FORMULIR INSPEKSI MINGGUAN / WEEKLY INSPECTION CHECK LIST

PERANCAH / SCAFFOLDING
HSE DEPARTEMENT / HSE DEPARTMENT
Tanggal Inspeksi
Date of Inspection :
Lokasi :
Location
Nama Proyek : …………………………………..
Project
Condition / Kondisi
No Description / Deskripsi N/A TIDAK TERSEDIA Remarks / Catatan
GOOD / BAIK POOR / TIDAK BAIK
A PAGAR PENGAMAN / Hand Rail
1 Terpasang kuat / kencang
Strongly Installed
2 Tinggi = 90 cm - 120 cm
Height = 90 - 120 cm

B LANTAI PENGAMAN / SAFETY FLOOR

1 Jarak antara papan cukup rapat untuk mencegah benda jatuh
The distance between the boards is quite tight to prevent falling objects
2 Papan terkait dengan baik pada setiap pipa penahan papan
The board is well connected to each retaining pipe
3 Tidak ada yang retak / patah
Nothing cracked or broken
4 Tidak ada mata dan serat kayu serah dengan panjang papan
No eye and wood fiber in board direction length
5 Ujung papan tidak menonjol dari pipa penahan lebih dari 10 cm
The board end is not protruding from the retaining pipe more than 10 cm
6 Jarak antara pipa penahan papan max 1 m
The distance between the board retaining pipe is max 1 m
7 Papan pijakan dengan ketebalan minimal 1 "
Bangkirai board with minimal thickness 1"
8 Lantai papan ketika diinjak tidak melengkung
The board floor is not curved when stepped on
9 Lebar lantai minimal 40 cm ( dua papan )
The floor width is at least 40 cm (2 boards)
C PIPA / PIPE
1 Tidak penyok / gepeng
Not dented /flat
2 Tidak lubang / luka
Not perforated
3 Tidak bengkok
Not crooked
4 Dipasang tidak menghalangi orang lewat
Installed by not preventing passing goods
5 Tidak menonjol keluar lebih dari 10 cm
Not protruding more than 10 cm
D TIANG / POLE
1 Tiang pipa berdiri tegak
Pipe pole stands up straight
2 Jarak antara tiang max 2 m untuk orang / 1.2 m untuk barang
The distance between the pole is max 2m for people / 1.2 m for goods
3 Atap tiang cukup kuat / stabil
The pole roof is quite strong/stable
4 Dipasang bracing
Installed bracing
5 Scaffolding tidak goyang
Scaffolding does not shake
E TANGGA NAIK / STRAIRS
1 Tangga naik dipasang
Installed stairs
2 Kemiringan sudut max 60º
Slope angle is max 60˚
3 Tangga cukup kuat dan tidak goyang
Stairs are quite strong and does not shake
4 Ujung atas tangga tidak kurang dari 1 m diatas papan lantai
The stairs top is not less than 1 m above the floor board
F SERTIFIKAT / CERTIFICATE
1 Scaffolder Dan Inspector Sertifikat
Scaffolder and Inspector Certificate
2 Scaffolding Tag Sertifikat
Scaffolding Tag Certificate
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
Inspected by, Acknowledge, Close Out
 Scaffolding Inspector HDEC Contruction Team
No :
 FORMULIR INSPEKSI MINGGUAN / WEEKLY INSPECTION CHECK LIST

STASIUN CUCI MATA / EYE WASH STATION

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi Nomor Peralatan :

Date of Inspection : Equipment No. :
Lokasi :
Location :
Nama Proyek :
Project :
Kondisi / Condition
No Deskripsi / Description Baik / Good Tidak Baik / Poor Catatan / Remarks
Tidak Tersedia / N/A
1 Air
Water
2 Depot isi ulang air
Water Refill Tag
3 Pembersih tubuh
Body Cleanliness
4 enutup semprotan
Spray Cover
5 Posisi
Position

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out

HSE Inspector HSE Coordinator

No :
 FORMULIR INSPEKSI BULANAN/ MONTHLY INSPECTION CHECK LIST

BOR TANGAN / HAND DRILL MACHINE

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTEMENT

Tanggal Inspeksi : Nomor Peralatan :

Date of Inspection Equipment No.
Lokasi :
Location
Nama Proyek :
Project
Kondisi / Condition
No Deskripsi / Description Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A Catatan / Remarks
1 Papan nama / Mesin RPM
Name plate / RPM machine
2 Tombol On/Off
On / Off Switch
3 Penutup roda bor
Drill Wheel Cover
4 Kondisi mesin bor
Drill Bit condition of Machine
5 Tipe isolasi ganda / 3 kawat kabel
Double Insulation type / 3 cord wire
6 Kondisi kabel dan konektor
Cable & Connector Condition
7 Stiker/Tag
Sticker / Tag
8 Kunci drive bor
Drive key for Drill Bit
9 Pegangan
Hand Stand

TINDAK LANJUT / FOLLOW UP

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledged Close Out

Electrical HDEC Construction Team

No :
 FORMULIR INSPEKSI BULANAN/ MONTHLY INSPECTION CHECK LIST

MESIN GERINDA/ GRINDING MACHINE

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT
Tanggal Inspeksi
Date of Inspection : Nomor Peralatan :
Lokasi Equipment No.
Location :
Nama Proyek
Project :

Kondisi / Condition
No Deskripssi / Description Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A Catatan / Remarks
1 Papan nama / Mesin RPM
Name plate / RPM machine
2 Tombol On / Off
On / Off Switch
3 Penutup roda gerinda
Grinding Wheel Cover
4 Cakram/piringan gerinda cocok dengan RPM mesin
Grinding Disc Match to RPM of Machine
5 Tipe isolasi ganda / 3 kawat kabel
Double Insulation type / 3 cord wire
6 Kondisi kabel dan konektor
Cable & Connector Condition
7 Stiker/Tag
Sticker / Tag
8 Kunci drive cakram/piringan gerinda
Drive key for Grinding Disc

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledged Close Out

Electrical LEW HDEC Construction Team

No :
 INSPECTION CHECK LIST
POWER TOOLS
HYUNDAI E & C HSE DEPARTEMENT
Equipment type : Grinder Saw Cutter Blower Impactor Pump Etc

Date of Inspection : Equipment No. :

Location :
Project :
Condition
No Description Good Poor N/A Remarks
1 Cable Connector
2 Earth System
3 Installation Part
4 Disc Condition
5 Hand Switch
6 Safe Guard Moving Part
7 Others Safety Precautions

FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledged Close Out Approved by

No :
 FORMULIR INSPEKSI TRIWULANAN / QUARTERLY INSPECTION CHECK LIST

MESIN LAS / WELDING MACHINE

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi : Nomor Peralatan :

Date of Inspection Equipment No.
Lokasi :
Location
Kondisi / Condition
No Deskripsi / Description Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A Catatan / Remarks

A MESIN & AKSESORIS

A ENGINE & ACCESSORIES
1 Kondisi Mesin
Engine Condition
2 Baterai
Battery
3 Level
Level
4 Konektor kabel
Cable Connector
5 Penutup
Cover
6 Alat penahan percikan
Spark Arrestor / Isolation
7 Tombol darurat
Emergency Shut Down (ESD)
8 Pembuangan uap
Exhaust
9 Pembersih udara
Air Cleaner
10 Sistem start
System Start
11 Sabuk mesin V
V - Belt
12 Tingkat minyak / viskositas
Level Oil / Viscosity
13 Saringan bahan bakar / separator air (menguras)
Fuel Pre Filter / Water Separator ( Drain )
14 Baut / Mur tertutup
Bolt / Nuts Cap
15 Kontrol mesin
Engine Control
16 Tombol jalan/berhenti
Run / Stop Switch
17 Tombol mulai
Start Push Botton
18 Lampu Indikator bahan bakar
Fuel Level Gauge & Light
19 Lampu Indikator tekanan minyak
Oil Pressure Gauge & Light
20 Lampu indikator Generator arus bolak balik
Engine Alternator Ammeter & Light
21 Indikator waktu pemakaian
Hour Meter
B LISTRIK
B ELECTRIC
1 Kabel pentanahan
Grounding Cable
2 Cek volt / amp (240 Volt AC / 44 A)
Check Volt / Amp ( 240 Volt AC / 44 A)

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out
 Electrical LEW HDEC Construction Team
No :
 FORMULIR INSPEKSI TRIWULANAN/ QUARTERLY INSPECTION CHECK LIST

TRAFO LAS / WELDING MACHINE TRAVO

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi : Nomor Peralatan :

Date of Inspection Equipment No.
Lokasi :
Location
Kondisi / Condition
No Deskripsi / Description Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A Catatan / Remarks
A MESIN DAN AKSESORIS
A ENGINE & ACCESSORIES
1 Sistem pemasangan knalpot
Insulation System of Exhaust
2 Koneksi Kabel Listrik
Electrical Cable Connection
3 Isolasi Kabel Listrik
Electrical Cable Isolation
4 Stopkontak / Koneksi Catu Daya
Socket / Connection Power Supply
5 Indikator Ampere
Ampere Indicator
6 Tombol Indikator (ON/OFF)
Switch Indicator ( ON/OFF )
7 Saklar Pengaman Arus Sisa (SPAS)
ELCB / ViQi Installation
8 Indikator waktu pemakaian
Hour Meter
9 Koneksi Baterai
Battery Connection
10 Kabin mesin
Body ( Cabin )
11 Kondisi dan Sertifikat Lubang pengait
Lifting Pad Eye Condition & Certificate
12 Kondisi Umum
General Condition
13 Buku Catatan Pemeliharaan/pemeriksaan harian
Maintenance / Daily Check log Book
B KEAMANAN
B SAFETY
1 APAR
Fire Extinguisher
2 Kabel pentanahan
Grounding Cable
3 Tombol darurat
Emergency Shut Down ( ESD )

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
Inspected by, Acknowledged Close Out

Electrical HDEC Construction Team

No :
 FORMULIR INSPEKSI TRIWULANAN/ QUARTERLY INSPECTION CHECK LIST

LAMPU POTONG / CUTTING TORCH

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi : Nomor Peralatan :

Date of Inspection Equipment No.
Lokasi :
Location
Nama Proyek :
Project
Kondisi / Condition
No Deskripsi / Description Catatan / Remarks
Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A
A TABUNG GAS
GAS CYLINDERS
1 Kondisi tabung tegak berdiri dengan aman
The gas cylinder stands safely
2 Terlindung dari bunga api, panas & api
Protected from sparks, heat, and fire
3 Digunakan diruang terbuka, diberi pelindung / cover
Used in open space and covered
4 Di jauhkan dari kabel listrik
Kept away from power cord
5 Oxygen & LPG disimpan terpisah
Oxygen and LPG are separatedly stored
6 Tidak bocor ( di tes dengan air sabun )
Not leaking (tested with soapy water)
7 Disimpan terpisah dan ada label " KOSONG " / " PENUH "
Stored separatedly and labeled "EMPTY" or "FULL"
8 Tabung dilengkapi dengan tali pengikat (Chain, Rope)
Tubes are completed with a binder (rantai, tali)
B ALAT PENGUKUR
B REGULATOR
1 Berfungsi dengan baik
Works well
2 Tidak bocor ( di tes dengan air sabun )
Not leaking (tested with soapy water)

C SELANG DAN SAMBUNGANNYA

C HOSES & CONNECTION
1 Tidak bocor ( di tes dengan air sabun )
Not leaking (tested with soapy water)
2 Terhubung dengan aman dan terikat dengan jepitan
Connected and binded safely
3 Diberi label kedua ujung ( nama perusahaan )
Labeled on both ends (company name)
4 Tidak bersentuhan dengan benda / ujung yang tajam
No contacts with objects / sharp edges

D LAS PEMOTONG
D CUTTING TORCH
1 Berfungsi dengan baik
Works well
2 Tidak bocor ( di tes dengan air sabun )
Not leaking (tested with soapy water)
3 Terhubung dengan aman ke ujung pipa & selang
Connected to pipe and hose ends safely

E PERALATAN PENGAMAN
E SAFETY DEVICE
1 Alat pengaman arus balik pada pengatur dan alat potong
Savi Electrical backfeeding equipment on regulators and cutting tools
2 Pemadam api dekat dengan peralatan
The Fire extinguisher is near with the equipment

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out
 Fitter HDEC Construction Team
No :
 FORMULIR INSPEKSI BULANAN / MONTHLY INSPECTION CHECK LIST

ALAT ANGKAT / LIFTING GEAR

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi : Nomor Peralatan :

Date of Inspection Equipment no.
Lokasi :
Location
Nama Proyek : ……………………………..
Project
Kondisi / Condition
No Deskripsi / Description TIDAK TERSEDIA / Catatan / Remarks
BAIK / GOOD TIDAK BAIK / POOR N/A
A Katrol Rantai:
A Chain Block :
- Tanda SWL / SWL sign T

- Kode warna / Colour code

- Pengait / Hook

- Kait pengaman / Safety Latch

- Rantai / Chain

- Berfungsi / Operate

- Kondisi visual / Visual condition

B Kawat Sling / Wire Rope Sling :

- Tanda SWL / SWL sign T

- Kode warna / Colour code

- Mata sling lunak / Soft Eyes

- Penjepit pelat baja / Clamp/ Plate

- Kondisi Visual / Visual condition

C Segel pengait / Shackle

- Tanda SWL / SWL sign T

- Kode warna / Colour code

- Sekrup / Screw

- Pengait pengaman / Safety Pin

- Kondisi visual / Visual condition

D Alat pengangkat (lainnya)

- Tanda SWL / SWL sign T

- Kode warna / Colour code

- Lubang pengait / Pad Eyes

- Kondisi Visual / Visual condition

E Kanvas sling / webbing sling

- Tanda SWL / SWL sign T

- Kode warna / Colour code

- Mata sling lunak / Soft Eyes

- Kondisi ikatan / Stitch Conditions

- Kondisi visual / Visual condition

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
Inspected by, Acknowledge,
 Rigging Inspector HDEC Construction Team
No :
 FORMULIR INSPEKSI TRIWULANAN/ QUARTERLY INSPECTION CHECK LIST

KOMPRESOR / COMPRESSOR
HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location
Operator :
Operator
Nomor seri Peralatan / Equipment S / N :

Kondisi / Condition
No Deskripsi / Description Catatan / Remarks
Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A
A Umum / General
1 Tombol mulai / Start On/ Off
2 Kondisi peralatan / Equipment condition
3 Nomor seri peralatan / Equipment Serial Number
4 Kode warna / Colour Code
5 Tanda SWL / SWL Sign
6 Sistem Kontrol / Control System
7 Penjepit selang / Clamp Hose
8 Indikator Tekanan / Pressure Gauge
9 Indikator bahan bakar / Fuel Gauge
10 Indikator waktu pemakaian / Hour Meter
11 Indikator pendingin / Coolant Temp. gauge
12 Indikator RPM / RPM Indicator
13 Sensor Temperatur Udara Keluar / Discharger Air temp. sensor
14 Sensor Tekno / Techno Sensor
15 Level Tekanan Oli / Enginee Oil Pressure level
16 Tombol Pendingin / Coolant Temp. switch
17 Motor penggerak / Motor Stepper
18 Dioda / Diode
19 Kotak Sekring / Fuse Box
20 Pengatur waktu / QOS. Timer
21 Sensor / QOS. Sensor
22 Glow relay
23 Busi / Glow Plug
24 Kenop bahan bakar / Fuel Drop stop relay
25 Sistem kontrol mesin/ Engine speed slow down controler
26 Tombol stop / Stop relay
27 Dioda / Diode ( 1 ) - ( 2 )
28 Charger baterai / Battery Relay Charger
29 Pompa elektromagnetik / Electomagnetic Pump
30 Alternator (generator listrik) / Alternator
31 Standing unit fuel drop
32 Starter Genamo
33 Baterai & penutup / Battery & Cover
34 Kabel & isolasi listrik / Electric Cable & Isolation
35 Panel instrumen / Instrument Panel
36 Kabel pentanahan / Grounding Cable
B Sinyal indikator / Lighting Indicator/ Signal
1 Cahaya Merah / Red Light
2 Cahaya hijau / Green Light
C KNALPOT / EXHAUST
1 Penahan api / Flame Arrestor
2 Isolasi panas / Thermal Insulation
3 Pipa knalpot / Exhaust pipe
D KEAMANAN / SAFETY
1 APAR / Fire Extinguisher
2 Tombol Darurat / ESD System
E DOKUMEN / DOCUMENT
1 Sertifikat Peralatan / Equipment Certificate
2 Kartu Servis / Service card
3 Buku Catatan Penelitian / Log Book
4 Instruksi Operasi / Operating Instruction
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK

Inspected by, Acknowledge, Close

Mechanic / Electrician SM / CM Subcont / JO

No :
 QUARTERLY INSPECTION CHECK LIST
BLOWER TANGAN / ELECTRIC HAND BLOWER
HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location
Operator :
Operator
Nomor seri Peralatan / Equipment S / N :

Condition/
Kondisi Remarks/ Ket
No Deskripsi / Description
Ok No Na
A Umum / General
1 Tombol mulai / Start On/ Off
2 Kondisi peralatan / Equipment condition
3 Nomor seri peralatan / Equipment Serial Number
4 Kode warna / Colour Code
6 Sistem Kontrol / Control System
7 Penjepit selang / Clamp Hose
8 Indikator Tekanan / Pressure Gauge
9 Indikator Voltase / Voltage Indicator
10 Indikator waktu pemakaian / Hour Meter
12 Indikator RPM / RPM Indicator
13 Sensor Temperatur Udara Keluar / Discharger Air temp. sensor
17 Motor penggerak / Motor Stepper
19 Kotak Sekring / Fuse Box
20 Pengatur waktu / QOS. Timer
21 Sensor / QOS. Sensor
25 Sistem kontrol mesin/ Engine speed slow down controler
26 Tombol stop / Stop relay
28 Charger baterai / Battery Relay Charger
29 Pompa elektromagnetik / Electomagnetic Pump
33 Baterai & penutup / Battery & Cover
34 Kabel & isolasi listrik / Electric Cable & Isolation
B Sinyal indikator / Lighting Indicator/ Signal
1 Cahaya Merah / Red Light
2 Cahaya hijau / Green Light
D KEAMANAN / SAFETY
2 Tombol Darurat / ESD System
E DOKUMEN / DOCUMENT
1 Sertifikat Peralatan / Equipment Certificate
2 Kartu Servis / Service card
3 Buku Catatan Penelitian / Log Book
4 Instruksi Operasi / Operating Instruction
TINDAK LANJUT / FOLLOW UP
Remedial Action/ Tindakan Perbaikan Close Out OK

Inspected by, Acknowledge,

Mechanic / Electrician HDEC Construction Team
 FORMULIR INSPEKSI / INSPECTION CHECK LIST

ALAT BERAT / HEAVY EQUIPMENT

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi : PERALATAN / EQUIPMENT

Date of Inspection
Lokasi : Derek / Crane Excavator
Location Traktor / Dozer Alat pemindah / Forklift
Operator
Operator : Perata Jalan / Grader Truk muatan / Dump Truck
Nomor Seri
Serial Number : Alat pemuat / Loader Trailer / Trailer / Lowboy / Highboy
Backhoe Kendaraan ringan / Light Vehicle

Condition
No Description Remarks
Good Poor N/A
A Umum / General
1 Kondisi peralatan / Equipment condition
2 Nomor seri peralatan / Equipment Serial Number
3 Kode warna / Colour Code
4 Tanda SWL / SWL Sign
5 Truk Boom / Boom
6 oist utama & hoist tambahan / Main & Auxiliary Hoist
7 Kawat & Kait / Wire & Hook Kawat & kail /
8 Sistem kontrol / Control System
9 Stabilisator / Stabilisator
10 Indikator muatan / Load indicator
11 Anti-dua blok / Anti two Block
12 Indikator sudut / Boom angle gauge
13 Selang hidrolik / Hydraulic hose
14 Pengukur berat / Counter Weight
15 Bantalan penstabil / Outrigger Wear Pads
16 Stopper teleskopik / Telescopic Boom Stopper
17 Lengan pengayun / Swing Arm
18 Jarak aman ayunan / Clear Swing Area
19 Selang pengikat / Clamp Hose
20 Crane roda rantai / kondisi ban Crawler/ Tire Condition
21 Ember kontainer / Bucket
22 Garpu palet / Fork
23 Spion / Spion
24 Penyeka / Wiper
25 Klakson / Horn
26 Kerekan / Winches
B INTERIOR
1 Ruang kabin / Cabin Interior
2 Tempat duduk penumpang / Passanger Seat
3 Pendingin ruangan / AC
4 Panel Instrumen / Instrument Panel
C DOKUMEN / DOCUMENT
1 Kartu Servis / Service card
2 Sertifikat operator / Operator certificate
3 Buku catatan / Log Book
4 SIM / Driving licence
5 Sertifikat peralatan / Equipment Certificate
6 Instruksi pemakaian / Operating Instruction
D MESIN /MACHINE
1 Tombol mulai / on/off / Start On/ Off
2 Tombol Darurat / Emergency Shut Down ( ESD )
3 Instalasi kabel listrik / Power cable installation
4 Saluran bahan bakar / Fuel line
5 Busi / Injector
6 Kondisi mesin / Machine condition
7 Sabuk alternator / Alternator belt
8 Transmisi / Transmission
9 Sistem pendingin / Cooling System
10 Indikator bahan bakar / Fuel Level
11 Penyaring oli / Oil filter
12 Penyaring udara dan oli / Air & Oil filter
13 Baterai / Battery

No

Page 18 of 32
 INSPECTION CHECK LIST

HEAVY EQUIPMENT
HYUNDAI E & C HSE DEPARTEMENT

Condition
No Description Remarks
Good Poor N/A
E KNALPOT / EXHAUST

1 Penahan api / Flame Arrestor

2 Isolasi panas / Heat Insulation

3 Pipa knalpot / Exhaust pipe
F REM / BRAKE
1 System kerja rem / Brake Performance System
2 Rem tangan / hand brake
G CAHAYA / LIGHT
1 Lampu besar / Big Lamp
2 Lampu belakang / Back lamp
3 Lampu isyarat / Signal lamp
4 Lampu rem / Break light
5 Lampu Rotary/ Signal / Lamp / Signal lamp
H KEAMANAN / SAFETY
1 Pertolongan pertama / First Aid
2 Rompi penyelamat / Life jacket
3 APAR / Fire Extinguisher
4 Segitiga keamanan / Safety Triangle
5 Sabuk pengaman / Safety Belt

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out

Rigging Inspector HDEC Construction Team

No :

Page 19 of 32
 ALAT PELINDUNG DIRI /PERSONAL PROTECTIVE EQUIPMENT
Departemen HSE / HSE DEPARTMENT
Tanggal Inspeksi : Nama Pegawai :
Date of Inspection Employee
Lokasi : Jabatan :
Location Position
Departemen : …………………………….
Department
Kondisi / Condition
No Description Baik / Good Tidak Baik / Poor Catatan / Remarks
Tidak tersedia / N/A
Uniform
1
Pakaian Kerja
Safety Helmet
2
Helm Keselamatan
Goggles
3
Kaca mata
Face Shields
4
Pelindung Muka
Earplug
5
Penyumbat Telinga
Respirator
6
Alat Pernapasan
Masker
7
Masker
Breathing Aparatus
8
Tabung Pernapasan
Hand Gloves
9
Sarung Tangan
Apron/ Welding Jacket
10
Jacket Las
Safety Body Harness
11
Pengaman Keselamatan
Safety Shoes
12
Sepatu Keselamatan
Life Jacket
13
Pelampung Keselamatan
14 Work Vest
Pelampung Kerja

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out

HSE HJU HSE KINE

No :
 FORMULIR INSPEKSI BULANAN/ MONTHLY INSPECTION CHECK LIST

APAR / FIRE EXTINGUISHER

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi
Date of Inspection :
Lokasi
Location :
Nama Proyek
Project : ……………………………..

Kondisi / Condition
No Deskripsi / Description Baik / Good Tidak baik / Poor Tidak Tersedia / N/A Catatan / Remarks
Merk / Brand :
Jumlah / Quantity :
Nomor Seri / Serial Number :
Tanggal kadaluwarsa / Expire Date :

* Kondisi Tabung / Cylinder Condition

* Warna / Cat Tabung / Cylinder color/paint
* Selang Tabung / Cylinder hose
* Penghubung antara Selang dengan Tabung / Hose and Cylinder connector
* Segel Katup Cincin O / O-Ring valve seal
* Alat Pengungkit dan Pegas / Lever and Spring
* Pin pengaman / Safety Pin
* Indikator tekanan / Pressure Gauge
* Kawat Segel Utama / Main wire seal
* Gantungan / Hanger
* Troli dan Roda / Trolley and wheel
* Papan ceklis / Check List Tag

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out

HSE Inspector HSE Manager

No :
 FORMULIR INSPEKSI MINGGUAN / IWEEKLY NSPECTION CHECK LIST

OBAT-OBATAN STANDAR / STANDART MEDICINES

HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi
Date of Inspection :
Lokasi
Location :
Nama Proyek
Project :
Kondisi / Condition
No Deskripsi / Description BAIK / GOOD TIDAK BAIK / POOR TIDAK TERSEDIA / N/A Catatan / Remarks
1 Alkohol 70 % / Alcohol 70%
2 Rivanol / Rivanol
3 Obat tetes mata / Eye drops
4 Kapas / Cotton
5 Perban / Bandage
6 Hansaplast / Band Aid
7 Plester / Plaster
8 Kain kasa Steril / Steril gauge
9 Balsem / Balm
10 Minyak kayu putih
11 Betadine / Obat luka
12 Entrostop / Obat sakit perut
13 Promag / Obat sakit lambung
14 Obat sakit kepala / Eucalyptus oil
15 Obat batuk / Caugh medicine
16 Obat Malaria / Mexaquin
17 Obat flu / Cold medicine
18 Oralit / ORS
19 Gunting kecil / Small scissors
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out

HSE Inspector HSE Manager

No :
 FORMULIR INSPEKSI / INSPECTION CHECK LIST

PERLAKUAN PANAS SETELAH PENGELASAN / POST WELDING HEAT TREATMENT

HYUNDAI E & C Departemen HSE / HSE Department

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location

Kondisi / Condition
No Description YA / YES TIDAK / NO TIDAK TERSEDIA / N/A Catatan / Remarks
Apakah kondisi sumber daya listrik cukup untuk voltase
1
240/380/480 VAC 3PH, 50/60HZ?
Is the condition of the supplying electrical power enough
for voltage : 240 / 380 / 480 / VAC 3 PH, 50 / 60 HZ ?
2 Apakah dilengkapi dengan sirkuit alarm?
Is there completed by alarm circuit ?
3 Apakah peralatan mempunyai satuan tenaga 50KVA?
Is the equipment has unit powered on 50 KVA ?
4 Apakah kondisi auto programmer sudah dicek?
Has all ready check condition of auto programmer ?
5 Apakah kondisi perekam sudah dicek?
Has all ready check condition of the recorder ?
6 Apakah kondisi kabel termokopel sudah dicek?
Has all ready check condition of the thermo couple cable ?
7 Apakah kondisi kabel daya sudah dicek?
Has all ready check condition of all cable power ?
8 Apakah kondisi tripel kabel sudah dicek?
Has all ready check condition of all cable triple ?
9 Apakah kondisi elemen penahan sudah dicek?
Has all ready check condition of all element / resistent ?
10 Apakah kondisi mesin pendingin sudah dicek?
Has all ready check condition of the coolermaster ?
11 Apakah kondisi kabel ekstensi T/C sudah dicek?
Has all ready check condition of T / C Extention cable ?
12 Apakah kondisi splitter feed sudah dicek?
Has all ready check condition of splitter feed ?
13 Apakah kondisi splitter return sudah dicek?
Has all ready check condition of splitter return ?
14 Apakah kondisi elemen pemanas sudah dicek?
Has ready check condition of the heating element ?
15 Apakah kondisi kontrol suhu sudah dicek?
Has ready check condition of the temperature controllers ?

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out

PWHT Team HDEC Construction Team

No :
 FORMULIR INSPEKSI / INSPECTION CHECK LIST

PERLAKUAN PANAS PENGELASAN / BUTT FUSION MACHINE

HYUNDAI E & C Departemen HSE / HSE Department

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location

Kondisi / Condition
No Description YA / YES TIDAK / NO TIDAK TERSEDIA / N/A Catatan / Remarks
Apakah kondisi sumber daya listrik cukup untuk voltase
1
240/380/480 VAC 3PH, 50/60HZ?
Is the condition of the supplying electrical power enough
for voltage : 240 / 380 / 480 / VAC 3 PH, 50 / 60 HZ ?
2 Apakah dilengkapi dengan sirkuit alarm?
Is there completed by alarm circuit ?
3 Apakah peralatan mempunyai satuan tenaga 50KVA?
Is the equipment has unit powered on 50 KVA ?
4 Apakah kondisi plate pemanas sudah dicek?
Has all ready check condition of heating plate ?
5 Apakah kondisi hydraulic sudah dicek?
Has all ready check condition of the hydraulic ?
6 Apakah kondisi kabel termokopel sudah dicek?
Has all ready check condition of the thermo couple cable ?
7 Apakah kondisi kabel daya sudah dicek?
Has all ready check condition of all cable power ?
8 Apakah kondisi tripel kabel sudah dicek?
Has all ready check condition of all cable triple ?
9 Apakah kondisi elemen penahan single clamp sudah dicek?
Has all ready check condition of all element / resistent ?
10 Apakah kondisi frame sudah dicek?
Has all ready check condition of the frame ?
11 Apakah kondisi kabel ekstensi T/C sudah dicek?
Has all ready check condition of T / C Extention cable ?
12 Apakah kondisi tombol/tuas pengontrol sudah dicek?
Has all ready check condition of button/lever controller ?
13 Apakah kondisi ELCB pada generator sudah dicek?
Has all ready check condition of generator ELCB ?
14 Apakah kondisi hidrolik pengukur sudah dicek?
Has ready check condition of the hydraulic gauge ?
15 Apakah kondisi kontrol suhu sudah dicek?
Has ready check condition of the temperature controllers ?

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out

Mechanical/elecrtical Team HDEC Constrution Team

No :
 FORMULIR INSPEKSI / INSPECTION CHECK LIST

KAPAL KECIL / SMALL MARINE

HYUNDAI E & C Departemen HSE / HSE Department
Tanggal Inspeksi Kapal cepat Perahu
Date of Inspection : Speed Boat Long Boat
Lokasi Truk pengangkut Kapal Motor (KM)
Location : Sea Truck Motor boat

Kondisi / Condition
No Description Catatan / Remarks
Layak / Fair Tidak layak / Poor Tidak tersedia / N/A
A KONDISI UMUM EKSTERIOR
A GENERAL CONDITION BOAT EXTERIOR
1 Badan kapal / Body
2 Jendela / Penyeka / Window/ Wiper
3 Lampu sorot / Search Light
4 Lampu navigasi / Navigation Light
5 Klakson / Horn
6 Tali Tambat / Mooring Rope
7 Tonggak penambat kapal / Bollard
8 Peredam benturan / Fender
9 Jangkar / Anchor
10 Dek / Deck
11 Akses tangga / Stair Acces
B KONDISI UMUM INTERIOR
B GENERAL INTERIOR
1 Kabin penumpang / Passenger Cabin
2 Ruang makan / Mess Room
3 Lampu / Interior Light
4 Dapur / Kitchen
5 Kamar tidur / Bed Room
6 Kamar mandi / Bath Room
7 Tempat sampah / Waste Disposal
C RUANG NAVIGASI
C NAVIGATION ROOM
1 Kemudi / Steering
2 Radio VHF / VHF Radio
3 Sistem Navigasi Satelit / GPS
4 Buku catatan harian / Log Book
D DOKUMEN
D DOCUMENT
1 Sertifikat kapal / Boat Certificate
2 Izin berlayar / Marine Permit
3 SIM / Driver License
4 Peta / Map (Mahakam Delta Chart)
E MESIN
E ENGINE
1 Perawatan ruang mesin / House Keeping in Engine Room
2 Baterai / Battery
3 Sistem listrik / Electrical System
4 Pompa bahan bakar / Fuel Pump
5 Sistem pendingin / Cooling System
6 Indikator bahan bakar / Fuel Level
7 Indikator oli / Oil Level
8 Tombol darurat / ESD System
9 Selang / Hose
10 Knalpot / Exhaust
E KESELAMATAN
F SAFETY
1 Pelampung keselamatan / rompi kerja / Life Jacket/ Work Vest
2 Pertolongan Pertama / First Aid
3 Tanda Keselamatan / Safety Sign
4 APAR / Fire Extinguisher
5 sekoci darurat / Life Raft
6 Pelampung / Buoy
7 Titik berkumpul / Muster Point
8 Alarm / Alarm
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
Inspected by, Acknowledge, Close Out

HSE Inspector HSE Coordinator

No :
 FORMULIR INSPEKSI / INSPECTION CHECK LIST

KAPAL BESAR / BIG MARINE

HYUNDAI E & C HSE/ FORM/ C - 09-2
Tanggal Inspeksi
Date of Inspection : Kapal perairan dangkal Kapal tunda
Lokasi LCT Tug Boat
Location : Tongkang kran Kapal pemasok
Nama proyek Crane Barge Supply Boat
Project :

No Kondisi / Condition
Deskripsi / Description Catatan / Remarks
Layak / Fair Tidak layak / Poor Tidak tersedia / N/A
A UMUM / GENERAL
1 Lambung kapal / Hull Classification
2 Kondisi lambung kapal / Hull Condition
3 Kelayakan kapal / Seaworthiness
4 Lambung timbul / Draft/ Loadline Mark
5 Peredam benturan / Fender
6 Tonggak penambat kapal / Bollard
7 Dek & Jalur pejalan kaki / Deck & Walk Way
8 Pegangan tangga / Hand Rail
9 Tangga / anak tangga / Stairs & Steps
10 Tangga naik / Boat Ladders
11 Lubang intip & Jendela / Portholes & Windows
12 Jangkar / Anchor
13 Penyimpanan/ Gudang / Store/ Warehouse
14 Tangki (penutup & lubang angin) / Tank ( Man Hole & Vent )
15 Lampu navigasi / Navigation Light
16 Lampu dek / Deck Light
17 Lampu sorot / Spot Light
18 Sistem penambat / Mooring System
19 Kondisi umum kawat / Wires General Condition
20 Klakson / Horn
21 Bendera lontong / Wind Sock
22 Pintu ram / Ram Door

B INTERIOR UMUM / GENERAL INTERIOR

1 Kondisi kabin awak / Condition Cabin Crew
2 Ventilasi ruang awak / Ventilation of Cabin Crew
3 Ruang makan / Mess Room
4 Lampu / Interior Light
5 Dapur / Kitchen
6 Kompor LPG / LPG Stove
7 Kamar tidur / Bed Room
8 Kamar mandi / Bath Room
9 Kondisi penyimpanan / Store Condition
10 Tempat pembuangan / Waste Disposal
11 Sanitasi / Sanitary

C Derek / Peralatan angkat / Crane/ Lifting Gear

1 Tanda SWL / SWL Marked
2 Sistem kontrol / Control Market
3 Tes sertifikasi alat / Crane Test Certification
4 Operator pesawat angkat migas / Crane Operator Migas
5 Alarm / Alarms
6 Kondisi kawat / Wire Condition
7 Kait pengaman / Safety Hook
8 Kode warna peralatan angkat / Lifting Gear Colour Code

D RUANG NAVIGASI / NAVIGATION ROOM

1 Kemudi / Steering
2 Radio komunikasi / Radio Communication
3 Sistem Navigasi satelit / GPS
4 Pengukur kedalaman air / Echo Sounder
5 Teropong / Binoculars
6 Buku catatan harian / Log Book
 FORMULIR INSPEKSI / INSPECTION CHECK LIST
PROSES PEMBERSIHAN KARAT & PENGECATAN / SAND BLASTING & PAINTING
HYUNDAI E & C Departemen HSE / HSE Department

Tanggal Inspeksi
Date of Inspection :
Lokasi
Location :

Kondisi / Condition
No Deskripsi / Description Layak / Fair Tidak layak / Poor Tidak Tersedia / N/A Catatan / Remarks
1 Penampung pasir / Sand Pot
2 Penampung cat / Paint Pot
3 Pompa air / Water Pump
4 Regulator udara / Air Regulator
5 Separator udara / Air Separator
6 Mulut pipa / Sand Blasting Nozzle
7 Penyemprot cat / Painting Spray Gun
8 Sikat kawat rotary / Rotary Wire Brush
9 Sikat tangan / Hand Brush
10 Pneumatik pistol jarum / Pneumatic Needle Gun
11 Palu chipping / Chipping Hammer
12 Selang blasting / Blasting Hose
13 Selang suplai udara / Air Supply Hose
14 Koneksi selang / Hose Connection
15 Suplai air / Water Supply
16 Tombol darurat / Emergency Shut Down
17 Pengontrol suhu panas / Heat Temperatur Control
18 Pengontrol tekanan udara / Air Pressure Control
19 Kondisi kabel / Cable Condition
20 Knalpot penangkap percikan / Exhaust Spark Arrestor
21 Penyimpanan bahan / Storage Material
22 Alat Pelindung Diri / Personal Protective Equipment
* Helm dan pakaian / Sand Blasting Helmet & Clothes
* Masker pengecatan & debu
Painting Masker & Dust Masker
* Sarung tangan / Hand Gloves
* Penutup telinga / Ear Plug
* Sabuk keselamatan / Safety Belt
* Sepatu keselamatan / Safety Shoes
* Kacamata / Goggles
* Pertolongan pertama / Firs Aid Kit
* APAR / Fire Extingusher

TINDAK LANJUT / FOLLOW UP STATUS

Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK
-
-
-
-
-
-
-
-
-
Inspected by, Acknowledge, Close Out

Painting Blasting Team HDEC Construction Team

No :
 FORMULIR INSPEKSI TRIWULANAN/ QUARTERLY INSPECTION CHECK LIST
MESIN PEMADATAN / STEMPER MACHINE
HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location
Operator :
Operator
Nomor seri Peralatan :
Equipment S / N

Kondisi / Condition
No Deskripsi / Description Catatan / Remarks
Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A
A Umum / General
1 Tombol mulai / Start On/ Off
2 Kondisi peralatan / Equipment condition
3 Nomor seri peralatan / Equipment Serial Number
4 Kode warna / Colour Code
5 Kondisi plate tumbuk / base plate condition
6 Sistem Kontrol / Control System
7 Kondisi kaki hentak / spring condition
8 Kondisi tangki bahan bakar / fuel tank condition
9 Motor penggerak / Motor Stepper
10 Busi / Glow Plug
11 Sistem kontrol mesin/ Engine speed slow down controler
12 Tombol stop / Stop relay
13 Charger baterai / Battery Relay Charger
14 Pompa elektromagnetik / Electomagnetic Pump
15 Starter Genamo
16 Panel instrumen / Instrument Panel
B KNALPOT / EXHAUST
1 Penahan api / Flame Arrestor
2 Isolasi panas / Thermal Insulation
3 Pipa knalpot / Exhaust pipe
C KEAMANAN / SAFETY
1 APAR / Fire Extinguisher
2 Holding steer / pegangan pengarah
E DOKUMEN / DOCUMENT
1 Kartu Servis / Service card
2 Buku Catatan Penelitian / Log Book
3 Instruksi Operasi / Operating Instruction
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK

Inspected by, Acknowledge, Close Out

Electrical / Mechanical Team HDEC Construction Team

No :
 FORMULIR INSPEKSI TRIWULANAN/ QUARTERLY INSPECTION CHECK LIST
TALI KESELAMATAN / LIFELINES
HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location
Scaffolder Inspector :
Inspektur perancah
Nomor seri Peralatan :
Equipment S / N

Kondisi / Condition
No Deskripsi / Description Catatan / Remarks
Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A
A Umum / General
1 Label utuh dan terbaca / Label (intact and legible)
2 Tanda yang sesuai ANSI/OSHA/CSA / Appropriate ANSI/OSHA/CSA markings
3 Inspeksi terkini / Inspection are current and up-to-date
4 Tanggal pertama digunakan / Date of first use
5 Dampak indikator / Impact indicator (Signs of deployment)
B Perangkat (Gesper dan D-ring) / Hardware (buckles & D-Ring)
6 Konektor (pengunci dan pengaman) / Connector (Self-closing and locking)
7 Hook pembuka/tekanan/paku keling / Hook gate / Tensioner / Rivets
8 Korosi / Corrosion
9 Kondisi lubang torehan / Pitting or nicks condition
C Bahan kabel atau tali / Material (Cable or rope)
10 Rusak/hilang/jahitan / Broken / missing / loose stitching
11 Terminasi (jahitan, sambatan atau swage) / Termination (stitch, splice, or swage)
12 Keausan berlebihan / Excessive wear (Fraying or broken stand)
13 Terputus, terbakar/berlubang / Cuts / burn / holes
14 Melengkung / Kinks
15 Pemisahan atau / Separation or big caging
D Shock pack (if present)
16 Bahu/dada/tali belakang / Shoulder / chest / Leg / back straps
17 Rusak/ berjumbai/ jahitan rusak / Damage / fraying / broken stitching
18 Dampak indikator / Impact indicator (signs of deployment)
E Bahan tali pengaman / Lifeline Materials:
21 Kabel / Cable lifelines
22 Kernmatle lifelines
23 Polyester lifelines
24 Panjang Tali Pengaman / Length lifelines
25 Diameter tali pengaman / Diameter lifelines
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%)

Inspected by, Acknowledge, Close Out

ERT Team HDEC ERT Coordinator

 FORMULIR INSPEKSI TRIWULANAN/ QUARTERLY INSPECTION CHECK LIST
MESIN PEMOTONG BESI / CUTTING REBAR MACHINE
HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location
Operator :
Operator
Nomor seri Peralatan :
Equipment S / N

Kondisi / Condition
No Deskripsi / Description Catatan / Remarks
Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A
A Umum / General
1 Tombol mulai / Start On/ Off
2 Kondisi peralatan / Equipment condition
3 Nomor seri peralatan / Equipment Serial Number
4 Kode warna / Colour Code
5 Kondisi Pisau / Plate Cutter condition
6 Sistem Kontrol / Control System
7 Kondisi Tombol Kaki / Leg spring condition
8 Kondisi tangki bahan bakar / fuel tank condition
9 Motor penggerak / Motor Stepper
10 Sistem kontrol mesin/ Engine speed slow down controler
11 Tombol stop / Stop relay
12 Charger baterai / Battery Relay Charger
13 Starter Dynamo
14 Fan Belt / Fan Belt
15 Gear Box / Gear Box
16 Panel instrumen / Instrument Panel
B KEAMANAN / SAFETY
1 APAR / Fire Extinguisher
2 Holding steer / pegangan pengarah
C DOKUMEN / DOCUMENT
1 Kartu Servis / Service card
2 Buku Catatan Penelitian / Log Book
3 Instruksi Operasi / Operating Instruction
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog(%) OK

Inspected by, Acknowledge, Close Out

Electrical / Mechanical Team HDEC Construction Team

No :
 FORMULIR INSPEKSI TRIWULANAN/ QUARTERLY INSPECTION CHECK LIST
MESIN PEMBENGKOK BESI /BENDING REBAR MACHINE
HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location
Operator :
Operator
Nomor seri Peralatan :
Equipment S / N

Kondisi / Condition
No Deskripsi / Description Catatan / Remarks
Baik / Good Tidak Baik/Poor Tidak Tersedia / N/A
A Umum / General
1 Tombol mulai / Start On/ Off
2 Kondisi peralatan / Equipment condition
3 Nomor seri peralatan / Equipment Serial Number
4 Kode warna / Colour Code
5 Kondisi Pin / Steel Pin Condition
6 Sistem Kontrol / Control System
7 Kondisi kaki hentak / spring condition
8 Kondisi tangki bahan bakar / fuel tank condition
9 Motor penggerak / Motor Stepper
10 Sistem kontrol mesin/ Engine speed slow down controler
11 Tombol stop / Stop relay
12 Charger baterai / Battery Relay Charger
13 Starter Dynamo
14 Fan Belt / Fan Belt
15 Gear Box / Gear Box
16 Panel instrumen / Instrument Panel
B KEAMANAN / SAFETY
1 APAR / Fire Extinguisher
2 Holding steer / pegangan pengarah
C DOKUMEN / DOCUMENT
1 Kartu Servis / Service card
2 Buku Catatan Penelitian / Log Book
3 Instruksi Operasi / Operating Instruction
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK

Inspected by, Acknowledge, Close Out

Electrical / Mechanical Team HDEC Construction Team

No :
 FORMULIR INSPEKSI TRIWULANAN/ QUARTERLY INSPECTION CHECK LIST
MESIN PEMADATAN MINI VIBRATORY / MINI VIBRATORY ROLLER
HYUNDAI E & C DEPARTEMEN HSE / HSE DEPARTMENT

Tanggal Inspeksi :
Date of Inspection
Lokasi :
Location
Operator :
Operator
Nomor seri Peralatan :
Equipment S / N

Kondisi / Condition
No Deskripsi / Description Catatan / Remarks
Baik / Good Tidak Baik / Poor Tidak Tersedia / N/A
A Umum / General
1 Tombol mulai / Start On/ Off
2 Kondisi peralatan / Equipment condition
3 Nomor seri peralatan / Equipment Serial Number
4 Kode warna / Colour Code
Kondisi Handle Pengarah Tinggi/ Lever For Adjusting
5
Handle Height Condition
6 Sistem Kontrol / Control System
7 Kondisi Tuas Operasi / Condition Lever Operation
8 Kondisi Tuas Vibrator / Condition Lever Vibrator
9 Kondisi tangki bahan bakar / fuel tank condition
10 Motor penggerak / Motor Stepper
11 Busi / Glow Plug
12 Sistem kontrol mesin/ Engine speed slow down controler
13 Tombol stop / Stop relay
14 Charger baterai / Battery Relay Charger
15 Pompa elektromagnetik / Electomagnetic Pump
16 Starter Dynamo
Air Pembuangan & Air pengisian / Water Tank Filling &
17
Drainase
17 Panel instrumen / Instrument Panel
B KNALPOT / EXHAUST
1 Penahan api / Flame Arrestor
2 Isolasi panas / Thermal Insulation
3 Pipa knalpot / Exhaust pipe
C KEAMANAN / SAFETY
Baut Proteksi Samping Dan Atas / Bolt Side & Upper Protection
1
Cover
2 Baut Pengikis / Bolt Scraper Adjusment
E DOKUMEN / DOCUMENT
1 Kartu Servis / Service card
2 Buku Catatan Penelitian / Log Book
3 Instruksi Operasi / Operating Instruction
TINDAK LANJUT / FOLLOW UP STATUS
Remedial Action/ Tindakan Perbaikan Target (date) Close Out In prog.(%) OK

Inspected by, Acknowledge, Close Out

Electrical / Mechanical Team HDEC Construction Team

No :