Asuransi kesehatan, policy mengenai pengobatan

Answer:
Yes, We have industrial hygiene program including anticipation, recognize, evaluation and control for
industrial hygiene matters such as noise measurement and control, hygiene and sanitation, and other
environmental hazard

b) Do you have a risk assessment, or similar type effort, for identifying work place hazards?
Please describe this process.
Apakah anda mempunyai penilaian risiko, atau usaha serupa, untuk mengidentifikasi bahaya di
tempat kerja? Jelaskan proses ini!

Lampirkan: contoh Risk Assessment yang dibuat

Answer:
Yes, Please see our 2013 HIRARC, identifying painting sandblast workplace at 4.1 answer

c) If you introduce hazardous materials/substances into the work site, describe the process you
will use to document and control them.
Jika anda mendatangkan bahan/zat berbahaya ke tempat kerja proses yang akan anda gunakan
untuk mendokumentasi dan mengawasinya.

Lampirkan: Flow chart.

Answer:
We conduct Risk Assessment, Work Permit
Please see our Prosedur Penyimpanan, Penanganan dan Pemindahan B3 No. 02/013/OHS/2007

11
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

4.7. Drugs and Alcohol

Do you have a drugs and alcohol policy in your organization? If so, does it include pre-employment
and random testing?
Apakah anda mempunyai kebijakan mengenai obat-obatan dan minuman keras dalam organisasi
anda? Kalau demikian, apakah itu termasuk dalam ujian penerimaan karyawan dan pengujian acak?

Lampiran: Policy & sanction, halaman yg mengacu hal ini.

Answer:
Yes, it’s included in medical check up

SECTION 5: PLANNING AND PROCEDURES

SECTION 5: PROSEDUR DAN MANUAL OPERASI
5.1. HSE or Operations Manuals
1). Do you have a company HSE manual or Operations Manual with relevant sections on HSE which
describes in detail your company approved HSE working practices and safety instructions such as
those covering scaffolding, lifting, heavy equipment, pressurized cylinders or excavation?
Apakah anda mempunyai buku panduan K3LL perusahaan atau buku panduan operasi yang sesuai
dengan aturan-aturan K3LL yang dijelaskan secara rinci dalam cara kerja K3LL dan aturan
keselamatan yang disahkan oleh perusahaan seperti yang menyangkut perancah, alat pengangkat,
alat-alat berat, bejana tekan atau penggalian? Yes / Ya No / Tidak
If the answer is “Yes” please attach a copy of supporting documentation!
Jika jawabannya Ya,

lampirkan copy dari dokumen pendukungnya! 3.7e

Answer:
Yes, Please see attachment

2). How do you ensure that the working practices and procedures used by your employees on-site are
consistently in accordance with your HSE policy objectives and arrangements?
Bagaimana anda memastikan bahwa cara kerja dan prosedur yang digunakan oleh karyawan di
lapangan konsisten dengan tujuan dan pengaturan kebijakan K3LL anda?

Lampirkan : Work permit, HSE pocket

Answer:
Our HSE officer will ensure that the working practices and procedures used by our employees on site are
consistently in accordance with our HSE policy objectives and arrangements. Project manager responsible
to ensure safety working practices and procedures used by all employees including subcontractor on site.

5.2. Equipment Control and Maintenance / Pengawasan dan Perawatan Peralatan

How do you ensure that plant and equipment used within your premises, on-site, or at other locations
by your employees are correctly registered, certified with regulatory requirement, inspected,
controlled and maintained in a safe working condition?
Bagaimana anda memastikan bahwa plant dan peralatan yang digunakan di wilayah kerja anda, lokasi
atau pada lokasi lain oleh karyawan anda, didaftarkan, disertifikasi sesuai tuntutan peraturan,
diinspeksi, diawasi dan dirawat dengan benar dan dalam kondisi kerja yang baik?

Lampirkan: Maintenance Schedule & Maintenance Records

12
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

Answer:
We act in accordance with government regulation or industrial standard to ensure that plant and
equipment used within our promises, on site or at other location by our employees are correctly registered,
certified with regulatory requirement, inspected, controlled and maintained in a safe working condition.

5.3. Transport Safety Management and Maintenance / Penanganan dan Perawatan

Keselamatan Transportasi
What arrangement does your company have for vehicle incidents prevention?
Pengaturan apa yang dimiliki perusahaan anda untuk pencegahan kecelakaan kendaraan?

Lampirkan: Ref procedures, posters & driving safety check list.

Answer:
Please see our Prosedur Operasi Kendaraan Darat No. 02/019/OHS/2007

SECTION 6: IMPLEMENTATION AND PERFORMANCE MONITORING

SECTION 6: IMPLEMENTASI DAN PEMANTAUAN KINERJA K3L
6.1. HSE Management and Performance Monitoring of Work Activities
a) What arrangement(s) does your company have for supervision and monitoring of HSE
performance?
Pengaturan apa yang dimiliki perusahaan anda untuk pengawasan dan pemantauan kinerja
K3LL ?

Lampirkan: Meeting Schedule & speaker, MOM & clear topics

Answer:
Please see our Manual PTG-HSE-002 page 23-25

b) What type of performance criteria are used in your company? give examples!
Kriteria kinerja seperti apa yang digunakan dalam perusahaan anda ? Berikan contoh!

Lampirkan ; prosedure (Ref of pages)

Answer:
Please see our Manual PTG-HSE-002 page 23-25

c) What arrangements does your company have for passing on any results and findings of this
supervision and monitoring to your:
Pengaturan apa yang dipunyai perusahaan anda untuk menyampaikan setiap hasil dan
termuan dari pengawasan dan pemantauan kepada :

Answer:
i) Base management ?
Base management anda ? Answer : Weekly meeting

ii) Site employees?

Karyawan lapangan ? Weekly or monthly report, field visit

13
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

d) Has your company received any award for HSE performance achievement?
Pernahkah perusahaan anda menerima penghargaan untuk prestasi kinerja K3LL ?
Yes / Sudah No / Belum

Lampirkan: copy penghargaan

Answer:
Yes, from Conoco Phillips.

6.2. Safety Program/Program Keselamatan

a) Do you organize in-house safety meetings?
Apakah anda menyelenggarakan satety meeting ditempat anda sendiri ?
Yes / Ya No / Tidak
Please describe the frequency, attendance and topics !
Jelaskan frekwensi, peserta, dan topiknya !

Lampiran: sama dgn 6.1

Answer:
Yes, Safety Talk, HSE Management Meeting. Please see our HSE Program Time Table

b) Do you organize campaigns to stimulate safe working practices?

Apakah anda mengorganisir kampanye untuk menstimulir cara kerja yang aman ?
Yes / Ya No / Tidak
If so, please give details !
Kalau Ya, berikan rincian !

Lampirkan: Sosialisasi attendance list, posters, awards receiver (name)

Answer:
Yes, through Safety Talk, Management Meeting, News posted on board, email

6.3. Statutory Notifiable Incidents/Dangerous Occurrences, Improvement Requirement and

Prohibition Notices
Has your company suffered any improvement requirement or prohibition notices on statutory
notifiable incidents/dangerous occurrences by the relevant national body, regulatory body for HSE or
other enforcing authority or been prosecuted under any HSE legislation in the last five years?
Pernahkan peusahaan anda mengalami keharusan perbaikan atau pemberitahuan larangan dalam hal
insiden/kejadian berbahaya menurut undang-undang oleh lembaga nasional terkait, badan yang
berwenang dalam K3LL, atau otoritas penegak hukum lainnya atau diperkarakan dibawah undang-
undang K3LL selama lima tahun terakhir ini ? Yes / Ya No / Tidak

If your answer is Yes, please give details !

Jika jawaban anda Pernah, berikan rinciannya !

Lampirkan: HSE statistics 5 year coverage for the following data 6.4

Answer: NONE. For the Statistic you could see in atttachment

6.4. HSE Performance Records

a) Have you maintained records of your incidents and HSE performance for the last five years?
Apakah anda menyimpan catatan mengenai insiden dan kinerja K3LL anda untuk lima tahun
terakhir ? Yes / Ya No / Tidak

14
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

If yes, Please provide the following :

Jika Ya, berikan yang berikut ini :
• Number of Fatalities/Jumlah korban
• Lost Time Injuries
• Lost Workday Cases/Kasus kehilangan hari kerja
• Medical Treatment Cases/Kasus tindakan medis
• Restricted Work Day Cases
• Fatal Accident Rate
• Lost Time Injury Frequency
• Total Recordable Incident Rate for each year

Please include your company definitions of the above-mentioned terms in separate pieces of
paper!
Sertakan definisi perusahaan anda mengenai istilah-istilah diatas dalam lembaran terpisah !

Lampirkan: definisi dalam prosedur (pages or ref.)

Answer: Please see attachment

b) How is health performance recorded?

Bagaimana kinerja kesehatan didokumentasikan ?

Lampirkan: dokumentasi kinerja kesehatan.

Answer:
Human Resources Department recorded any data of health performance from employee’s base on
Hospital evaluation and test.

c) How is environmental performance recorded?

Bagaimana kinerja lingkungan didokumentasikan ?

Lampirkan: dokumentasi kinerja.

Answer:
HSE Department recorded any report of environmental performance on monthly basis

d) How often is HSE performance reviewed? By whom ?

Setiap berapa lama kinerja K3LL anda ditinjau ? Oleh siapa ?

Lampirkan: dokumentasi hasil pengkajian yang dilakukan.

Answer:
Monthly, by HSE Manager and it is discussed with all manager on former weekly meeting every month

6.5. Incident Investigation and Reporting

a) Do you have a procedure for the investigation, reporting and follow-up of accidents, dangerous
occurrences or occupational illnesses? If yes, please attach
Apakah anda mempunyai prosedur untuk investigasi, pelaporan, dan tindak lanjut insiden,
kejadian berbahaya atau penyakit ditempat kerja ?

15
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

Lampirkan: prosedur Investigasi, pelaporan dan tindak lanjut insiden.

Answer:
Yes, Please see our Prosedur Pelaporan dan Penyelidikan Kecelakaan No. 02/010/OHS/2007

b) How are the findings following an investigation, or a relevant incident occurring elsewhere,
communicated to your employees?
Bagaimana temuan dari investigasi maupun insiden lain yang relevan yang terjadi ditempat lain
dikomunikasikan kepada karyawan anda ?

Lampirkan: dokumentasi distribusi, apakah melalui B. Boards, Reports list, MOM?

Answer:
We communicate in HSE Management meeting for management, Investigation meeting with supervisor
and project manager. The investigation result was communicated to employees through safety talk,
poster, email

c) Are near miss safety learning reported ?

Apakah pembelajaran keselamatan dari near miss dilaporkan ?

Lampirkan: dokumentasi pelaporan, sample of near miss report

Answer:
Yes, Please see attachment. Every worker feel free to tell all the near miss in safety talk so others could
learn spontaneously at that moment or direct to supervisor

d) Please provide copies of investigation reports for the last 12 months !

Sediakan copy dari laporan investigasi untuk dua belas bulan terakhir !

Lampirkan : laporan investigasi yang dilakukan selama 12 bulan terakhir

Answer:
Yes, Please see attachment.

SECTION 7: AUDIT AND REVIEW

SECTION 7: AUDIT DAN PENGKAJIAN K3L
a) Do you have a written policy on HSE auditing?
Apakah anda mempunyai kebijakan tertulis mengenai audit K3L
Yes / Ya No / Tidak

Lampirkan : copy prosedur audit. K3L

Answer:
Yes, Described in procedure, please see our audit record and also HSE Time Table Program/Plan

b) How does this policy specify the standards for auditing, including unsafe act auditing and the
qualifications for auditors?
Bagaimanakah kebijakan tersebut menjelaskan standar audit, termasuk mengenai tindakan
yang tidak aman dan kualifikasi untuk auditor?

Lampiran: Audit yang dilakukan

16
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

Answer:
The standars is OHSAS 18001:2007 clause 4.5.5 (Occupational Health and Safety Management System
Requirement) Audit would be done to see weather the policy has been implemented, maintained in every
organization activities, minor to major. Audit result would be checked again for validation.

Auditor : Our self (Manager, Supervisor from every department) for internal auditing, and WQA for
external Auditing.

c) Do your company HSE Plans include schedules for auditing?

Apakah rencana K3LL perusahaan anda menyertakan jadwal audit?
Yes / Ya No / Tidak

What range of auditing is covered?

Bidang audit mana yang dicakup?

Lampiran: Ref HSE Plan for this year (copy)

Answer:
Yes, we have schedule twice in a year. Internal auditing cover all area in workplace as a HSE nature for
every individual, External auditing cover all Department as a HSE management system

d) How is the effectiveness of auditing verified and how does management report and follow up
audits?
Bagaimana efektifitas auditing diperiksa, dan bagaimana manajemen melaporkan dan
menindaklanjuti hasil audit?

Lampirkan: dokumentasi tindak lanjut terhadap Audit/inspection yang dilakukan, report/ copies

Answer:
We follow up the audit as soon as possible. Please see management Minutes of Meeting and also evidence
of follow up

SECTION 8: EMERGENCY RESPONSE PROCEDURE

SECTION 8: PROSEDUR TANGGAP DARURAT
Do you have an emergency response plan? Yes / Ya No / Tidak
Apakah anda mempunyai rencana tanggap darurat?

Please provide a list of procedures!

Describe how emergency preparedness is maintained and the command structure in case of emergency!
Berikan daftar prosedurnya!
Jelaskan bagaimana kesiapan darurat dijaga dan bagaimana struktur komando dalam keadaan darurat.

Lampirkan: Procedures, Daftar petugas dengan tanggung jawab masing-masing?

Answer:
Yes, Please see our Prosedur Penanggulangan Keadaan Darurat No. 02/006/OHS/2007
Fire Drill training internal and external (cooperate with Pemadam Kebakaran Jakarta Barat),
Improving Procedure, Socialization, Special Training (First Aid : Basic Life Support in Medevac Case,
Fire Fighting)

17
 Contractor Safety, Health and Environment Management Systems
Pre
SISTEM PENGELOLAAN Qualification
KESELAMATAN, KESEHATAN KERJA DAN LINGKUNGAN Questionnaire
KONTRAKTOR

SECTION 9: SHE MANAGEMENT – ADDITIONAL FEATURES

SECTION 9: PENGELOLAAN K3L – PROGRAM-PROGRAM TAMBAHAN
a) Describe the nature and extent of your company’s participation in relevant industry, trade, and
governmental organizations?
Jelaskan sifat dan sejauhmana partisipasi anda dalam organisasi yang relevan dengan industri,
perdagangan dan pemerintahan?

Lampiran : Program K3L tambahan yang dilakukan.

Answer:
Kadin, Gapensi, Sertifikat Badan Usaha Jasa Pelaksana Konstruksi, Ijin Usaha dari Pemkot DKI

b) Does your company have any other HSE features or arrangements not described elsewhere in your
Response to the questionnaire?
Apakah perusahaan anda mempunyai program lain atau kepesertaan dalam sistim ataupun program K3LL
lain yang belum dicantumkan pada tanggapan anda dalam kuestioner?

Lampirkan: HSE membership cards or certificates

Answer:
Our HSE Management Systems already certified by WQA, our Quality Management System certified by
TUV. Our Company participate in The Society for Occupational Health & Safety Specialist. And 3
persons in our company are member of Anggota Ahli Keselamatan dan Kesehatan Kerja.

18