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1. GENERAL INFORMATION /KETERANGAN UMUM

1. Company Name PT. WIDODO LINTAS Phone
SAMUDRA
Nama Perusahaan Telepon
Street Address Mailing Address
Alamat Jalan Alamat Surat-Menyurat

2. Officers Name Years with company

Pejabat Nama Lama bekerja di perusahaan
President (General Manager)
Pimpinan
Vice President (Director)
Wakil Pimpinan
Treasurer
Bendaharawan
3. How many years has your organisation been in business under your present firm name?
Berapa tahun organisasi Anda telah berusaha menggunakan nama perusahaan yang sekarang?
4. A. Parent Company Name
Nama Perusahaan Induk
City State I Zip Code
Kota Negara Kode Zip
Subsidiaries -
Anak-anak perusahaan
B. Principal Company Name -
Nama Perusahaan Prinsipal
City - State - Zip Code -
Kota Negara Kode Zip
5. Under Current Management since (date)
Di bawah Manajemen Sekarang sejak (tanggal)
6. Contact for Insurance Information
Kontak untuk keterangan asuransi
Title Phone Fax
Jabatan Telepon Fax
7. Insurance Carrier(s)
Penanggung Asuransi
Name Type of Coverage Phone
Nama Jenis Asuransi Telephone
Personel Accident and Medical
PT. JAMSOSTEK
Care/Hospitalization
021. 788 47212-5

8. Are you self insured for Worker’s Compensation Insurance? Yes No

Apakah Anda menanggung sendiri risiko untuk Asuransi Kecelakaan Kerja Bagi Karyawan Anda? Ya Tidak
9. Contact for Requesting Bids
Kontak untuk Permintaan Penawaran
Title
Jabatan Telepon Fax
10. PQF completed and signed by Name
FPK diisi dan ditandatangani oleh Nama
*) This Pre-Qualification Questionnaire must be completed and signed by the Company’s authorised
first level Management
Signature
Daftar Pertanyaan Pra-kualifikasiini harus diisi dan diketahui oleh Pimpinan Perusahaan yang
berwenang.
Title Phone
Jabatan Telephone Fax

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ORGANISATION / ORGANISASI
Form of Business
11. Firma/CV Perseroan Terbatas Others/Lain-lain ______________
Bentuk Usaha

List other types of work within the services yhou normally perform that you sub-contract to others
12. Uraikan jenis pekerjaan lain dalam kelompok jasa yang biasa Anda lakukan yang Anda sub-kontrakkan kepada
pihak lain:

COMPANY WORK HISTORY / RIWAYAT PEKERJAAN PERUSAHAAN

Major jobs in progress (use additional papers as necessary)
13.
Pekerjaan-pekerjaan besar yang sedang dikerjakan (pakai kertas tambahan bila perlu)
Customer / Location Type of Work Size (in US$ M) Customer Contact Phone
Pelanggan / Lokasi Jenis Pekerjaan Nilai (US$ Juta) Kontak Pelanggan Telepon

Major Jobs in the past 3 years

14.
Pekerjaan besar yang diselesaikan dalam tiga tahun terakhir
Customer/location Type of Work Size (in US$ M) Customer Contact Phone
Pelanggan/Lokasi Jenis Pekerjaan Nilai (US$ Juta) Kontak Pelanggan Telepon

15.
Are there any judgements, claims or suits pending or outstanding against your company?
Apakah perusahaan Anda sedang menghadapi masalah, klaim atau tuntutan yang belum tuntas?

If Yes, please attach the details Yes No

Jika Ya, harap lampirkan rincian Ya Tidak
16. Are you now (or have you ever been) involved in any bankruptcy or re-organisation proceedings?
Apakah Anda sedang (atau pernah) mengalami pailit atau perombakan organisasi karena tuntutan hukum?
If Yes, please attach the details Yes No
Jika Ya, harap lampirkan rincian Ya Tidak

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2. HSE MANAGEMENT SYSTEM Reference

SISTEM MANAJEMEN K3LL Acuan
2.1 POLICY STATEMENT/ PERNYATAAN KEBIJAKAN
2.1.1 Has a HSE Policy Statement been developed for the Company?
Please provide copy (ies)
Apakah Pernyataan Kebijakan K3LL sudah dibuat untuk
Perusahaan?
Harap melampirkan salinannya.
Answer:
Attachment 1:
Yes. PT. WIDODO LINTAS SAMUDRA has HSE Policy and Other
PT. WIDODO LINTAS
company Policies. Please refer to attachment 1:
SAMUDRA’ HSE Policy
PT. WIDODO LINTAS SAMUDR’ HSE Policy Statement & Drugs and
Statements & Drugs and
Alcohol Policy and other policies related HSE
Alcohol Policy and other
policies related HSE.

2.1.2 Define who is responsible for monitoring HSE activities?

Menjelaskan siapa yang bertanggung jawab untuk memantau
aktivitas K3LL?

Answer:

 The President Director assumes overall responsibility for Attachment 2:

Health, Safety & Environment (HSE) for PT. WIDODO LINTAS PT. WIDODO LINTAS
SAMUDRA operations. Operations Manager is accountable to SAMUDRA’ HSE Roles
the President Director for all matters related to HSE. and Responsibilities.

 Line Manager has overall responsibility for HSE for individual

PT. WIDODO LINTAS SAMUDRA operations. They are
accountable to the Operations Manager for all matters related
to HSE on the Project / services.

 Line Supervision: PT. WIDODO LINTAS SAMUDRA line

supervision has direct responsibility for HSE for individual
tasks under their supervision. They are accountable to their
Managers for all matters related to HSE under their
supervision.
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2.1.3 Has the HSE Policy Statement been communicated to the

workforce, and if yes, how? Please provide evidences of policy
communication.

Apakah Pernyataan Kebijakan tersebut telah dikomunikasikan

kepada para pekerja, jika ya, dengan cara bagaimana?Lampirkan
bukti pelaksanaanya

Answer:

Yes, Methods of communication: Attachment 3:

Evidence of PT.
 All PT. WIDODO LINTAS SAMUDRA offices display policy WIDODO LINTAS
statements on their notice boards and other prominent SAMUDRA’s HSE Policy
places e.g.: Jakarta and site offices, etc. Display at the prominent
places
 PT. WIDODO LINTAS SAMUDRA President Director issues
policies to be applied on PT. WIDODO LINTAS SAMUDRA Attachment 4:
projects PT. WIDODO LINTAS
SAMUDRA’s Minutes of
 HSE Coordinator introduces, discusses and explains HSE Meeting discuss HSE
policy statements to the PT. WIDODO LINTAS SAMUDRA Policy
management team, local offices and employees.
Attachment 5:
This is routinely carried out during: PT. WIDODO LINTAS
SAMUDRA’ HSE Hand
(1) Operations Meetings (Management) Book. In the HSE Hand
Book is explained PT.
(2) Supervisor Safety Meeting WIDODO LINTAS
SAMUDRA’ HSE Policy.
(3) Pre Task Briefing/Toolbox Safety Meeting
Attachment 6:
PT. WIDODO LINTAS
SAMUDRA’ Intern Memo
with subject PT.
WIDODO LINTAS
SAMUDRA’ HSE Policy
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2.2. HSE OBJECTIVES/ SASARAN K3LL Reference

Acuan
2.2.1 Has an HSE Objective been established, and does it include HSE
targets?
Apakah Sasaran K3LL telah dibuat, dan apakah juga termasuk
target-targetnya?

Answer: Attachment 7:
Yes. PT. WIDODO LINTAS SAMUDRA has been HSE Objective PT. WIDODO LINTAS
established and include HSE targets. SAMUDRA’ HSE
Objectives and Programs
2010

2.3 HSE STRUCTURE/ STRUKTUR ORGANISASI K3LL Reference

Acuan
2.3.1 Has a clear HSE structure been established in the Company?
If yes, provide copy of organization and Job Description.

Apakah struktur organisasi K3LL yang jelas telah dibuat dalam

Perusahaan?
Jika ya, harap berikan salinan Uraian Tugas.

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA’ HSE Structure has been Attachment 2:
establish. Please refer to attachment 2 and attachment 6. PT. WIDODO LINTAS
SAMUDRA’ HSE Roles
and Responsibilities.

Attachment 8:
PT. WIDODO LINTAS
SAMUDRA’
Organization Chart.
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2.4 HSE RESPONSIBILITIES/ TANGGUNG JAWAB K3LL Reference

Acuan
2.4.1 Senior Management,
Does Senior Management Job Description include clear
statements with regards to HSE responsibilities? Please submit
copy, including description of roles and responsibilities.
Manajemen Senior,
Apakah Uraian Tugas Manajemen Senior ada menjelaskan
tanggung jawab terhadap K3LL? Harap lampirkan salinannya
beserta penjabaran wewenang dan tanggung jawab.

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA,s Senior Management Job Attachment 2:
Description include clear statements with regards to HSE PT. WIDODO LINTAS
responsibilities. Please refer to attachment 2. SAMUDRA’ HSE Roles
and Responsibilities.
2.4.2 Employee Responsibility,
How is the individual employee HSE responsibility communicated
to them? (Please give evidences in details how this is practiced)
Tanggung Jawab Karyawan,
Bagaimana cara memberi tahu tentang tanggung jawab pribadi
karyawan kepada mereka? (Lampirkan bukti rincian praktek
pelaksanaannya)

Answer:
President Director, Manager, Supervisor and HSE Coordinator Attachment 2:
introduces, discusses and explains employee HSE responsibility. PT. WIDODO LINTAS
This is routinely carried out during: SAMUDRA’ HSE Roles
1. Operations Meetings (Management) and Responsibilities.
2. Supervisor Safety Meeting Attachment 5:
3. Pre Task Briefing/Toolbox Safety Meeting PT. WIDODO LINTAS
SAMUDRA’s HSE Hand
Book. In the HSE Hand
Book is explained PT.
WIDODO LINTAS
SAMUDRA’s Employee
Responsibility.
Attachment 9:
PT. WIDODO LINTAS
SAMUDRA’ Employee
HSE Orientation
Program
Attachment 10:
PT. WIDODO LINTAS
SAMUDRA’s HSE Memo
that show employee HSE
responsibility
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2.4.3 HSE Staff,

Is there a job Description for the HSE staff members? (Please
provide a copy)
Staf K3LL
Apakah Uraian Tugas anggota staf K3LL tersedia?
(Harap lampirkan salinannya)

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA have job description for the
HSE staff members. Please refer to attachment 2. Attachment 2:
PT. WIDODO LINTAS
SAMUDRA’ HSE Roles
and Responsibilities.

2.4.4 Who is the most senior person for coordinating HSE

matters and what is his experience?
Siapa posisi paling senior untuk mengkoordinir masalah K3LL
dan apakah pengalamannya?

Answer:
HSE Coordinator has responsibilities in managing of safety matters. Attachment 11:
Our HSE Coordinator qualifications are: Resume of PT. WIDODO
 5 years experience in HSE practical for oil and gas operations LINTAS SAMUDRA’ HSE
 Capable to conduct training course Coordinator
 Have good communication and leadership

2.5 HSE PROGRAM/ PROGRAM K3LL Reference

Acuan
2.5.1 Has a HSE program been developed for the Company?
Apakah K3LL program untuk Perusahaan telah dibuat?

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been developed HSE Attachment 7:
Manual and Procedures PT. WIDODO LINTAS
Please refer to Attachment 12 and complete HSE Manual and SAMUDRA’ HSE
Procedures in the separate attach. And please refer to attachment 7 Objectives and Programs
2010
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Attachment 12:
List of PT. WIDODO
LINTAS SAMUDRA’ HSE
Manual and Procedures.
and 5 Sample PT.
WIDODO LINTAS
SAMUDRA’ HSE
Procedure.
Complete HSE Manual
and Procedure please
refer to separated
attachment.

2.6 HAZARD IDENTIFICATION AND RISK ASSESSMENTS/ Reference

IDENTIFIKASI BAHAYA DAN PENILAIAN RESIKO Acuan

2.6.1 Has procedures and requirements for Hazard Identification

and Risk Assessments been established in the Company?
(Please prive copis)
Apakah prosedur dan persyaratan Pengidentifikasian Bahaya dan
Penilaian Resiko telah dibuat pada Perusahaan? (harap
melampirkan salinannya)

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been developed Attachment 13:
procedures and requirements for Hazard Identification and Risk PT. WIDODO LINTAS
Assessment. Please refer to Attachment 13. SAMUDRA’ Hazard
Identification and Risk
Assessment Procedure

2.6.2 Does this procedure include guidelines for control or

elimination of the Hazard or Risk? (Please provide copies)
Apakah prosedur tersebut telah mencakup petunjuk untuk
mengendalikan atau menghilangkan Bahaya atau Resiko? (harap
melampirkan salinannya)

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been developed Attachment 13:
procedures and requirements for Hazard Identification and Risk PT. WIDODO LINTAS
Assessment include guidelines for control or elimination of Hazard SAMUDRA’ Hazard
or Risk. Please refer to Attachment 13. Identification and Risk
Assessment Procedure
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2.6.3 Is regular review carried out? (If, yes. Please provide

evidences in detail how this practiced)
Apakah persyaratan ini dilakukan secara reguler?m (Jika ya,
lampirkan bukti rincian praktek pelaksanaannya)

Answer:
Yes.
PT. WIDODO LINTAS SAMUDRA applies Hazard Identification and Attachment 14:
Risk Assessment, which equipped with Job Safety Analysis (JSA) Sample of PT. WIDODO
and its follow up. LINTAS SAMUDRA’
Hazard Identification and
Risk Assessment.

Attachment 15:
Sample of PT. WIDODO
LINTAS SAMUDRA’ Job
Safety Analysis.

2.7 PERMIT TO WORK SYSTEM / SISTEM IJIN KERJA Reference

Acuan
2.7.1 Does the Company operates a Work Permit System for critical
activities, and has critical activities in the Company been defined
and identified? (Please provide copy of Permit to work Procedure and
give evidences in details how this practiced).

Apakah Perusahaan menjalankan Sistem Ijin Kerja untuk aktivitas

yang kritikal, dan apakah aktivitas kritikal tersebut telah
ditentukan dan didentifikasi? (Harap melampirkan salinan prosedur
dan bukti rincian praktek pelaksanaanya)

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA operates a Permit To Work Attachment 16:
System for critical activities. PT. WIDODO LINTAS
Please refer to attachment 16 and attachment 17. SAMUDRA’ Work Permit
System

Attachment 17:
Sample of
Implementation Permit
To Work System
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2.8 PERSONNEL PROTECTIVE EQUIPMENT (PPE)/ ALAT PELINDUNG Reference

DIRI (APD) Acuan

2.8.1 Has procedure for the provision and use of PPE been established
for the Company? (Please provide copies)

Apakah prosedur untuk penyediaan dan penggunaan APD telah

dibuat oleh Perusahaan? (Harap lampirkan salinannya)

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been established Attachment 18:
procedure for the provision and use of PPE. Please refer to PT. WIDODO LINTAS
attachment 18. SAMUDRA’ Personal
Protective Equipment
Procedure

2.8.2 What PPE’s are provided? (Please provide a list of the PPE for the
scope of this work)

Apakah macam APD yang disediakan? Harap berikan daftar PPE

sesuai lingkup pekerjaan ini.

Answer:
During the work on site personnel will be equipped with Attachment 18:
appropriate PPEs, including not limited to: PT. WIDODO LINTAS
 Gloves, SAMUDRA’ Personal
 Coverall, Protective Equipment
 Safety helmet, Procedure.
 Safety boots,
 Protection glasses/full face visors where required, Attachment 18a.:
 Work vests (when required), Evidence of PT.
 Safety harshness (when required), WIDODO LINTAS
SAMUDRA’ Distribution
 Protective apron (for arc welding and sand blasting operations),
of Personal Protective
 Gloves (for handling hard or sharp objectives, irritant or dirty
Equipment to Employee.
products and for hot work),
 Acid-resistant overall (when applicable),
 Anti noise helmets or earplugs for use in noisy areas,
 Respiratory protection (when applicable),
 Any other protective equipment identified during the Hazard
Identification and Risk Assessment.

Note: The use of safety boots and hard hats is mandatory on

site, at all time.
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2.9 PLANNED MAINTENANCE/ PEMELIHARAAN YANG TERENCANA Reference

Acuan
2.9.1 Have the Company established systems for planned
maintenance, examination and routine testing of rig or
equipment? (Please provide copies and give evidences in details how
this practiced).

Apakah Perusahaan telah membuat system untuk pemeliharaan,

pengujian dan pemeriksaan rig atau peralatan? (Harap
melampirkan salinannya dan bukti rincian praktek pelaksanaanya)

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been established systems Attachment 19:
for planned maintenance, examination and routine testing of PT. WIDODO LINTAS
equipment. SAMUDRA’ HSE
Please refer to attachment 19 and Attachment 20. Inspection, and
Observation Procedure

Attachment 20:
PT. WIDODO LINTAS
SAMUDRA’ Equipment
Management Procedure

2.9.2 Have procedures for such activities been developed, including the
requirements for Quality Records, certification/test certificates and
documentation that the equipment is “fit for purpose”. (Please
provide copies and give evidences in details how this practiced).

Apakah prosedur untuk semacam aktivitas tersebut telah dibuat,

termasuk persyaratan tentang Catatan Kualitasnya, sertifikasi,
sertifikat pengujian dan dokumentasi bahwa peralatan tersebut
“layak digunakan”. (Harap melampirkan salinannya dan bukti rincian
praktek pelaksanaanya)
Answer: Attachment 19:
Yes. Please refer to attachment 19 , 20 & 20a. PT. WIDODO LINTAS
SAMUDRA’ HSE
Inspection, and
Observation Procedure

Attachment 20:
PT. WIDODO LINTAS
SAMUDRA’ Equipment
Management Procedure

Attachment 20a:
Sample of PT. WIDODO
LINTAS SAMUDRA’
Equipment Certificate
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2.10 COMPETENCY AND TRAINING/ KOMPETENSI DAN PELATIHAN Reference

Acuan
2.10.1 Has the Company established a training procedure and plans?
(Please provide copies and give evidences in details how this practiced).

Apakah Perusahaan telah menetapkan prosedur mengenai

pelatihan dan perencanaannya? (Harap melampirkan salinannya dan
bukti rincian praktek pelaksanaanya)

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been established a Attachment 21:
training procedure and plans. PT. WIDODO LINTAS
Please refer to attachment 21. SAMUDRA’ Training and
Competencies
Procedure.

2.10.2 Does this Training Procedure include requirements for:

Apakah Prosedur mengenai Pelatihan termasuk persyaratan-
persyaratan:

a. Induction? Attachment 21:

Yes/No PT. WIDODO LINTAS
Induction? SAMUDRA’ Training and
Answer: Yes Competencies
Procedure.
b. Training in Emergency response, for relevant personnel?
Yes/No Attachment 22:
Pelatihan Tanggap Darurat untuk personil yang relevan? PT. WIDODO LINTAS
Answer: Yes SAMUDRA’ HSE
Training Need Analysis/
c. Emergency response drills? Training Matrix
Yes/No
Latihan gladi keadaan darurat? Attachment 23:
Answer: Yes Photos as evidence that
PT. WIDODO LINTAS
SAMUDRA’s employee
given HSE Induction

Attachment 24:
Sample Statement Letter
from PT. WIDODO
LINTAS SAMUDRA’
Employee after given
HSE Induction.
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2.11 COMMUNICATION/ KOMUNIKASI Reference

Acuan
2.11.1 Have routines for communicating HSE issues within the Company
been established? (Please provide copies and give evidences in details
how this practiced).

Apakah bentuk-bentuk komunikasi tentang K3LL di Perusahaan

telah dibuat? (Harap melampirkan salinannya dan bukti rincian
praktek pelaksanaanya)
Attachment 25:
Answer: PT. WIDODO LINTAS
Yes. Please refer to attachment 25, 26, 27, 28, 29 and 6 SAMUDRA’ Group
Meeting Procedure

Attachment 26:
PT. WIDODO LINTAS
SAMUDRA’ HSE
Communication and
Information

Attachment 27:
Sample of PT. WIDODO
LINTAS SAMUDRA’ HSE
Poster

Attachment 28:
Sample of PT. WIDODO
LINTAS SAMUDRA’
Buletin

Attachment 29:
Sample of PT. WIDODO
LINTAS SAMUDRA’
Safety Alert

Attachment 30:
Sample of Minutes of
Meeting conducted by
PT. WIDODO LINTAS
SAMUDRA

Attachment 6:
PT. WIDODO LINTAS
SAMUDRA’ Intern Memo
with subject PT.
WIDODO LINTAS
SAMUDRA’ HSE Policy
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2.11.2 Does this HSE Communication include requirements for:

Apakah komunikasi K3LL mencakup persyaratan tentang:

a. Pre-task briefing? Attachment 25:

Briefing awalan kerja? PT. WIDODO LINTAS
Yes/No SAMUDRA’ Group
Answer: Yes Meeting Procedure
b. Tool box talks?
Yes/No Attachment 26:
Answer: Yes PT. WIDODO LINTAS
c. Information notice boards? SAMUDRA’ HSE
Yes/No Communication and
Informasi yang diperoleh melalui papan pengumunan? Information Procedure
Answer: Yes
Attachment 27:
Please refer to attachment 25, 26, 27, 28, 29 and 6 Sample of PT. WIDODO
LINTAS SAMUDRA’
Poster

Attachment 28:
Sample of PT. WIDODO
LINTAS SAMUDRA’s
Bulletin

Attachment 29:
Sample of PT. WIDODO
LINTAS SAMUDRA’
Safety Alert

Attachment 30:
Sample of Minutes of
Meeting conducted by
PT. WIDODO LINTAS
SAMUDRA

Attachment 6:
PT. WIDODO LINTAS
SAMUDRA’s Intern
Memo with subject PT.
WIDODO LINTAS
SAMUDRA’ HSE Policy
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2.12 INSPECTION AND CHECKLIST/ INSPEKSI DAN CHECKLIST Reference

Acuan
2.12.1 Has requirements for regular inspection, checklist etc.
been established including but not limited to the following been
established:
Apakah persyaratan-persyaratan untuk inspeksi, pemeriksaan
dengan sistem checklist, dll. telah dibuat termasuk hal-hal berikut,
walau tidak terbatas:

Answer: Attachment 19:

Yes. Please refer to attachment 19 & attachment 31. PT. WIDODO LINTAS
SAMUDRA’ HSE
a. HSE Management inspections?: Inspection, and
Yes/No Observation.Procedure
Inspeksi Oleh Manajemen K3LL?
Attachment 31:
Answer: Yes Sample HSE Inspection
Report
b. Safety Monitoring?
Yes/No
Pantauan K3LL?

Answer: Yes

c. Operations checklist(s)?:
Yes/No
Checklist operasi?

Answer: Yes

(Please provide copies and give evidences in details how this practiced).
(Harap melampirkan salinannya dan bukti rincian praktek
pelaksanaanya)
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2.13 HSE OBSERVATION/ OBSERVASI K3LL Reference

Acuan
2.13.1 What arrangement(s) does your company have for supervision
and monitoring of HSE performance in line with safe behaviour?
(Please provide copies and give evidences in details how this
practiced).

Program apa yang diterapkan oleh perusahaan anda untuk

pengawasan dan pemantauan kinerja K3LL berdasarkan prilaku
aman? (Harap melampirkan salinannya dan bukti rincian praktek
pelaksanaanya)

Answer:
PT. WIDODO LINTAS SAMUDRA applies unsafe acts and condition Attachment 19:
management program, which are basic safety behaviors standard PT. WIDODO LINTAS
to improve safety performance in our operations. We also SAMUDRA’ HSE
encourage a free open dialogue with employees on all safety Inspection, Audit and
matters through daily pre-task briefing, HSE meeting and Observation.
Management/ Operation meeting.

Please refer to attachment 31.a. Sample of HSE Observation Report. Attachment 31.a:
Sample of HSE
Observation Report

2.14 ACCIDENT, INCIDENT AND NEAR MISS INVESTIGATION AND Reference

REPORTING/ INVESTIGASI KECELAKAAN DAN NYARIS CELAKA Acuan

2.14.1 Have routines and standard reporting formats been established?

If so, please provide copy procedure. ? If so, please provide copy
procedure.

Apakah formulir-formulir laporan rutin dan standar telah dibuat?

Jika ya, harap lampirkan salinan procedure.

Answer: Attachment 32:

Yes. PT. WIDODO LINTAS SAMUDRA have been established PT. WIDODO LINTAS
routines and standard reporting formats. Please refer to SAMUDRA’ Standards
attachment 32 and attachment 33. Accident/Incident
reporting and
Investigation formats.

Attachment 33:
PT. WIDODO LINTAS
SAMUDRA’
Accident/Incident
Reporting and
Investigation Procedure
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2.14.2 Please provide copies of investigation reports for the last 12 (twelve)
months.
Harap lampirkan salinan semua laporan penyelidikan kecelakaan dalam
12(duabelas) bulan terakhir.

Are the result of accident investigations communicated to the

employees? Please give examples.

Apakah hasil penyelidikan kecelakaan dikomunikasikan kepada pekerja?

Harap lampirkan contoh cara komunikasinya.

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA, zero accident for the Attachment 33:
last 12 month. If any accident, PT. WIDODO LINTAS PT. WIDODO LINTAS
SAMUDRA have accident reporting and investigation SAMUDRA’
procedure, result of investigation ( root cause) Accident/Incident
communicated to all employee through safety memo, safety Reporting and
alert and safety meeting. Investigation Procedure
Attachment 25:
Please refer to attachment 33, 25, 26, 27, 28,29 and 30. PT. WIDODO LINTAS
SAMUDRA’ Group
Meeting Procedure
Attachment 26:
PT. WIDODO LINTAS
SAMUDRA’ HSE
Communication and
Information Procedure

Attachment 27:
Sample of PT. WIDODO
LINTAS SAMUDRA’
Poster

Attachment 28:
Sample of PT. WIDODO
LINTAS SAMUDRA’s
Bulletin
Attachment 29:
Sample of PT. WIDODO
LINTAS SAMUDRA’
Safety Alert
Attachment 30:
Sample of Minutes of
Meeting conducted by
PT. WIDODO LINTAS
SAMUDRA
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2.15 STATISTICAL DATA/ DATA STATISTIK Reference

Acuan
2.15.1 What type of safet HSE records do you maintain e.g.
Macam-macam pencatatan K3LL apa saja yang anda buat &
pelihara?

1. Facilities (Kematian)
2. Injuries (Cedera)
3. Dangerous occurrences (Near Miss,
Anomaly) - (Kejadian Berbahaya (Nyaris, Penyimpangan)
4. Environmental damaged costs (Biaya
kerugian pencemaran lingkungan)
5. Property and or vehicle damaged costs
(Biaya kasus kerusakan barang dan/ atau kerusakan
kendaraan)

Answer: Attachment 34:

The following Safety Records are maintained; PT. WIDODO LINTAS
 Fatality Reports & Investigation SAMUDRA’ HSE record
 Lost Time Injury Reports & Investigation Keeping and
 Restricted Work Case Performance Reporting
 Medical Treatment Case Procedure
 First Aid
 Near Miss (Dangerous Occurrence) Reports
 Material Damage Reports
 Environmental Pollution Reports

Please refer to attachment 34.

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Attachment 35:
2.15.2 Please show the details of your annual safety record for the last PT. WIDODO LINTAS
three (3) years SAMUDRA’ Statistical
Mohon lihatkan rincian statistic/ catatan K3 untuk 3 tahun Safety Performance
terakhir?

1. Number of facilities (Jumlah kasus

kematian)
2. Number of lost work day case injuries
(Jumlah Kasus hilang hari kerja)
3. Number of total recordable injuries (Lost
Work Day Case, Restricted Work Day Case, Medical
Treatment Case)
(Jumlah kasus kecederaan yang masuk pencatatan – Kasus
Kec. Hilang Hari Kerja, Kasus Kec. Berakibat Kerja Ringan,
Kasus Kec. Memerlukan Perawatan Medis)
4. Number of days lost (Jumlah hari kerja
yang hilang)
5. Number of relevant exposure hours
(Jumlah jam kerja)

Answer:
Please refer to attachment 35: Statistical Safety Performance 2007-
Nov. 2010.

2.16 HSE DOCUMENTS, PROCEDURES AND HAND BOOKS/ DOKUMEN, Reference

PROSEDUR DAN BUKU SAKU Acuan

2.16.1 Has related HSE Procedures (Safe Working and

Administration) for the Company developed? If yes, list applicable
procedures and attach at least the existing 5 procedures.
Apakah Prosedur K3LL (Prosedur Kerja Aman dan Adminstrasi)
sudah dibuat untuk Perusahaan? Jika, ya buat daftar prosedur
yang ada dan lampirkan minimal 5 prosedur kerja aman.

Answer: .
PT. WIDODO LINTAS SAMUDRA has HSE Manual and Procedures Attachment 12:
and HSE Hand Book. List of PT. WIDODO
Please refer to attachment 12 and 46. LINTAS SAMUDRA’ HSE
Manual and Procedures.
And 5 Sample PT.
WIDODO LINTAS
SAMUDRA’ HSE
Procedure.
Complete HSE Manual
and Procedure please
refer to separated
attachment.
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Attachment 46:
PT. WIDODO LINTAS
SAMUDRA’s HSE Hand
Book.

2.16.2 Have personal safety handbooks been developed and issued

to all personnel?
Apakah buku pegangan untuk perorangan telah dibuat dan
dibagikan kepada semua personil?.

Answer: Attachment 46:

Yes. PT. WIDODO LINTAS SAMUDRA have been developed personal PT. WIDODO LINTAS
safety handbooks and issued to all personnel. Please refer to SAMUDRA’s HSE Hand
attachment 46. Book.
.

2.17 SUBCONTRACTORS/ SUBKONTRAKTOR Reference

Acuan
2.17.1 Do you have procedure to control the HSE performance of your (sub)
contractors? (Please provide copy if any)
Apakah Anda mempunyai prosedur untuk mengawasi kinerja HSE (sub)-
kontraktor Anda sendiri? (Harap lampirkan salinan, jika ada)

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA have been established HSE Attachment 36:
requirements for Subcontractor. Subcontractor carrying out PT. PT. WIDODO LINTAS
WIDODO LINTAS SAMUDRA works will ensure that PT. WIDODO SAMUDRA’
LINTAS SAMUDRA standards and requirements are complied with. Subcontractor and
Operations Director will ensure that prior to contract award, any supplier HSE Control
subcontractor being considered are included in the “Acceptable Procedure
Subcontractor List”. Please refer to attachment 36.
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2.18 EMERGENCY RESPONSE/ TANGGAP DARURAT Reference

Acuan
2.18.1 Has a Contingency or Emergency response plan been established?
(Please provide copies and give evidences in details how this practiced
(drill schedule, result etc.).

Apakah Kontigensi atau Rencana Tanggap Darurat telah dibuat oleh

Perusahaan? (Harap lampirkan salinannya dan bukti pelaksanaanya
(jadual latihan, hasil dll))

Answer: Attachment 37:

Yes. PT. WIDODO LINTAS SAMUDRA has been established PT. WIDODO LINTAS
contingency or Emergency response plan. Please refer to SAMUDRA’ Emergency
attachment 37 and 38 Response Plan
Procedure

Attachment 38:
PT. WIDODO LINTAS
SAMUDRA’ Emergency
Response Drill Report

2.19 CONTROL OF HAZARDOUS SUBSTANCES/ PENGENDALIAN Reference

BAHAN-BAHAN BERBAHAYA Acuan
2.19.1. Have procedures been developed for identifying hazardous substances,
and are procedures in place for limiting and controlling such substances?
(Please provide copies and give evidences in details how this practiced

Apakah prosedur untuk mengidentifikasi bahan-bahan berbahaya telah

dibuat dan dilaksanakan untuk membatasi pengendalian bahan-bahan
tersebut? (Harap lampirkan salinannya dan bukti pelaksanaanya)
Attachment 39:
Answer: PT. WIDODO LINTAS
Yes. PT. WIDODO LINTAS SAMUDRA have developed Hazardous SAMUDRA’ Hazardous
Substances Control Procedure. Please refer to attachment 39 and Substances Control
40. Procedure

Attachment 40:
Sample of PT. WIDODO
LINTAS SAMUDRA’
Material Safety Data
Sheet
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2.20 OCCUPATIONAL HEALTH / KESEHATAN KERJA Reference

Acuan
2.20.1 Has a Medical Advisor/ Paramedic been appointed?
Apakah ada Dokter Penasehat Medis/ Paramedik yang ditunjuk?
Yes/No
Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been appointed Paramedic. Attachment 41:
The Paramedic are employed as a contract basis. Please refer to PT. WIDODO LINTAS
attachment 41, attachment 42 and attachment 1. SAMUDRA’ Occupational
Health Procedure

Attachment 42:
PT. WIDODO LINTAS
SAMUDRA’ Medical
Check Up Policy and
Medical Check Up
Report.

Attachment 1:
PT. WIDODO LINTAS
SAMUDRA, Drug and
Alcohol Policy
Statement.

2.20.2 Is pre-employment medical performed for Company personnel?

Apakah pemeriksaan kesehatan untuk karyawan baru masuk
kerja dilakukan?

Answer: Attachment 41:

Yes. PT. WIDODO LINTAS SAMUDRA has been performanced pre PT. WIDODO LINTAS
employment medical. Please refer to attachment 41. SAMUDRA’ Occupational
Health Procedure

Attachment 42:
PT. WIDODO LINTAS
SAMUDRA’ Medical
Check Up Policy and
Medical Check Up
Report.

Attachment 1:
PT. WIDODO LINTAS
SAMUDRA, Drug and
Alcohol Policy
Statement.
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2.20.3 Are the Company facilities regularly reviewed for suitability

(hygiene, food and water control, cleanliness etc.)?
Apakah fasilitas Perusahaan secara reguler ditinjau ulang untuk
kesesuiannya (hygiene, pengendalian makanan dan
pengendalian air, kebersihan, dll.?
Attachment 41:
Answer: PT. WIDODO LINTAS
Yes. PT. WIDODO LINTAS SAMUDRA has been reviewed facilities SAMUDRA’ Occupational
regularly for suitability (hygiene, food and water control, cleanliness Health Procedure
etc.). Please refer to attachment 41 and attachment 41.a
Attachment 41a.:
PT. WIDODO LINTAS
SAMUDRA’ House
keeping and Higienes
Inspection report.

2.20.4 Has a policy for use and abuse of alcohol and drugs been
established? If yes, please provide copy of the policy.
Apakah kebijakan tentang konsumsi minuman keras dan obat-
obatan telah ditetapkan? Jika ya, harap lampirkan salinannya.

Attachment 1:
Answer: PT. WIDODO LINTAS
Yes. PT. WIDODO LINTAS SAMUDRA has been established policy SAMUDRA, Drug and
for use and abuse of alcohol and drugs. Please refer to attachment Alcohol Policy
1. Statement.
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2.21 ENVIRONMENT/ LINGKUNGAN HIDUP Reference

Acuan
2.21.1 Have a policy and procedures for environmental control been
established? If yes, please provide copy of the policy.
Apakah kebijakan dan prosedur tentang pengendalian
lingkungan telah dibuat? Jika ya, harap lampirkan salinannya.

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been established a policy Attachment 43:
and procedure for environmental control. Please refer to attachment PT. WIDODO LINTAS
1 and attachment 43. SAMUDRA’ Waste
Management and
Environment Monitoring
Procedure

Attachment 1:
PT. WIDODO LINTAS
SAMUDRA’ HSE and
Drug & Alcohol Policy
Statement

2.22 INTERNAL HSE AUDITS/ AUDIT K3LL INTERNAL Reference

Acuan
2.22.1 Has a program for HSE Audits been established? ? (Please provide
copy of program for HSE Audit)

Apakah program Audit K3LL ditetapkan? (Harap lampirkan

salinannya)

Answer :
Yes. PT. WIDODO LINTAS SAMUDRA has been established a Attachment 44:
program for HSE Audits. PT. WIDODO LINTAS
Please refer to attachment 44 and 44.a. SAMUDRA’ HSE
Management System
Audit

Attachment 44a:

PT. WIDODO LINTAS

SAMUDRA’ HSE Internal
Audit Report
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2.22.2 Have routines for control and close out of such reports been
established? (Please provide copy of implementation)
Apakah secara rutin pengendalian dan penutupan laporan tersebut
ditetapkan? (Harap lampirkan bukti pelaksanaannya)

2.22.3 Have routines for control and close out of such reports been
established?
Apakah secara rutin pengendalian dan penutupan laporan
tersebut ditetapkan?

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA,s procedure for HSE Audits Attachment 44:
has been established routines for control and close out of reports. PT. WIDODO LINTAS
Please refer to attachment 44 and 44.a. SAMUDRA’ HSE
Management System
Audit Procedure

Attachment 44a:

PT. WIDODO LINTAS

SAMUDRA’ HSE Internal
Audit Report

2.23 MANAGEMENT REVIEWS/ TINJAUAN ULANG OLEH MANAJEMEN Reference

Acuan
2.23.1 Has requirements for, and is regular review of HSE matters
carried out in the Company?
Apakah persyaratan untuk peninjauan ulang secara tetap
terhadap masalah K3LL dilaksanakan di Perusahaan?

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been carried out Attachment 44:
requirement for, and is regular review of HSE matters. PT. WIDODO LINTAS
Please refer to attachment 44 & 45 SAMUDRA’ HSE
Management System
Audit Procedure
Attachment 45:
PT. WIDODO LINTAS
SAMUDRA’ HSE
Management Review
Procedure
Attachment 45a:
Attendance List &
Minutes of Meeting of
Management Review.
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2.23.2 Have requirements and routine follow up procedures been Attachment 44:
established? PT. WIDODO LINTAS
Apakah persyaratan dan prosedur untuk peninjauan ulang secara SAMUDRA’ HSE
tetap terhadap masalah K3LL dilaksanakan di Perusahaan? Management System
Audit Procedure

Answer:
Yes. PT. WIDODO LINTAS SAMUDRA has been established Attachment 45:
requirements and routine follow up procedures. PT. WIDODO LINTAS
Please refer to attachment 44, 45 & 45a.. SAMUDRA’ HSE
Management Review
Procedure

Attachment 45a:
Attendance List &
Minutes of Meeting of
Management Review.