INSPEKSI TERENCANA

Rev. Tgl Terbit Hal No. Info. Dokumen

02 11 Mei 2020 1 F-HES-002

Rev. 20.07.05

DAFTAR PERIKSA INSPEKSI WELL WORK RIG

RIG INSPECTION CHECKLIST

The purpose of this HES Inspection Checklist is to provide the rig HES Auditor the means to identify
potentially unsafe conditions that may exist in the various work areas and the associated equipment of the
land drilling unit. This checklist provides details of what should be looked for when conducting an
inspection. The details provided on this checklist are the results of an accumulation of safety requirements
and practices that are identified by various governmental regulatory agencies, the CPI Rig Repair and
Inspection Standards book, and through Industry Best Practices and Acceptable Standards. This CALTEX
Rig Safety Check List For Onshore Operation also meets the pre-start up requirements of MIGAS.
Wherever a specific Safety Concern on this checklist is related to a MIGAS requirement, it is noted in the
Item Column with an alphabetical reference number 1that is the reference number from the MIGAS
checklist.Dokumentasi yang harus ditemukan di lokasi rig terdapat di kantor Ahli Kendali Wellwork atau
Catatan untuk pemeriksa / Note for Inspector :
Perwakilan
 YA /Perusahaan. Inspector
“YES” – Kondisi dapat(yang melakukan
diterima, inspeksi)untuk
tidak disarankan adalah crew rig.perbaikan
melakukan sedangkan/ Acceptable
Auditor
condition, no corrective action recommended
adalah Reliability & Compliance Team. Mereka harus memastikan bahwa dokumen ada dan dipergunakan
 TIDAK / “NO”– Tidak dapat dibenarkan, perlu dilakukan tindakan perbaikan / Not acceptable,
di lokasi.corrective
Kondisi yang tidak
action aman, sebagian mungkin disebabkan oleh tidak adanya dokumen terse but di
needed
 rig“NA”
lokasi – Tidak
atau mereka dapat
tidak diterapkan dokumen
menggunakan / Not Applicable
tersebut sebagai sumber referensi.
 CATATAN / “REMARKS”– Catatan pada ketidakpatuhan / Note on the non compiance

“TIDAK” harus disertai lampiran rekomendasi tindakan perbaikan yang diperlukan / “NO” answers
must have a recommendation for corrective action noted in the Recommendations for Corrective
Actions section.

Alternate corrective actions other than those recommended are acceptable as long as the problem is corrected
and agreed upon by responsible persons. A written response from the Business Partner/Contractor is required
for any item for which there is a disagreement as to it being an unsafe condition. Closure to all items requiring
corrective action must be tracked and completed within a reasonable time period.
Hal : 1
Whoever conducts an HES Inspection, the findings should be discussed with the rig site Toolpusher and
Companyman so there is no misunderstandings as to the observations requiring corrective action.
 DAFTAR PERIKSA K3L OPERASI RIG
TOPIK :DOKUMENTASI,
RIG OPERATIONS KANTOR, DAN&PERSEDIAAN
HEALTH ENVIRONMENT SAFETY CHECKLIST

TOPIC : DOCUMENTATION, OFFICE AND INVENTORY (DOC)

Tanggal (Date) : Business Partner

Nama Rig (Rig Name) : Lokasi Rig (Rig Location)
Companyman : Status Operasi (Operation status)
Toolpusher : Single Accountability : Tool Pusher

Code SAFETY CONCERN PERIHAL KESELAMATAN YA TDK NA CATATAN

DOCUMENTATION DOKUMENTASI YES NO NA REMARKS
I Certificate of special oil & Gas Technician Sertifikat Tenaga Teknik Khusus Rig
MIGAS Certificate, Level III Toolpusher, Level MIGAS Sertifikat, AP III, JB II, OMB II, OLB II
DOC-001 III Driller, Level II Derrickman, Level II Rotary
Helper
DOC-002 Welder Certificate Sertifikat Juru Las
Driver Certificate (Rig, Pick up, Bus Sertifikat Pengemudi (Rig, Pick up, Bus
II
CrewFoco, Crane & Dozer) CrewFoco, Crane & Dozer)
DOC-003 B-II / B I Driving License SIM B II / B I

DOC-004 Operator License (SIO) Surat Ijin Operator (SIO)

DOC-005 BP Driving Permit Ijin Mengemudi dari BP

DOC-006 SILO Rig & Crane/Foco SILO Rig & Crane/Foco

III Training Documentation Catatan Pelatihan/Traning

DOC-007 Well Control Pengendalian Sumur (well control)

DOC-008 First Aid/CPR P3K

Work Permits (GWP, Excavation, Hot work, etc.) Ijin Kerja (GWP, Penggalian, Hot work, dll)
DOC-009

DOC-010 Respiratory Protection & Hearing conservation Pelindung Pernapasan/Pernapasan buatan

Using & Maintenance Personal Protective Penggunaan & Perawatan Alat Pelindung Diri
DOC-011 Equipment (PPE : hard Hat, Glasses, Ear Plug, (PPE : Topi, Kacamata, Ear Plug, Sarung Tangan,
Hand Gloves, etc.) dll.)
Using & Maintenance Fall Protection Equipment Penggunaan & Perawatan Alat Pelindung Jatuh
DOC-012

DOC-013 Fire Watch Penanganan Kebakaran

DOC-014 Safety Observation (SWA/BBS) Observasi Keselamatan (Laporan At risk)

DOC-015 Hazcom (MSDS) Penanganan Bahan Berbahaya (MSDS)

DOC-016 Emergency Response (ERP) Keadaan Darurat (ERP)

Safe Rigging Practices (All-location & move) Praktek Rigging yang aman (Rig up/down/moving)
DOC-017

DOC-018 Confined Space Entry Masuk Ke Ruang Terbatas

DOC-019 Safe Welding Operations Operasi pengelasan yang aman

DOC-020 Lock Out – Tag Out (LOTO) Lock Out – Tag Out (LOTO)

DOC-021 Job Safety Analysis (JSA) Analisa Kerja Yang Aman (JSA)

DOC-022 Safe Operating Procedure (SOP) Prosedur Kerja Yang Aman (SOP)

DOC-023 HES Orientation Orientasi HES

DOC-024 Motor Vehicle Safety Keselamatan Mengendara Kendaraan

DOC-025 Hand and fingers safety Keselamatan Tangan dan Jari

DOC-026 Falling Equipment Preventing (DROPS) Pencegahan benda jatuh (DROPS)

DOC-027 Fundamental Safe Work Practice (FSWP) Fundamental Safe Work Practice (FSWP)

DOC-028 Rig Inspection(CWSI) Inspeksi Rig (CWSI)

IV Standard Operating Procedure (SOP) Manual Prosedur Manual Khusus Rig (SOP)

DOC-029 Rigging up and down Memasang/Menurunkan, Rig Up&Down

DOC-030 BOP Stack BOP Stack

DOC-031 Placement of equipment skid Penempatan perlatan pada skid

DOC-032 Remove & replace horse head Memindahkan/menganti kepala kuda

DOC-033 Picking up tubulars Mengangkat Tubular

DOC-034 Repair of mud pump Memperbaiki pompa lumpur

DOC-035 Changing out electric motors Penggantian motor elektrik

DOC-036 Mixing chemicals Mencampur bahan kimia

Total 1 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager. F-HES-002 Hal: 1
 DAFTAR PERIKSA K3L OPERASI RIG
TOPIK :DOKUMENTASI,
RIG OPERATIONS KANTOR, DAN&PERSEDIAAN
HEALTH ENVIRONMENT SAFETY CHECKLIST

TOPIC : DOCUMENTATION, OFFICE AND INVENTORY

Code SAFETY CONCERN PERIHAL KESELAMATAN YES NO NA REMARKS/CATATAN
Work pemits (GWP, Excavation, Hot work, Ijin Kerja (GWP, Penggalian, Hot work, Masuk
DOC-037
Confined Space Entry, etc) Ruang Terbatas, dll)
DOC-038 Lock Out – Tag Out (LOTO) Lock Out – Tag Out (LOTO)

DOC-039 SOP book from BP Buku SOP dari BP

DOC-040 SOP WWnC Buku SOP WWnC

DOC-041 Equipment placement Plan for location Skema Penempatan Peralatan

DOC-042 JSA book / Binder Buku JSA

DOC-043 MSDS (Material Safety Data Sheet) binder Buku MSDS (Data Keselamatan Bahan)
CPI Rig Repair & Inspection Standard (Blue
DOC-044 Buku inspeksi rig (Blue book)
book)
V Incident / Injury Investigation Report File Laporan investigasi kecelakaan / Cidera

DOC-045 Lost Time Incident (LTI) Insiden Kehilangan Hari Kerja (LTI)

DOC-046 Reduce/Restricted Work Cases (RWC) Kasus Kerja Terbatas (TRI)

DOC-047 Medical Treatment cases (MTC) Kumpulan Peristtiwa K3L

DOC-048 First Aid Cases (FAC) Kasus P3K (FAC)

DOC-049 Near hit / near miss At risk dan Hampir celaka (nearmiss)

DOC-050 Equipment damage Kecelakaan Peralatan

DOC-051 Motor Vehicle Crash (MVC) Kecelakaan Kendaraan Bermotor

DOC-052 Environmental incident (Spill) Pencemaran Lingkungan (Spill)

DOC-053 Security Disturbance at Rig Location Gangguan Keamanan di area rig

VI Routine Activity files Arsip - arsip kegiatan rutin
DOC-054 BBS observation file Dokumen Pengamatan BBS

DOC-055 Well Control Drill Situation Practice Latihan Keadaan Well Control Drill

DOC-056 HES Alerts file binder Dokumen Kepedulian HES

DOC-057 Medical Treatment log Catatan Perawatan/pemeriksaaan Medis

DOC-058 Previous CWSI Inspection and Audit file Inspeksi CWSI dan Audit
Prevention Falling Equipment Inspection
DOC-059 Inspeksi pencegahan benda jatuh (DROPS)
(DROPS)
DOC-060 Fire Extinguisher Equipment Inspection Inspeksi Alat Pemadam Api

DOC-061 Lifting gear register (ie slings & winch wires)
Safety Meeting Report File ( TGM, Pre Job
DOC-062
Meeting and Monthly HES meeting)
DOC-063 Emergency Eye Wash Station Inspection
DOC-064 “Tonne Mile” drilling line Report
Daftar peralatan angkat (Ct: Sling dan Winch)
Safety Meeting ( Tail Gate meeting, Pre Job
Meeting dan Monthly HES meeting)
Pemeriksaan/penggantian air Stasiun Pencucian
Mata Keadaan Darurat
Catatan “Tone Mile” drilling line

DOC-065 Potable Water Testing (chlorine) Pengujian Air Minum (clorine)

DOC-066 Crown-O-Matic Check report file Pengecekan Crown O Matic

DOC-067 FSWP Assesment Penilaian FSWP

Work pemits (GWP, Drilling, Hot work, Confined Ijin Kerja (GWP, Penggalian, Hot work, Masuk
DOC-068
Space Entry, etc) Ruang Terbatas, dll)
DOC-069 Lock Out – Tag Out (LOTO) Lock Out – Tag Out (LOTO)

DOC-070 Migas Safety Check List Migas Safety Check List

DOC-071 Weekly Emergency Drill Training Latihan Keadaan darurat mingguan

DOC-072 Guy Line Anchor Check Pengecekan Guy Line Anchor

DOC-073 Rem Drawwork Adjustment Penyetelan Rem Drawwork

DOC-074 Deadline anchor / drilling line inspection Inspeksi Deadline anchor/Drilling line

DOC-075 H2S safety training for personnel Latihan keselamatan H2S untuk personil
Pre Trip Inspection for Journey Management Pre Trip inspeksi dan Journey Management
DOC-076
System System
VII Toolpusher / CPI WSM Kantor WWR / Perwakilan CPI

DOC-077 There is a sign to identify WWR office Terdapat tanda kantor WWR

3 Clean hard hats, safety boots, ear plug are Tersedia 3 (tiga) kacamata, topi, sepatu, tutup
DOC-078 available for the visitor and replacement PPE for telinga yang bersih untuk pengunjung atau
the crew. pengganti PPE crew yang rusak
The trailer is clean and maintained in an orderly Portacamp bersih dan rapih
DOC-079
manner Clerk
DOC-080 The trailer is properly grounded Terdapat Grounding System yang baik

DOC-081 There is a fully stocked first aid kit Tersedia kotak yang P3K lengkap

DOC-082 There is a stretcher Tersedia tandu

Total 2 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager. F-HES-002 Hal: 2
 DAFTAR PERIKSA K3L OPERASI RIG
RIG OPERATIONS HEALTH ENVIRONMENT
TOPIK :DOKUMENTASI, KANTOR, DAN&PERSEDIAAN
SAFETY CHECKLIST

TOPIC : DOCUMENTATION, OFFICE AND INVENTORY

Code SAFETY CONCERN PERIHAL KESELAMATAN YES NO NA REMARKS/CATATAN
There are emergency telephone numbers and Tersedia daftar no. telephone keadaan darurat
other relative information pertaining to availability yang menunjukkan informasi mengenai personil
DOC-083 of medical personnel, transportation, and medical medis, transportasi fasilitas medis, managemen
facilities posted CPI dan BP

There are emergency contact numbers of Terdapat nomor telepon darurat dari kontraktor
DOC-084 contractor and CPI management personnel dan management CPI yang ditempelkan di fasilitas
posted rig
DOC-085 Stairs leading to office are in good condition Tangga masuk dalam keadaan baik Clerk
A copy of the CPI HES Policy & Procedures Tersedia salinan Peraturan HES CPI & manual
DOC-086
Manual & the BP's HES manual are available Prosedur & Manual HES dari BP's
There is radio &/or telephone communication Tersedia radio komunikasi dan/atau telepone
DOC-087 with offsite management personnel & emergency untuk berkomunikasi dengan pihak manajemen &
services. balai pengobatan
There is an emergency response equipment box Tersedia box peralatan keadaan darurat yang
DOC-088 available that contains Fire Axes, Fire Blanket, berisi kapak api. selimut api dan pakaian anti api
and Fire Suits

DOC-089 There is daily IFO board Terdapat papan IFO harian

DOC-090 Terdapat Alat Pendeteksi Asap

Smoke Detector Provided
DOC-091 Copy of H2S Regulations Salinan peraturan H2S yang semestinya
DOC-092 Electrical wiring & outlets in good order Pemasangan kabel listrik dan stop kontak dalam Electrician
keadaan
Dua pintubaik
DOC-093 Two means of exit provided keluar yang tersedia
DOC-094 Fire extinguisher/hose provided Alat pemadam api tersedia
DOC-095 Ventilation, heating/air conditioning provided Tersedia ventilasi atau penyejuk udara
DOC-096 Emergency Lighting Lampu Darurat
DOC-097 Door handles satisfactory Pegangan pintu dalam keadaan baik Clerk
wellwork program: signed IC, WS, WO Program wellwork : IC, WS, WO yang sudah
DOC-098 ditandatangani

Is there an operational PC and printer available Terdapat Komputer dan printer (mesin pencetak)
to provide hard copies of HES related information yang dapat digunakan untuk
DOC-099 for the crews to review. mencetak/menyediakan informasi yang dapat
ditinjau oleh crew

VIII Work Permit Izin Kerja/Work Permit

DOC-100 General Work Permits Izin Kerja Umum / General Work/ Confined
Permits Space
Izin Masuk Ke Ruang Terbatas
DOC-101 Confined Space Entry Entry
DOC-102 Hot Work Permit Izin Kerja Panas / Hot Work Permit
DOC-103 Excavation Permit Izin Penggalian / Excavation Permit
DOC-104 Lock Out - Tag Out (LOTO) Lock Out - Tag Out (LOTO)
DOC-105 Hot Line Permit Hot Line Permit
Total 0 0 0
0 0 0
Note / Catatan:

Signature/Tanda tangan :

PIC Tool Pusher Toolpusher WSR

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager. F-HES-002 Hal: 3
 RIG OPERATIONS HEALTH ENVIRONMENT
TOPIK : LOKASI/ & SAFETY CHECKLIST
WELL PAD

TOPIC : LOCATION/ WELL PAD (LOC)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Floorman

Code SAFETY CONCERN PERIHAL KESELAMATAN YA TDK NA CATATAN

Field Location Lokasi Lapangan YES NO NA REMARKS
I General Condition Keadaan Umum
LOC-001 Complete Direction Sign Petunjuk Arah Lengkap

LOC-002 Wide Enough for Road Capacity Kapasitas Jalan Lokasi Cukup Lebar

Condition of location - general condition (is dura Kondisi lokasi - kondidi scr umum (apakan
LOC-003 base required) and equipment proximity to durabase diperlukan) dan kedekatan
perimeter (2metres from edge of re-dress) perlengkapan ke garis keliling (2metres dari
pinggir lokasi yang telah di re-dress)
LOC-004 Level and allows good drainage Lokasi Rata dan drainase cukup
Large enough for appropriate spacing of guy Cukup ruang untuk guy lines dan derrick
LOC-005
lines and derrick emergency escape line emergency escape line
LOC-006 Properly compacted and not muddy Cukup padat dan tidak berlumpur
The condition of location such as that all vehicles
kondisi dari lokasi seperti tanah datar sehingga
can transverse or move about it all time and
LOC-007 seluruh kendaraan dapat bebas bergerak setiap
maintain a level position and not encounter free
saat tanpa selip
spinning of wheels
There is an outhouse on location and it is
LOC-008 Terdapat Kakus dan dirawat secara teratur
maintained on a regular basis
Terdapat garda penunjuk arah angin &
Windsocks available & located in an area to
LOC-009 ditempatkan di area yang bagus untuk
provide good indication of wind direction
menunjukan tanda arah angin
Bidang kantor, area makan dan di sekitar
Field office, eating area and around all
semua perlengkapan dengan penyanggah
LOC-010 equipment skids there are board walkways in
harus mempunyai papan jalan - subyek untuk
place - subject to condition of location muddy etc.
kondisi lokasi berlumpur dll
Derrick/mast is located at least 10 feet plus the
Jarak dari puncak derrick/mast dengan kabel
height of the derrick/mast plus appurtenances
LOC-011 listrik minimum 10 feet sebagaimana standard
(antennas) from all power lines as per API
API
recommendations

There is a designated muster point for Ada titik apel yang ditunjuk untuk situasi
LOC-012 emergency situations and it is located up wind keadaan darurat dan ditemukan ke atas angin
from the well bore (alternative muster) dari sumur bor baik (alternatif area berkumpul)

There is physical barrier installed around canal in Terdapat Physical Barrier yang terpasang di
LOC-013
the entry way of well pad sekitar kanal pada jalan masuk well pad
II Sign\Board Announcement Tanda-tanda/Papan Pengumuman
LOC-013 There is safety signs Terdapat Tanda-tanda Keselamatan

LOC-014 Well Name Plate Papan Nama Sumur

LOC-015 Smoking In Designated Areas Only Tanda Dilarang Merokok

LOC-016 Authorized Personnel Only Otorisasi Personil

No Radio Transmitting (during handling of Larangan Penggunaan Radio Transmisi
LOC-017
explosives) (selama membawa bahan peledak)
Use PPE - hardhat area, safety glasses, safety
LOC-018 Menggunakan PPE
boots
Respiratory Protection and Hearing Protection Pelindung Pernapasan dan pendengaran di
LOC-019
on Specific Area tempat tertentu
LOC-020 Fall Protection Peralatan Anti Jatuh

LOC-021 No Parking Near Rig Dilarang parkir dekat rig

All Visitor Are Required To Sign In At The Tamu harus lapor ke WWR atau Toolpusher
LOC-022
Toolpusher Trailer (AP III) (AP III)
LOC-023 Mustering Point Mustering Point

LOC-024 Access Gate Control Access Gate Controll

LOC-025 Reverse Parking Sign Rambu Parkir Mundur

Bahan mudah terbakar harus diletakan jauh dari
LOC-026 Combustibles are kept away from light fixtures
sumber panas
Total 1 0 0 0
Note:

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager. F-HES-002 Hal: 4
 TOPIK : LOKASI/ WELL PAD

TOPIC : LOCATION/ WELL PAD

Code SAFETY CONCERN PERIHAL KESELAMATAN YES NO NA REMARKS/CATATAN
III Guy Line Guy Line
Jangkar ke guy line diberi bendera untuk
LOC-027 All guy lines are flagged mencegah bahaya tersangkut dan tertabrak
kendaraan
All guy lines have a minimum of 3 cable clamps
LOC-028 at each end and the clamps are properly Klem dipasang dengan benar
attached
All shackles / clevises used for guy lines
connections have appropriate pins and are they Shackle / Clevis menggunakan pin yang benar
LOC-029
secured to prevent vibration from backing them untuk mencegah bahaya tercabut
out? (Plastic tie wrap or wire)
Total 2 0 0 0
0 0 0
Note / Catatan:

Signature :

Floorman Toolpusher Wellwork Representative

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

 RIG OPERATIONS HEALTH ENVIRONMENT
TOPIK : MENARA RIG & SAFETY CHECKLIST

TOPIC : RIG MAST (RM)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Derrickman
Code SAFETY CONCERN PERIHAL KESELAMATAN YA TDK NA CATATAN
RIG MAST MENARA RIG YES NO NA REMARKS
I Climbing Tools Alat Panjat
Proper safety signage posted at the base of the
Tanda-tanda keselamatan terpasang di dasar
derrick ladder - 'Fall Protection required when
RM-001 tangga derrick:
working in the derrick'

The derrick climber assist installed and in good
RM-002
condition.
Counter balance weight secured properly to
RM-003
cable and with a safety line.
Sheave at crown secured properly and turns
RM-004
freely
Climber’s safety belt (body harness) and/or
RM-005
climbing device and hooks in good condition
The system assist the climber to go all the way to
the crown (this type of system is not fall
RM-006
protection and must be used with an anti-fall
system that prevents the climber from falling).
There is a fall protection device that protects the
RM-007
climber from the rig floor all the way to the crown.
The derrick ladder in good condition Tangga menara dalam kondisi baik (tidak ada yang
RM-008 (No broken, bent, or missing step rungs, secured retak, pecah, bengkok, anak tangga hilang dan
properly to derrick) terpasang dengan baik ke menara)
II Equipment at Mast
Mud standpipe secured to the derrick properly
RM-009
(all clamps and related nuts and bolts in place)
Alat bantu memanjat terpasang dan dalam
keadaan baik
Berat penyeimbang terpasang baik ke kabel dan
dengan tali penyelamat
“Sheave” pada crown terpasang baik dan bebas
berputar
Sabuk pengaman pemanjat dan atau climbing
device serta kait dalam kondisi baik
Sistim memudahkan pemanjat untuk menuju ke
crown (sistem dari tipe ini tidak mencegah dari
bahaya terjatuh dan harus menggunakan sistem
anti-fall untuk melindingi kru dari bahaya terjatuh)
Terdapat alat pelindung jatuh yang melindungi
pemanjat dari Crown ke lantai bor menuju ke
crown.
Peralatan di Menara
Pipa tegak untuk lumpur (stand pipe) terpasang
baik pada menara (semua kelem, baut dan mur
terpampang pada tempatnya )

Swivel / Safety cables/chains attached on each
end of the mud hose between the mud standpipe
RM-010
and kelly or top drive/swivel (attached on the
hose and not the hammer union parts)
Rantai pengaman terpasang pada setiap ujung
selang lumpur antara pipa tegak dan kelly atau
swivel (terpasang pada selang, bukan pada union
hammer)

There is a bumper board immediately below the
crown sheaves to protect it from accidental
contact with the blocks. The bumper
RM-011
board is covered with expanded metal to prevent
large pieces of wood from falling below in the
event of contact with the blocks.
Tersedia bumpeer board yang terpasang dibawah
crown untuk melindungi dari benturan dengan
block. Bumper board dilapisi dengan lapisan logam
yang lebar untuk melindungi potongan kayu yang
besar jatuh kebawah pada saat terbentur dengan
block.

Kelly swivel or Power Swivel free of mud leaks Kelly Swivel atau Power Swivel bebas dari bocoran
RM-012
and hydraulic oil leaks lumpur atau minyak hidrolik
Other hard pipe lines properly secured to the Pipa-pipa lainnya (Pipa Hidrolik) terpasang dengan
RM-013
derrick (i.e. hydraulic line) baik ke menara bor
All derrick lights in good condition ( all lights
Seluruh lampu menara dalam kondisi yang baik
working; safety chain on each light; protective
(menyala semua, ada rantai dan sling pengaman,
covers in place, clean, and in good condition;
RM-014 ada penutup yang bersih dan baik kondisinya, plug
matching plug in with electric line outlet;
yang sesuai, cocok dengan klasifikasi area ) .
conforms to area classification ). Emergency
Tersedia lampu darurat
lighting available
There is a working flashing red aircraft warning Terdapat lampu peringatan warna merah menyala
RM-015
light on the crown pada crown
Semua kabel listrik pada menara bor dalam
All electrical lines in derrick in good condition
keadaan baik (Terpasang dengan semestinya pada
RM-016 ( Properly secured to derrick; no splices; proper
menara bor; tidak ada sambungan; kabel
junction boxes at connecting lines)
disambungkan dalam kotak yang semestinya
Total 1 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager. ACS-F-HES-002 Hal : 6

Code SAFETY CONCERN
All wire ropes in the derrick routed so that they
RM-017 do not rub against structural members or high
pressure flexible mud lines (Kelly hose)
Are the hydraulic cylinders used for raising the
derrick in good condition and attached properly
RM-018
to derrick ( All yoke pins in place with safety
keeper pins, no noticeable hydraulic leaks)
If derrick is raised/lowered by use of large
diameter steel cables and the traveling block,
RM-019
they are in good condition and properly attached
to the derrick.
Where pins are used to secure two derrick
sections together or for attaching monkey board
RM-020
and/or stabbing board and the pins appropriate
size and with safety keeper pins in place
All sheaves hanging in the derrick have safety
cables properly attached ( Safety cable routed
RM-021 below sheave wheel and between the air winch
line in order to suspend the load should the
wheel fail )
The crown have proper handrails, midrails, and
RM-022 toe boards around it and they are in good
condition, of proper height and spacing
The drill line sheaves have protective pins across
RM-023 them that prevent the drill line from jumping out
of the sheave
All guy lines in good condition and properly
RM-024 attached to the derrick with safety pins in place
All derrick assembly pins and safety keeper pins
RM-025
in place
DROPS - The derrick free of all trash, hand tools,
RM-026 or other objects that could fall during high winds
or derrick lowering operations
All Protection Required When Working In The
RM-027 Derrick (tail rope, anti fall, full body harness,
PPE) is available and in good condition
There is noticeable hydraulic oil, water, mud, or
RM-028
air leaks from equipment or piping in the derrick
There is a documented derrick register system
that ensures all OBJECTS carried up in the
derrick for equipment repairs, rigging operations,
or maintenance are identified prior to
RM-029
commencing the task and accounted for after
completing the task (Ensures no loose items are
left in the derrick that could fall and strike
workers below)
There are no noticeable hydraulic oil, water, Tidak terdapat tanda-tanda yang jelas dari
RM-030 mud, or air leaks from equipment or piping in the kebocoran oli hidrolik, air, lumpur, atau udara dari
derrick peralatan atau pipa-pipa di derrick
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.
TOPIK : MENARA RIG
TOPIC : RIG MAST
PERIHAL KESELAMATAN YES NO NA REMARKS/CATATAN
Seluruh wire rope pada derrick diatur sehingga
tidak menggesek bagian struktur atau pipa fleksibel
lumpur bertekanan tinggi (Selang Kelly)
Silinder Hidrolik yang digunakan untuk mengangkat
derrick dalam kondisi baik dan terpasang ke derrick
dengan benar (Seluruh Yoke pin dilengkapi
dengan safety keeper pin, tidak dijumpai kebocoran
pada hydraulic)
Jika derrick ditarik/diturunkan mengunakan kabel
baja berdiameter besar dan travelling block, dia
harus dalam keadaaan bagus dan baik untuk dilalui
oleh derrick.
Jika pin dipergunakan untuk mengamankan dua
bagian derrick atau untuk memasang monkey
board , maka menggunakan ukuran pin yang benar
dan “safety keeper pins” dipakai dengan benar
Seluruh Sheaves yang tergantung pada derrick
dilengkapi dengan rantai keselamatan yang
semestinya (Rantai keselamatan dipasang dibawah
sheaves wheel dan diantara kabel air winch untuk
menahan beban jika wheel tidak berfungsi)
Crown memiliki handrail, midrail dan toe board
disekelilingnya, kondisinya baik, tinggi dan
spasinya sesuai
Sheaves dari drill line memiliki pin pelindung yang
melintang untuk mencegah terlepas drill line keluar
dari sheaves
Kondisi semua Guy Line dalam keadaan baik dan
terpasang dengan benar pada derrick dilengkapi
dengan pin keselamatan
Seluruh derrick assembly pin dan “safety keeper”
pin terdapat pada rangkaian derrick
Derrick bersih dari sampah, “hand tools, atau
benda-benda lain yang dapat jatuh ketika angin
kencang atau operasi penurunan derrick
Semua APD yang diperlukan saat bekerja di
derrick (tail rope, anti fall, full body harness, PPE)
tersedia dan dalam keadaan yang bagus
Tidak terdapat tanda-tanda yang jelas dari
kebocoran oli hidrolik, air, lumpur, atau udara dari
peralatan atau pipa-pipa di derrick
Terdapat sistim dokumentasi pencatatan derrick
untuk memastikan dilaksanakannya perbaikan
peralatan, operasi “rigging” atau perawatan
sebelum dan setelah menyelesaikan pekerjaan
tersebut (Untuk mencegah tertinggalnya peralatan
di derrick yang dapat terjatuh dan menimpa pekerja
yang ada di bawah)
0 0 0
Total 2
 TOPIK : MENARA RIG

TOPIC : RIG MAST

III Monkey Board Monkey Board
Code SAFETY CONCERN PERIHAL KESELAMATAN YES NO NA REMARKS/CATATAN

Monkey Board Menara dan “finger” dalam kondisi

The derrick monkey board and fingers in good
baik:
condition
a) Fingers tidak bengkok dan dilengkapi dengan
a) Fingers not bent and with safety cables
rantai keselamatan
b) Handrails, midrails, and toe boards in place
b) Pegangan tangan atas, tengah, dan toe board
around monkey board area and they are in good
RM-031 sekeliling monkey board dalam kondisi baik, spasi
condition of proper height and spacing
dan tingginya sesuai
c) Hardness completed with safety rope and in
c) Harness dilengkapi dengan tali keselamatan dan
good condition
kondisinya baik
d) All ropes in good condition, safety cable
d) Seluruh tali dalam kondisi baik; Rantai
attached to board
keselamatan terpasang ke lantai monkey board

There is an emergency escape system in place
RM-032
at the monkey board (i.e. escape chair)
The emergency escape system meets the
following API standards;
a) 7/16 inch minimum diameter wire rope in good
condition. Have a safety buggy (Geronimo) with
adequate braking or a controlled descent device
installed on the wire line and readily available for
RM-033
use in an emergency.
b) Allow the person to stop 20 - 25 feet
from the anchor point.
c) Have an angle of descent not more than 35°
d) Properly anchored to support derrickmans
weight.
Terdapat sistim penyelamatan darurat pada
monkey board (escape chair)
Sistem penyelamatan darurat mengikuti standard
API : a) Diameter
minimum wire rop 7/16” dalam kondisi baik;
Geronimo dilengkapi dengan sistem pengereman
yang memadai atau peralatan pengendali
kemiringan pada wire line dan siap digunakan dlam
keadaan darurat
b) Dapat dihentikan dalam jarak antara 20 –
25 feet dari tiang gawang
c ) Sudut kemiringan tidak lebih
dari 35° d) Dijangkarkan dengan
semestinya untuk menahan berat badan
Derrickman

There are no bent girts or beams in the derrick Tidak terdapat tiang yang bengkok pada derrick
RM-034
that may compromise the integrity of the derrick yang membahayakan keutuhan derrick

There is a 5 minute emergency escape ELSA Terdapat sistem penyelamatan darurat 5 menit -
RM-035 (Emergency Life Support Apparatus) at the ELSA (Emergency Life Support Apparatus) di
monkeyboard for H2S Operations monkey board untuk operasi berpotensi H2S

Total 3 0 0 0
0 0 0
Note:

Signature / Tanda tangan :

Derrickman Toolpusher Wellwork Representative

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

 TOPIK : LANTAI BOR/SUBSTRUCTURE

TOPIC : RIG FLOOR/SUBSTRUCTURE (RF)

Tanggal (Date) : Business Partner 0
Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Driller
Code SAFETY CONCERN PERIHAL KESELAMATAN YA TDK NA CATATAN
I Rig Floor/Substructure Lantai Bor/Substructure YES NO NA REMARKS
General Condition Keadaan Umum

Safety signage posted at the main stairway or so

Rambu2 keselamatan terpasang & baik :
that it is noticed as soon as one enters the rig
a) Harus memakai PPE : topi,
floor area such as :
kacamata, sepatu, sarung tangan
a) Wear PPE : hard hat, safety glasses,
b) Peringatan
safety boot, Hand Gloves
dilarang merokok c)
RF-001 b) The Warning no smoking
Peringatan awas benda jatuh, awas tangan anda
c) The Warning be careful the object fell, be
terjepit
careful your hands were hemmed in
d) Dipasang samping tangga utama
d) Was installed samping the main ladder so as
sehingga orang mengetahuinya ketika ia
the person knew him when he entered the area
memasuki area lantai bor
of the floor of the bore

General housekeeping of the rig floor good;
a) All trash in proper trash containers
b) All hand tools in toolbox or on tool board
c) All subs in sub racks or stored in
an orderly manner & not laying around the
RF-002
rigfloor
d) Rigfloor and equipment reasonably clean
e) Water hoses & cat lines rolled up
when not in use
Kebersihan secara umum di lantai bor bagus;
a) Semua sampah diletakan di tempat sampah
b) Semua peralatan diletakan didalam toolbox
atau toolboard
c) Semua rak atau tempat perlatan diletakan
dengan bai & tidak berserakan disekitar lantai
bor
d) Lantai bor dan perlatan dalam keadaan bersih
e) Selang air & cat lines digulung ketika tidak
digunakan

Rig floor free of slip, trip, and fall hazards;
a) No bent or missing floor plates
b) No grease or oil on floor
c) Trip hazards that cannot be moved are
RF-003 painted in yellow and black stripes for easy
identification.
d) Around the table use a non-slip surface
e) All unused floor holes covered
Lantai bebas dari bahaya terpeleset dan jatuh;
a) lantai tidak bengkok dan hilang/berlobang
b) tidak terdapat minyak/gemuk di lantai
c) bahaya tersandung yang tidak dapat
dipindahkan diberi cat strip warna kuning dan
hitam untuk memudahkan pengidentifikasian
d) Sekeliling permukaan lantai meja memakai
lantai anti selip
e) Seluruh lubang di lantai tertutup

There are 2 stair exits from the rig floor and are Terdapat sedikitnya 2 jalan keluar dari lantai rig
RF-004
they unobstructed dan tidak terhalang

Seluruh anak tangga dari / ke lantai bor dalam

All stairs to/from the rig floor in good condition
a) All steps level, secured, and no obstructions.
Equal or greater than a 1:1 slope
b) All stair treads uniform, non slip surface. All
RF-005
have handrails and midrails. c)
Stairs are properly secured in place. Ensure
substructure handrails secured with pin/cotter
pins or bolts/huts.
keadaan baik :
a) Anak tangga datar, aman
dan tidak terhalang, kemiringan sama atau lebih
besar dari 1:1
b) Seluruh anak tangga seragam, tidak licin;
dilengkapi "handrails" dan "midrails"
c) Tangga terpasang dengan baik, Pastikan
hand rail terpasang dengan kuat dilengkapi
dengan pin/ cotter pin dan baut/ nut.

Around the rig floor are appropriate guardrails, Sekeliling lantai bor diberi pagar pengaman yang
RF-006 midrails, and toe boards in good condition and in cukup, toe board dalam kondisi baik,
place and of proper height and spacing tinggi/spasinya sesuai
Rantai pengaman atau pagar digunakan pada
There is a safety chain or gate used at the V-
bagian terbuka - rantai hanya digunakan dalam
RF-007 door opening - Chain is short term only and will
jangka pendek dan akan diganti dengan pintu
be replaced by a gate
(gate)
Semua air winches harus dilindungi dengan
All air winches have a protective guard over the
RF-008 penutup disekeliling line drum dan diberi tanda
line drum and are marked with SWL
SWL nya

Wire cable air winches in good operating Tali kabel dari air winches pada kondisi operasi
condition; a) yang baik;
control handle operates properly a) control handle beroperasi dengan baik
b) brake works properly b) Rem bekerja dengan baik
RF-009
c) wire cable is free of any mashed sections & c) tali kabel bebas dari semua bagian yang kusut
broken strands dan helai yang rusak
d) Chain is not used as attachment to wire d) Rantai tidak boleh disambungkan ke tali kabel
cable as part of lifting arrangement. sebagai agian dari alat pengangkatan.

Total 1 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.
 TOPIK : LANTAI BOR/SUBSTRUCTURE
RIG OPERATIONS HEALTH ENVIRONMENT & SAFETY CHECKLIST
TOPIC : RIG FLOOR/SUBSTRUCTURE
II Equipment Support
All equipment guards properly in place
a) Drawworks
b) Rotary chain drive
c) Couplings between electric motors and pumps
RF-010
or fans
d) Fans
e) Other drive belts
f) Chains, gears, shafts etc
Are all hand tools in good condition and properly
stored
a) Hammer heads not flared out
b) No metal handles welded to hammer heads,
wooden handles not cracked
c) Pipe wrenches do not have bent handles and
bite properly when used
d) Chain tongs with chains properly attached &
RF-011 sufficient length to go around tubulars
e)
Sockets not cracked and socket wrench works
properly in both directions f)
spanners or adjustable/crescent wrench close &
hold properly on nuts or bolt heads
All hoses on rig floor have crows feet
connections and safety pins are used when
RF-012
hoses are attached (no pipe nipples with
radiator / worm gear clamps)
Is the lighting for the rig floor in good condition:
a) All lights working
b) Safety cables on overhead lights
c) Protective covers in place, clean, and in good
RF-013 condition
d) Matching plug in with electric line outlet
e) No splices in electrical lines
f) Electrical components conform with area
classification
Power tongs / pipe spinners in good condition
a) Snub line proper length, no broken wire
strands, and attached properly
b) Power air or hydraulic lines attached correctly
and do not leak
c) exhaust directed away from workers
d) Properly suspended in derrick or attached to
RF-014 air winch line
e) Controls properly marked and operate
correctly
f) Safety guards in place
Drill Collar clamp (dog collar) in good condition
a) Proper
tightening tool available b)
RF-015 Extra links available (if required)
c) All connecting pins with safety chains attached
d) handles in
good condition
There is a TIW and/or a Dart valve and
appropriate wrench available for well control
RF-016 emergencies while tripping pipe (wrench with
large ring welded to it to prevent it falling down
the hole)
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.
Peralatan Penunjang YA TDK NA REMARKS/CATATAN
Seluruh penutup peralatan ditempatkan dengan
semestinya :
a) Drawwork
b) Rotary chain drive
c) Kopling antara motor listrik & pompa
d) Fan
e) Drive belt lainnya
f) Rantai, roda gigi, shafts, dll
Seluruh peralatan tangan dalam kondisi baik dan
disimpan dengan benar :
a) Kepala palu tidak dilas tangkainya, tangkai
palu dari kayu tidak retak
b) Kunci pas atau kunci inggris berfungsi dengan
baik
c) Kunci pipa tidak bengkok tangkainya dan
menggigit dengan baik
d) Kunci rantai dilengkapi dengan rantai yang
sesuai dan panjangnya sesuai dengan lingkaran
pipa
e) "Socket" tidak retak "Socket Wrench"
berfungsi dengan baik dalam dua arah
f) Kunci pas atau kunci inggris tertutup & terkunci
dengan baik oleh mur atau bautnya
Seluruh selang di lantai bor memiliki sambungan
crows feet yang baik, dan pakai safety chain
(tidak ada pipe nipples dengan radiator/worm
gear clamps)
Penerangan di area dalam kondisi baik:
a) Seluruh lampu menyala
b) Rantai / sling pengaman terpasang
c) Terdapat penutup pelindung yang bersih dan
baik
d) Plug in sesuai dengan outletnya
e) Tidak ada kerusakan pada kabel elektrik
f) Sesuai dengan klasifikasi area
Power tongs/pipe spinners dalam kondisi baik:
a) Snub line sesuai panjangnya, tidak ada
kerusakan untaian kabel dan terpasang dengan
benar
b) Selang hidrolik atau selang udara terpasang
dengan benar dan tidak bocor dan diberi safety
chain/sling
c) Exhaust ditempatkan jauh dari jangkauan kru
d) Tergantung dengan benar di derrick atau
terpasang ke kabel air winch
e) Diberi tanda pengendalian dan dioperasikan
dengan benar
f) Pelindung keselamatan dipasang  
Clamp Drill Collar (dog collar) dalam kondisi
yang bagus
a) Tersedia alat pengikat yang bak
b) Tersedia link tambahan (jika diperlukan)
c) Semua pin penyambung dilengkapi dengan
rantai keselamatan
d) handle dalam kondisi bagus
Terdapat TIW and/atau Dart Valve dan kunci
yang sesuai tersedia untuk keadaan darurat
pada saat tripping pipe (kunci skrup dengan ring
yang dilas unutk mencegahnya jatuh kedalam
lubang)
Total 2 0 0 0
ACS-F-HES-002 Hal:10
 TOPIC : LANTAI BOR/SUBSTRUCTURE

RIG OPERATIONS HEALTH ENVIRONMENT & SAFETY CHECKLIST

TOPIC : RIG FLOOR/SUBSTRUCTURE
Code SAFETY CONCERN PERIHAL KESELAMATAN YA TDK NA REMARKS/CATATAN
Kellly hose attached with safety chain Selang Kelly dilengkapi dengan rantai
RF-017
keselamatan
Kelly dan Kelly Bushing sesuai dengan rotary
The Kelly bushing fit properly in the rotary table
RF-018 table (Roller di dalam Kelly Bushing berputar
(The rollers in the Kelly bushing roll freely)
bebas)

Kelly cock wrench accessible (Has large ring Kelly Cock Wrench mudah dijangkau (Suatu
RF-019 welded to it to prevent it from falling down the cincin besar dilas supaya bila alat tersebut jatuh
hole) tidak masuk ke lubang sumur)
Hole covers for rotary table and Tersedia/terpasang penutup terbuka dari meja
RF-020 mousehole/rathole is available and of proper size putar dan mousehole/rathole dan ukuran yang
to adequately cover the hole sesuai dengan penutup dari lubang
The Rat holes and mouseholes are properly
installed so that they sit flush with the rig floor Rat hole dan mouse hole terpasang dengan baik
RF-021 and do not create trip hazards. sehingga kedudukannya sesuai dengan lantai rif
dan tidak menimbulkan bahaya tersandung.

RF-022 Crown-O-Matic installed on drawworks & Crown-O-Matic terpasang dengan baik di draw
operates properly work dan beroperasi dengan benar
RF-023 Blowers are in good condition Blower terpasang dengan baik

Tong dalam kondisi yang baik

The tongs are in good condition;
a) Seimbang, tergantung rata
a) Properly balanced, hang level
b) Terdapat handle dan tidak rusak / retak
b) handles are in place not broken or cracked
c) Dies dalam kondisi bagus dan terpasang pada
c) Dies in good condition and held in place with
RF-024 tempatnya
proper keepers
d) Ukuran head yang sesuai
d) Proper size heads
e) Latch dalam kondisi yang bagus
e) Latch in good condition
f) Terpasang dengan baik tali penarik & dalam
f) Pull lines properly attached & in good condition
kondisi bagus

The Tong snub lines are in good condition
a) No broken wire strands
b) Proper length
RF-025 c) Eyes made properly with 3 clamps attached
correctly or with manufactured eye
d) No jagged ends exposed
The Tong line Torgue or load indicator is in good
condition;
a) Attached to tongs and pull line correctly
b) Provides accurate gauge reading at Drillers
RF-026 console
c) Date Gauge was last callibrated
_____________
Tong snub lines dalam kondisi bagus;
a) Tidak ada lilitan kabel yang rusak
b) Panjang yang sesuai
c) Eyes terdiri dati 3 clamps yang dipasang
dengan benar / menggunakan eye dari pabrik
d) Tidak bergerigi pada ujungnya
Tong line torgue / indikator beban dalam kondisi
bagus;
a) Terpasang di tong dan tersambung dengan
baik
b) Tersedia alat ukur yang akurat di Drilling
Console
c) Kalibrasi terakhir dari alat ukur
_____________

Total 3 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.
 TOPIK : LANTAI BOR/SUBSTRUCTURE

RIG OPERATIONS HEALTH ENVIRONMENT & SAFETY CHECKLIST

TOPIC : RIG FLOOR/SUBSTRUCTURE
Code SAFETY CONCERN PERIHAL KESELAMATAN YA TDK NA REMARKS/CATATAN
The tong counter balances are in good condition

a) Moves freely up/down, no sticking or hanging
up
RF-027 b) All weights inside counterbalance bucket c)
Adequate overhead clearance
Counter balance dari tong dalam kondisi bagus;
a) Bergerak dengan bebas keatas/kebawah,
tidak tersendat / tersangkut
b) Semua berat terdapat dalam counter balance
bucket
c) Dapat terlihat dengan jelas ke atas

Drawwork and rotary clutches operate properly
RF-028
when field tested
The bales or elevator links properly installed ( No
RF-029
signs of any welding or cutting torch activities)
Elevators (drill pipe, drill collars, casing, tubing) Elevator (drill pipe, drill collars, casing, tubing)
are in good operating conditions
a) No noticeable cracks
RF-030 b) Latch opens and closes properly
c) No signs of any welding or cutting torch
activities
Fire extinguisher(s) available and in good
condition:
a) 5 year hydro test date noted on units
b) Monthly inspection noted on unit(s)
c) Fully charged
d) Nozzle and hose in good condition
e) Safety pin in place
f) No rust at seams or bottom of units
RF-031 g) Hanging bracket in good condition
h) Protective cover on units stored outside
i) Access to units not blocked
j) Number size and type of units per contract
Drawwork dan rotary clucth beroperasi dengan
baik ketika diuji
Terdapat Bales atau elevator link yang terpasang
dengan benar (tidak terlihat bekas pengelasan
atau pemotongan)
dalam kondisi baik;
a) Tidak ada bekas pengelasan atau
pemotongan
b) Latch dapat dibuka dan ditutup dnegan baik
c) Tidak ada tanda2 bekas pengelasan /
potongan
Tersedia pemadam api dan dalam kondisi baik:
a) Tanggal 5 tahunan tes hydro dari setiap unit
b) Inspeksi bulanan pada unit
c) terisi penuh
d) Selang dan nozzle dalam kondisi baik
e) Terdapat pin keselamatan
f) Pinggir dan bawah unit tidak berkarat
g) Braket tergantung dengar benar
h) Unit yang ada di luar diberi tutup pelindung
i) Jalan ke unit tidak terhalang
j) Nomor ukuran dan tipe setiap unit sesuai
kontrak

All Controls at the drillers console are properly
RF-032
identified (Indonesian Bahasa)
All gauges are in good condition (weight
indicator, rotary rams, tong pull torque, pump
RF-033 strokes counter, etc.)
a)Provide accurate readings
b)Glass covers not broken
Seluruh pengendali pada Driller’s console terlihat
English version
dengan jelas (Bahasa Indonesia)
Seluruh alat ukur dalam kondisi baik (weight
indicator, rotary rams, tong pull torque, pump
strokes counter, etc) :
a) Pembacaan akurat
b) Tutup kaca tidak pecah

The brake handle is in good condition:
a) No cracks
RF-034 b) Tie down chain
c) Adequate clearance from protective guard to
protect Drillers hand from pinchpoint
Tongkat rem dalam kondisi baik;
a) Tidak retak
b) Diikat kebawah dengan rantai
c) Bebas dari pelindung untuk melindungi tangan
Driller dari titik jepit

There is a manual or automatic emergency horn

RF-035 Terdapat klakson darurat manual atau otomatis
available
There are emergency lights on the rigfloor that Tersedia lampu darurat di lantai bor yang scr
RF-036 automatically turn on when there is a power otomatis nyala ketika terjadi
failure kesalahan/kerusakan pada energi
There is a gas sensor located on the rig floor and Tersedia sensor gas yang diletakan di lantai bor
RF-037
it is connected to the alarm system dan disambungkan ke sistem alarm
The spider slips the proper size for the pipe and Ukuran “Slips” untuk pipa sesuai dan beroperasi
RF-038 do they operate correctly (No air or hydraulic oil dengan benar (Tidak ada kebocoran
leaks) udara/hidrolik)
Drill pipe and drill collar slips in good condition
Slip dari tubing dan drill pipe dalam kondisi baik
RF-039 (handles not bent; Hinges not cracked; Dies in (pegangan tidak bengkok, engsel tidak retak;
good condition) Gigi kondisi baik)
Kendali BOP diberi tanda dengan benar
The BOP controls properly marked (open/closed) (buka/tutup) dan dalam posisi siap siaga
RF-040
and in the correct standby position

The blind ram control handle covered or Gagang pengendali blind ram ditutup atau
RF-041 protected to prevent accidental engagement dikunci untuk mencegah beroperasi secara tidak
sengaja
There is a good layer of protective lubricant (pipe Drill line diberi lapisan pelumas (pipe dope) pada
dope) on the drill line spool (new drill line that is drill line spoolnya (Drill line yang putus diganti
RF-042 yang baru)
spooled off when cut and slip operations are
conducted)
The drill line is spool up properly on the Drill line spool menggulung dengan baik pada
RF-043
drawworks drum drawworks drum
The drill line anchor have the required 3 wraps of Jangkar drill line memiliki 3 lilitan
RF-044
drill line on it
Total 4 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.
 TOPIK : LANTAI BOR/SUBSTRUCTURE

RIG OPERATIONS HEALTH ENVIRONMENT & SAFETY CHECKLIST

TOPIC : RIG FLOOR/SUBSTRUCTURE
Code SAFETY CONCERN PERIHAL KESELAMATAN YA TDK NA REMARKS/CATATAN
The drill line anchor clamp in place and are the 6 Terdapat kelem jangkar drill line dan ke 6
RF-045
nuts properly tightened bautnya dikencangkan dengan benar
Is the weight indicator diaphragm: Diafragma dari weight indicator :
RF-046 a) Properly attached to the dead line a) Terpasang pada dead line dengan benar
b) Have a safety cable attached to it b) Terpasang kabel keselamatan
RF-047 The swab line spool up properly on the drum Swab line terlilit dengan benar pada drum-nya
Swab line memiliki connector di ujungnya dan
The swab line have an appropriate connector on terhubung dengan swab tools
RF-048
the end that properly attaches to swabbing tools

When not in use is all slack in the swab line that

Jika swab line tidak dipergunakan dan kendur,
may interfere with other equipment or the
RF-049 kekenduran itu tidak mengakibatkan kerusakan
drawworks drum and drill line safely out of the
peralatan drawwork drum dan drill line
way
The swab line in good condition Swab line dalam kondisi baik
a) Lubricated to prevent rusting a) Dilumasi unutk mencegah karat
RF-050 b) Free of any flat spots or signs of having been b) Bebas tanda / papan yang sudah rusak
crushed c) Tidak terdapat kawat yang rusak
c) No noticeable broken strands
Last date of inspection of choke panel Gauges & Tanggal terakhir inspeksi pada gauge & panel
Controls: a) Air control:
pressure gauge b) a) Air pressure gauge b)
RF-051
Hydraulic pressure Gauge c) Hydraulic pressure Gauge c)
Stroke counter d) Stroke counter d)
hydraulic Hand Pump hydraulic Hand Pump
Tombol penutup tenaga dalam keadaan darurat
RF-052 Emergency power shutdown of driller console
di meja juru bor
Total 5 0 0 0
0 0 0
Note:

Signature/Tanda tangan :

PIC Driller Toolpusher Wellwork Representative

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

 TOPIK : BOPE / WPF/Pipe Rack/Trailer (BOP)

ABOUT : BOPE / WPF/Pipe Rack/Trailer (BOP)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Driller

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

I Blow Out Preventer Equipment Peralatan Blow Out Preventer YES NO NA REMARKS
BOP BOP

All studs and nuts properly installed in the
connectors/flanges of the BOP stack and
wellhead
BOP-001
a) Proper size.
B) All nuts fully threaded with the stud/bolt
threads (No exposed threads on the nut).
Baut/mur BOP dipasang dengan benar di
connector/flange terpasang benar di rangkaian
BOP dan Kepala Sumur :
a) Ukuran sesuai
b) Seluruh mur di-drat penuh ( tidak ada bagian
drat yang tertinggal)

All high pressure lines to the BOP stack /

Seluruh pipa tekanan tinggi disambungkan ke
Annulas are properly connected and in good
rangkaian BOP / annular dan dalam kondisi baik
condiition
:
BOP-002 a) Free of oil leaks.
a) Tidak bocor
b) No crushed or flat spots.
b) Tidak hancur dan penyok
c) Safety cables between connections.
c) Terdapat safety chain diantara sambungan

There are wheeled handles attached to the Terdapat pembuka/penutup manual yang
BOP-003 different BOP rams that allow manual operation berbentuk roda pada BOP ram
to open/close the rams
The pitcher nipple (bell nipple) properly Pitcher nipple (bell nipple) terpasang dengan
BOP-004 attached (Does not leak fluids at the flange benar (tidak ada kebocoran fluida pada
connection) sambungan flange)
Safety cables on Choke and kill lines on the Fill up line/killing line terpasang dengan benar
BOP-005
BOP stack ke spool/casing valve
The annular preventer operate properly when Annular preventer beroperasi dengan baik saat
BOP-006
tested diuji
The pipe and blind rams operate properly when Pipe, blind, share ram berfungsi dengan baik
BOP-007
tested saat di test
The choke and kill lines in the proper sequence Choke dan Kill line terpasang dengan benar
BOP-008 on the BOP stack (below the blind ram) pada BOP Stack (di bawah dari blind/shear ram)

There is documentation to support the pressure Terdapat dokumentasi yang menunjukkan

level and time pressure was held on the last
BOP-009 BOP test (Date of last BOP
Test:_______________ )
The valves on the choke manifold marked to
II Choke Manifold
indicate the proper open /closed position and
are they in the proper position?
BOP-010
(Note: Choke manifolds may be located on the
rig floor.)
All valve on the choke manifold in the proper
standby position and are the handles marked to
BOP-011
identify if they are in the open = “O” or closed =
“X” position
adanya pengujian tekanan terakhir pada BOP
( Tanggal pengujian BOP yang terakhir:
______________ )
Choke Manifold
Valve di choke manifold diberi tanda yang
menunjukkan arah membuka / menutup dan
dalam posisi yang benar
Seluruh valve pada choke manifold dalam posisi
siap,pegangannya diberi tanda yg menunjukkan
apakah berada dalam posisi buka =Ö atau tutup
=X

There safety cables between all line Terdapat Rantai Pengaman antara seluruh
BOP-012
connections sambungan
The blow line properly anchored to prevent it
Panic dan Divert line terjangkar dengan benar
BOP-013 from whipping about when discharging gas or
agar tidak mengayun ketika ada gas atau fluida
fluids
Return line from choke manifold to the tank is Return line dari chocke manifold ketangki
BOP-014
connected tersambung
Housekeeping in the area to acceptable Housekeeping di area sesuai standard yang
standards baku
BOP-015 a) No trash.
a) tidak ada sampah
b) No hand tools laying around. b) tidak ada peralatan berserak disekitarnya
BOP-016 Pressure gauge accurate Pressure gauge akurat
Total 1 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

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 TOPIK : BOPE / WPF/Pipe Rack/Trailer (BOP)

ABOUT : BOPE / WPF/Pipe Rack/Trailer

III Accumulator Unit Unit Accumulator YA TDK NA CATATAN
BOP-017 Switch power is always on auto position Switch power selalu pada posisi auto

All hydraullic pressurized channel are having a Seluruh saluran hidrolik bertekanan tinggi ke
BOP-018 safety cable, located at connection, free from oil BOP memiliki kabel keselamatan,terpasang
leak diantara sambungan/bebas dari kebocoran oli
Oil hydraulic tank is filled up with standard Tangki penampung oli hidrolik diisi sesuai
BOP-019 volume dengan standar yang ditentukan
Pressure measurement are standardized by : Pembacaan tekanan untuk alat dibawah ini
a) Precharge Pressure 1000 psi sesuai dengan standar :
b) Akumulator Pressure : 3,000 psi a) Tekanan Precharge 1000 psi
BOP-020 c) Manifold Pressure: 1,500 psi b) Tekanan Akumulator: 3,000 psi
d) Annular Pressure: 800-1200 Psi. c) Tekanan Manifold : 1,500 psi
d) Tekanan Annular : 800-1000 psi

Is the lighting for the area in good condition?
a) All lights working.
b) Safety cables on overhead lights.
c) Protective covers in place, clean, and in
good condition.
BOP-021 d) Matching plug in with electric line outlet.
e) No splices in electrical lines.
f) Conform
Penerangan di area dalam kondisi baik:
a) Seluruh lampu menyala
b) Rantai / sling pengaman terpasang
c) Terdapat penutup pelindung yang bersih dan
baik
d) Plug in sesuai dengan outletnya
e) tidak terdapat kerusakan pada kabel listrik
f) Sesuai

BOP-022 Handle 4 way-valve is always in open position Handle 4 way-valve selalu dalam posisi terbuka

BOP-023 Air line to air pump is connected Line angin ke air pump terpasang

BOP-024 Air Valve to air pump opened Valve angin ke air pump terbuka
IV Pipe Rack/Trailler Rak pipa
BOP-025 The pipe rack level and stable Trailler/rak untuk pipa rata dan stabil

Proper metal pin pipe stops on the ends of the Terdapat pin logam diujung trailler/rak untuk
BOP-026
pipe rack to prevent pipe from falling off menahan pipa supaya tidak jatuh
Stripping boards used between the rows of Papan penahan diletakkan antara deretan pipa-
BOP-027
tubulars pipa
A pipe stop used when the pipe is in the V-door Protector pipa terpasang sesuai dengan pipanya
BOP-028
The catwalk free of potential trip/slip hazards
Catwalk bebas dari bahaya terpeleset,
BOP-029
tersandung, tergelincir
Trailer/rak bebas is free from slip Trailler/rak bebas dari bahaya terpeleset
BOP-030
/tersandung
Pipe rolled from the ends and not by standing Pipa digelindingkan dari ujungnya dan tidak
BOP-031
on them and rolling with the feet boleh digelindingkan dengan kaki
Tubing board is completed with toe board and Tubing board dilengkapi toe board dan tidak
BOP-032
not leak bocor
BOP-033 Tubing board is on stable position Tubing board diletakkan rata dan stabil

BOP-034 There is adequate lighting for the area
If pipe bins are used, the the tubulars are
stacked inside the bin with stripping boards
BOP-035 between rows so that a sling can be wrapped
around the pipe for safe removal
Cukup penerangan pada area tersebut
Jika tempat pipa dipergunakan, maka
pengganjal pipa disusun didalamnya agar sling
dapat mudah masuk untuk mengangkat pipa

The Housekeeping in the area is good
a) No trash.
b) Broken stripping boards discarded.
c) Lifting slings, stripping boards, hand tools
BOP-036 stacked or stored in an orderly manner and not
left laying around.
Housekeeping di area dalam kondisi baik:
a) Bebas sampah
b) Pengganjal pipa yang rusak dibuang
c) Sling pengangkat, pengganjal pipa, peralatan
tangan disimpan pada tempatnya dan tidak
berserakan

Proper lifting caps or lifting subs available for Terdapat tutup pengangkat untuk menaik
BOP-037 picking up / laying down drill collars turunkan drill collar

Mechanical spilce lifter sling is fit with the size Sling pengangkat mechanical spilce dan sesuai
BOP-038
dengan ukurannya
BOP-039 Metal and glass cup is prohibited Cangkir minum kaca dan logam dilarang
Total 2 0 0 0
0 0 0
Signature/Tanda tangan :

Driller Toolpusher Wellwork Representative

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

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 DAFTAR PERIKSA K3L OPERASI RIG

TOPIK : Genset, Fuel Tank, Compressor and Hydraulic Pump (GS)

TOPIC : Genset, Fuel Tank, Compressor and Hydraulic Pump (GS)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Mechanic

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

Genset, Fuel Tank, Compressor and Genset, Fuel Tank, Compressor and
YES NO NA REMARKS
Hydraulic Pump Hydraulic Pump
Genset Genset
The lights in good operating condition Penerangan di area dalam kondisi baik:
a) All lights working. a) Seluruh lampu menyala
b) Safety cables on overhead lights. b) Rantai / sling pengaman terpasang
GS-001 c) Protective covers in place, clean, and in c) Terdapat penutup pelindung yang bersih dan
good condition. baik
d) Matching plug in with electric line outlet. d) Plug in sesuai dengan outletnya
e) Conform to area classification. e) Sesuai dengan area klasifikasinya

The engines are free of any visible oil leaks and Mesin bebas dari kebocoran dan memiliki
GS-002 with good housekeeping standards standard housekeeping yang baik
GS-003 The skid/trailer properly grounded Landasan/trailer digrounding dengan benar
Proper safety signage posted at all entrances to Rambu keselamatan yang semestinya
the skid/trailer dipasang pada jalan masuk ke landasan/trailer :
GS-004 a) Hearing Protection Required a) Harus memakai pelindung pendengaran
b) No Water Hose Usage Allowed b) Dilarang menggunakan selang air

ear plugs or ear muffs) are provided at the
GS-005 entrance(s) to the skid/trailer
Guards are in place around all drive shafts,
GS-006 belts, fans and other moving parts
Exhaust piping which present a danger to
GS-007
temperature extremes are properly guarded
Non conducting rubber floor mats are in place
GS-008 in front of all electrical panels
Pelindung pendengaran (ear plug/ear muff)
disediakan pada jalan masuk ke
landasan/trailer
Pelindung digunakan di sekeliling drive shafts,
belts, fans dan komponen bergerak lainnya
Pipa pembuangan yang panasnya tinggi yang
menimbulkan bahaya diberi pelindung
Pelapis lantai dari karet yang tidak menghantar
listrik diletakkan di depan panel listrik

All fuses and breakers are properly installed Sekering dan pemutus arus dipasang dengan
GS-009 and of proper rating for the equipment they benar dan ukurannya sesuai dengan peralatan
apply to yang dipergunakan
All electrical panel doors are closed properly Seluruh penutup panel listrik ditutup dengan
GS-010
benar
All switches and controls are properly marked Switch dan alat pengontrol ditandai dengan
GS-011
semestinya
All electric line outlets have protective caps in Seluruh outlet kabel listrik diberi tutup
GS-012
place when not in use pelindung jika tidak dipergunakan
All connecting electric lines have appropriate Seluruh sambungan kabel listrik memiliki
connectors that match up with the outlets (If connector yang sesuai dengan outletnya (Jika
GS-013 outlets have screw on caps then all electric outlet ada sekrup ditutupnya, maka seluruh
lines must have matching screw together plugs kabel listrik harus memiliki plug yang sesuai
as well.) sekrupnya)
/ All electric line are routed so that vehicle Seluruh kabel listrik diletakkan sedemikian rupa
GS-014
traffic can not run over the lines sehinga tidak terlindas kendaraan
Electric lines that are routed in vehicle paths Kabel listrik yang direntangkan di atas jalan,
GS-015 have signs to prevent being damaged when run berketinggian minimal 20 feet dab diberi tanda
over
Fire extinguisher(s) available and in good Tersedia pemadam api dan dalam kondisi baik:
condition: a) Tanggal 5 tahunan tes hydro dari setiap unit
a) 5 year hydro test date noted on units b) Inspeksi bulanan pada unit
b) Monthly inspection noted on unit(s) c) terisi penuh
c) Fully charged d) Selang dan nozzle dalam kondisi baik
d) Nozzle and hose in good condition e) Terdapat pin keselamatan
e) Safety pin in place f) Pinggir dan bawah unit tidak berkarat
GS-016 f) No rust at seams or bottom of units g) Braket tergantung dengar benar
g) Hanging bracket in good condition h) Unit yang ada di luar diberi tutup pelindung
h) Protective cover on units stored outside i) Jalan ke unit tidak terhalang
i) Access to units not blocked j) Nomor ukuran dan tipe setiap unit sesuai
j) Number size and type of units per contract kontrak

LOTO used on electric panel to de-energize LOTO dipergunakan untuk panel listrik yang
GS-017 equipment under repair? (Lock Out / Tag Out) sedang dalam perbaikan.

Total 1 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager. ACS-F-HES-002 Hal:16

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 TOPIK : Genset, Fuel Tank, Compressor and Hydraulic Pump (GS)

TOPIC : Genset, Fuel Tank, Compressor and Hydraulic Pump

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN
II Fuel Tank Tangki Minyak YES NO NA REMARKS
There is adequate lighting for the area and are Terdapat lampu Penerangan dan dalam kondisi
GS-018 the lights in good operating condition: (look no. operasi yang baik: (lihat no. 1.1)
1.1)
The tank is properly labeled with “Danger Sisi tangki diberi label dengan benar dengan
GS-019 Diesel Fuel” and “No Smoking or Open tulisan :”Dilarang Merokok atau Dilarang
Flames”. Menyalakan Api”
The tank have a sight glass that indicates the Tangki dilengkapi gelas transparan untuk
GS-020
volume level melihat level volume tangki
There a valve between the tank and the fuel Terdapat valve diantara tangki dan selang
GS-021 hose used to fill various equipment fuel tanks bahan bakar untuk mengisi berbagai jenis
tangki bahan bakar
The fuel hose have a dead man nozzle on the Selang bahan bakar dilengkapi dead man
GS-022 end that would prevent accidental discharge of nozzle pada ujungnya yang dapat mencegah
fuel tumpahnya bahan bakar
The tank have a proper vent Tanki dilengkapi dengan lubang udara yang
GS-023
benar
There are fuel transfer procedures and are they Terpasang prosedur pengisian bahan bakar
GS-024
posted
Fire extinguisher(s) available and in good Tersedia pemadam api dan dalam kondisi baik:
GS-025
condition: (look no I. 19) (lihat no I. 19
Fuel tanks safely located Tangki bahan bakar ditempatkan dengan aman
GS-026
Housekeeping in the immediate area up to Housekeeping pada area tersebut memenuhi
GS-027
acceptable standards standard
Pressurized tanks rated for pressure Tekanan yang diijinkan untuk tangki bertekanan
GS-028
tinggi
Flammable liquids stored properly & labelled Cairan yang mudah terbakar disimpan dengan
GS-029
semestinya
Trash containers; covered container for oil Tong sampah, kontainer bertutup untuk kain
GS-030
saturated rags pembersih yang kena minyak
GS-031 Walkways clean Walkways bersih

Combustibles away from light fixtures Barang mudah terbakar jauh dari perlengkapan
GS-032
listrik
III Air Compressor Kompresor Udara
There is adequate lighting for the area and are Terdapat lampu Penerangan dan dalam kondisi
GS-033 the lights in good operating condition: (see I.1) operasi yang baik: (lihat I.1)

The compressor have safety signage warning
GS-034 the equipment starts automatically
The air tanks have pressure relief pop off
GS-035
valves
The exhaust lines to the pressure relief pop off
GS-036 valves are directed in such a manner that they
can not accidentally vent on personnel
Terdapat rambu peringatan bahwa peralatan
dihidupkan secara otomatis
Tangki udara dilengkapi dengan relief pop off
valves
Pipa pembuangan dari pressure relief pop off
valves diarahkan sedemikian rupa sehingga
tidak mengarah ke pekerja

GS-037 The skid/trailer is properly grounded Landasan/trailer digrounding dengan baik

Fire extinguisher(s) available and in good
GS-038
condition.:(see no I.19)
Guards are in place around all drive shafts,
GS-039 belts, fans and other moving parts
Tersedia pemadam api dan dalam kondisi baik:
(lihat no I.19)
Pelindung digunakan di sekeliling drive shafts,
belts, fans dan komponen bergerak lainnya

Explosion proof junctions for electric lines is in Junction yang anti meledak untuk kabel listrik
GS-040
good condition ( Not sealed with paint) dalam kondisi baik (tidak dilapisi dengan cat)
The air tank have a valve before the air line Tangki udara dilengkapi dengan valve sebelum
GS-041
outlet outlet saluran udara
There is a pressure gauge on the air tank and Terdapat pengukur tekanan pada tangki udara
GS-042
is it in good condition dan dalam kondisi baik
All air lines to the air tank have proper Seluruh selang udara ke tangki udara
GS-043 connections ( Crows feet connectors, no pipe dilengkapi dengan sambungan yang
nipples with radiator/worm gear clamps) semestinya
IV Hydraulic Pump Unit Unit Pompa Hidrolik
There is adequate lighting for the area and are Terdapat lampu Penerangan dan dalam kondisi
GS-044
the lights in good operating condition (see I.1) operasi yang baik (lihat I.1)
Total 2 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

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 TOPIK : Genset, Fuel Tank, Compressor and Hydraulic Pump (GS)

TOPIC : Genset, Fuel Tank, Compressor and Hydraulic Pump

Code SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN
Fire extinguisher(s) available and in good Tersedia pemadam api dan dalam kondisi baik
GS-045
condition. (seeI.19) (lihat I.19)
Guards are in place around all drive shafts, Pelindung digunakan di sekeliling drive shafts,
GS-046 belts, fans and other moving parts belts, fans dan komponen bergerak lainnya

The compressor have safety signage warning
GS-047 the equipment starts automatically
Explosion proof junctions for electric lines is in
GS-048
good condition ( Not sealed with paint)
Housekeeping in the immediate area up to
acceptable standards
GS-049 - All trash in proper trash containers.
- Hand tools properly stored.
Terdapat rambu peringatan bahwa peralatan
dihidupkan secara otomatis
Junction yang anti meledak untuk kabel listrik
dalam kondisi baik (tidak dilapisi dengan cat)
Housekeeping pada area tersebut memenuhi
standard:

GS-050 The equipment is free of any oil leaks Peralatan bebas dari kebocoran oli

Drums of hydraulic oil: Drum dari oli hidrolik:

a) Properly stored. a) Disimpan dengan benar
b) Not leaking. b) Tidak bocor
c) Have HMIS (Hazardous Material Information c) Dilengkapi dengan Stiker Informasi Bahaya
Sticker) attached. Material (HMIS)
d) Proper valve for pouring (No butterfly valves d) Valve yang sesuai untuk menuangkan
GS-051 that do not lock in the open or closed position, e) Drip pans
gate valves or hand pumps preferred).
e) Drip pans.

Total 3 0 0 0
0 0 0
Note:

Signature / Tanda tangan :

Mechanic/Electrician Toolpusher Wellwork Representative

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

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 TOPIK : POMPA LUMPUR

TOPIC : MUD PUMP (MP)

Tanggal (Date) : Business Partner 0
Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Derrickman

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

I Mud Pump Pompa Lumpur YES NO NA REMARKS
Mud Pump Pompa Lumpur
Housekeeping is good in the area : Housekeeping di area baik :
a) No Trash a) Bebas sampah
b) Water hoses rolled up when not in use b) Selang air digulung bila tidak digunakan
MP-001 c) Hand tools stacked or stored in an orderly c) Peralatan tangan disimpan pada tempatnya
manner and not left laying around dan tidak berserakan

The lights are in good operating condition:
a) All lights working
b) Safety cables on overhead lights
c) Protective covers in place, clean, and in good
MP-002 condition
d) Matching plug in with electric line outlet
e) No electric line splices with electrical tape
Penerangan di area dalam kondisi baik:
a) Seluruh lampu menyala
b) Rantai / sling pengaman terpasang
c) Terdapat penutup pelindung yang bersih
dan baik
d) Plug in sesuai dengan outletnya
e) Tidak menggunakan tape elektrik pada
kabel elektrik

The pump trailer / skid properly grounded
MP-003
Fire extinguisher(s) available and in good
condition:
a) 5 year hydro test date noted on units
b) Monthly inspection noted on unit(s)
c) Fully charged
d) Nozzle and hose in good condition
e) Safety pin in place
f) No rust at seams or bottom of units
MP-004 g) Hanging bracket in good condition
h) Protective cover on units stored outside
i) Access to units not blocked
j) Number size and type of units per contract
Landasan trailer pompa Lumpur digrounding
dengan benar
Tersedia pemadam api dan dalam kondisi
baik:
a) Tanggal 5 tahunan tes hydro dari setiap unit
b) Inspeksi bulanan pada unit
c) terisi penuh
d) Selang dan nozzle dalam kondisi baik
e) Terdapat pin keselamatan
f) Pinggir dan bawah unit tidak berkarat
g) Braket tergantung dengar benar
h) Unit yang ada di luar diberi tutup pelindung
i) Jalan ke unit tidak terhalang
j) Nomor ukuran dan tipe setiap unit sesuai
kontrak

All protective guard over shafts, pony rods, rod Seluruh shafts, pony rods, rod lubricator
MP-005 lubricator motor/pump etc are in place motor/pump dilengkapi dengan tutup
pelindung

Gas nitrogen pressure on pulsation dampners:
Pressure at Mudpump #1 ___ PSI
Pressure at Mudpump #2 ___ PSI
MP-006
N/A ______
Terdapat tekanan gas nitrogen pada pulsation
dampners yang sesuai
Tekanan pada Mudpump #1 ___ PSI
Tekanan pada Mudpump #2 ___ PSI
N/A _______

MP-007 Pressure can be read on Mud Pump(s) Tekanan dapat terbaca pada Mud Pump

The heads and valve have covers/guards fully Penutup/pelindung kepala dari mud pump
MP-008
bolted in place dikencangkan dengan baut
There is a pressure relief valve (pop off) on the Terdapat pressure relief valve (pop off) pada
MP-009 discharge side of the mud pump fluid end bagian luar dari mud pump fluid end (tekanan
(Operation pressure:______1200_____psi ) operasi :_______ psi)
The shear pin pressure relief valve is covered Shear pin pressure relief valve diberi tutup
MP-010
pelindung
A proper shear pin is used in the pressure relief Shear pin yang standard dipergunakan pada
MP-011
valve, no nails pressure relief valve
The discharge line from the pressure relief valve Pipa pressure relief valve harus bersudut 135
to the mud pits is free of any 135 degree in it and derajat dan dilengkapi dengan rantai
MP-012 it have safety lines between connections pengaman diantara sambungannya
Note: D&C question states 90 degrees?? Note: D&C menyebutkan 90 derajat??
Both ends of the high pressure mud vibrator Kedua ujung dari high pressure mud vibrator
MP-013 hose have safety snub lines attached between all hose dilengkapi dengan safety snub lines yang
connections terpasang diantara seluruh sambungan
All electrical switches and electric lines are in Semua panel dan kable elektrik pada kondisi
good condition and properly marked bagus dan diberi tanda
MP-014 a) Conforms to area classification a) Tersedia di setia area yg diklasifikasi
b) No exposed wiring or splices with electrical b) Tidak ada kabel / kawat yg rusak
tape menggunakan tape elektrik
Total 1 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.
 TOPIK : POMPA LUMPUR

TOPIC : MUD PUMP

Code SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN
The mud pump free of any leaking gear oil, rod Pompa tidak boleh bocor dan keluar fluida
MP-015
lubricating fluid, and mud pada gear dan rod
Proper tools are available for performing repairs Tersedia peralatan yang sesuai untuk
MP-016 to the mud pumps and they are in good condition memperbaiki pumpa Lumpur dan peralatan
tersebut dalam kondisi baik
The decking/ floor plates / grating around the Lantai / pelat lantai / kisi sekitar pompa
mud pumps are in good condition (secured in Lumpur dalam kondisi baik (Diamankan dan
MP-017 place and level not creating trip hazards) permukaannya tidak menimbulkan bahaya
tersandung)
The mud pressure gauge operate properly Alat pengukur tekanan (gauge) beroperasi
MP-018
(proper psi rating) dengan benar (Tekanannya sesuai)
Total 2 0 0 0
0 0 0
Notes:

Signature /Tanda tangan :

Derrickman Toolpusher Wellwork Representative

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

 TOPIK : TANGKI LUMPUR

TOPIC : MUD TANK (MT)

Tanggal (Date) : Business Partner 0
Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Roustabout
Code SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN
MUD TANK TANGKI LUMPUR
I Circulating tank dan mixing Tanki sirkulasi dan pencampuran
The lights are in good operating condition: Penerangan di area dalam kondisi baik:
a) All lights working a) Seluruh lampu menyala
b) Safety on overhead lights b) Rantai / sling pengaman terpasang
c) Protective cover in place, clean, and in c) Terdapat penutup pelindung yang bersih
MT-001 good condition dan baik
d) Matching plug in with electric line outlet d) Plug in sesuai dengan outletnya
e) Conform to area classification. e) Sesuai dengan area yg diklasifikasi

There is protective cover on the shaft
MT-002
motor/pump connection
MT-003 Water pump and tank are not leaks
ON/OFF Switch and electricity cable to pump
MT-004
motor in good condition
The bridge or cross over from rig floor in good
MT-005
condition
MT-006 The tank is properly grounded
There is an equipment for washing eye/face
MT-007
at tank
MT-008 The tank is identified as a confined space
Housekeeping in the immedite area around
MT-009 the tank is at acceptable standars
Terdapat tutup pelindung pada sambungan
shaft motor/pompa
Pompa air dan tangkinya tidak bocor
Switch on/off dan kabel listrik ke motor pompa
dalam kondisi baik
Jembatan atau cross over dari lantai bor/rig
dalam kondisi baik
Tangki digrounding dengan benar
Terdapat peralatan untuk pencuci mata/muka
ditangki
Tangki dinyatakan sebagai ruangan tertutup
Housekeeping pada area disekeliling tangki
tersebut memenuhi standar

II Swab/Storage Tank Tangki Swab/Storage Tank

Tank ladder in good condition:
a) Located at least 150 feet from wellhead
(swab tank)
b) Proper ladder : All stair treads uniform,
have handrails and midrails
MT-010
c) Walkaway not blocked which is can be
cause of slip or trip hazard (all grating plate
are level, no bend and secure)
Tangga Tangki Tank dalam kondisi baik:
a) Diletakkan minimal 150 feet dari wellhead
(Tangki swab)
b) Tangga baik : Anak tangga seragam,
terdapat pegangan tangan
c) Jalan tidak ada hambatan yang
menyebabkan bahaya terpeleset atau
tersandung (Seluruh grating plate di lantai rata,
tidak bengkok dan aman)

All valve handles that could be a trip hazards Seluruh pegangan valve yang dapat
painted yellow or in such a manner as to
MT-011 make them stand out against surrounding
area
MT-012 Use Toe Board
All valve open/close properly
MT-013
Eye/face washer and protective equipment is Pencuci mata/muka dan peralatan pelindung
MT-014
available and easy to get
The lights are in good operating condition
MT-015
(notice I,1)
Housekeeping in the area is in good condition Housekeeping di area dalam keadaan baik
MT-016
Water hoses and cat lines rolled up when not
MT-017
in use
Fire extinguisher(s) available and in good
condition:
a) 5 year hydro test date noted on units
b) Monthly inspection noted on unit(s)
c) Fully charged
d) Nozzle and hose in good condition
e) Safety pin in place
MT-018 f) No rust at seams or bottom of units
g) Hanging bracket in good condition
h) Protective cover on units stored outside
i) Access to units not blocked
j) Number size and type of units per contract
mengakibatkan bahaya tersadung dicat kuning
sedemikian rupa agar terlihat dengan jelas
Memakai Toe Board
Seluruh valve dapat terbuka/tertutup dengan
baik
tersedia yang mudah dicapai
Penerangan dalam kondisi operasi yang baik
(lihat I,1)
Selang air digulung jika tidak dipergunakan
Tersedia pemadam api dan dalam kondisi baik:
a) Tanggal 5 tahunan tes hydro dari setiap unit
b) Inspeksi bulanan pada unit
c) terisi penuh
d) Selang dan nozzle dalam kondisi baik
e) Terdapat pin keselamatan
f) Pinggir dan bawah unit tidak berkarat
g) Braket tergantung dengar benar
h) Unit yang ada di luar diberi tutup pelindung
i) Jalan ke unit tidak terhalang
j) Nomor ukuran dan tipe setiap unit sesuai
kontrak

MT-019 The tank is leaks free Tidak ada kebocoran pada tangki

All openings to the mud pits properly covered Seluruh bagian terbuka dari mud tank ditutup
MT-020 or with barrier post and chains around them dengan benar dengan menggunakan tonggak
yang dilengkapi rantai disekelilingnya
Total 1 0 0 0
Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.
 TOPIK : TANGKI LUMPUR

TOPIC : MUD TANK

Code SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN
“Confined Space Entry Permit Required” Dipasang rambu “Ijin memasuki ruang terbatas”
MT-021 safety signage are posted at all openings to pada seluruh bagian terbuka dari mud tank
mud tanks

MT-022 the proper implements are available Terdapat alat ukur yang semestinya

The mud line (flow line) properly are attached
MT-023
from BOPE to the swab tank
Miscellaneous - 45 Gallon/205 litre drums are
MT-024 not to be used for any other purpose than
intended. Do not cut or modify
Pipe line (flow line) terpasang dengan benar
dari BOPE ke swab tank
Hal lainnya - 45 Gallon/205 liter drum tidak
boleh digunakan untuk berbagai fungsi. Tidak
boleh di potong atau dimodifikasi

Total 2 0 0 0
0 0 0
Notes:

Signature / Tanda tangan:

Roustabout Toolpusher Wellwork Representative

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

 TOPIK : POWER SWIVEL

TOPIC : POWER SWIVEL (PS)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Derrickman
Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN
Power swivel Power swivel YES NO NA REMARKS
Power swivel Power swivel
Housekeeping in the area is good : Housekeeping di area baik :
a) No trash a) Bebas sampah
PS-001 b) Water hoses rolled up when not in use b) Selang air digulung bila tidak digunakan
c) Hand tools stacked or stored c) Peralatan tangan disimpan pada tempatnya
dan tidak be
The Power Swivel trailer is properly Landasan trailer Power Swivel digrounding
PS-002
grounded dengan benar
Fire extinguisher(s) available and in good Tersedia pemadam api dan dalam kondisi baik:
condition: a) Tanggal 5 tahunan tes hydro dari setiap unit
a) 5 year hydro test date noted on units b) Inspeksi bulanan pada unit
b) Monthly inspection noted on unit(s) c) terisi penuh
c) Fully charged d) Selang dan nozzle dalam kondisi baik
d) Nozzle and hose in good condition e) Terdapat pin keselamatan
e) Safety pin in place f) Pinggir dan bawah unit tidak berkarat
f) No rust at seams or bottom of units g) Braket tergantung dengar benar
g) Hanging bracket in good condition h) Unit yang ada di luar diberi tutup pelindung
PS-003 h) Protective cover on units stored outside i) Jalan ke unit tidak terhalang
i) Access to units not blocked j) Nomor ukuran dan tipe setiap unit sesuai
j) Number size and type of units per contract kontrak

All protective guards over shafts, pony rods,

Seluruh shafts, pony rods, rod lubricator
PS-004 rod lubricator motor/pump, etc. are in place
motor/pump dilengkapi dengan tutup pelindung

All high pressure lines to the Swivel stack

are properly connected and in good
condiition :
PS-005 a) Free of leaks
b) No crushed or flat sp
c) Safety cables between connections
Seluruh pipa tekanan tinggi disambungkan ke
rangkaian Swivel dalam kondisi baik:
a) Tidak bocor
b) Tidak hancur dan penyok
c) Terdapat safety chain diantara sambungan

Arm power swivel is not crack and safety pin Arm power swivel tidak ada keretakan dan pin
PS-006
attach properly
PS-007 Ground anchor attach properly
Hydraulic pump may not leak and free of
PS-008
spill
Proper tools are available for performing
PS-009 repairs to the Power swivel and they are in
good concition
The decking / floor plates / grating around
the power swivel are in good condition
PS-010 (Secured in place and level not creating trip
hazards)
The pressure gauge operate properly
PS-011
(proper psi rating)
PS-012 LOTO installed correctly
dipasang dengan benar
Ground anchor terpasang dengan baik
Pompa hydraulic tidak boleh bocor dan keluar
fluida
Tersedia peralatan yang sesuai untuk
memperbaiki Power swivel dan peralatan
tersebut dalam kondisi baik
Lantai / pelat lantai / kisi sekitar Power swivel
dalam kondisi baik (Diamankan dan
permukaannya tidak menimbulkan bahaya
tersandung)
Alat pengukur tekanan (gauge) beroperasi
dengan benar (Tekanannya sesuai)
LOTO terpasang dengan benar
Total 0 0 0

Notes/Catatan:

Signature/Tanda tangan:

Derrickman Toolpusher Wellwork Representative

Distribution : Rig, R & C, North Wellwork Team Leader, BP Area Manager.

 TOPIK : Penyimpanan Bahan Kimia

CHECK LIST K3LL RIG OPERATION

PERIHAL : CHEMICAL STORAGE (CS)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Floorman

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

I Chemical Storage Penyimpanan Bahan Kimia YES NO NO REMARKS

Chemical Storage
There is adequate lighting for the area and
are the lights in good operating condition :
a) All lights working
b) Safety chain installed corectly
CS-001 c) Protective covers in place, clean, and in
good condition
d) Plug in instaled at outlet
e) Conform to area classification.
Penyimpanan Bahan Kimia
Penerangan di area dalam kondisi baik:
a) Seluruh lampu menyala
b) Rantai / sling pengaman terpasang
c) Terdapat penutup pelindung yang bersih dan
baik
d) Plug in sesuai dengan outletnya
e) Sesuai dengan area yang diklasifikasi

Fire extinguisher(s) available and in good
condition:
a) 5 year hydro test date noted on units
b) Monthly inspection noted on unit(s)
c) Fully charged
d) Nozzle and hose in good condition
e) Safety pin in place
f) No rust at seams or bottom of units
CS-002 g) Hanging bracket in good condition
h) Protective cover on units stored outside
i) Access to units not blocked
j) Number size and type of units per contract
Tersedia pemadam api dan dalam kondisi baik:
a) Tanggal 5 tahunan tes hydro dari setiap unit
b) Inspeksi bulanan pada unit
c) terisi penuh
d) Selang dan nozzle dalam kondisi baik
e) Terdapat pin keselamatan
f) Pinggir dan bawah unit tidak berkarat
g) Braket tergantung dengar benar
h) Unit yang ada di luar diberi tutup pelindung
i) Jalan ke unit tidak terhalang
j) Nomor ukuran dan tipe setiap unit sesuai
kontrak

The chemicals stored in an orderly manner: Bahan kimia disimpan dengan cara semestinya:
a) a) Bahan kimia
Stored by sameness b) yang sama disatukan b)
CS-003 No torn sacks c) Sak tidak ada yang bocor
Protected from the elements (rain, hig c) Diberi penutup pelindung dari hujan,
angin kencang, matahari (bila perlu)

CS-004 Area ventilation is in good condition Ventilasi area baik

All pallets and other chemical containers Seluruh pallet dan kontener penyimpanan bahan
each have a HMIS (Hazardous Material kimia lainnya dilengkapi dengan Stiker Informasi
CS-005
Information Sticker) on them Bahaya Material (HMIS) = MSDS

Torn sacks of chemical are placed inside Sampai bahan tersebut dipergunakan Karung
another sack, bag or container to prevent bahan kimia yang bocor dimasukkan kedalam
CS-006 further spillage and contact with the worker karung lainnya, untuk menghindari terjadinya
and environment until it is used ceceran dan kontak dengan pekerja dan
lingkungan
Housekeeping in the immediate area around Housekeeping di area tersebut disekeliling
CS-007 the chemical storage are at acceptable tempat penyimpanan bahan kimia memenuhi
standards standard yang ditentukan
No asbestos products (“Flo-seal”) etc on Tidak ada produk asbestos (flo-seal dll) di lokasi
CS-008
location
Each outlet equipped with HMIS sticker on Setiap outlet dilengkapi dengan stiker HMIS di
CS-009
the top or near it atas atau di dekatnya
There is a means for containment in the even Bila terjadi tumpahan atau ceceran yang besar,
of a major leak or spill terdapat suatu alat untuk menampung ceceran
CS-010
atau tumpahan tersebut

Ventilation, heating/air conditioning is Ventilasi, pemanas, penyejuk udara yang

CS-011
provided tersedia
Total 0 0 0
Notes/catatan:

Signature/tanda tangan:

Floorman Toolpusher Wellwork Representative

Distribution: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
TOPIK: PENYIMPANAN PELUMAS
CHECKING LIST K3LL RIG OPERATION
TOPIC : LUBRICANT STORAGE (LS)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Mechanic

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

Lubricant Storage Penyimpanan Pelumas YES NO NA REMARKS
Lubricant Storage Penyimpanan Pelumas
There adequate lighting for the area and are the Penerangan di area dalam kondisi baik:
lights in good operating condition? a)   Seluruh lampu menyala
a) All lights working. b)   Rantai / sling pengaman terpasang
b) Safety cables on overhead lights. c)   Terdapat penutup pelindung yang bersih dan
c) Protective covers in place, clean, and in good baik
LS-001 condition. d)   Plug in sesuai dengan outletnya
d) Matching plug in with electric line outlet. e) Sesuai dengan area yang diklasifikasi
e) Conform to area classification.

Fire extinguisher(s) available and in good
condition:
a) 5 year hydro test date noted on units
b) Monthly inspection noted on unit(s)
c) Fully charged
d) Nozzle and hose in good condition
e) Safety pin in place
LS-002 f) No rust at seams or bottom of units
g) Hanging bracket in good condition
h) Protective cover on units stored outside
i) Access to units not blocked
j) Number size and type of units per contract
Tersedia pemadam api dan dalam kondisi baik:
a) Tanggal 5 tahunan tes hydro dari setiap unit
b) Inspeksi bulanan pada unit
c) terisi penuh
d) Selang dan nozzle dalam kondisi baik
e) Terdapat pin keselamatan
f) Pinggir dan bawah unit tidak berkarat
g) Braket tergantung dengar benar
h) Unit yang ada di luar diberi tutup pelindung
i) Jalan ke unit tidak terhalang
j) Nomor ukuran dan tipe setiap unit sesuai
kontrak

If bulk storage tanks are used for dispensing lube Tangki penyimpanan dipergunakan untuk
oil the valve outlets to the various lubricant oils are mengeluarkan minyak pelumas, outlet valve yang
LS-003 properly marked as to the type of oil they dispense menuju bermacam-macam minyak pelumas
tersebut diberi tanda sesuai dengan jenis minyak
pelumasnya
Each outlet have the appropriate HMIS sticker Setiap outlet dilengkapi dengan stiker HMIS di
LS-004 place above or near it atas atau di dekatnya
The lube oil day tanks are properly labeled Tangki penyimpan minyak pelumas yang
LS-005 dipergunakan setiap hari diberi label dengan benar
There is a drip pan located under the lube oil Drip pan terdapat dibawah outlet minyak pelumas
LS-006
outlets and is it drained on a regular basis dan dibersihkan secara teratur
There is a means for containment in the event of a Bila terjadi tumpahan atau ceceran yang besar,
LS-007 major leak or spill terdapat suatu alat untuk menampung ceceran
atau tumpahan tersebut
Available ventilation, heater, and air conditioner Ventilasi, pemanas, penyejuk udara yang tersedia
LS-008
Total 0 0 0
Note/catatan:

Signature/tanda tangan:

Pelaksana Mechanic Toolpusher Wellwork Representative

Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
TOPIK : FOCO
CHECKING LIST K3LL RIG OPERATION
TOPIC : FOCO TRUCK (FT)
Tanggal (Date) : Business Partner 0
Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Operator dan Swamper

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

Foco Truck Foco Truck YES NO NA REMARKS
A Standard Safety Devices Peralatan Keselamatan Standard
Safety Belt / Seat – Driver / Operator - Sabuk Pengaman /kursi – Driver / Oprt - operator
Seats for all vehicles all passengers - Seat Tempat duduk untuk semua penumpang -
FT-001 belt lock mechanism working Sistim penguncian sabuk pengaman bekerja
dengan baik
View Mirrors (Sides & Rear) - The Kaca Spion (Samping & Belakang) operator
FT-002 mirror in good condition and/or damage to obstruct - Kaca spion dalam kondisi bagus dan/atau pecah
views sehingga menghalangi pandangan
Signal Lights, Stop, Turn, Head, amber Beacon, Lampu2 Sign, Berhenti, Belok, Depan, lampu operator
brake Light - All lights hazard, lampu rem -
FT-003 and equipment itself must be in working order Semua lampu dan peralatannya harus berfungsi
dengan baik
All Cables Condition - Kondisi Kabel2 - swamper
FT-004 All cables must in good condition and arrange in Semua kabel listrik dalam kondisi bagus dan
safe position tersusun aman dan rapi
Horn - Klakson operator
FT-005 The horn must sound in strong enough to hear by -Klakson harus bersuara cukup keras agar
others terdengar oleh orang lain
Windshield wiper & Windshield glass - Kaca Depan & Penghapus Kaca - swamper
Clean, no major cracks or damage to obstruct Kondisi bersih, tidak ada keretakan besar atau
FT-006 vision. - kerusakan lainnya sehingga mengganggu
Windshield wipers working penglihatan.
- Penghapus kaca depan berfungsi baik
Boom Hoist Limiting Device - Alat Pembatas Boom Hoist - swamper
FT-007 Safety devices must be in working order Peralatan Keselamatan harus berfungsi dengan
baik
Boom Back Stop / Boom Pawl Lock - Boom Back Stop / Boom Pawl Lock - swamper
FT-008 Ensure that safety devices are in good condition Pastikan peralatan keselamatan dalam kondisi
bagus dan berfungsi dengan baik
Boom Angle Indicator / Load Rating Chart - Petunjuk Sudut Boom / Tabel Tingkat Beban - swamper
Safety devices must be in working order - Load Peralatan keselamatan harus berfungsi dengan
chart/all signage & labels in Indonesian baik - Tabel
FT-009
beban/semua tanda & label dalam bahasa
Indonesia

Swing Brakes Take Rem Swing operator

FT-010 a swing and stop to know the condition is running Lakukan swing dan rem untuk mengetahui
well kondisinya bagus dan berfungsi

Anti Two Block & Alarm - Anti Two Block & Alarm - operator
FT-011 Its safety devices must running well and ensure Peralatan keselamatan ini harus dipastikan
that it is maintain properly berfungsi dan terawat dengan baik
Hook Latch Hook Latch operator
FT-012 Ensure that latch & spring is working properly Pastikan pemalang hook & per-nya berfungsi
dengan baik

Backup Alarm Alarm Mundur operator

FT-013 Ensure that alarm working properly and sound Pastikan alarm tanda mundur bekerja dengan baik
good strong enough dan berbunyi cukup keras
Parking Brakes & services Brakes Rem Tangan & Rem Kaki operator
FT-014 Ensure that safety devices are working order Pastikan peralatan ini berfungsi dengan
Odometer (KM Reading), Engine Hour, for baik
Odometer (KM Reading), Engine Hour, hanya operator
wheel type only - untuk type ban -
FT-015 Safety devices must be in working order Peralatan keselamatan harus berfungsi dengan
baik
Outrigger Outrigger swamper
FT-016 Ensure that out rigger in good condition and as per Pastikan out rigger dalam kondisi baik and sesuai
manufacturing design dengan design pabrik.
Expired Document & Crane certificate Document Kadaluarsa & Sertifikat Foco operator
FT-017 Ensure that this document is in valid condition Pastikan dokumen masih berlaku
FT-018 Journey Management System is already done Telah melakukan Journey Management System operator
The headache ball and block are painted a bright Headache ball dan blocknya dicat dengan warna swamper
FT-019 color (yellow or florescent red) so that it is readily yang cerah (kuning atau merah florescent)
noticeable at all times sehingga mudah dikenali setiap saat
The lights are mounted in the boom that illuminates Terdapat lampu yang terpasang di boom yang swamper
FT-020 the load and immediate work area during nighttime menerangi beban dan area tersebut selama
operations operasional malam hari
Proper hand signals for crane operations are Kode tangan untuk operasional foco terpasang swamper
FT-021
posted on the crane pada foco
Total 1 0 0 0
Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
TOPIK : FOCO

CHECKING LIST K3LL RIG OPERATION

TOPIC : FOCO
Code SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN

Terdapat tutup pelindung yang benar disekeliling operator

Proper guards are in place around all fans, belts,
kipas angin, sabuk (v-belt), transmission shaft dan
FT-022 transmission shafts, and temperature extreme
bagian yang terkena paparan panas (sistim
exposure (exhaust systems)
pembuangan )
FT-023 There is an emergency shut down device Terdapat alat pemati mesin darurat operator

The crane is equipped with the means to prevent Foco dilengkapi dengan suatu alat yang dapat operator
FT-024 free falling of the load in the event of a power mencegah jatuhnya beban akibat mati mesin
failure (manual / mechanical brake)
FT-025 All lifting sling used mechanical splice Semua sling pengangkat mechanical splice swamper

B Limited use
Triangle Red Cones, Red Flags & First Aid Kit Triangle Red Cones, Bendera Merah & kotak swamper
(if applicable) Ensure this P3K (jika ada) Pastikan
FT-026 equipment available and adequate for emergency peralatan ini tersedia dan dalam jumlah yg cukup
untuk kondisi emergency
Expired CPI Permit / SIO / Govt. License Ensure Expired CPI Permit / SIO / Govt. License. operator
FT-027
permit / documentation is valid Pastikan semua dokumen masih berlaku
Hour Meter Check Hour Meter Check operator
FT-028
the hour meter is in working order the hour meter dalam kondisi bagus
Door Operator / Driver Cabin Door Door Operator / Driver Cabin Pintu swamper
FT-029 Operator Door handles on inside and outside in Operator dan gagang pintu didalam dan diluar
working order cabin dalam kondisi bagus
C Mechanical / Need Assistance
Oil Engine / Transmission / hydraulic Oil operator
Oli Mesin / Transmisi / Oli hydraulik Periksa
FT-030 Check the condition from leakages or any other
apakah ada kebocoran atau kerusakan lainnya
defective
Water Radiator / Driver Belt / Brake Fluid Check Air Radiator / Belt Pemutar / Minyak Rem Check operator
FT-031
the function in working order berfungsi dan dalam kondisi baik
Battery Level / Fuel / Gear Oil Check the Level Air Baterai / BBM / Minyak Pelumas gigi operator
FT-032 condition & function Check
kondisi dan fungsinya
Steering / Master Clutch / Service Brake Check Steering / Master Clutch / Service Brake. Check operator
FT-033 and ask to Operator those function dan minta kepada Operator untuk men-testnya

Air Gauge / Oil Gauge / Water Gauge Air Gauge / Oil Gauge / Water Gauge operator
FT-034 Check in cabin and ask the operator for well Check dalam kabin and minta operator untuk men-
function testnya
Control Level / Brake Lining AC Check Control Level / Brake Lining AC swamper
FT-035
and ask to operator those function Check and minta operator untuk men-testnya
Tyre (Including spare) / Spring / Track Pin Ban (termasuk Ban Serap) / Per / Track Pin swamper
FT-036
Check the tyres as per manufacturing in design Check ban-ban sesuai dengan design pabriknya
Drive Chain / Sprocket / Rollers Check Drive Chain / Sprocket / Rollers swamper
FT-037 those function as per lifting equipment used Check apakah berfungsi sesuai dengan peralatan
angkat yg digunakan
Hook cable / Pendant Cable / Boom Hoist Cable Hook cable / Pendant Cable / Boom Hoist swamper
Check those Cable Check
FT-038 equipment as Rigging practices peralatan tersebut sesuai dengan Rigging
practices
Turn Cable Gear / Out Rigger / Boom Lock Turn Cable Gear / Out Rigger / Boom Lock swamper
FT-039
Check the Check fungsi
function and any leakages
Boom Connection and Pin / Counter Weight dan
Boomkebocoran jika ada
Connection and Pin / Counter Weight swamper
FT-040

FT-041 The boom is free of bent or cracked members Bagian-bagian Boom tidak bengkok atau retak swamper

swamper
FT-042 There is a spark arrester on the exhaust system Terdapat spark arrester pada sistim pembuangan

FT-043 operator
Drive Right Drive Right
Total 2 0 0 0
0 0 0
Note/catatan:

Signature/tanda tangan :

Operator/Swamper Toolpusher Wellwork Representative

Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
TOPIK : CRANE
CHECKING LIST K3LL RIG OPERATION
TOPIC : CRANE (CR)
Tanggal (Date) : Business Partner 0
Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Operator

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

Crane Crane YES NO NA REMARKS
A Standard Safety Devices Peralatan Keselamatan Standard
Safety Belt / Seat – Driver / Operator - Sabuk Pengaman /kursi – Driver / Oprt -
Seats for all vehicles all passengers - Seat Tempat duduk untuk semua penumpang -
CR-001 belt lock mechanism working Sistim penguncian sabuk pengaman bekerja
dengan baik
View Mirrors (Sides & Rear) - The Kaca Spion (Samping & Belakang)
CR-002 mirror in good condition and/or damage to obstruct - Kaca spion dalam kondisi bagus dan/atau pecah
views sehingga menghalangi pandangan
Signal Lights, Stop, Turn, Head, amber Beacon, Lampu2 Sign, Berhenti, Belok, Depan, lampu
brake Light - All lights hazard, lampu rem -
CR-003 and equipment itself must be in working order Semua lampu dan peralatannya harus berfungsi
dengan baik
All Cables Condition - Kondisi Kabel2 -
CR-004 All cables must in good condition and arrange in Semua kabel listrik dalam kondisi bagus dan
safe position tersusun aman dan rapi
Horn - Klakson
CR-005 The horn must sound in strong enough to hear by -Klakson harus bersuara cukup keras agar
others terdengar oleh orang lain
Windshield wiper & Windshield glass - Kaca Depan & Penghapus Kaca -
Clean, no major cracks or damage to obstruct Kondisi bersih, tidak ada keretakan besar atau
CR-006 vision. - kerusakan lainnya sehingga mengganggu
Windshield wipers working penglihatan.
- Penghapus kaca depan berfungsi baik
Boom Hoist Limiting Device - Alat Pembatas Boom Hoist -
CR-007 Safety devices must be in working order Peralatan Keselamatan harus berfungsi dengan
baik
Boom Back Stop / Boom Pawl Lock - Boom Back Stop / Boom Pawl Lock -
CR-008 Ensure that safety devices are in good condition Pastikan peralatan keselamatan dalam kondisi
bagus dan berfungsi dengan baik
Boom Angle Indicator / Load Rating Chart - Petunjuk Sudut Boom / Tabel Tingkat Beban -
Safety devices must be in working order - Load Peralatan keselamatan harus berfungsi dengan
chart/all signage & labels in Indonesian baik - Tabel
CR-009
beban/semua tanda & label dalam bahasa
Indonesia

Swing Brakes Take Rem Swing

CR-010 a swing and stop to know the condition is running Lakukan swing dan rem untuk mengetahui
well kondisinya bagus dan berfungsi

Anti Two Block & Alarm
CR-011 Its safety devices must running well and ensure
that it is maintain properly
Hook Latch
CR-012 Ensure that latch & spring is working properly
- Anti Two Block & Alarm -
Peralatan keselamatan ini harus dipastikan
berfungsi dan terawat dengan baik
Hook Latch
Pastikan pemalang hook & per-nya berfungsi
dengan baik

Backup Alarm Alarm Mundur

CR-013 Ensure that alarm working properly and sound Pastikan alarm tanda mundur bekerja dengan baik
good strong enough dan berbunyi cukup keras
Parking Brakes & services Brakes Rem Tangan & Rem Kaki
CR-014 Ensure that safety devices are working order Pastikan peralatan ini berfungsi dengan
baik
Odometer (KM Reading), Engine Hour, for Odometer (KM Reading), Engine Hour, hanya
wheel type only - untuk type ban -
CR-015 Safety devices must be in working order Peralatan keselamatan harus berfungsi dengan
baik
Outrigger Outrigger
CR-016 Ensure that out rigger in good condition and as per Pastikan out rigger dalam kondisi baik and sesuai
manufacturing design dengan design pabrik.
Expired Document & Crane certificate Document Kadaluarsa & Sertifikat Crane
CR-017 Ensure that this document is in valid condition Pastikan dokumen masih berlaku

CR-018 Journey Management System is already done Telah melakukan Journey Management System
The headache ball and block are painted a bright Headache ball dan blocknya dicat dengan warna
CR-019 color (yellow or florescent red) so that it is readily yang cerah kuning sehingga mudah dikenali setiap
noticeable at all times saat
The lights are mounted in the boom that illuminates Terdapat lampu yang terpasang di boom yang
CR-020 the load and immediate work area during nighttime menerangi beban dan area tersebut selama
operations operasional malam hari
Proper hand signals for crane operations are Kode tangan untuk operasional crane terpasang
CR-021
posted on the crane pada crane
Total 1 0 0 0
Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

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Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
TOPIK : CRANE

CHECKING LIST K3LL RIG OPERATION

CRANE
Code SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN

Terdapat tutup pelindung yang benar disekeliling

Proper guards are in place around all fans, belts,
kipas angin, sabuk (v-belt), transmission shaft dan
CR-022 transmission shafts, and temperature extreme
bagian yang terkena paparan panas (sistim
exposure (exhaust systems)
pembuangan )

CR-023 There is an emergency shut down device
The crane is equipped with the means to prevent
CR-024 free falling of the load in the event of a power
failure
CR-025 All lifting sling used mechanical splice
Terdapat alat pemati mesin darurat
Crane dilengkapi dengan suatu alat yang dapat
mencegah jatuhnya beban akibat mati mesin
(manual / mechanical brake)
Semua sling pengangkat mechanical splice

B Limited use
Triangle Red Cones, Red Flags & First Aid Kit Triangle Red Cones, Bendera Merah & kotak
(if applicable) Ensure this P3K (jika ada) Pastikan
CR-026 equipment available and adequate for emergency peralatan ini tersedia dan dalam jumlah yg cukup
untuk kondisi emergency
Expired CPI Permit / SIO / Govt. License Ensure Expired CPI Permit / SIO / Govt. License.
CR-027
permit / documentation is valid Pastikan semua dokumen masih berlaku
Hour Meter Check Hour Meter Check
CR-028
the hour meter is in working order the hour meter dalam kondisi bagus
Door Operator / Driver Cabin Door Door Operator / Driver Cabin Pintu
CR-029 Operator Door handles on inside and outside in Operator dan gagang pintu didalam dan diluar
working order cabin dalam kondisi bagus
C Mechanical / Need Assistance
Oil Engine / Transmission / hydraulic Oil
Oli Mesin / Transmisi / Oli hydraulik Periksa
CR-030 Check the condition from leakages or any other
apakah ada kebocoran atau kerusakan lainnya
defective
Water Radiator / Driver Belt / Brake Fluid Check Air Radiator / Belt Pemutar / Minyak Rem Check
CR-031
the function in working order berfungsi dan dalam kondisi baik
Battery Level / Fuel / Gear Oil Check the Level Air Baterai / BBM / Minyak Pelumas gigi
CR-032 condition & function Check
kondisi dan fungsinya
Steering / Master Clutch / Service Brake Check Steering / Master Clutch / Service Brake. Check
CR-033 and ask to Operator those function dan minta kepada Operator untuk men-testnya

Air Gauge / Oil Gauge / Water Gauge Air Gauge / Oil Gauge / Water Gauge
CR-034 Check in cabin and ask the operator for well Check dalam kabin and minta operator untuk men-
function testnya
Control Level / Brake Lining AC Check Control Level / Brake Lining AC
CR-035
and ask to operator those function Check and minta operator untuk men-testnya
Tyre (Including spare) / Spring / Track Pin Ban (termasuk Ban Serap) / Per / Track Pin
CR-036
Check the tyres as per manufacturing in design Check ban-ban sesuai dengan design pabriknya
Drive Chain / Sprocket / Rollers Check Drive Chain / Sprocket / Rollers
CR-037 those function as per lifting equipment used Check apakah berfungsi sesuai dengan peralatan
angkat yg digunakan
Hook cable / Pendant Cable / Boom Hoist Cable Hook cable / Pendant Cable / Boom Hoist
Check those Cable Check
CR-038 equipment as Rigging practices peralatan tersebut sesuai dengan Rigging
practices
Turn Cable Gear / Out Rigger / Boom Lock Turn Cable Gear / Out Rigger / Boom Lock
CR-039
Check the Check fungsi
function
Boom and any leakages
Connection and Pin / Counter Weight dan
Boomkebocoran jika ada
Connection and Pin / Counter Weight
CR-040

CR-041 The boom is free of bent or cracked members Bagian-bagian Boom tidak bengkok atau retak

CR-042 There is a spark arrester on the exhaust system Terdapat spark arrester pada sistim pembuangan

Others Notes Lain-lain

CR-043 for other non-compliances not shown on above Catat jika ada temuan lainnya yg tidak tercakup
description dalam daftar diatas
Total 2 0 0 0
0 0 0
Note/catatan:

Signature/tanda tangan:

Operator/Swamper Toolpusher Wellwork Representative

Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
PERIHAL : DOZER
CHECKING LIST K3LL RIG OPERATION
DOZER (DZR)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Operator

Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

Dozer
A Standard Safety Devices
Safety Belt / Seat – Driver / Operator
Seats for all vehicles all passengers
DZR-001 Seat belt lock mechanism working
View Mirrors (Sides & Rear) - The Kaca Spion (Samping & Belakang)
DZR-002 mirror in good condition and/or damage to
obstruct views
Horn The Klakson
DZR-003 horn must sound in strong enough to hear by
others
Backup Alarm
DZR-004 Ensure that alarm working properly and sound
good strong enough
Parking Brakes & services Brakes
DZR-005 Ensure that safety devices are working order
DZR-006 All controls properly labeled as to their function
There is a warning horn that indicates the vehicle Terdapat klakson mundur yang menandai bahwa
DZR-007
is operating in reverse
B Limited use
Winch Cable
DZR-008 Ensure the winch is in working order and the
cable/sling is rigged as per rigging practices
Amber Beacon
DZR-009 Ensure that safety devices are working order
Hour Meter Check
DZR-010
the hour meter is in working order
Expired CPI Permit / SIO / Govt. License
DZR-011
Ensure permit / documentation is valid
DZR-012 Mechanical / Need Assistance
Oil Engine / Transmission / hydraulic Oil
DZR-013 Check the condition from leakages or any other
defective
Water Radiator / Driver Belt / Brake Fluid
DZR-014
Check the function in working order
Battery Level / Fuel / Gear Oil Check
DZR-015 the condition & function
Steering / Master Clutch / Service Brake
DZR-016 Check and ask to Operator those function
Dozer YES NO NA REMARKS
- Sabuk Pengaman /kursi – Driver / Oprt -
- Tempat duduk untuk semua penumpang -
Sistim penguncian sabuk pengaman bekerja
dengan baik
- Kaca spion dalam kondisi bagus dan/atau pecah
sehingga menghalangi pandangan
-Klakson harus bersuara cukup keras agar
terdengar oleh orang lain
Alarm Mundur
Pastikan alarm tanda mundur bekerja dengan baik
dan berbunyi cukup keras
Rem Tangan & Rem Kaki
Pastikan peralatan ini berfungsi dengan
baik
Seluruh alat pengendali diberi label sesuai dengan
fungsinya
dozer tersebut sedang bergerak mundur
Winch Cable
Pastikan winch berfungsi dengan baik dan
cable/sling terpasang sesuai dengan praktek
prosedur rigging
Lampu Hazard
Pastikan peralatan ini berfungsi dengan baik
Hour Meter Check
the hour meter dalam kondisi bagus
Expired CPI Permit / SIO / Govt. License.
Pastikan semua dokumen masih berlaku
Oli Mesin / Transmisi / Oli hydraulik Periksa
apakah ada kebocoran atau kerusakan lainnya
Air Radiator / Belt Pemutar / Minyak Rem Check
berfungsi dan dalam kondisi baik
Level Air Baterai / BBM / Minyak Pelumas gigi
Check
kondisi dan fungsinya
Steering / Master Clutch / Service Brake. Check
dan minta kepada Operator untuk men-testnya

Air Gauge / Oil Gauge / Water Gauge Air Gauge / Oil Gauge / Water Gauge
DZR-017 Check in cabin and ask the operator for well Check dalam kabin and minta operator untuk men-
function testnya

Track shoes / Bolts / Connection Link Track shoes / Baut2 / Connection Link
DZR-018
Ensure that all are functioning & working order Pastikan berfungsi dengan baik
Sprocket / Idlers /Rollers Check Sprocket / Idlers /Rollers
DZR-019
the condition is in working order Check apakah berfungsi dengan baik
Total 1 0 0 0
Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
TOPIK : DOZER

CHECKING LIST K3LL RIG OPERATION

TOPIC : DOZER
Code SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN

Body / Engine Hood Body / Engine Hood

DZR-020 Check the body and cabin housekeeping and
engine hood condition
DZR-021 No exposed wiring.
DZR-022 All gauges work properly.
Proper guards are in place around all fans, belts,
DZR-023 transmission shafts, and temperature extreme
exposure (exhaust systems)
Check body, kebersihan cabin dan kondisi ruang
mesin bagus
Tidak ada kabel yang terbuka
Sabuk pengaman tersedia dalam kondisi layak
pakai
Terdapat tutup pelindung yang benar disekeliling
kipas angin, sabuk, transmission shaft dan bagian
yang terkena paparan panas (sistim
pembuangan )

DZR-024 There is a spark arrester on the exhaust system Terdapat spark arrester pada sistim pembuangan

Others Lain-lain
DZR-025 Notes for other non-compliances not shown on Catat jika ada temuan lainnya yg tidak tercakup
above description dalam daftar diatas
Total 2 0 0 0
0 0 0
Note/catatan:

Signature/tanda tangan:

Operator/Swamper Toolpusher Wellwork Representative

Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
TOPIK : TANDEM TRUCK
CHECKING LIST K3LL RIG OPERATION
TOPIC : TANDEM TRUCK (TT)
Tanggal (Date) : Business Partner 0
Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Operator dan Swamper
Code SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN
Tandem Truck Tandem Truck YES NO NA REMARKS
A Standard Safety Devices
Safety Belt / Seat – Driver / Operator - Sabuk Pengaman /kursi – Driver / Oprt - Operator
Seats for all vehicles all passengers - Tempat duduk untuk semua penumpang -
TT-001 Seat belt lock mechanism working Sistim penguncian sabuk pengaman bekerja
dengan baik
View Mirrors (Sides & Rear) - Kaca Spion (Samping & Belakang) Operator
TT-002 The mirror in good condition and/or damage to - Kaca spion dalam kondisi bagus dan/atau pecah
obstruct views sehingga menghalangi pandangan
Signal Lights In Lampu2 Sign, Operator
TT-003
working order & good condition -Berfungsi dengan baik
Brake Lights In Lampu rem Operator
TT-004
working order & good condition -Berfungsi dengan baik
Head Lights In Lampu Depan Operator
TT-005
working order & good condition -Berfungsi dengan baik
Backup Alarm Alarm Mundur Operator
TT-006 Ensure that alarm working properly and sound Pastikan alarm tanda mundur bekerja dengan baik
good strong enough dan berbunyi cukup keras
Horn Klakson Operator
TT-007 The horn must sound in strong enough to hear -Klakson harus bersuara cukup keras agar
by others terdengar oleh orang lain
Windshield wiper & Windshield glass Kaca Depan & Penghapus Kaca - Operator
-Clean, no major cracks or damage to obstruct Kondisi bersih, tidak ada keretakan besar atau
TT-008 vision. - kerusakan lainnya sehingga mengganggu
Windshield wipers working penglihatan.
- Penghapus kaca depan berfungsi baik
Parking Brakes & services Brakes Rem Tangan & Rem Kaki Operator
TT-009 Ensure that safety devices are working order Pastikan peralatan ini berfungsi dengan
baik
Odometer (KM Reading), Engine Hour, - Odometer (KM Reading), Engine Hour Operator
TT-010 Safety devices must be in working order - Berfungsi dengan baik
Door Locks / Cabin Locks Door Door Operator / Driver Cabin Pintu Operator
TT-011 Operator Door handles on inside and outside in Operator dan gagang pintu didalam dan diluar
working order cabin dalam kondisi bagus
Expired Document & Crane certificate Document Kadaluarsa & Sertifikat Crane Operator
TT-012 Ensure that this document is in valid condition Pastikan dokumen masih berlaku
Seluruh alat pengendali diberi label sesuai dengan Operator
TT-013 All controls properly labeled as to their function
fungsinya
There is a warning horn that indicates the Terdapat klakson mundur yang menandai bahwa Operator
TT-014
vehicle is operating in reverse Kenderaan tersebut sedang bergerak mundur
B Limited use
Winch Cable Swamper
Winch Cable
Pastikan winch berfungsi dengan baik dan
TT-015 Ensure the winch is in working order and the
cable/sling terpasang sesuai dengan praktek
cable/sling is rigged as per rigging practices
prosedur rigging
Fire Extinguisher (if applicable) Racun Api (jika ada) Swamper
TT-016 Check condition. Secure position and tag to see Check condition. Pastikan posisi dan
it is regularly inspected tag untuk mengetahui tanggal inspeksi berkala
Amber Beacon Lampu Hazard Swamper
TT-017
Ensure that safety devices are working order Pastikan peralatan ini berfungsi dengan baik
Triangle Red Cones, Red Flags & First Aid Triangle Red Cones, Bendera Merah & kotak Swamper
Kit (if applicable) Ensure this P3K (jika ada) Pastikan
TT-018 equipment available and adequate for peralatan ini tersedia dan dalam jumlah yg cukup
emergency untuk kondisi emergency
Total 1 0 0 0
Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3LL OPERASI RIG
TOPIK : TANDEM TRUCK

CHECKING LIST K3LL RIG OPERATION

TOPIC : TANDEM TRUCK (TT)

ITEM SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN

Expired CPI Permit / SIO / Govt. License
TT-019
Ensure permit / documentation is valid
Cabin Condition (Engine smoke, water
TT-020 leaks, corrosion)
Check all equipment is in good condition
C Mechanical / Need Assistance
Oil Engine / Transmission / hydraulic Oil
TT-021 Check the condition from leakages or any other
defective
Water Radiator / Driver Belt / Brake Fluid
TT-022
Check the function in working order
Battery Level / Fuel / Gear Oil Check
TT-023 the condition & function
Steering / Clutch / Service Brake Check
TT-024 and ask to Operator those function
Tyre (Including spare) / Wheel nuts / Spring / Ban (termasuk Ban Serap) / Baut roda / Per
AC Check the tyres
TT-025 as per manufacturing in design
Expired CPI Permit / SIO / Govt. License. Operator
Pastikan semua dokumen masih berlaku
Kondisi Kabin (Asap mesin, kebocoran Operator
coolant, pengkaratan)
Pastikan peralatan berfungsi dengan baik
Operator
Oli Mesin / Transmisi / Oli hydraulik Periksa
apakah ada kebocoran atau kerusakan lainnya
Air Radiator / Belt Pemutar / Minyak Rem Check Operator
berfungsi dan dalam kondisi baik
Level Air Baterai / BBM / Minyak Pelumas gigi Operator
Check
kondisi dan fungsinya
Steering / Master Clutch / Service Brake. Check Operator
dan minta kepada Operator untuk men-testnya
Swamper
Check ban
sesuai dengan desain pabriknya

Body / Engine Hood Body / Engine Hood Swamper

TT-026 Check the body and cabin housekeeping and Check body, kebersihan cabin dan kondisi ruang
engine hood condition mesin bagus
Swamper
TT-027 There is a spark arrester on the exhaust system Terdapat spark arrester pada sistim pembuangan

Terdapat tutup pelindung yang benar disekeliling Operator

Proper guards are in place around all fans,
kipas angin, sabuk, transmission shaft dan bagian
TT-028 belts, transmission shafts, and temperature
yang terkena paparan panas (sistim
extreme exposure (exhaust systems)
pembuangan )

TT-029 Drive Right Operator

Drive Right
Total 2 0 0 0
0 0 0
Note/catatan:

Signature/tandatangan:

Operator/Swamper Toolpusher Wellwork Representative

Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3L OPERASI RIG
TOPIK : VACUUM TRUCK (VT)

RIG OPERATIONS HEALTH ENVIRONMENT & SAFETY CHECKLIST

TOPIC : VACUUM TRUCK (VT)

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Operator dan Swamper

ITEM SAFETY CONCERN SAFETY CONCERN YA TDK NA CATATAN

Vacuum Truck Vacuum Truck YES NO NA REMARKS
A Standard Safety Devices
Safety Belt / Seat – Driver / Operator - Sabuk Pengaman /kursi – Driver / Oprt Operator
Seats for all vehicles all passengers -
Seat belt lock mechanism working - Tempat duduk untuk semua
1 penumpang
- Sistim penguncian sabuk pengaman bekerja
dengan baik

View Mirrors (Sides & Rear) - The Kaca Spion (Samping & Belakang) Operator
2 mirror in good condition and/or damage to - Kaca spion dalam kondisi bagus dan/atau
obstruct views pecah sehingga menghalangi pandangan
Signal Lights In Lampu2 Sign, Operator
3
working order & good condition -Berfungsi dengan baik
Brake Lights In Lampu rem Operator
4
working order & good condition -Berfungsi dengan baik
Head Lights In Lampu Depan Operator
5
working order & good condition -Berfungsi dengan baik
Backup Alarm Alarm Mundur Operator
6 Ensure that alarm working properly and sound Pastikan alarm tanda mundur bekerja dengan
good strong enough baik dan berbunyi cukup keras
Horn The Klakson Operator
7 horn must sound in strong enough to hear by -Klakson harus bersuara cukup keras agar
others terdengar oleh orang lain
Windshield wiper & Windshield glass - Kaca Depan & Penghapus Kaca Operator
Clean, no major cracks or damage to obstruct -Kondisi bersih, tidak ada keretakan besar
8 vision. - atau kerusakan lainnya sehingga mengganggu
Windshield wipers working penglihatan.
- Penghapus kaca depan berfungsi baik
Parking Brakes & services Brakes Rem Tangan & Rem Kaki Operator
9 Ensure that safety devices are working order Pastikan peralatan ini berfungsi
dengan baik
Odometer (KM Reading), Engine Hour Odometer (KM Reading), Engine Hour Operator
10 - Safety devices must be in - Berfungsi dengan baik
working order
Door Locks / Cabin Locks Door Door Operator / Driver Cabin Pintu Operator
11 Operator Door handles on inside and outside in Operator dan gagang pintu didalam dan diluar
working order cabin dalam kondisi bagus
Expired Document & Crane certificate Document Kadaluarsa & Sertifikat Crane Operator
Ensure that this document is in valid condition Pastikan
12
dokumen masih berlaku

Seluruh alat pengendali diberi label sesuai Operator

13 All controls properly labeled as to their function
dengan fungsinya
Terdapat klakson mundur yang menandai Operator
There is a warning horn that indicates the vehicle
14 bahwa Kenderaan tersebut sedang bergerak
is operating in reverse
mundur
B Limited use
Racun Api (jika ada) Swamper
Fire Extinguisher (if applicable)
Check condition. Pastikan posisi
15 Check condition. Secure position and tag to see it
dan tag untuk mengetahui tanggal inspeksi
is regularly inspected
berkala
Total 1 0 0 0
Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak
 DAFTAR PERIKSA K3L OPERASI RIG
TOPIK : VACUUM TRUCK (VT)

RIG OPERATIONS HEALTH ENVIRONMENT & SAFETY CHECKLIST

TOPIC : VACUUM TRUCK (VT)
ITEM SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN

Amber Beacon Lampu Hazard Swamper

16 Ensure that safety devices are working order Pastikan peralatan ini berfungsi dengan baik

Triangle Red Cones, Red Flags & First Aid Kit Triangle Red Cones, Bendera Merah & Swamper
(if applicable) Ensure this kotak P3K (jika ada)
17 equipment available and adequate for emergency Pastikan peralatan ini tersedia dan dalam
jumlah yg cukup untuk kondisi emergency
Expired CPI Permit / SIO / Govt. License Expired CPI Permit / SIO / Govt. License. Operator
18 Ensure permit / documentation is valid Pastikan semua dokumen masih berlaku
Cabin Condition (Engine smoke, water leaks, Kondisi Kabin (Asap mesin, kebocoran Swamper
19 corrosion) Check all coolant, pengkaratan)
equipment is in good condition Pastikan peralatan berfungsi dengan baik
C Mechanical / Need Assistance
Operator
Oil Engine / Transmission / hydraulic Oil Oli Mesin / Transmisi / Oli hydraulik
20 Check the condition Periksa apakah ada kebocoran atau kerusakan
from leakages or any other defective lainnya

Water Radiator / Driver Belt / Brake Fluid Air Radiator / Belt Pemutar / Minyak Rem Operator
21 Check the function in working order Check berfungsi dan dalam kondisi baik
Battery Level / Fuel / Gear Oil Check Level Air Baterai / BBM / Minyak Pelumas Operator
22 the condition & function gigi
Check kondisi dan fungsinya
Steering / Clutch / Service Brake Check Steering / Master Clutch / Service Brake. Operator
23 and ask to Operator those function Check dan minta kepada Operator untuk men-
testnya
Tyre (Including spare) / Wheel nuts / Spring / Ban (termasuk Ban Serap) / Baut roda / Per Swamper
24 AC Check the tyres Check
as per manufacturing in design ban sesuai dengan desain pabriknya
Body / Engine Hood Body / Engine Hood Swamper
25 Check the body and cabin housekeeping and Check body, kebersihan cabin dan kondisi
engine hood condition ruang mesin bagus
Terdapat spark arrester pada sistim Swamper
26 There is a spark arrester on the exhaust system
pembuangan
Terdapat tutup pelindung yang benar Operator
Proper guards are in place around all fans, belts,
disekeliling kipas angin, sabuk, transmission
27 transmission shafts, and temperature extreme
shaft dan bagian yang terkena paparan panas
exposure (exhaust systems)
(sistim pembuangan )
28 Operator
Drive Right Drive Right
Total 2 0 0 0
0 0 0
Note/Catatan:

Signature/tanda tangan:

Operator Vacuum Toolpusher Wellwork Representative

Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

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 DAFTAR PERIKSA K3L OPERASI RIG
TOPIK : CARGO TRUCK

RIG OPERATIONS HEALTH ENVIRONMENT & SAFETY CHECKLIST

TOPIC : CARGO TRUCK

Tanggal (Date) : Business Partner 0

Nama Rig (Rig Name) : Lokasi Rig (Rig Location) 0
CPI Companyman : Status Operasi (Operation status) 0
Toolpusher : Single Accountability : Operator dan Swamper

ITEM SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN

Cargo Truck Cargo Truck
A Standard Safety Devices
Safety Belt / Seat – Driver / Operator - Sabuk Pengaman /kursi – Driver / Oprt Operator
1 Seats for all vehicles all passengers - Seat
belt lock mechanism working - Tempat duduk untuk semua
penumpang
View Mirrors (Sides & Rear) - The Kaca- Sistim penguncian
Spion (Sampingsabuk pengaman bekerja
& Belakang) Operator
2 mirror in good condition and/or damage to obstruct dengan baik
- Kaca spion dalam kondisi bagus dan/atau
views pecah sehingga menghalangi pandangan
Signal Lights In Lampu2 Sign, Operator
3
working order & good condition -Berfungsi dengan baik
Brake Lights In Lampu rem Operator
4
working order & good condition -Berfungsi dengan baik
Head Lights In Lampu Depan Operator
5
working order & good condition -Berfungsi dengan baik
Backup Alarm Alarm Mundur Operator
6 Ensure that alarm working properly and sound good Pastikan alarm tanda mundur bekerja dengan
strong enough baik dan berbunyi cukup keras
Horn The Klakson Operator
7 horn must sound in strong enough to hear by others -Klakson harus bersuara cukup keras agar
terdengar oleh orang lain
Windshield wiper & Windshield glass - Kaca Depan & Penghapus Kaca Operator
Clean, no major cracks or damage to obstruct -Kondisi bersih, tidak ada keretakan besar atau
8 vision. - kerusakan lainnya sehingga mengganggu
Windshield wipers working penglihatan.
- Penghapus kaca depan berfungsi baik
Parking Brakes & services Brakes Rem Tangan & Rem Kaki Operator
9 Ensure that safety devices are working order Pastikan peralatan ini berfungsi
dengan baik
Odometer (KM Reading), Engine Hour Odometer (KM Reading), Engine Hour Operator
10 - Safety devices must be in working - Berfungsi dengan baik
order
Door Locks / Cabin Locks Door Door Operator / Driver Cabin Pintu Operator
11 Operator Door handles on inside and outside in Operator dan gagang pintu didalam dan diluar
working order cabin dalam kondisi bagus
Expired Document & Crane certificate Document Kadaluarsa & Sertifikat Crane Operator
12 Ensure that this document is in valid condition Pastikan
dokumen masih berlaku
Seluruh alat pengendali diberi label sesuai Operator
13 All controls properly labeled as to their function
dengan fungsinya
Terdapat klakson mundur yang menandai Operator
There is a warning horn that indicates the vehicle is
14 bahwa Kenderaan tersebut sedang bergerak
operating in reverse
mundur
B Limited use
Racun Api (jika ada) Swamper
Fire Extinguisher (if applicable) Check
Check condition. Pastikan posisi
15 condition. Secure position and tag to see it is
dan tag untuk mengetahui tanggal inspeksi
regularly inspected
berkala
Amber Beacon Lampu Hazard Swamper
16 Ensure that safety devices are working order Pastikan peralatan ini berfungsi dengan baik
Triangle Red Cones, Red Flags & First Aid Kit (if Triangle Red Cones, Bendera Merah & kotak Swamper
applicable) Ensure this equipment P3K (jika ada) Pastikan
17 available and adequate for emergency peralatan ini tersedia dan dalam jumlah yg
cukup untuk kondisi emergency

Total 1 0 0 0
Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

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 RIG OPERATIONS HEALTH ENVIRONMENT & SAFETY CHECKLIST
PERIHAL : CARGO TRUCK
ITEM SAFETY CONCERN SAFETY CONCERN YES NO NA REMARKS/CATATAN
Expired CPI Permit / SIO / Govt. License Ensure Expired CPI Permit / SIO / Govt. License. Operator
18 permit / documentation is valid Pastikan semua dokumen masih berlaku

Swamper
Cabin Condition (Engine smoke, water leaks, Kondisi Kabin (Asap mesin, kebocoran
19 corrosion) Check all coolant, pengkaratan)
equipment is in good condition Pastikan peralatan berfungsi dengan baik

C Mechanical / Need Assistance

Operator
Oil Engine / Transmission / hydraulic Oil Oli Mesin / Transmisi / Oli hydraulik
20 Check the condition from Periksa apakah ada kebocoran atau kerusakan
leakages or any other defective lainnya
Water Radiator / Driver Belt / Brake Fluid Check Air Radiator / Belt Pemutar / Minyak Rem Operator
21 the function in working order Check berfungsi dan dalam kondisi baik

Battery Level / Fuel / Gear Oil Check the Level Air Baterai / BBM / Minyak Pelumas Operator
22 condition & function gigi
Check kondisi dan fungsinya
Steering / Clutch / Service Brake Check and Steering / Master Clutch / Service Brake. Operator
23 ask to Operator those function Check dan minta kepada Operator untuk men-
testnya
Tyre (Including spare) / Wheel nuts / Spring / AC Ban (termasuk Ban Serap) / Baut roda / Per Swamper
24 Check the tyres as per Check
manufacturing in design ban sesuai dengan desain pabriknya

Swamper
Body / Engine Hood Body / Engine Hood
25 Check the body and cabin housekeeping and Check body, kebersihan cabin dan kondisi
engine hood condition ruang mesin bagus

Terdapat spark arrester pada sistim Operator

26 There is a spark arrester on the exhaust system
pembuangan
Terdapat tutup pelindung yang benar Operator
Proper guards are in place around all fans, belts,
disekeliling kipas angin, sabuk, transmission
27 transmission shafts, and temperature extreme
shaft dan bagian yang terkena paparan panas
exposure (exhaust systems)
(sistim pembuangan )

28 Operator
Drive Right Drive Right
Total 2 0 0 0
0 0 0
Note/
catatan
:

Signature/tanda tangan :

Pelaksana Mechanic Toolpusher Wellwork Representative

Distribusi: Rig, R & C, North Wellwork Team Leader, BP Area Manager.

Document Uncontrolled When Printed.

Dokumen Tidak Terkendali Apabila dicetak