REFERENCE TO CHECKLIST INSPEKSI K3L (Safety Patrol )

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MATERIAL B3 MATERIAL B3
1 Wadah penyimpanan bahan dalam kondisi baik (tidak bocor / rusak) Material storage containers in good condition (no leaking / damaged)
2 Wadah penyimpanan bahan memiliki label yang jelas Material storage containers labeled clearly
3 Tempat penyimpanan bahan bersih dari ceceran / spill bahan Storage area clean of spilled material / substance spill
4 MSDS tersedia di ruang penyimpanan bahan MSDS are available in the material storage space
5 Disediakan bahan penyerap tumpahan di ruang penyimpanan Supplied spill absorbent material in the storage room
6 APD dan kotak P3K disediakan dalam ruangan penyimpanan PERSONAL PROTECTIVE EQUIPMENT and P3K box provided in the storage room
PEKERJA & CARA KERJA WORKERS AND HOW TO WORK
1 Pekerja menggunakan APD yang dipersyaratkan Workers using PERSONAL PROTECTIVE EQUIPMENT required
2 Pekerjaan dilakukan sesuai dengan cara / metode kerja yang telah ditetapkan Work was carried out in the manner / method of work that has been set
3 Menggunakan peralatan kerja dengan benar Use work equipment correctly
4 Mengoperasikan mesin sesuai dengan persyaratan teknis Operate the engine in accordance with the technical requirements
5 Adanya rambu-rambu peringatan yang jelas The presence of warning signs clear
6 Adanya pembatasan ijin masuk pada daerah-daerah berbahaya / resiko tinggi The restrictions on admission in hazardous areas / high risk
7 Pekerja telah mendapat pelatihan sesuai tugasnya Workers have received training in accordance with their duties
8 Pekerja bekerja dengan serius / tidak bercanda Workers work seriously / no kidding
9 Posisi tubuh benar saat mengangkat beban/bekerja Correct body position when lifting weights / work
MESIN / PERALATAN MACHINE / EQUIPMENT
1 Alat pengaman mesin / peralatan terpasang pada tempatnya Machine safety devices / equipment are in place
2 Mesin / peralatan dalam kondisi baik dan telah diperiksa sebelum dioperasikan Machinery / equipment is in good condition and have been checked before it is operated
3 Kondisi sekitar mesin / peralatan bersih dari ceceran oli / cairan lain Conditions around machinery / equipment net of scattered oil / other liquids
4 Mesin / peralatan yang dalam perbaikan diberi penandaan (Tag Out) yang jelas Machinery / equipment in the repair labeled (Tag Out) clear
5 Sarana informasi tanggap darurat tersedia dan berfungsi dengan baik Means of emergency response information is available and functioning properly
6 Instruksi pengoperasian mesin / peralatan ada / terpasang Operating instructions for machinery / equipment existing / installed
LINGKUNGAN KERJA WORK ENVIRONMENT
1 Lantai bersih dari ceceran oli atau tumpahan lainnya Floor clean of oil spills or other spills
2 Jalur untuk jalan bebas dari halangan / benda-benda Paths to roads free of obstruction / objects
3 Kabel tertata rapi dan aman Wires neat and secure
4 Penempatan barang sesuai dengan lokasi yang telah ditentukan Placement of goods in accordance with a predetermined location
5 Tempat kerja memiliki penerangan yang memadai The workplace has adequate lighting
6 Tempat kerja memiliki ventilasi udara yang memadai The workplace has adequate ventilation
7 Tempat kerja telah disediakan APAR The workplace has been provided APAR
8 APAR terletak pada tempat yang mudah dicapai dan tidak terhalang APAR is located in a convenient place and unobstructed
9 APAR yang terpasang telah diperiksa APAR installed has been checked
10 Terdapat tanda jalur evakuasi yang jelas terlihat There is an evacuation route signs are clearly visible
Record of Safety Patrol Date ____________ Assessor Name: ________________________

AREA 1 : Production Area

MATERIAL WORKERS MACHINE / WORK
No PIC Name Area AND HOW EQUIPMENT ENVIRONME SCORE (%) Record of Finding
B3 TO WORK NT

PRODUCTION
Production 1st Floor Area
Production 2nd Floor Area
Anis, Budi & Material Preparation Area
1 Production Boiler Room & yard
Team Stair & Emergency Stair
Table Lifter
ABCG inside building area,
ABCG outside building area

FILLING
Rest Room
Filling Area.
Endan (L) &
2 Cooling Tower Area,
Filling Team
Waste Grease (outside area)
Drum Empty (outside area)
1st Floor Mesh Cleaning

DECANTING
Employee Toilet,
Decanting Room,
David (L) & Packaging Storage Area
3
Decanting Team Decanting WIP Area,
Waiting Inspection Area.
Non Conforming Product Area.

PPIC
Shipping Area,
Good Product Storage Area
Raw Material Storage Area
Satria (L) & PPIC
4 Base Oil Pump Facility
Team
Base Oil Tank & Floor Area.
Base Oil Land (behind Tank).
Base Oil Loading Street
Forklift Parking Area

LABORATORY
Arifah (L)
5 Laboratory Area
Tatok
Sample Storage Place

Score Criteria: G : Good Implementation

Example : Result of patrol on any location.
L = Leader

NG : Not Good Implementation Material =G, Worker = G, Machine = G, Environment = NG

Total Number of "G" x 100% So, the score = (3/4) x 100% = 75%
(%) Score :
Total Number of check item.
Record of Safety Patrol Date ____________ Assessor Name: ________________________

AREA 2 : Administration & Public Area

MATERIAL WORKERS MACHINE / WORK
No PIC Name Area AND HOW EQUIPMENT ENVIRONME SCORE (%) Record of Finding
B3 TO WORK NT

OFFICE ROOM
Frans (L)
1
Sendy Office Room
Medical Room

PUBLIC AREA
(INSIDE BUILDING )

Tini (L) Office Warehouse

2 Azis Pantry , Canteen & Corridor.
Tito Locker Male & Female
Toilet Male & Female
Production Toilet
Pray Room (Male & Female)

MEETING ROOM & LOBBY

Sri (L)
3 Sunarso Meeting Room.
Rener Guest Room.
Lobby & Terrace

PUBLIC AREA
(OUTSIDE BUILDING )

All Green Yard Area

Driver Room & Toilet
Purwanto (L),
Security Room
4 Sunarso, Ansor Smoking Area
Driver
Waste Building & Yard
All Parking Area
Waste Water Treatm. Facility
Factory Frontside Area
 Driver Room & Toilet
Purwanto (L),
Security Room
4 Sunarso, Ansor
Smoking Area
Driver
Waste Building & Yard
All Parking Area
Waste Water Treatm. Facility
Factory Frontside Area
Workshop

Score Criteria: G : Good Implementation Example : Result of patrol on any location. L = Leader
NG : Not Good Implementation Material =G, Worker = G, Machine = G, Environment = NG

Total Number of "G" x 100% So, the score = (3/4) x 100% = 75%
(%) Score :
Total Number of check item.
 REPORT INSPECTION SAFETY PATROL
AREA : ....
DATE : ....

No. LOCATION FINDINGS PROPOSED IMPROVEMENT PIC TIME STATUS

NOTE :

CHEKED Mengetahui,

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