PT.

PRANATA DWI MULIA V K A N

INSPECTION & CERTIFICATION SERVICES Komite Akreditasi Nasional

LI-130-IDN

Nomor : 174/DIR-PDM/VI/2021
Lampiran : Tiga Berkas
Hal : Penyampaian Hasil Pemeriksaan Teknis dan Keselamatan Pesawat Angkat

Yang Terhormat
Direktur PT. Pratama Widya
Gedung ITC Lt. 2B
Widya Griya Headquarter
Jl. Kelapa Buaran PLN No. 92A-D- Cikokol Tangerang

Berdasarkan Hasil Pemeriksaan Teknis dan Keselamatan Pesawat Angkat milik PT. Prata Widya,
bersama ini kami Perusahaan Inspeksi PT. Pranata Dwi Mulia menyampaikan 3 (Tiga) dokumen
sebagai berikut :

1. Berita Acara Inspeksi dan Pemeriksaan Keselamatan Pesawat Angkat No 387/56-

430/PA/DMT/2021.
2. Sertifikat Inspeksi No. 098/PDM/LA1/VI/2021 Tertanggal 25 Juni 2021.
3. Laporan Inspeksi No. 098/PDM/LA1/VI/2021.

Berdasarkan hasil evaluasi teknis terhadap data atau dokumen serta pemeriksaan teknis di
lapangan menunjukan bahwa 1 (Satu) unit pesawat angkat termaksud telah memenuhi peraturan
yang berlaku, standar dan spesifikasi teknis yang diacu serta layak dan aman untuk dioperasikan
dan digunakan pada kegiatan usaha minyak dan gas bumi.

Atas perhatiannya, kami ucapkan terima kasih.

Bekasi, 25 Juni 2021

PT. Pranata Dwi Mulia

Dwi Martono
Direktur

0 Q 0 D 0 B
Office: Cibubur Times Square Ruko Madison Blok C l No. 16
Jl. Raya Transyogi Km.3, Jatikarya, Jatisampuma, Kota Bekasi, Jawa Barat 17435
Telepon : (021) 8431 0608, Fax : (021) 8431 0609
Web : www.pranatadwimulia.com g lo b a l g lo b a l K £SK g lo b a l K K B
E m ail: marketingptpdm@gmail.com
 PT. PRANATA DWI MULIA
INSPECTION & CERTIFICATION SERVICES
V K A N
Komite Akreditasi Nasional

LI-130-IDN

L e m b a r Ke 1/2

S e rtifik a t In sp e k si
C e r tif ic a te O f I n s p e c t i o n
098/PD M /LA1/VI/2021

PT. P R A N A T A D W I M U L IA
B e r d a s a r k a n / B a s ed On

1. P e ra tu ra n M e n teri E S D M N o . 18 ta h u n 2 0 1 8
2. Hasil P e m e r ik s a a n T e k n is d e n g a n n o m o r la p o ra n : 0 9 8 / P D M / L A 1 / V I / 2 0 2 1 , te r t a n g g a l 14 Juni 2021
3. Berita a ca ra I n s p e k s i d a n P e m e r ik s a a n K e s e la m a t a n P e s a w a t A n g k a t N o m o r : 3 8 7 / 5 6 - 4 3 0 / PA/ D M T/ 2 0 2 1 ,
te rta n g g a l 14 Juni 2 0 2 1 .

T e la h m e la k s a n a k a n in s p e k s i t e k n is t e r h a d a p :
has ca rried o u t ind ep en d en t inspection o f

PESAW AT ANGKAT
L ifting E quipm ent

D e n g a n in fo rm a si dan hasil s e b a g a i b e rik u t b e rik u t ini :

w ith the in fo rm a tio n a nd re s u lts as below

P e m ilik / O w n e r PT. P r a ta m a W id y a T b k
P e m a k a i / U se r PT. P r a ta m a W id y a T b k
D e s k rip s i P era la ta n / D e s c r ip tio n E q u ip m e n t T r u c k M o u n te d C r a n e
P a b rik P e m b u a t / M a n u f a c t u r e r H IA B
N o m o r Item / Item N u m b e r
N o m o r Model / M odel N u m b e r 288EP-3C LXE
N o m o r S eria l / S eria l N u m b e r 28802939
K a p a s it a s / C a p a c ity 1 0 .1 0 0 Kg, pada p a n ja n g b o o m 2 .5 0 m e te r , r a d iu s 2 .5 0 m eter.
T a h u n P e m b u a t a n / Y e a r Build 2013
T a h u n P e n g g u n a a n / Y e a r Used 2013
Tali Baja Load H o is t / W ire ro pe Load H o ist
- Tali Baja U ta m a / Main H o is t : N /A
- Tali Baja B a n tu / A u x i l ia r y H o ist : N /A
Lokasi I n sp e k si / L oc a tio n I n s p e c tio n : W o r k s h o p PT. P rim a I ndah M u t ig u n a - B e k a s i.
Lokasi D ig u n a k a n / L o c a tio n U se d : A re a In d o n e sia
T a n g g a l I n sp e k si / D a te o f I n s p e c tio n : J u n e 14, 2021
R e fe re nsi / R e fe re n c e (s) : - A S M E B 3 0 .5 M o b ile and L o c o m o t iv e C r a n e s
- A S M E B 3 0 .1 0 H o o k s
- A S M E B 3 0 .9 S lin g s
L in g k u p I n sp e k si / S c o p e o f I n s p e c tio n : P e n e la a h a n d o k u m e n , v e r if ik a s i dan in s p e k s i la p a n g a n

P e n g u jia n B e b a n / Load T e s t

Panjang B o o m Sudut R a d iu s Kerja Uji Beban B e b a n K e rja A m a n C a ta ta n

No. B o o m Length A n g le W o r k in g R a d iu s T e s t Load S a fe W o r k in g Load Rem arks
(m e te r) (d e r a ja t) (m e te r) (Kg) (Kg )
M a in H o is t
1 . 8.0 0 - 8 .0 0 2 .5 0 0 2 .9 8 0 8 3 % x S W L , Baik
2. 6.0 0 - 6.0 0 4.050 4 .0 5 0 1 0 0 % x S W L , B a ik
3. - - - - - -
A u x H o is t
1 . - - - - - -
 PT. PRANATA DWI MULIA
INSPECTION & CERTIFICATION SERVICES Komite Akreditasi Nasional

LI-130-IDN

L e m b a r Ke 2/2
No. S e r t if ik a t : 0 9 8 / P D M / L A 1 / V I / 2 0 2 1

K e s im p u la n / C o n c lu s io n
1. B e r d a s a r k a n hasil s e s u a i lin g k u p in s p e k s i, p e ra la ta n t e r s e b u t di a ta s m e m e n u h i p e r s y a r a t a n regu la si
p e m e r in ta h dan r e fe r e n s i y a n g diacu.
Based on re s u lt w ith re la te d scope o f inspection, the e q u ip m e n t s ta te d above was fo u n d co m p ly to g o v e rn m e n t
regulation and re fe rre d standards.
2. S e r t if ik a t ini m e n d e k s r i p s ik a n t e m u a n pada sa a t dan di t e m p a t p e m e r ik s a a n . PT. P r a n a ta D wi Mulia
m e n e r b itk a n s e r t if ik a t ini y a n g d ib u a t d e n g a n s e b e n a r - b e n a r n y a .
This ce rtifica te describes the fin ding s on and a t the exam in a tion site. PT. Pranata D w i Mulia publishes this
ce rtifica te which is m ade in tru th .
3. P e s a w a t A n g k a t ini h a n y a d a p a t d io p e r a s ik a n se s u a i d e n g a n b e b a n k erja a m a n d ia t a s o le h o p e r a t o r dan r ig g e r
y a n g tela h m e m p u n y a i s e r t if ik a t B id a n g Migas.
This Lifting E q uip m e nt can o nly be o pe ra te d in accordance w ith the safe w orkload above by the operators and
riggers who alrea d y have a c e rtific a te o f Oil a nd Gas Field.
4. PT. P ra ta m a W id y a T b k b e r t a n g g u n g ja w a b s e p e n u h n y a a tas k e s e la m a t a n p e n g o p e r a s ia n P e ra la ta n t e r s e b u t di
atas.
PT. Pratam a Widya Tbk m u s t take fu ll re s p o n s ib ility fo r the sa fety the ope ra tion o f the e q u ip m e n t above.
5. S e l a m b a t - l a m b a t n y a tig a b u la n s e b e lu m b e r a k h ir n y a m a s a b e rla k u S e r t if ik a t , PT. P r a ta m a W id y a T b k w ajib
m e la k u k a n p e m e r ik s a a n t e k n is t e r h a d a p p e ra la ta n t e r s e b u t di atas.
No la te r than three m o n th s before the end o f the e ffe c t o f c e rtifica te , PT. Pratam a Widya Tbk are re q u ire d to
conduct e xam ination te chn ical o f the e q u ip m e n t above.
6. A p a b ila terja d i h a l-h a l y a n g d a p a t m e n y e b a b k a n P e ra la ta n t e r s e b u t t id a k la y a k dan t id a k a m a n u n tu k
d io p e ra s ik a n m a k a S e r t if ik a t I n s p e k s i ini t id a k be rlaku.
I f there is things th a t can cause e q u ip m e n t is n o t eligible to and u n co m fo rta b le to be o perated so this
C ertificate o f In spe ction does n o t apply.

S e r t if ik a t ini b e rla k u s e ja k t a n g g a l d it e rb it k a n . (3 ta h u n )
This ce rtifica te take e ffe ct as o f the date issued. ( 3 years)

D it e rb it k a n di / p u b lis h e d B e ka s i

T a n g g a l / Date 25 Juni 20 21

B e rla k u s a m p a i / E x p ire d D ate 24 Juni 2 0 2 4

D ir e k t u r
 KEMENTERIAN ENERGI DAN SUMBER DAYA MINERAL
REPUBLIK INDONESIA
D IR E K T O R A T J E N D E R A L M IN Y A K D A N G A S B U M I
G E D U N G !B N U S U T O W O , J A L A N . H.R R A S U N A S A ID K A V B -5 , J A K A R T A 1 2 9 1 0

K O T A J^P O ^^!9 6 M IU \1 0 0 /lj^^T E L E P O J^j5 2 j> 8 ^^

BERITA ACARA
INSPEKSI DAN PEMERIKSAAN KESELAMATAN PESAWAT ANGKAT
Nomor: 387 / 56-430 /P A / DMT/ 2021

Pada hari ini Senin tanggal 14 Juni 2021 telah dilaksanakan inspeksi dan pemeriksaan keselamatan atas l (satu) unit
Pesawat Angkat milik PT. Pratama Widya Tbk, Yang Berlokasi di Workshop PT. Prima Indah Multiguna-Bekasi,
berdasarkan surat No. B-5797/MG.06/DMT/2021 tangga 09 Juni 2021. Perihal petugas pemeriksaan keselematan pesawat
angkat. Pemeriksaan Teknis tersebut diatas dilakukan oleh Perusahaan Inspeksi (PI) PT. Pranata Dwi Mulia, direview
oleh Petugas Direktorat Jenderal Minyak dan Gas Bumi serta perwakilan dari PT. Pratama Widya Tbk.

I. Ruang lingkup pemeriksaan keselamatan kerja sebagai berikut

1. Penelaahan dokumen
2. Pemeriksaan fisik/visual
3. Non Destructive Test (NDT) Metode Magnetic Test
4. Uji Fungsi
5. Uji Beban

II. DATA UMUM

Adapun data Teknis Pesawat Angkat tersebut adalah sebagai berikut:
Pemilik PT. Pratama Widya Tbk
Item No -

Serial No 28802939
Model No 288EP-3CLXE
Tipe Unit Truck Mounted Crane - Telescopic Boom
Kapasitas 10.100 Kg, pada panjang boom 2.50 meter, radius 2.50 meter.
Panjang Main Boom 10.20 meter
Main Hoist Diameter N/A
Auxiliary Hoist Diameter N/A
Pabrik Pembuat HLAB
Tahun Pembuatan 2013
Tahun Digunakan 2013
Pabrik Mesin UD Truck
Model No / Serial No. GH8E / GH8*471237*A1 *P
Putaran Mesin 206 K w /2.200 Rpm
Hook Utama Kapasitas 8.000 Kg
Hook Bantu N/A
Lokasi Digunakan Area Indonesia
Standart / Code ASME B 30.22 Articulating Boom Cranes

Hasil Inspeksi dan Pemeriksaan keselamatan kerja atas peralatan 1 (satu) unit pesawat angkat tersebut diatas adalah
sebagai berikut:

1. Pada proses penelaahan dokumen, tidak ditemukan kekurangan dokumen pada unit pesawat angkat tersebut.
2. Pada proses pemeriksaan secara visual/cek fisik tidak ditemukan kekurangan dan kerusakan pada peralatan
pesawat angkat tersebut.
3. Pada proses uji Non Destructive Tesi (NDT) metode Magnetic Test tidak ditemukan kerusakan atau Indikasi
cacat.
4. Pada proses uji fungsi peralatan, peralatan pesawat angkat dapat berfungsi dengan baik.
 KEMENTERIAN ENERGI DAN SUMBER DAYA MINERAL
REPUBUK INDONESIA
D IR E K T O R A T JE N D E R A L M IN YA K DAN G A S BUMI
G E D U N G IB N U S U T O W C t JA L A N . H .R. R A S U fiA S A ID KA V B-5. J A K A R T A 12910

KOTAK POS: 1296/JKT.100.12

UL Hasil uji beban dari pesawat angkat adalah sebagai berikut:

Panjang Boom Sudut Radius Uji Beban SWL Keterangan / Hasil
No.
(meter) (derajat) (meter) (Kg) (Kg)
Main Hoist
1. 8.00 - 8.00 2.500 2.980 83% x SWL, Baik
2. 6.00 - 6.00 4.050 4.050 100% x SWL, Baik
3. - - - - - •

Aux Hoist
1. - - - - - -

IV. Kesimpulan
Berdasarkan dari hasil pemeriksaan dan pengujian diatas. kami mem impuikan bahwa Truck Mounted Crane-Telescopic
Boom model 288EP-3CfJCE Serial No. 28802939 masih dalam kondisi dapat diterima, aman untuk dioperasikan dengan
beban kerja aman sesuai table beban dan pabrik pembuat, untuk dioperasikan dan digunakan pada kegiatan usaha minyak
dan gas bumi sesuai dengan masa berlaku sebagaimana tertera dalam Sertifikat Hasil Inspeksi (Certificate o f Inspection ).

Bekasi. 14 Juni 2021

NO. INSTANSI i PERUSAHAAN NAMA TANDA TANGAN
1. DITJEN MIGAS Jauhar Fuadi
NIP. 197403172005021001

2. PT. PRATAMA WIDYA Tbk

p;

A
PT. PRANATA DWI MULIA B igas Adv Kusuma
420/L1-RO/IPA/MTGAS/2019
(Inspektur Pesawat .Angkat)
 PT. PRANATA DWI MULIA
INSPECTION & CERTIFICATION SERVICES

REPORT OF INSPECTION
REPORT No. 098/PDM/LA1/VI/2021

PT. PRATAMA WIDYA Tbk

TRUCK MOUNTED CRANE-ARTICULLATING BOOM
CAPACITY 10.100 KG
MODEL 288EP-3CLXE
SERIAL No. 28802939

^HIRB
LOADER CRANE

S E R IA L N O

M A N U F .Y E A R

Cargotec Sweden AB. Hiab

S6-824 83 HUDIKSVAIL SWEDEN
344 6263

y KAN
Komite Akreditasi Nasional

OS 181139 C LI-130-IDN
A d d re s s :
Cibubur Times Square Telp : (021) 8431 0608
Blok C l No. 16 Fax : (021) 8431 0609
Jl. Transyogi Km.3 Jatisampurna Bekasi E m ail: marketingptpdm@ gmail.com
Jawa Barat 17435 - Indonesia Web : www.pranatadwimulia.com
ES 181140 C QS 181138 C
 TABLE OF CONTENTS
NO D E S C R I P T I O N _______________
I MIGAS APPOINTMENT LETTER
SURAT PENUNJUKAN MIGAS

II EXECUTIVE SUMMARY
RINGKASAN

HI STATEMENT OF FACT
BERITA ACARA PENGUJIAN BEBAN

IV MIGAS FORM (TI-UJ-PA)

FORMAT MIGAS (TI-UJ-PA)

v CHECK LIST REVIEW DOCUMENT

CATATAN PENELAHAAN DOKUMEN

VI INSPECTION & VERIFICATION RECORD

REKAMAN PEMERIKSAAN D A N VERIFIKASI

a. PHYSYICAL VERIFICATION & DIMENTION INSPECTION RECORD

CATATAN PEMERIKSAAN FISIK D A N DIMENSI

b. FUNCTTION TEST REPORT

LAPORAN UJI FUNGSI

c. LOAD TEST REPORT

LAPORAN UJI BEBAN

d. AFTER LOAD TEST INSPECTION REPORT

LAPORAN PEMERIKSAAN SETELAH PENGUJIAN

e. NONCONFORMANCE RECORD (NCR)

CATATAN KETIDAKSESUAIAN

VII NON DESTRUCTIVE TEST (NDT)

PENGUJIAN TIDAK MERUSAK

V III ATTACHMENT
LAMPIRAN

PHOTOGRAPH
MANUAL BOOK D A N LOAD CHART
I MIGAS APPOINTMENT LETTER
SURAT PENUNJUKAN MIGAS
 KEMENTERIAN ENERGI DAN SUMBER DAYA MINERAL
REPUBLIK INDONESIA
D IREKTO RAT JEN DER A L MINYAK DAN GAS BUMI
G E D U N G IBNU SUTOWO, JALAN. H.R. RASUNA SAID KAV B-5, JAKARTA 12910

KOTAK POS: 1296/JKT.100.12 TELEPON : 5268910 (Hunting) FAKSIMILE : (021) 5269114 e-mall : mlaas@miaas.esdm.go.id

Nomor 9 Juni 2021

B-5797/MG.06/DMT/2021
Lampiran
Hal Petugas Pemeriksaan Keselamatan Pesawat Angkat

Yang terhormat,
Direktur PT. Pratama Widya Tbk.
Widya Griya Headquarter
Jl. Kelapa Buaran PLN No 92A-D Cikokol Tangerang

Berdasarkan surat HSE Koordinator PT.Pratama Widya Tbk. Nomor 001/PW-

INSA/l/2021 tanggal 31 Mei 2021 yang kami terima tanggal 8 Juni 2021 perihal Undangan
Pemeriksaan Keselamatan Pesawat Angkat, dan merujuk pada Surat Keputusan Presiden
Nomor 12 Tahun 2020 tentang Penetapan Bencana Nonalam Penyebaran Corona Virus
Disease 2019 {Covid-19) sebagai Bencana Nasional, dengan ini kami menugaskan:

Nama Jabatan NIP

Jauhar Fuadi Inspektur Migas 197403172005021001

Untuk melaksanakan tugas pemeriksaan keselamatan atas pesawat angkat termaksud

dengan melakukan pemeriksaan keselamatan terhadap hasil inspeksi pemeriksaan teknis
oleh Perusahaan Inspeksi PT. Pranata Dwi Mulia.

Kami sampaikan pula dalam melaksanakan inspeksi pemeriksaan teknis,

diharapkan BU/BUT dan Perusahaan Inspeksi tetap harus memperhatikan SOP pencegahan
penyebaran virus Corona dengan memakai APD, menggunakan hand sanitizer serta menjaga
jarak aman.

Atas perhatian dan kerja sama Saudara, kami ucapkan terima kasih.

Direktur Teknik dan Lingkungan Migas,

Selaku Kepala Ispeksi

Wakhid Hasyim

Tembusan :
1. Sekretaris Ditjen Migas
2. Direksi PT. Pranata Dwi Mulia
II EXECU TIVE SUM M ARY
RINGKASAN
 PT. PRANATA DWI MULIA Proc. No. PDM-PRO-OPS-SPA-01

EXECUTIVE SUMMARY Report No. 098/PDM/LA1/V1/2021

RINGKASAN PEMERIKSAAN IK No. PDM-IK-OPS-SPA-01

Date Of Insp June 14,2021
Page 1 Of 2

Introduction
In co m p lian ce with M IGAS a p p oinm e n t le tte r No. B-5797/MG.06/DMTV2021 date on June 09, 2021, Inspectors o f PT.Pranata Dwi
M ulia has been conducted an inspection o f cran e on Ju n e 14, 2021 a t W o rksh o p PT. Prim a Inti M ultiguna-Bekasi.

Ref./ Code
T he inspection standard o f crane according with AS M E B 30.22, AS M E B 30.10, AS M E B 30.26, A W S D14.3

Scope
In th e inspection w e have a ste p as fo llo w s : review docu m e n t, verification, physical/visual inspection, function and Load test
including reporting.

Reviewing Document
Quality System
T h e Q uality System o f th e user has been review ed in th e random audit w a s found th a t ge n era lly th e y have im p le m e n te d their
quality system .

Manufacturer's Operation and Maintenance Manual Book

T h e O peration and M aintenance m anual b ook has been reviewed and co m p lied with standard and cran e specification.

NDT Procedure, Personnel and Equipment.

N D T Procedure, qualification record o f th e N D T personnel w ill pe rfo rm N D T and N D T E q u ip m e nt have been review ed and found
in a ccordiance w ith standard/code.

Verification
During our attendance on site th e w e a th er is good, and th e crane w a s p la ce d / m ounted on a plain and th e firm ed g round, th a t has
enough bearing capacity to sa fe operation, inspection and testing.
T h e C rane is used fo r G eneral lifting service with th e p rofile are as fo llo w s :
C rane T ru ck M ounted C rane - A rticullating Boom Y e a r B uilt/ Used 2 013 / 2013
Item No. U ser PT. Pratam a W idya T bk
M anufacturer HIAB C apacity 10.100 Kg
Serial N o ./ M odel 2 8 8 02939 / 2 8 8E P -3C LX E Boom Length 10.20 m eter

Boom Hoist Mechanism

B oom configuration are 1 (one) L ow er as a base, 3 (Three) section as a insert and 1 ( o n e ) as a top, T ele sco p ic Boom .

Hoisting Mechanism
Main Hoist
T he w irerope construction is N/A
Max. rated load 4.050 Kg / S W L 4.050 Kg, w ithin th e hook b lo ck capacity 8.000 Kg.

Aux. Hoist
T he w irerope construction is N/A

Traveling Mechanism
T h e C a rrie r w as driven by,R ubber and th a t is powered by six cylinders turbo diesel engine.
Slewing Mechanism
Slewing th e boom are g e nerated by hydraulic m oto r th a t attached on th e chasis o f th e carrier, co m p le te d with swing lock.

Outrigger Assembly
T he outrigge rarm w a s jo in n e d to the chassis o f a truck/carrier, at the fro n t o r driving cabin, and th e hydraulic ja c k joined
vertical to th e arm .
 PT. PRANATA DWI MULIA Proc. No. PDM-PRO-OPS-SPA-01

EXECUTIVE SUMMARY Report No. 098/PDM/LA1/W2021

RINGKASAN PEMERIKSAAN IK No. PDM-IK-OPS-SPA-01

Date Of Insp. June 14,2021
2 Of 2
Physical Inspection
Structure Inspection
T he structure integrity o f th e crane have been visualy inspected, I e:
- Hoisting M echanism - H o o k & B lock
- Traveling, slew ing M echanism - W e lding, Bolting and hinge jo in ts
- O utrigger A sse m b ly - Boom
- U pper Structure

T he R esult o f th e final inspection w ere found w h e re the m inor, m a jo r a n o m a lie s had been closed

Hydraulic System
T h e hydraulic system have been inspected physically in hose, tubing, connections, seals, hydraulic pum p, cylinders, reservoir
valves, that found in good condition, w ithout any leakages.

Operator Cabin
T h e Driving cabin w a s insulated, w hen th e cran e operated beyond th e sa fe ty lim its,and visual a la rm w a s sounded inside the cabin
and fire extinguisher replaces inside the cabin.

Non Destructive T e s t:
S pot N D T has been carried o u t by qualifed MPI - II, fo r th e suspected pa rt i.e : M ain Hook, O utrigger, etc.
No significant indication w as fo u nd during th e test, see detail o f N D T R ecord.

Function Test
T he Function T e st have been perfo rm e d fo r all crane m echanism , engine, safety devices, and accessories as fo llo w s :
Engine and A ccessories : - Engine, control (O n /O ff)
- E m ergency Shutdown (O n /O ff)
- Lighting, horn (O n /O ff)
C rane M echanism
Articulating, O utrigger, stabilizer ( Extended, retracted Slew ing M echanism , ( Left, R ig h t)
T raveling M echanism ( Forw ard, R e v e rs e d )
S afety Devices
Boom ( Hoisting, lo w e rin g )

T he re w a s not found any an o m a lie s during the test, see detail o f Function T e st Record.

Non Conformance Record

During inspection in the fie ld w e found so m e n o n con fo rm a n ce s and then w e issued Non C o n fo rm a n ce R ecord prior to final
inspection all N C R have been rectified and closed o u t report are m ade ( see N C R R e c o rd ).

Proof Load Test

W ith refe re n ce to AS M E B 30.22 th e te st sh o u ld be perfo rm e d 100% th e rated load. During a ttendance th e cran e w as loaded
g ra d u a lly fro m the low est load.
Load T est as fo llo w s :
Boom Length Radius Angle Test Load SWL
No. Part Partline
( m e te r ) ( m e te r ) (degree) (Kg) (Kg)
1. 8.00 8.00 - 2.500 2.980 -

2. Main Hoist 6.00 6.00 - 4.050 4.050 -

3. - - - - - -

1. Aux Hoist - - - - - -
T he tests w e re satisfactory

Conclusion
Based on th e d o cu m e n t review ed and field inspection report,and o u r b e st know ledge, w e co m e to the conclusion th a t the crane
m entioned above is good and fit condition to be operated.
R eco m m e n d in g issued fo r e q u ip m e n t use
Ill STATEMENT OF FACT
BERITA AC AR A PENGUJIAN BEBAN
 PT. PRANATA DWI MULIA v KA W
INSPECTION & CERTIFICA1 ION SERVICES Komii* Akreditasi Nasional

U-1NMDN

BERITA ACARA
PEMERIKSAAN TEKNIS DAN PENGUJIAN BEBAN
098/PDM/LA1/VI/2021
Pada hari ini Senin tanggai 14 Juni 2021, PT Pranata Dwi Mulia telah melaksanakan Pemeriksaan Teknis dan
Pengujian Beban terhadap 1 (satu) unit Pesawat Angkat yang disaksikan oleh PT. Pratama Widya Tbk dengan
spesifikasi sebagai berikut:

Peralatan Truck Mounted Crane - Articullating Boom

Pemilik PT. Pratama Widya Tbk
Nomor Seri 28802939
Nomor Model 288EP-3CLXE
Pemanufaktur HIAB
Panjang Boom 10.20 meter
Nomor Item
Kapasitas max. 10.100 Kg, pada pa ijang boom 2.50 meter, radius 2.50 meter.
Tahun Pembuatan 2013
Tahun Penggunaan 2013
Penggunaan General Lifting
Diameter Wire Rope - Main Hoist N/A
- Aux. Hoist N/A
Lokasi Inspeksi Workshop PT. Prima Indah Mutiguna-Bekasi.
Referensi / Standard ASM E B 30.22 Artie jlating Boom Cranes
UJI BEBAN :

Panjang Boom Radius Sudut Boom Uji Seban SWL

No. Hasil
{ meter) (meter) ( derajat) (<9) ( Kg)
MAIN HOIST
1. 8.00 8.00 - 2 500 2.980 83% x SWL. Baik
2. 6.00 6.00 - 4 050 4.050 100 % x SWL, Baik
- - - - - * -
AUX HOIST :
- - i........................- I - l- ■ - ........ . I :
Catatan Hasil P engujian:
1. Pengujian Beban dilakukan sesuai dengan Tabel Beban HIAB M'xJel 288EP-3CLXE dengan Kapasitas Pesawat
Angkat 6.100 Kg.
2. Hasil pemeriksaan, pengujian fungsi dan beban, pesawat angkat dalam kondisi baik, tidak ada penurunan boom,
beban dan dapat diterima berdasarkan standar yang dipersyaratkan spesifikasi.

R ekom endasi:
1. Pesawat angkat dioperasikan sesuai petunjuk operasi dan oleh ojrerator yang memiliki Surat Ijin Operator.
2. Pesawat angkat tidak boleh dioperasikan melebihi kapasitas kerja aman (SWL) atau Rated Load.

Demikian Berita Acara ini dibuat untuk dapat dipergunakan sebagaimana mestinya.

Bekasi. 14 Juni 2021

PT. Pratama Widya Tbk PT. Pranata Dwi Mulia Petugas Inspektur Migas

widya Tbk y : ,
estl98l
Baaas Adv Kusuma Jauhar Fuadi
420/L1-RO/IPA/MIGAS/2019 NIP.197403172005021001

O lik e Cibubur Timc$ Square Ruko M a d ro n BU>k C1 N». 16

i| Raya Transycvgt. K m k Jati'karya» Jausampuma. Kt>ia Btefcasi. J&w« Barat i 74.55
Telepon 102 h «431 0*0*. Fax 8411 0600
Web /. www,pranatadwinmba.com
mail 111arktfliftgpipdt gnt uil,v.oia
IV MIGAS FORM (TI-UJ-PA)
FORMAT MIGAS (TI-UJ-PA)
 fierHUkri-lU-PA

DIREKTORAT TEKNIK DAN LINGKUNGAN MIGAS

PENGUJIAN PESAWAT ANGKAT
(Testing o f Lifting Equipment)
Page! o f3
DATA

Pemakai (User) PT. Pratama Widya Tbk

Lokasi (Location) Workshop PT. Prima Indah Mutiguna-Bekasi.
Nomor Item (Item Number) -
Pemanufactur (Manufactured by) HIAB
Kapasitas ( Capacity ) 10.100 Kg
Nomor Seri / Model (Serial No. / Model) 28802939 / 288EP-3CLXE
T ahun pembuatan (Year built) 2013
T ahun penggunaan (Year user) 2013
Penggunaan (Services) General Lifting
Panjang Boom (Boom length) 10.20 meter
Mesin Penggerak Utama (Main engine drive) Diesel Engine

a. Pemanufaktur (Manufactured by) UD Truck

b. Nomor seri / Model (Serial Number) GH8E / GH8*471237*A1*P
c. Tahun pembuatan (Year built) 2019
d. T ahun penggunaan (Year used) 2019
e. Tenaga, Voltage (Power, Voltage, RPM -

Amper Ampere, HP) -

Seling (Hoist line / wire rope)

a.
b.
c.
Utama
Bantu
Boom
(Main hoist) & (Type/size)
(Aux. hoist) & (Type/size)
(Boom hoist) & (Type/Size)
_
-

Main Hook Block

a. Pemanufaktur (Manufactured by) HIAB

b. Nomor seri (Serial Number) 16-8
c. Ukuran (Size) T.O x B-H x S (mm) 87 x 64 x 36mm
Jip/Whip Line Hook

a. Pemanufaktur (Manufactured by) -

b. Nomor seri (Serial Number) -

c. Ukuran (Size) T.O x B-H x S (mm) -

 B to trittrU tP A

DIREKTORAT TEKNIK DAN LINGKUNGAN MIGAS

PENGUJIAN PESAWAT ANGKAT
(Testing o f Lifting Equipment)
Page 2 o f 3

PENGUJIAN LAPANGAN
(Field Test)

I. FUNGSIONAL TEST Tanpa Beban Dengan Beban

(Without load) (With load)
1 Pengangkatan dan penurunan seling
(Lifting and Lowering Hoist) N/A Not Available
2 a. Pengangkatan dan penurunan boom
(Lifting and Lowering Boom) Baik Baik
b. Gerak, geser trolley & bridge
(Trolley and Bridge Travel) N/A Not Available
3 Operasi rem dan kopling
(Brakes and Clutches) Baik Baik
4 Batas jangkau dan penguncian
(Limit & Witches and Locking) Baik Baik
5 Piranti pengaman
(Safety Devices) Baik Baik
6 Gerak Pesawat Angkat
(Crane Movement) Baik Baik
7 Penyalaan lampu
(Lighting System) Baik Baik
8 Gerak putar
(Rotation Movement) Baik Baik

9 Kecepatan naik turun kait

(Lifting and Lowering Speed)

a. Kait bantu naik / turun

(Auxiliary Hook, Up/Down)
-M inimum N/A Not Available
- Maximum N/A Not Available

b Kait utama naik / turun

(Main Hook, up/Down)
- Minimum Baik Baik
- Maximum Baik Baik
 lim rnk TM 'J-PA

DIREKTORAT TEKNIK DAN LINGKUNGAN MIGAS

PENGUJIAN PESAWAT ANGKAT
(Testing o f Ufting Equipment)
Page 3 o f 3

II. TEST BEBAN I Load Test 1

S.N t Model : 28802939 / 288EP-3CLXE

Item No. . -
Tanggal ( Date) June 14.2021

Panjang Boom Radius Sudut Uji Beban SW L Catatan

No. (Boom Length) (Angle) (Test Load)
( meter) ( meter ) ( degree) (kg) ( Kg) ( Remarks )
MAIN HOIST
1 8.00 8.00 - 2.500 2.980 83% x SWL, Baik
2. 6.00 6.00 - 4.050 4.050 100% x SWL, Baik
3. - - - - - -

AUX. HOIST
L - * - * -
-

CATATAN HASIL PENGUJIAN (Recommendation):

Pada saat di lakukan uji beban dengan hasil baik, layak serta aman untuk di operasikan sesuai dengan tabel beban /
Load chart pesawat angkat HI.4B model 288EP-3CU(E dengan Bebai 4.050 Kg

PT. Pratama Widva Tbk Petugas Ditjen Migas

tam a widya Tbk

est.1981
L'n5O 0*S *
Bacas A'dv Kusuma Jauhar Fuadi
420/L1-RO/1PA/MIGAS/2019 NIP 197403172005021001
 P age l o f 2
C H E C K L I S T F O R M IG A S C E R T IF IC A T IO N

LrescFtpuon
Equipment (Peralatan) Truck Mounted Crane - Articullating Boom
Manufacturer (Pemanufaktur) HIAB
Owner / user (Pemilik / Pemakai) PT. Pratama Widya Tbk
Item No. (No. Item) -

Serial no./Model (No. Seri/Model) 28802939 / 288EP-3CLXE

Boom Length (Panjang Boom) 10.20 meter
Capacity (Kapasitas) 10.100 Kg
Year Built (Tahun Pembuatan) 2013
Year Used (Tahun Penggunaan) 2013
Services (Digunakan) General Lifting

G ENERAL:
Ite m in s p e c t f o r C ondition
All Controls Adjustment Good Accepted
Air Controls W ear Contamination N/A Not Available
Air System Leakage or Deterioration Good Accepted
Hydraulic Oil Leakage or Deterioration Good Accepted
Safety Devices Function Good Accepted
Crane Hook Crack or Deformation Good Accepted
Rope Reeving Correctness Good Accepted
Electrical Part Function, Deterioration & Good Accepted
Contamination

C O M P L E T E D IN S iP E C T I O N :
ite m Lonam on
Crane Structure Cracks, Corrosion, Deformation Good Accepted
Bolt and Rivets Tightness, Corrosion Good Accepted
Automatic Boom Cut-Off Function Good Accepted
Sheaves Wear or Crack N/A Not Available
Boom Angle Indicator Accuracy N/A Not Available
Load Indicator (s) Accuracy N/A Not Available
Engine for Motor Performance & Safety Compliance Good Accepted
Chain Wear and Stretch N/A Not Available
Chain Sproket Wear N/A Accepted
Drums or Drums Flanges Wear or Cracks N/A Not Available
Brake & Clutch Lining Excerssive Wear Good Accepted
Brake & Clutch Surface Wear-, Cracks, Distortion Good Accepted
 Page 2 o f2

COMPLETED INSPECTION :
: Item Imped for Condition Result
P aw ls & D ogs W ear C ra ck s, D isto rtio n N /A N o t V ailable

P in s, S h afts, A xles W ea r C rack s, D isto rtio n G ood A ccep ted

B earin g & R ollers W ea r C rack s, D isto rtio n G ood A ccepted

G ears W ear C rack s, D isto rtio n G ood A ccep ted

K ey, Snap R in g & L o ck in g D ev ices W ear C rack s, D isto rtio n G ood A ccep ted

T ires & W heels E x cessiv e W ear D am ag e, G ood A ccep ted

T rav el, S teerin g , B rak in g & L ock Fun ctio n G ood A ccepted

D ev ices
M ain D ru m B rak e F u n c tio n , A d ju stm e n t
L ining - E x cessiv e N /A N o t A vailable

D ru m B ra k in g Surface - W ear C ra ck s, D isto rtio n N /A N o t A vailable

L in k ag e a n d P in s - W ea r C ra ck s, D isto rtio n N /A N o t A vailable

A ctu atin g C yl. & F itting ( if an y ) - L eak ag e o r D eterio ratio n N /A N o t A vailable

A uxiliary D ru m B rak e F u n ctio n , A d ju stm en t

L in in g - E xcessive N /A N o t A vailable

D ru m B rak in g S u rface - W ea r C rack s, D isto rtio n N /A N o t A vailable

L in k ag e an d P in s - W ear C rack s, D isto rtio n N /A N o t A vailable

A ctu atin g C yl. & F itting ( i f any) - L eak ag e o r D eterio ratio n N /A N o t A vailable

3 rd D ru m B rak e ( if an y ) F u n ctio n , A d ju stm en t

L ining - E x cessiv e N /A N o t A vailable

D ru m B ra k in g S u rface - W ear C rack s, D isto rtio n N /A N o t A vailable

L in k ag e a n d P in s - W ear C ra ck s, D isto rtio n N /A N o t A vailable

A ctu atin g C yl. & F itting ( if any) - L eak ag e o r D eterio ratio n N /A N o t A vailable

B o o m H o ist B rak e F u n ctio n , A d ju stm en t

L in in g - E x cessiv e N /A N o t A vailable

D ru m B rak in g S u rface - W ear C rack s, D isto rtio n N /A N o t A vailable

L in k ag e a n d P in s - W ear C rack s, D istortion N /A N o t A vailable

A ctu atin g C yl. & F itting ( i f an y ) - L eak ag e o r D eterio ratio n N /A N o t A vailable

T rav el B ra k e o r Lo ck s F u n ctio n , A d ju stm en t

L ining - E x cessiv e G ood A ccepted

D ru m B ra k in g S u rface - W ea r C ra ck s, D isto rtio n G ood A ccep ted

L in k ag e a n d P in s - W ear C rack s, D isto rtio n G ood A ccep ted

A ctu atin g C yl. & Fitting ( if an y ) - L eak ag e o r D eterio ratio n G ood A ccep ted

L o a d B lock Fun ctio n

H ook - E xcessiv e, W ear G ood A ccep ted

H o o k Sw ivel - W ear C ra ck s, D isto rtio n G ood A ccep ted

S h eav es - W ea r C rack s, D isto rtio n G ood A ccep ted

W h ip B lo ck o r B all F u n ctio n
H ook - E x cessiv e, W ear G ood A ccep ted

H o o k Sw ivel - W ear C rack s, D istortion N /A N o t A vailable

S h eav es ( if any) - W ea r C ra ck s, D isto rtio n N /A N o t A vailable

B o o m P o in t S heaves - W ear, C rack s, D isto rtio n N /A N o t A vailable

H o o k R o p e D ead E n d - W ear, C ra ck s, D isto rtio n G ood A ccep ted

W h ip R o p e D ead E n d - W ear, C rack s, D isto rtio n G ood A ccepted

A uxiliary R o p e D ead E n d - W ear, C ra ck s, D isto rtio n N /A N o t A vailable

H ook Rope - D iam eter, W ear, B ro k en N /A N o t A vailable

W hip R o p e - W ires, C o rro sio n , K in k s N /A N o t A vailable

3 rd D ru m R ope - C ru sh in g , U n -stran d in g N /A N o t A vailable

P en d an ts N /A N o t A vailable

T agline N /A N o t A vailable

B o o m H o ist R o p e N /A N o t A vailable
V CHECK LIST REVIEW DOCUMENT
CATATAN PENELAHAAN DOKUMEN
 Form No. PDM-FRM-OPS-02

Check List Review Document

Date 25 September 2018
Revisi 00
Page 1 Of 1

Customer PT. Pratama Widya Tbk Serial No. : 28802939 DateOflnsp : June 14,2021
Name Of Equipment Truck Mounted Crane-Articullating Boom Model : 288EP-3CLXE Location ; Workshop PT. Prima Inti
Multiguna-Bekasi.

No. Review Document Actual Verification Verification Result

1. Manufacture Data Record (MDR) Operation manual book crane Comply

Spesifikasi Crane Comply

Owner document Inspection Test Plant Comply

SIO Operattor Certificate Comply
2
Previous SKPP Migas Comply

3. Dokument 3 Party Personil Inspector Crane Certificate Comply

Personil inspector NDT Level II Certificate Comply

Calibration equipment inspection Comply

.................... ~ ~ '
VI INSPECTION & VERIFICATION RECORD
REKAMAN PEMERIKSAAN DAN VERIFIKASI
a. PHYSYICAL VERIFICATION & D IM EN TIO N INSPECTION RECORD
C A T A T A N P EM E RIK SA A N FISIK D A N D IM ENSI
 Proc, No. PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA Report No. 098/PDM/LA1A/I/2021

/ P i J i y s VISUAL CHECK & VERIFICATION DIMENTION RECORD IK No. PDM-IK-OPS-SPA-01

PEMERIKSAAN FISIK & VERIFIKASI DIMENSI PESAWAT DateOflnsp. June 14.2021

ANGKAT BERGERAK Page 1 O f8

1 DATA VISUAL CHECK & VERIFICATION RECORD

a. Name Of Equipment Truck Mounted Crane - Articullating Boom
b. Owner PT. Pratama Widya Tbk
c. User PT. Pratama Widya Tbk
e. Serial No. 28802939
f. Model 288EP-3CLXE

g Type Telescopic
h. Manufacturer/ Brand HIAB
i. Capacity 10.100 Kg
j. Boom Length 10.20 meter
k. Year Built/Used 2013/2013
; i. Location of Inspection Workshop PT. Prima Indah Mutiguna-Bekasi.
m. For Used at Area Indonesia
n. Services General Lifting
n. PRIME MOVER (ENGINE)
a. Brand/ Manufacturer UD Truck
b. Model No. GH8E
c. Serial No. GH8*471237*A1*P
d. Power / RPM 206 K w /2.200 Rpm
f. Year Built/Used 2019 / 2019
g- Cyl 6
1.2. INSPECTION CUSS
a. Certification Yes b. Periodical Inspection
b. Recertification ■ Montly Inspection - ■ Quartelly Inspection - ■Annual Inspection
2. REFERENCE OF STNDARD / CODE
a. ASME B30.5 Mobile and Locomotive Cranes
b. ASME B30.9 Slings
c. ASME B30.10 Hooks
d.
2.1. DOCUMENT VERIFICATION
No. Description Verification Record Remark

a. Operation & Maintenance Manual Book (MDR) V Completed

b. History Of Maintenace Record N/A Not Available
c. Drawing N/A Not Available
d. Mills Certificate N/A Not Available
e. Non Destructive Test Report N/A Not Available
f. Engineering report N/A Not Available
g RLA Report N/A Not Available
h. Calibration Certificate N/A Not Available
i. Previous Inspection Report V Comply

i Inspection Test Plan V Comply

k. Operator Certifcate (SIO) V Comply
Legend Comment: Inspected by;
-J = Comply Verification data visually wiih docum ent unit crane compatible manufacture Crane Inspector / J t & 4 2 0 ^ v \
N/A = Not Available
N/A = Not Applicable
BaaaS Adv
42C/L1-RO/IPA/MIGAS/2019

No. Dokumen :PDM-FRM-OPS-Q3_______________________________________________________________________________________ Revisi: 2

T gl Berlaku: September 25, 2018

 Proc. No. : PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA Report No. : 098/PDM/LA1/V1/2021
P D M 7
VISUAL CHECK & VERIFICATION DIMENTION RECORD IK No. : PDM-lht-OPS-SPA-01

r PEMERIKSAAN FISIK & VERIFIKASI DIMENSI PESAWAT Date Of Insp. : June 14,2021
ANGKAT BERGERAK Page : 2 Of 8

Descriptioi Inspection for Condition Of Part Remark

II N°-
3. VISUAL CHECK & VERIFICATION RECORD
3.1. Verifikasi General Data Crane
a. General Data Name Plate, Name Plate Engine Good Accepted

Name Plate, Load Chart Good Accepted

b. Kapasitas maks.
Name Plate Good Accepted
j C. Model / Serial No.
Name Plate Good Accepted
d. Tahun Pembuat
Accepted
! e. Pabrik Pembuat Name Plate Good

Dimention Good Accepted

t. Dimensi (PxLxT)
3.2. Operator Cabin, Crane Control & Indicator
a. Atap kabin (Cab Root) F it distortion, corrosion Good Accepted

b. Kursi Operator (O perator Seat and Backrest) F it loosen, distortion Good Accepted

; c. Kaca Jendela {Windows Glass) Crack, distortion Good Accepted

d. Pembersih Kaca (Wiper) Availablelity, function Good Accepted

e. Pintu Operator (Doors, proper restraint) Distortion, crack Good Accepted

f. Lampu Penerangan (Cab Lighting/Fixtures) Function, avilablelity Good Accepted

g Kendali Suara (Audible control is accessible) Soundness, accessible Good Accepted

j h. Klakson (Horn) Accuracy Good Accepted

! i. Tuas, Pedal,Tombol Kontrol (Control Unit) Availablelity, Legible, Function Good Accepted

j- Kecepatan putaran mesin (Tacho meter) Accuracy N/A Not Available

: k- Suhu Mesin (Engine Temp Gauge) Accuracy N/A Not Available

I. Amper .Tegangan (A m p , Volt meter) Accuracy N/A Not Available
m. Tekanan Hidrolik (Hyd. Press.Gauge) Accuracy Good Accepted
! j n. Tekanan pelumas (Lubrication Gauge) Accuracy N/A Not Available

j 0. Tekanan udara (A ir Press Gauge) Accuracy N/A Not Available

p- Indikator Beban (Load Indicator) Accuracy, Legible Good Accepted

N/A Not Available
g.. Panjang, Tinggi Boom (Radius, Boom Indicator) Accuracy, Legible

r. Sudut (Angle Indicator) Accuracy, Legible Good Accepted

I s. Tanda Keadaan Darurat (Alarm) Accuracy, Safety N/A Not Available

t Kecepatan Angin (W ind Speed Indicator) Accuracy, Legible N/A Not Available

3.3. Travel Mechanism & Swing Mechanism

3.3.1. Power Plant

i 3- Mesin, dudukan mesin (Engine, mounting) Fitness, loosen, broken Good Accepted

sb. Radiator (Radiator) Level, contamination, protection Good Accepted

I c Kipas & Tali (Fan & belt) Loosen, protection Good Accepted

d. Gigi (Gear) Dry, protection Good Accepted

e. Rantai, sproket (Chain, sprocket) Dry, protection Good Accepted

f. Kopling (Clutch) Oil/ water splash, protection Good Accepted

g Tangki B. Bakar (Fuel Tank) Distortion, oil splash, leakage Good Accepted

I h- Pengumpul Asap (Manifold, Muffler) Leakage, loosen, protection Good Accepted

I Knalpot (Exhaust Gases) Properly,loosen.guarded,insulation Good Accepted

i- Knalpot Anti Api (Spark arrestor) Property,aplicable Good Accepted

3.3.2. Hook Block
a. Kait Utama ( M ain hook) Broken, Crack, wear, corrosion Good Accepted
b. Kait Bantu ( Aux. hook) Broken, Crack, wear, corrosion N/A Not Available
I i: c. Sheave Pully Groove weafTcbffugationTfbpe
N/A Not Available
imprint
d. Pin Crack, wear, corrosion N/A Not Available

No. Dokumen PD M -FRM -Q PS-03 | R e v isi: 2

T gl Berlaku: September 25, 2018

 Proc. No. : PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA Report No. : 098/PDM/LA1/VI/2021
P D M V IS U A L C H E C K & V E R IFIC A TIO N D IM EN TIO N RECO RD IK No. : PDM-ltC-OPS-SPA-01
PEMERIKSAAN FISIK & VERIFIKASI DIMENSI PESAWAT DateOflnsp. : Junel 4,2021
ANGKAT BERGERAK Page : 3 Of 8

No. Descriptioi Inspection for Condition Of Part Remark

3.3.3. Wire Rope
a. Kawat Baja Load Hoist (Wire rope Load Hoist) Reduction, kinking, birdcaging,
Utama (Main Hoist) crushing, twisting, worn, cracked, N/A Not Available
broken wire, improper spooling N/A Not Available
Bantu Aux. Hoist)
b. Kawat Baja Boom Hoist (Wire rope Boom Hoist) Reduction, kinking, birdcaging,
crushing, twisting, worn, cracked, N/A Not Available
broken wire, improper spooling
| c. Kawat Baja Tetap (Wire rope Pendant Line) Reduction, kinking, birdcaging,
crushing, twisting, worn, cracked, N/A Not Available
broken wire, improper spooling
3.3.4. Drum
a. Drum Spooling Strand crushing, core protrusion,
abrasion, excessive strand gaps, Not Available
N/A
loosen and uneven spooling, rope
imprint
b. Pawl and Dog Loosen, function, broken N/A Not Available

c. Brake system Funtion, distrotion, loosen N/A Not Available

Not Available
d. Gear, Bearing Wear, loosen, deformation, damage N/A

e. Flange Broken, chipped, crack N/A Not Available

f. Weld connection, Pin, Bolt Crack weld, wear, corrosion N/A Not Available

g- Hyd. System N/A Not Available

h. Motor Hyd., Line Hyd,, Link Hyd. Leakage, distortion, broken N/A Not Available
I 3.3.5. Dead End Connection
Wire rope Corroded, broken wire, cracked,
worn, or improperly applied end N/A Not Available
connection
Wedge Socket and Clips
Wear, illegible identification, rough
edges, burrs, wear, roundness,
properly seated, bent twisting, N/A Not Available
distorsion, streched, elongation,
cracked, broken, excessive, nick or
gouges, heat damage, corrosion
4.4. Struktur Chasis, Hoisting, Platform, Gantry (A Frame) & Foundation
4.4.1.a Lattice Boom
a. Batang Boom (Boom Chord) Bent, crack weld, deformation,
N/A Not Available
corrosion
b. Rangka penguat (Boom Lacing) Missing, broken, crack weld, bent N/A Not Available
c. Boom Tengah (Intermediate Boom) Bent, crack weld, deformation,
N/A Not Available
corrosion
d. Kapala Boom (Boom Head) Bent crack weld, deformation,
corrosion
Sheave Assy. ffeedon of rotation, sheave guard N/A Not Available
Sheave Groove Groove wear, corrugation, rope
N/A Not Available
imprint
Pin, Blot welding Crack weld, defromation, corrosion N/A Not Available
f. Boom Jib (Boom Jib) Bent crack weld, defromation,
N/A Not Available
corrosion
g Poros boom (Boom Pivot/Boom Heel) Crack, defromation, corrosion N/A Not Available
4.4.1.b Telescopic Boom
j 3 Batang Boom (Boom Box) Bent crack weld, deformation, Accepted
Good
corrosion
b. Boom Tengah (interm ediate Boom) Bent crack weld, deformation, Accepted
Good
corrosion
j c. Kapala Boom (Boom Head) Bent crack weld, deformation,
corrosion
Sheave Assy. freedon of rotation, sheave guard N/A Not Available
Sheave Groove Groove wear, corrugation, rope
N/A Not Available
imprint
Pin Crack, wear, corrosion N/A Not Available
Bushing and bearing Wear, Dry N/A Not Available
Drum Flange Broken, crack, chipped flange N/A Not Available

No. Dokumen :PDM -FRM -Q PS-03______________________________________|________________________________________________ R e v isi: 2

T g l Berlaku: September 25, 2018

 Proc. No. PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA Report No. 098/PDM/LA1/VI/2021
VISUAL CHECK & VERIFICATION DIMENTION RECORD IK No. PDM-IK-OPS-SPA-01
PEMERIKSAAN FISIK & VERIFIKASI DIMENSI PESAWAT Date Of Insp. June 14,2021
ANGKAT BERGERAK 4 Of 8
No. Description Inspection for Condition Of Part Remark

d. Sambungan Boom (Connecting Boom)

Pin, Blot welding Good Accepted
Crack weld, defromation, corrosion
f. Poros boom (Boom Pivot/Boom Heel) Crack, defromation, corrosion Good Accepted

4.4.1 .c Boom Extension 8>Jib

a. Batang Boom (Boom Chord) Bent, crack weld, deformation, N/A Not Available
corrosion ..
b. Rangka penguat (Boom Lacing) Missing, broken, crack weld, bent N/A Not Available
c. Batang Boom (Boom Box) Bent, crack weld, deformation,
N/A Not Available
corrosion
d. Kapala Boom (Boom Head) Bent, crack weld, deformation,
N/A Not Available
corrosion
Sheave Assy. Freedon of rotation, sheave guard N/A Not Available
Sheave Groove Groove wear, corrugation, rope
N/A Not Available
imprint

Pin Crack, wear, concision N/A Not Available

Bushing and bearing Wear, Dry N/A Not Available

Drum Flange Broken, crack, chipped flange N/A Not Available

e. Sambungan Boom (Connecting Boom) N/A Not Available

Pin, Blot, welding N/A Not Available

Crack weld, defromation, corrosion
4.4.1.d. Actuating and Telescoping Cylinder
a. Silinder Hidrolik (Hyd. Cylinder) Leakage, distortion Good Accepted
b. Lengan Hidrolik (Hydraulic Arm) Crack, distortion Good Accepted
c. Sambungan (Connecthn) Loosen, broken

Pin, Blot, welding Crack weld, corrosion, deformation Good Accepted

d. Plat Alas (Shoe/base plat) Loosen, distortion, defromation Good Accepted

4.4.1 .e. Bridle Assembly
a. Bridle Sheave Crack Distortion, corrosion, N/A Not Available
b. Sheave Assy. Freedon of rotation, sheave guard N/A Not Available
Groove wear, corrugation, rope
c. Sheave Groove N/A Not Available
imprint
d. Pin Crack, wear, corrosion N/A Not Available
e. Bushing and bearing Wear, Dry N/A Not Available
f. Couter Pin Missing, distrotion N/A Not Available

9 Drum Flange Broken, crack, chipped flange N/A Not Available

4.4.1.f Equalizer Assembly
a. Bridle Sheave Crack Distortion, corrosion, N/A Not Available
b. Sheave Assy. Freedon of rotation, sheave guard N/A Not Available
Groove wear, corrugation, rope
c. Sheave Groove N/A Not Available
imprint
d. Pin Crack, wear, corrosion N/A Not Available
e. Bushing and bearing Wear, Dry N/A Not Available
f. Couter Pin Missing, distrotion N/A Not Available
g Drum Flange Broken, crack, chipped flange N/A Not Available
4.4.2. Platform, Gantry, Mast, A-F rame, Walkways & Acces Platform
4.4.2.a Gantry, Mast, A-F rame
a. Rangka (Frame) Bent crack weld, deformation,
N/A Not Available
corrosion
b. Rangka penguat (B racin glacing) Missing, broken, crack weld, bent N/A Not Available

c. Sambungan-sambungan (Any Connection) Crack weld, defroamtion, corrosion N/A Not Available

4.4.2.b Walkways & Acces Platform

Corrosion, deformation, missing,
a. Pembatas (Guardrail) NA Not Applicable
broken
b. Lantai (Floor) Rust, dirty, resistant slip NA Not Applicable
Corrosion, deformation, missing,
c. Pagar (Railing) NA Not Applicable
broken
Corrosion, deformation, missing,
d. Pegangan tangan (Handhold) NA Not Applicable
broken
e. Tangga (Ladder) Crack, defromation, broken NA Not Applicable

No. Dokumen :PDM-FRM-OPS-Q3______________________________________|________________________________________________ R e w si: 2

T gl Berlaku: September 25, 2018

 Proc. No. PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA Report No. 098/PDM/LA1/VI/2021
VISUAL CHECK & VERIFICATION DIMENTION RECORD IK No. PDM-IK-OPS-SPA-01
PEMERIKSAAN FISIK & VERIFIKASI DIMENSI PESAWAT Date Of Insp. June 14,2021

No. Description Inspection for Condition Of Part Remark

4.4.2 c Foundation
a. Dudukan dasar (Base Mounting) Crack, corrosion, deformation Good Accepted

b. Sambungan (Connection) Loosen, broken., Crack weld,

Pin, Blot, welding corrosion, deformation Good Accepted
c. Rangka penguat (Lacing) Missing, broken, crack weld, bent NA Not Applicable
4.4.3. Swing Mechanism
a. Meja Putar (Turn Table) Wear, proper wallowing, wobbling, Good Accepted
load popping noise,imegualr, jerky,
bumpy
b. Sambungan Baut, Pin, Las- (Bolt, Pin, W elding connection) Wear, corrosion, loosen, Accepted
Good
lasan deformation
Bolt torque, streching, rust pitting,
imorooer size
4.4.4. Travel Mechanism
4.4.4.a. Crawler
a. Bagian Track (Track Assembly) Deformation, corrosion, broken N/A Not Available
b. Gigi Penggerak (Drive Sproket) Wear, broken, deformation N/A Not Available
I C. Rol Pembawa (Carrier Rollers) Wear, broken, deformation N/A Not Available
d Idler Depan (Front Idler) Wear, broken, deformation N/A Not Available
e. Rol Jalur (Track Rollers) Wear, broken, deformation N/A Not Available
f. Kerangka Jalur (Track Frame) Deformation, corrosion, broken N/A Not Available

9- Sambungan-sambungan (Connection) Crack weld, deformation, corrosion N/A Not Available

4.4.4.b. Wheel Mounted

a. Struktur Chasis (Chasis Assy.) Deformation, corrosion, broken Good Accepted
b. Roda Penggerak (W heel Drive) Worn, damage fires Good Accepted
c. Roda Pengikut (R ear W heel) Worn, damage tires Good Accepted
d Gardan (Axle) Deformation, corrosion, broken Good Accepted
e. As Roda (Track Rollers) Wear, broken, deformation Good Accepted

f. Sambungan-sambungan (Connection) Crack weld, deformation, corrosion Good Accepted

4.4.5. Out Rigger

a. Lengan (Outrigger Arm) Bent, deformation, crack weld Good Accepted
b. Sepatu/telapak (Pad shoe) Bent, deformation, crack weld Good Accepted
4.5.5 Counterweight
a. Jumlah (Quantity) Actual Use N/A Not Available
b. Susunan (Configuration) Configuration N/A Not Available
4.6. HYDRAULIC SYSTEM / PNEUMATIC SYSTEM
Hydraulic System
a. Pompa & Motor (Hydraulic Pump and Motor) Leaks, loosen bolt unusual noise
and vibration, loss of operating Good Accepted
speed, loss of pressure
b. Cairan (Fluid) excessive heating of the fluid N/A Not Available
Crack in valve housing, improper
* Katub (Valve) return of spool, leaks, sticking spool, Good Accepted
defromation
Rod seal leaks, leaks at weld joint
d. Silinder Hidrolik (Hyd Cylinders) Good Accepted
scored, nicked, dented cylinder rod
e. Sambungan - sambungan (Connecting Joint) Loose, deformation, leaks Good Accepted
f. Saluran hidrolik (Hose, Fitting, Tubing) Surface leaks of hose, defromation,
Good Accepted
blisterinq
5.6.1. Pneumatic System
a. Tangki Pengumpul (Storage Tank) Leaks, loosen bolt unusual noise
and vibration, loss of operating NA Not Applicable
soeed. loss of Dressure
Katub (Valve) Crack in valve housing, improper

: return of spool, leaks, sticking spool, NA Not Applicable

defromation___________
! c. Silinder Pneumatik (Pnu. Cylinders) Rod seal leaks, leaks at weld joint,
NA Not Applicable
scored, nicked, dented cylinder rod

d. Sambungan - sambungan (Connecting Joint) Loose, deformation, leaks NA Not Applicable

e. Saluran hidrolik (Hose, Fitting, Tubing) Surface leaks of hose, defromation,
NA Not Applicable
blistering

No. Dokumen :PDM -FRM -O PS-03

T gl Berlaku: September 25, 2018

 Proc. No. : PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA Report No. : 098/PDM/LA1/VI/2021

P D M VISUAL CHECK & VERIFICATION DIMENTION RECORD IK No. : PDM-I (-OPS-SPA-01

PEMERIKSAAN FISIK & VERIFIKASI DIMENSI PESAWAT
Date Of Insp. : June 14,2021
ANGKAT BERGERAK
Paae : 6 Of 8

No. Description inspection for Condition Of Part Remark

4.7. Electrical System
a. Sistem kendali utama (Main Control system) Distortion, marking, protection Good Accepted

b. Sistem pengaman (Main Braker) Distortion, marking, protection Good Accepted

c. Sistem pembumian (Grounding Sys) Distortion, marking, protection N/A Not Available

d. Kabel elektrik (Wiring) Insullation, safety Good Accepted

e. Kendali Lokal (Local Control) Distortion, marking, protection Good Accepted

f. Tombol Darurat (Em ergency Shutdown) Distortion, marking, protection Good Accepted

g. Kotak Panel listrik (Panel Box) Distortion, marking, protection Good Accepted
4.8. Limits Device & Safety Devices
a. Anti-two-blocking (Main and Auxiliary Hoist) Function, distortion Good Accepted
b. Boom Hoist Limits (Upper Max. and Lower Min.) Function, distortion Good Accepted
c. Boom Back Stop (Upper Max.) Function, distortion, deformation N/A Not Available

e
d. Boom Stop (Boom Stop) Function, distortion, deformation N/A Not Available
d. Swing Lock System (Locking) Function, distortion Good Accepted
Drum Lock System (Pawl and Dog) Function, distortion Good Accepted
f. PPPK (First Aid Kit) Quantity, validity, safety Good Accepted

g- APAR (Portable Fire Extiguisher) Function, validity, safety Good Accepted

Legend Comment: Inspected by y 1 -----\
Good = Accepted A lte r inspection visually for component stm cture boom, Crane Inspector/
| | f/T20 \ v \
R = Reject system rigging, d rum brake, h y d ra u lic , e tc cra n e g o o d condition
flMW«US»TSlol
^-1 tip JxJ
N/A = Not Available U.1'
NA = Not Applicable

420/L1-RO/IPA/fflISAS/2019

No. Dokumen :PDM-FRM-OPS-Q3 | R e v isi: 2

Tgl Berlaku: September 25, 2018

 PT. PRANATA DWI MULIA
Proc. No. : PDM-PRO-OPS-SPA-01
Report No : 098/PDM/LA1A/I/2021

.p n m
VISUAL CHECK & VERIFICATION DIMENTION
IK No. : PDM-IK-OPS-SPA-01
' 7 RECORD
PEMERIKSAAN FISIK & VERIFIKASI DIMENSI PESAWAT Date Of Insp. : June 14,2021
ANGKAT BERGERAK Page : 7 Of 8

Customer : PT. Pratama Widya Tbk Serial No. 28802939 Item No.
Name of equipment : Truck Mounted Crane - Articullating Boom Model 288EP-3CLXE Location Workshop PT. Prima
Indah Mutiguna-Bekasi.

1. HOOK DATA
Description Main Hook Block 1 st Main Hook Block 2nd Aux. hook 3nd Aux. hook 1st

Manufacturer _ - - -

Serial No. 16-8 - - -

Model Shank Hook - - -

Capacity 7.500 Kg - - -

Number of sheave - - - -

Dimension of Hook (mm)

HOOK Rem ark
A B C D E F G

Main 1 st 82 70 61 185 210 51 42 Accepted

Main 2nd - - - - - - - N/A

Main 3nd - - - - - - - N/A

Auxiliary 1st - - - - - - - N/A

2. WIREROPE DATA
Description Main Hoist Aux. Hoist Boom Hoist Pendant Line

Manufacturer - _ - -

Construction - - - -

Lay Length - - - -

Number Of Partline - - - -

Dimension of Wire Rope

Description Specifiaction Actual Measurement
Remark
Diameter Length Diameter Length

Main Hoist - - - - N/A

Auxiliary Hoist - - - - N/A

Boom Hoist - - - - N/A

Pendant Line - - - - N/A

3. PULLEY DATA
Dimension of Pully (mm)
Pulley Remark
A B C D
Hook Block - - - - N/A
Boom Head - - - - N/A

Condition of Pulley
Pulley Remark
Groove Flens Pin Lubrication
Hook Block - - - - N/A
Boom Head - - - - N/A
Skecth:

] [

No. Dokumen :PDM-FRM-OPS-03 R e v is i: 2

Tgl Berlaku: September 25, 2018

 Proc. No. PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA
Report No. 098/PDM/LA1/VI/2021
VISUAL CHECK & VERIFICATION DIMENTION RECORD
IK No. PDM-IK-OPS-SPA-01

PEMERIKSAAN FISIK & VERIFIKASI DIMENSI PESAWAT ANGKAT Date Of Insp. June 14,2021
BERGERAK 8 Of 8
Customer : PT. Pratama Widya Tbk Serial No. : 28802939 Item No.
Name of equipment : Truck Mounted Crane - Articullating Boom Model : 288EP-3CLXE Location Workshop PT. Prima Indah
Mutiquna-Bekasi.________
1. MAIN BOOM
Description Remark

Type Of Boom Telescopic Accepted

Boom Length 10.20 meter Accepted
Max. Jib Length Not Available
Max. Luffing Length Not Available
DIMENSION OF MAIN BOOM
Lower Insert Section (Meter) Upper
Total Length
Description Section
1 2 3 4 5 6 7 8 9 10 n (Meter)
(meter) (Meter)
Specification - - - - - - - - - - - - - 10.20

Actual - - - - - - - - - - - - - 10.20
2. FLY JIB/LUFFING/BOOM TIP
Description Remark

Type Of Boom Not Available

Boom Tip Length Not Available

Max. Jib Length Not Available

Max. Luffing Length Not Available

DIMENSION OF FLY JIB/LUFFING BOOM
Lower Insert Section (Meter) Upper
Total Length
Description Boom Section
1 2 3 4 5 6 7 8 9 10 n (Meter)
(meter) (Meter)
Specification - - - - - - - - - - - - - -

Actual - - - - - - - - - - - - - -
3. MAST, GANTRY, A-FRAME
Description Remark

Type - Not Applicable

Length - Not Applicable

Heigth - Not Applicable

Width - Not Applicable

DIMENSION OF FLY JIB/LUFFING BOOM
Lower Insert Section (Meter) Upper
Total Length
Description Boom Section
1 2 3 4 5 6 7 8 9 10 n (Meter)
(meter) (Meter)
Specification - - - - - - - - - - - - - -
Actual - - - - - - - - - - - - - -
3. OUT RIGGER
Description Dimension Of Mobile Crane / Base (Meter) Remark
Length 3.9 Accepted
Width N/A Not Available

Note: -

Crane Inspector

/
f \ / / X / ' 420 \ ' ' * \
I M /J tE ,l,wullwswMS

p t <k A \jr iO y
( ‘ -) l t T tw«wp»x Baaas Adv KusufTTCr
420/L1 -RO/IPA/MIGAS/2019

No. Dokum en :PD M -FR M -O P S -0 3 R e v is i: 2

T gl Berlaku: Septem ber 25, 2018

b. FUNCTTION TEST REPORT
LAPORAN UJI FUNGSI
 Proc. No. ; PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA
Report No. : 098/PDM/LA1 /VI/2021

P D ^ : PDM-IK-OPS-SPA-01
FU N C TIO N T E S T R E P O R T IK No.

Date Of Insp. : June 14,2021

LAPORAN UJI FUNGSI PESAWAT ANGKAT BERGERAK
Page : 1 Of 1

Customer : PT. Pratama Widya Tbk Serial No. : 28802939 Item No.

Name of equipment : Truck Mounted Crane - Articullating Boom Model : 288EP-3CLXE Location : Workshop PT. Prima Indah
Mutiguna-Bekasi.

No. Description Inspection for Condition Of Psrt Result

A. Hoist And Rotation Part

1. Boom Hoist Mechanism Hoisting / Lowering Good Accepted

Extended / Retracted Good Accepted

2. Load Hoist Mechanism (Main and Aux.) Hoisting/Lowering Good Accepted

Hoisting/Lowering N/A Not Available

3, Swing Assembly Slewing,rotation Good Accepted

B. Limits Devices
1. Main hoist limit switch Up/ Down Good Accepted

2. Aux. Hoist limit switch Up/ Down N/A Not Available

3. Boom hoist limit switch Up/ Down N/A Not Available

4. Anti Two Block System - Main Hoist Function/alarm Good Accepted
- Aux. Hoist Function/alarm N/A Not Available
5. Boom Back Stop Function/alarm N/A Not Available
6, Lampu Belok (Turn Light) O n/O ff Good Accepted
7. Lampu Menara (TowerLight) O n/O ff N/A Not Available
8. Lampu jalan (Flood Light) O n/O ff Good Accepted
9. Bel (Horn) O n/O ff Good Accepted
10. Com. Radio (Com. Radio) O n/O ff N/A Not Available
11. Kec. Angin (Anemometer) Wind Level N/A Not Available
12. Load momment Indicator (LMI) Accuracy, Legible Good Accepted

Conclusion:
- based on the test function of the crane in a safe condition

Recommendation:
- the crane unit must be treated according to the operation of the manufacturer

Crane Ipspector

Baaas AdvKtidOffiiK
420/L1 -RO/IPA/MIGAS/2019

No. Dokumen :PDM-FRM-OPS-04 Revisi: 2

Tgl Berlaku: September 25, 2018
c. LOAD TEST REPORT
LAPORAN UJI BEBAN
 Proc. No. PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA
Report No. 098/PDM/LA1A/I/2021

LOAD TEST REPORT IK No. PDM-IK-OPS-SPA-01

LAPORAN PENGUJIAN BEBAN Date Of Insp. June 14,2021

Page 1 Of 1

Customer : PT. Pratama Widya Tbk Serial No. 28802939 Item No. : -

Name of equipment : Truck Mounted Crane - Articullating Boom Model 288EP-3CLXE Location : Workshop PT. Prima Indah
_____________ Mutiguna-Bekasi.________

A. Squence Of Load Test Of Main Hoist

Working Radius Boom Angle Boom Length Load Test Safe Working Load
NO. Remark (SWL % )
meter degree meter Kg Kg

1. 8.00 _ 8.00 2.500 2.980 83

2. 6.00 . 6.00 4.050 4.050 100

3. - - - - - -

B. Squence Of Load Test Of Aux. Hoist

Working Radius Boom Angle Boom Length Load Test Safe Working Load
No. Remark (SW L%)
meter degree meter ton ton

- - - - - - -

Reference:
ASME B 30.22 Articulating Boom Cranes

Conclusion:
- The test load of crane is satisfactory, nothing any deformation on primary structure and secondary structure and the test load 100 % from SWL / rated load

Recommendation:
- The operator must be regular check before operate of crane.

420/L1-RO/IPA/MIGAS/2019

No Dokumen :PDM-FRIVkOPS^6 Revisi: 2

Tgl Berlaku: September 25, 2018
d AFTER LOAD TEST INSPECTION REPORT
LAPORAN PEMERIKSAAN SETELAH PENGUJIAN
 Proc. No. : PDM-PRO-OPS-SPA-01
PT. PRANATA DWI MULIA Report No. | : 098/PDM/LA1A/I/2021
AFTER LOAD TEST REPORT IK No. : PDM-IK-OPS-SPA-01
LAPORAN PEMERIKSAAN SETELAH PENGUJIAN Date Of Insp. : June 14, 2021

Page : 1 Of 1

Customer : PT. Pratama Widya Tbk Serial No. : 28802939 Item No. : -

Name of equipment : Truck Mounted Crane - Articullating Boom Model : 288EP-3CLXE Location : Workshop PT. Prima Indah
Mutiguna-Bekasi.

No. Inspection for Condition Of Part Result

A. Structure and Hoisting Mechanism

1. Boom Hoist
Lattice Boom Bent, deformation, crack weld N/A Not Available
Boom Box Bent, deformation, crack weld Good Accepted
Boom Extension & Jib Bent, deformation, crack weld N/A Not Available
Actuating and Telescopic Cylinder Bent, deformation, crack weld Good Accepted
Connecting Joint (Pin, Bolt, Weld Joint) Deformation, crack weld, loosen Good Accepted

2. Rigging Hoist Component

Bridle Assembly Deformation, broken, loosen N/A Not available
Equalizer Asembly Deformation, broken, loosen N/A Not available
3. Load Hoist
Wire Rope Main Hoist Broken, deformation N/A N
Wire Rope Aux. Hoist Broken, deformation N/A Not Available
Hook Block Assy. Deformation, crack Good Accepted
Overhaul Ball/Aux. Hook Assembly Deformation, crack N/A Not Available
Connecting Joint (Pin, Bolt, Weld Joint) Deformation, crack weld, loosen Good Accepted
4. Drum /Winch Broken, deformation, loosen N/A NN
5. Gantry, A-Frame, Mast Bent, deformation, crack weld N/A Not Available
6. Out Ftigger Bent, deformation, crack weld Good Accepted
7, Swing Assembly
Turn Table Deformation Good Accepted
Connecting Joint (Pin, Bolt, Weld Joint) Deformation, crack weld, loosen Good Accepted
8. Drum Assembly
Flange Broken, deformation Good Accepted
Gear, Bearing Deformation, loosen Good Accepted
Connecting Joint (Pin, Bolt, Weld Joint) Deformation, crack weld, loosen Good Accepted
B. Hydraulic & Pneumatic System
1. Hose, Tubing Broken, leak Good Accepted
2. Valve Broken, leak Good Accepted
3. Connection Deformation, crack weld, loosen Good Accepted
C. Limits Devices & Safety Devices
1. Main Hoist Limits witch Function, fitness Good Accepted
2. Aux. Hoist limit switch Function, fitness N/A Not available
3. Boom Hoist Limit Switch function, fitness N/A Not available
4. Anti Two Block System - Main Hoist Function/alarm N/A Not available
- Aux. Hoist Function/alarm N/A Not available
5. Load momment Indicator (LMI) Accuracy, Legible, Function Good Accepted

N o te : Crane l n s p e c ^ ^ ~ ^
- Crane in condition good and accepted

Baaas Adv Kusuma

420/L1-RO/IPA/MIGAS/2019

No. Dokumen PDM-FRM-OPS-06 Revisi: 2

Tg! Berlaku: September 25, 2018
e. NONCONFORMANCE RECORD (NCR)
CATATAN KETIDAKSESUAIAN
No. Dokumen .PDM-FRM-OPS-27 Revisi: 2
Tgl Berlaku: September 25, 2018
VII. NON DESTRUCTIVE TEST (NDT)
PENGUJIAN TIDAK MERUSAK
 No : P D M -F R M -O P S -N D T -0 2

MAGNETIC PARTICLE TEST RECORD MOBILE CRANE D a te : 2 5 S E P TE M B E R 2 0 1 8

TELESCOPIC BOOM (GB-LA02) R e v is i : 01

P age : 1 O fl

MAGNETIC PARTICLE TEST RECORD

CLIENT PT. Pratama Widya Tbk REPORT NO 098/PDM/N DT-MT/VI/2021

DESCRIPTION Truck Mounted Crane - Articullating Boom PROCEDURE 05/QP-PDM/2012
SERIAL NUMBER / MODEL 28802939 / 288EP-3CLXE ACCEPTANCE CRITERIA AWSD14.3
LOCATION Workshop PT. Prima Indah Mutiguna-Bekasi. TEST DATE June 11,2021
STAGE OF EXAMINATION □PREPARED EDGE □BEFORE/AFTER PWHT □ b a c k c h ipin g

■ as WELD ■ b efo r e l o a d t e s t □ as c a s t in g

SURFACE PREPARATION □GRINDING ■BRUSHING

EQUIPMENT ■YOKE □AC ■DC
I S/N G67 ■PERMANENT MAGNET
TECHNIQUE □PROD ■ c o n t in u o u s □ RESIDUAL
BACKGROUND ■MAGNAFLUX WCP-2 □AEROSOL SRAY PAINT □.AS BASE MATERIAL
MAGNETIC PARTICLE ■MAGNAFLUX 7HF □DRY □WET □ fl o u r e sc e n t

INDICATION ACCEPT/REJECT
No PART CRANE SIZE REMAKS
YES NO YES NO
i. MAINT HOOK NO NO YES NO ACCEPTED

2. OUTRIGGER RIGHT.LEFT NO NO YES ACCEPTED

3. PIN BOOM CRANE NO NO YES NO ACCEPTED

SKECTH / DRAWING

Examined By

- Ryg-Ardhi SutW Gumelaf "

ASNT Level II C rane Inspector
Date : June 11,2021 Date : June 11,2021
 No : P D M -F R M -O P S -N D T -0 2

. p d W '7 MAGNETIC PARTICLE TEST RECORD MOBILE CRANE D a te : 2 5 S E P TE M B E R 2 0 1 8

TELESCOPIC BOOM (GB-LA02) R e v is i : 01
P age : 1 O fl

MAGNETIC PARTICLE TEST RECORD

CLIENT PT. Pratama Widya Tbk REPORT NO 098/PDM/NDT-MT/VI/2021

DESCRIPTION : Truck Mounted Crane - Telescopic Boom PROCEDURE : 05/QP-PDM/2012
SERIAL NUMBER / MODEL 28802939 / 288EP-3CLXE ACCEPTANCE CRITERIA : AWSD14.3
LOCATION Workshop PT. Prima Indah Mutiguna-Bekasi. TEST DATE : June 11,2021
STAGE OF EXAMINATION □PREPARED EDGE □BEFORE/AFTERPWHT DBACK CHIPING
■ as WELD ■ AFTER LOAD TEST DAS CASTING
SURFACE PREPARATION □ g r in d in g ■BRUSHING □
EQUIPMENT ■ yo k e □AC ■ dc

■ S/NG67 ■PERMANENT MAGNET

TECHNIQUE □ pr o d ■ c o n t in u o u s D r esid u a l
BACKGROUND ■MAGNAFLUX WCP-2 □AEROSOL SRAY PAINT □ AS BASE MATERIAL
MAGNETIC PARTICLE ■MAGNAFLUX 7HF □ dry Q w et □ f l o u r e sc e n t
INDICATION ACCEPT /REJECT
No PART CRANE SIZE REMAKS
YES NO YES NO
1. MAINT HOOK CAP 10 TON NO NO _ YES NO ACCEPTED
2. - - - - - - -

S K E C T H /DRAWING

Examined By

Rvo Ardhi Surva G umelar LEVEL I I I

ASNTTW StH ! Inspector
Date : June 11,2021 Date : June 11,2021
VIII. ATTACH M EN T
LAMPIRAN

- PHOTOGRAPH

- MANUAL BOOK & LOAD CHART

 Proc. No. PDM-PRO-OPS-SPA-01
P T. P R A N A T A D W I M U L IA
Report No. 098/PDM/LA1 A/l/2021
PHOTOGRAPH IK No. PDM-IK-OPS-SPA-01
FOTO HASIL INSPEKSI Date Of Insp. June 14,2021
1 Of 4

Customer : PT. Pratama Widya Tbk Serial No. : 28802939 Item No.
Name of equipment : Truck Mounted Crane - Articuliating Boom Model : 288EP-3CLXE Location Workshop PT. Prima
Indah Mutiguna-Bekasi.

View of Truck Crane - Telescopic Boom View of Name Plate Crane

gHlHB
CBANE
loader

TYPE l “ “
SERIAL NO
liflANUF.YEAR
C a tg o te c S w eden A B .■Hiab
J & -S 2 4 83 MUOiKSVALL SWEDEN

View of Main Hoist View of Ground Level

View of Oil Hydraulic View of Control Operator

View of Enginee Block Crane View of Name Plate Engine

 Proc. No. ; PDM-PRO-OPS-SPA-O1
P T. P R A N A T A D W I M U L IA
Report No. : 098/PDM/LA1A/l/2021
PHOTOGRAPH IK No. ; PDM-IK-OPS-SPA-01
FOTO HASIL INSPEKSI Date Of Insp. : June 14,2021
Page : 2 Of 4__________________
Customer PT. Pratama Widya Tbk Serial No. : 28802939 Item No. : -
Name of equipment Truck Mounted Crane - Articullating Boom |Model : 288EP-XLXE Location : Workshop PT. Prima
Indah Mutiguna-Bekasi.

View of Number Rangka Unit Crane View of Hydremic Boom Base

View of Control Outrigger View of Hydraulic Outrigger

View of Load Chart View of Swing Table

View of Baterai View of Rotary Lamp

 Proc. No. PDM-PRO-OPS-SPA-01
P T. P R A N A T A D W I M U L IA
Report No. 098/PDM/LA W I/2021

PHOTOGRAPH IK No. PDM-IK-OPS-SPA-01

FOTO HASIL INSPEKSI Date Of Insp. June 14,2021
3 Of 4
Customer : PT. Pratama Widya Tbk Serial No. 28802939 Item No.
Name of equipment : Truck Mounted Crane - Articullating Boom Model 288EP-3CLXE Location Workshop PT. Prima
Indah Mutiguna-Bekasi.
View of Function Test

TV
 Proc. No. PDM-PRO-O PS-SPA-01
P T. P R A N A T A D W I M U L IA
Report No. 098/P DM/LA1A/l/2021
P D M ^ PHOTOGRAPH IK No. PDM-IK-OPS-SPA-01
FOTO HASIL INSPEKSI Date Of Insp. June 14,2021
Page 4 Of 4
Customer : PT. Pratama Widya Tbk Serial No. : 28802939 Item No. : -
Name of equipment : Truck Mounted Crane - Articullating Boom Model : 288EP-3CLXE Location : Workshop PT. Prima
Indah Mutiguna-Bekasi.
View of Load Test

Load test with load 4.050 Kg, Length boom 6.0 meter boom radius 6.0 meter.
 TMC 10.1 TON PRATAMA WIDYA

10100 5700 4050 2980 2340