PROCEDURE CONTRACTOR SAFETY MANAGEMENT SYSTEM.DOC

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SUBCONTRACTOR'S SAFETY, HEALTH AND ENVIRONMENT (HSE) PRE-QUALIFICATION / ASESSMENT QUESTIONNAIRE

Project :

Subcontractor's Name :

Section I HSE Policy and Leadership

1. Does your company have an HSE policy document?

Apakah perusahaan anda mempunyai Kebijakan Keselamatan Kerja, Kesehatan dan Lingkungan?

Yes No

If yes, please attach / Jika Ya, silahkan untuk dilampirkan.

2. Who has overall and final responsibility for HSE in your organisation?

Siapa yang bertanggung jawab terhadap Keselamatan Kerja, Kesehatan dan Lingkungan diperusahaan anda?

3. Who is the most senior person in the organisation responsible for this policy being carried out at the premises and on site where his employees are working?

Siapa senior staff di perusahaan anda yang bertanggung jawab dalam implementasi kebijakan ini di project tempat anda bekerja?

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ection II G eneral O rganisation - M anagement S tructure / Organisation

4. Who has ultimate responsibility for HSE management in your organisation? Siapa yang bertanggung jawab terhadap management K3 di perusahaan anda?

Name: Job Title:

5. Please attach a current organisation chart showing reporting relationships from your Chief Executive Officer to lowest line manager / Silahkan lampirkan struktur organisasi perusahaan anda mulai dari Direktur Utama sampai ke Manager

Organization chart attached?

Yes No

6. Does a full time HSE Department exist in your organisation? Apakah Departement K3 tersedia di perusahaan anda?

Yes No

7. If answer to 6 above is yes, do you have job descriptions for the person(s) employed in your HSE Department?

Jika jawaban no 6 Ya, Apakah perusahaan anda mempunyai job description terhadap karyawan di Departement K3.

Yes No

If yes, Please give detail the position and responsibilities

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8. If the answer to item 7 above is no, who is responsible for providing safety advice and monitoring the implementation of HSE Management System at your work sites and what is their qualification? Jika jawaban no.7 Tidak ada, siapa yang bertanggung jawab dalam memberikan arahan K3 dan melakukan monitoring terhadap implementasi K3 management system ditempat perusahaan anda bekerja dan apa kualifikasi orang tersebut?

Person Responsible :

___________________________________________________________________ Qualification :

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ection III Organising for HSE - HSE P lanning

9. Do you produce an HSE Plan for each Project?

Apakah anda menyiapkan rencana pelaksanaa K3 dan Lindungan Lingkungan di project ini?

10. If answer to Question 9 above was no, briefly describe how you ensure that the required HSE Systems

are communicated and implemented on time.

Jika jawaban anda Tidak, Jelaskan bagaimana anda memastikan K3 dan Lindungan Lingkungan yang disyaratkan dapat terkomunikasi dan dilaksanakan dengan baik.

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ection IV Organising for HSE - HSE T raining

11. Do you have a HSE Training Matrix for your employees?

Apakah perusahaan anda mempunyai rencana training K3 dan Lindungan Lingkungan untuk karyawan anda?

Yes No

12. If the answer to Question 11 above was no, briefly describe how you identify and implement HSE Training for your staff.

Jika jawaban no 11 Tidak ada, Jelaskan bagaimana anda mengidentifikasi dan mengimplementasi kebutuhan trainining K3 dan Lindungan Lingkungan untuk karyawan anda.

13. Do you have a formal training program(s) for Supervisors their responsibilities in HSE Management as Supervisors?

Apakah perusahaan anda mempunyai program training untuk safety suprvisor ?

Yes No

14. If the answer to item 13 above is yes, briefly describe this program and who conducts this training. Jika jawaban no 13 Ya, Jelaskan bagaimana program ini berjalan dan siapa yang melakukan training tersebut.

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15. Do you have a formal HSE Orientation Programme for new employees?

Apakah perusahaan anda mempunyai Program Safety Orientation untuk karyawan baru?

Yes No

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ection V Organising for HSE - HSE Procedure

16. Does your Company have written HSE procedures?

Apakah perusahaan anda mempunyai procedure K3 dan Lindungan Lingkungan?

Yes No

17. If answer to Question 16 was yes, please attach HSE Procedure that you have.

Jika jawaban no.16 Ya, Silahkan lampirkan procedure K3 dan Lindungan Lingkungan yang perusahaan anda punyai.

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ection VI Managing HSE - Accident Performance Measurement

18. Do you measure environmental performance?

Apakah perusahaan anda mengukur performance lingkungan?

Yes No

If yes, state what and how

Jika Ya, Jelaskan apa yang di ukur dan Bagaimana What?

How?

19. Do you keep Accident/Incident Statistics for your Employees?

Apakah perusahaan anda menyimpan statistic kecelakaan terhadap karyawan anda?

Yes No

20. If the answer to item 19 above is yes, briefly describe the Accident/Incident Statistics you keep and the analysis you perform on these.

Jika jawaban no 19 Ya, jelaskan jenis kecelakaan yang anda muat di statistic tersebut.

21. Do you keep Accident/Incident Statistics on your Subcontractors?

Apakah perusahaan anda mempunyai statistic kecelakaan terhadap subcontractor anda?

Yes No

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ection VII Managing HSE - Monitoring and Improvement

22. Do your Senior Management use an HSE Audit and Inspection process at the work site?

Apakah senior management anda melakukan audit K3 dan Lingkungan dan melakukan inspeksi terhadap tempat anda melaksanakan pekerjaan?

Yes No

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23 Please provide the following information:

(A) Please provide your statistical HSE Performance for 3 last years:

Lampirkan statistic kecelakaan K3 dan Lingkungan untuk 3 tahun terakhir

Section IX Personnel Protective Equipment

24. Do you provide appropriate personal protective equipment (PPE) for your employees? Please provide a listing of the PPE for the scope of this work?

Apakah perusahaan anda menyiapkan alat pelindung diri untuk karyawan perusahaan anda? Silahkan list alat pelindung diri yang akan anda siapkan untuk pekerjaan ini?

25. Do you have a program to ensure that PPE is impacted and maintained?

Apakah perusahaan anda mempunyai program pemeliharaan alat pelindung diri?

Section X Hazards and Effect Environmental Management

26. Please provide the number of accident resulting in environmental damage in the amount greater than $ 50,000 for the last 24 months. Attach copies of any governmental reports submitted

Lampirkan kecelakaan lingkungan yang perusahaan anda terima dengan jumlah kerugian lebih dari Rp. 500.000.000 untuk dua tahun terkahir.

27. Who is the person in charge for coordinating environment matter and what is he/she experience? Siapa yang bertanggung jawab dalam menghandle untuk melakukan perlindungan lingkungan diperusahaan anda dan apa pengalaman orang tersebut?

Section XI Drugs and Alcohol

28. Do you have a drugs and alcohol policy in your organisation? If yes please attach.

If No, how do you ensure that your employees do not use drugs and alcohol during project. Apakah perusahaan anda mempunyai kebijakan pelarangan menggunakan obat dan minuman terlarang? Jika Ya silahkan lampirkan.

Jika Tidak, bagaimana perusahaan anda memastikan karyawan anda tidak menggunakan obat dan minuman terlarang selama project berjalan.

Section XII Safety Achievement or Awards

29. Please provide any significant achievements or awards? Lampirkan penghargaan safety yang pernah didapat.jika ada.

I understand, follow all the requirement and all the answer above is correctly and honest,

Saya mengerti, mengikuti semua persyaratan dan menjawab semua pertanyaan diatas dengan jujur dan benar. Signs,

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ATTACHMENT 3

SUBCONTRACTOR HSE BID EVALUTION

No Evaluation Item Evaluation Result Remarks

3 5 7

1 HSE Policy & Leadership

1.1 HSE Policy

1.2 Final Responsibility

1.3 Senior Person in Organization Sub Total

Total

2 Management Structure / Organization

2.1 Responsible for HSE Management 2.2 Organization Chart

2.3 HSE Department

2.4 Job Description in HSE Department 2.5 Responsible for safety advice & monitoring Sub Total

Total

3 HSE Planning

3.1 Produce HSE Plan 3.2 Implement plan for HSE Sub Total

Total

4 HSE Training

4.1 HSE Matrix Training

4.2 Identify and implement HSE Training 4.3 Training Program for Supervisor 4.4 Program & Conduct HSE Training 4.5 HSE Orientation

6.2 Keep of Accident Statistic of Employee 6.3 Describe of the Accident Statistic 6.2 Keep of Accident Statistic of Sub-cont Sub Total

Total

7 Monitoring and Improvement

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Sub Total Total

8 HSE Statistic Information

8.1 HSE Statistic Performance for 3 last year Sub Total

Total

9 Personal Protective Equipment

9.1 List of PPE

9.2 Maintenance PPE Program Sub Total

Total

10 Environmental Management

10.1 Accident of Environmental

10.2 Person in coordinating environmental Sub Total

Total

11 Drugs and Alcohol Program

11.1 Drug and Alcohol Policy Sub Total

Total

12 Safety Achievement or Awards

12.2 Award Achievement Sub Total

Total Total Score

Recommendation:

Note : Score achievement: > 50: High Risk, 35 – 50: Low Risk

Criteria Score:

3 = Can not answer the question and can not give attachment

5 = Can be answer the question but can not give attachment

7 = Can be complete the question

Prepared By : Name : Tittle of Job : Sign : Date :

NOTE: > 50: High Risk Category (Piping Work, Mechanical Work, Steel Structure Work, Electrical and Instrument, Insulation, Piling, Chemical Cleaning, NDT, X-Ray, Roofing & Siding, High Risk Building (more than 2 Floor), Excavation, Blasting & Painting).

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ATTACHMENT 4

HSE REQUIREMENT FOR SUBCONTRACTOR

I. COMMITMENT AND POLICY

Sub-contractor strongly request to write HSE Policy which is sign by Sub-contractor Directors. This HSE Policy must be socializing to all employees who will assign in this project.

This Policy should be in English or Indonesia.

II. LEGAL REQUIREMENTS AND REGULATIONS

Subcontractor shall comply with all applicable safety laws (international, national, regional, or local), regulations (including work permit system), and additional safe operating standards. Subcontractor shall take all necessary precautions to protect the work from un-safe work and un-safe condition, and protect all personnel, the environment, and property of Owner, Rekayasa, Subcontractor, and all third parties from accident.

III. SUBCONTRACTOR HSE PLAN

Sub-contractor shall issue its HSE Plan as a part of the bid proposal.

HSE Plan document shall be established by Sub-Contractor, defining all the HSE requirements applicable, how they are implemented and monitored for compliance.

After approval by HSE Manager PT. Rekayasa Industri, the agreed version of its HSE Plan must be propose before the kick-off meeting. Before HSE Plan approved by HSE Manager PT. Rekayasa Industri, sub-contractor does not allow to start work.

The agreed HSE Plan must be communicated to any involved personnel before the works start effectively on site.

The content of HSE Plan as minimum is:

- Purpose

- Scope of Work

- Responsibility each personal in team project related to HSE - Planning of HSE personal / coordinator resources

- Health Plan

- Personal Protective Equipment and Fire Extinguisher Plan - Emergency Response Plan

- Security Plan

- Construction / Commissioning Activities Plan.

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No Construction Activities Applicable

Office ProcedureNumber /

None

Sub-Contractor shall assign one HSE Coordinator, with 1 year for Low Risk and 3 years experience for High Risk in HSE related to this activity.

PT. Rekayasa will conduct interview for sub-contractor HSE Coordinator that will assigned to the project site on technical clarification or kick off meeting before sub-contractor mobilize the staff.

Sub-contractor HSE Coordinator will be become correspondent for managing the day to day HSE matters relating to Sub-Contractor activities. He will keep close contact with the PT. Rekayasa Industri site Health, Safety and Environment personnel.

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V. TERMINATION AND SUSPENSION

Any unsafe condition and unsafe work, which done by subcontractor and identified by Rekayasa through either jointly or separately by Owner and/or Rekayasa. Rekayasa has the right to stop all or any part of the work, until corrective action taken by sub-contractor.

VI. PUBLIC RELATION

Subcontractor shall promptly take such steps as necessary to maintain good relations with the public and local authorities with whom they will come into contact with during the course of the work. Subcontractor shall also require all employees to conduct themselves in a safe and courteous manner. Whenever necessary, Rekayasa may assist Subcontractor in the maintenance of good public relations.

VII. SAFETY REGULATION

VII.1 Responsibility for HSE

Rekayasa will require subcontractor to affirm that all managers, HSE representatives, and employees are responsible for ensuring that the work is performed in accordance with all applicable safety rules, regulations, and good working practices.

VII.2 Accident / Incident Reporting

Subcontractor shall follow an accident reporting system of PT. Rekayasa Industri standards. Any hazardous accident, near miss involving Owner, Rekayasa, Sub-contractor employees, any third party’s personnel, plant, and equipment shall be immediately reported to PT. Rekayasa Industri within 24 hours.

VII.3 HSE Meetings

Subcontractor is responsible for maintaining and enhancing the HSE awareness of its personnel. In principle, management subcontractor’s members should attend a HSE meeting that arrange by PT. Rekayasa Industri.

Subcontractor shall ensure that no employee of its subcontractor shall carry out work, until they have received basic HSE information (Safety Induction or Safety Orientation), which conduct by HSE PT. Rekayasa Industri.

VII.4 Scaffolding

Rekayasa will not allow using frame scaffolding for working in equipment. Scaffolding that we give permit is steel pipe tube scaffolding for working.

The standard that must be following is: AS 1576.3 with:

Minimum Yield Strength/Minimum Tegang Luluh: 200 MPa; Outside Diameter/Diameter Luar: 48.3 mm; Minimum Wall Thickness/Minimum Tebal (t): 4.0 mm; Max alignment: 0.0017 x 1 pipe.

Subcontractor must be providing scaffolder that having a licensed from Depnaker or any institution body to build the scaffolding at site.

VII.5 Work Permit System

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Supervisor must be responsible to make and process the work permit.

VII.6 Equipment / Material

Sub-contractor shall ensure that all its equipment and materials on PT. Rekayasa Industri site, must meet the HSE standard required by PT. Rekayasa Industri and Owner and listed in the Sub-contractor HSE Plan. Sub-contractor shall ensure that any equipment and materials under these standards called “sub-standard” are removed from the project site.

VII.7 Inspection

PT. Rekayasa Industri will conduct inspection regular at site and before mobilize to site for all machinery equipment, tools, cranes, trucks and cars before mobilize to site.

VII.8 Reporting System

Sub-contractor shall report daily to HSE PT. Rekayasa Industri the data resulting from its health, safety and environmental monitoring according to PT. Rekayasa Industri form.

VIII. ENVIRONMENT

VIII.1 General

Subcontractor shall pay due regard to the environment by acting to preserve air, water, animal and plant life from adverse effects of Subcontractor activities, and minimize any nuisance, which may arise from such operations.

Subcontractor shall adhere to existing national statutory regulations concerning environmental damage resulting from the performance of the Work and in particular any specific environmental requirements, which may apply to the project site and its surroundings.

Sub-contractor requires proper planning and safe work to ensure their no environmental damage during construction and commissioning.

VIII.2 Housekeeping and Site Restoration

Subcontractor shall be responsible for maintaining good housekeeping continuously throughout the duration of the work with due regard being paid to tidiness, ensuring that access ways and emergency exits are kept clear at all times and without exception.

Sub-contractor shall remove any equipment, material, and waste from the work-site before leave the project site.

Sub-contractor does not allow destroying the scrap and rubbish material at project site and surrounding by burning.

VIII.3 Safe Handling of Hazardous Material

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a. Chemical identification and data

b. Fire and explosion (Flash point temperature, flammable limit range, auto ignition temperature) c. Health aspects (nature of hazards TLV-STEL, TLV-TWA)

d. Emergency Procedure (Fire Fighting, agent, spillage, personnel exposure, first-aid) e. Environmental (emissions to atmosphere, spillage, neutralizer procedure, waste disposal) f. Transportation procedure

g. Personnel protective equipment to be worn h. Storage requirements

Subcontractor shall have in place a suitable means of communicating the safety requirements for handling all substances that have the potential to be health hazard and will ensure that appropriate handling equipment, and Personal Protective Equipment, as advised by the MSDS, is available and used each time such substances are handled.

Subcontractor shall ensure that all substance is stored in compliance with its MSDS.

VIII.4 Local Customs, Cultural and Religious Considerations

Subcontractor shall ensure that all local customs, cultural and religious requirements are respected and those suitable facilities are available for the observance of these by Local employees.

IX. PERSONAL PROTECTIVE EQUIPMENT

The minimum Personal Protective Equipment that must be providing for all employees at site are: - Safety Shoes: Follow ANSI Standard No. Z89.1 1997 or equivalent and for civil work must be

wearing safety rubber boot.

- Safety Helmet: Follow European Harmonize Standard BSEN 345: 1993 or equivalent: MSA Indonesia.

- Safety Belt for working bellow 1.5 - 6 meter and full body harness for working up to 6 meter: ANSI standard.

- All employees must be wearing cotton hand glove.

Any other PPE that require during project is sub-contractor cost responsibilities.

X. JOB SAFETY ANALYSIS & RISK ASSESSMENT

Sub-contractor shall produce a Job Safety Analysis and Risk Assessment for all activity.

For its evaluation of the JSA and Risk Assessment associated with performing the works, Subcontractor shall review with the PT. Rekayasa Industri before start the job.

Supervisor must be responsible to make the Job Safety Analysis and Risk Assessment.

XI. ALCOHOLIC, DRUG, CARRY WEAPON, AND NO SMOKING POLICY

Sub-contractor shall ensure that the prohibition of the alcoholic consumption and / or the use of drugs, carry weapon and smoking within the PT. Rekayasa Industri premises are strictly followed:

- on the work sites, during the working and non-working hours - when traveling from / to home – work site

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XII. AUDITS & INSPECTION BY PT. REKAYASA INDUSTRI

PT. Rekayasa Industri will be carrying out HSE inspection and audits at any time to ensure that the HSE requirements are being complied with 11 elements HSE Management System PT. Rekayasa Industri.

XIII. CORRECTIVE ACTION

Sub-contractor shall be following up any recommendation during inspection and audit into a corrective action.

XIV. KEY PERFORMANCE INDICATOR

PT. Rekayasa Industri will conduct monthly evaluation to the sub-contractor performance and it will affect to the sub-contractor monthly progress report.

Please see flow chart bellow for the process. Tool: HSE-FF-Z.1 (ATTACHMENT 7)

XV. HEALTH REQUIREMENT

Based on UU No.1 1970, OHSAS 18001:1999 requirement and Manpower Minister (Menteri Tenaga Kerja) Republik Indonesia Regulation No.Per.02/MEN/1980, sub-contractor shall conduct basic medical check-up for their key personal (start from supervisor) who will assign to project and it shall be repeated once a year.

The lists of laboratory checks for basic medical check-up are:

Star

t

Subcontractor HSE Performance

Indicator

Chief HSE

Receive Document Progress Report

Chief Construction Control

Submit monthly progress report

Subcontractor

Evaluate HSE Performance IndicatorForm

HSE Department Site

Send back to CCC to progress report

Submit to CCC to be follow-up by subcontractor

Proceed

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Hematology: LED, Hb, Ht, Leukosit (White Body Cell), Trombosit, Diff, VER, HER, KHER; Function of Liver: SGOT, SGPR;

Function of Kidney: Ureum, Kreatinim; Karbohidrat: Gula Darah Sewaktu (Blood Glucose without fasting); Urine Complete: Bj(Species Gravity), pH, Albumin, Glukosa, Bilirubin, Urobilinagen, Keton, Nitrit, Darah Samar(Blood Transparent), Sedimen and drug and alcohol test.

The result of the medical check-up must be consulted to doctor occupational medicine to know whether they fit to the job assignment or not.

XVI. LIFTING OPERATION

Lifts utilizing cranes, hoists, or other mechanical lifting devices will not commence unless:

- An assessment of the lift has been completed and the lift method and equipment has been determined by competent persons.

- Operators of powered, lifting devices are trained and certified for that equipment. - Rigging of the load is carried out by a competent person(s).

- Lifting devices and equipment has been certified for use within the last 12 months (at a minimum).

- Load does not exceed dynamic and/or static capacities of the lifting equipment. - Any safety devices installed on lifting equipment are operational.

- All lifting devices and equipment have been visually examined before each lift by a competent person(s).

XVII. MECHANICAL EQUIPMENT OPERATION

Sub-contractor shall ensure that only trained competent (certificated) person operates all mechanical equipment.

The equipment will include but may not be limited to the following: - Crane

- Fork lift

- Self Loading Truck - Trailer and Prime Movers - Compressor

- Temporary Electrical Distribution Boards - Scaffolding Equipment

- Rigging Equipment - Aerial Work Platform

XVIII. TOOLS AND EQUIPMENT

Sub-contractor shall ensure that a Sub-contractor’s machinery, tools and equipment, facilities, and other items associated with the works whether purchased or rented are maintained in a safe condition and to be operated by competent operators. Tools shall only be used for the job they were designated to perform with considering the presence of hydrocarbons at worksite.

All guards must be fitted and shall be in good condition at all times.

All grinding discs must be checked for correct size and speed prior to fitting.

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Sub-contractor shall repair or replace defective tools and equipment at Sub-contractor cost. Appropriate personal protective equipment must be worn at all times when using any tool or equipment.

XIX. COMPRESSED GAS CYLINDER

Sub-contractor shall ensure that:

- Compressed gas cylinders are stored, transported or used shall be in an upright position and secured to some substantial object or structure by a chain or other suitable means capable of supporting the weight of cylinder. This applies to all cylinders, whether empty or full.

- Cylinder valves shall be closed and hoses depressurized when cylinder are not in use.

- Cylinders shall have protective valve caps in place while they are being transported / stored.

- Cylinders shall be returned promptly to a suitable storage area after use. They shall not be left at any site. Cylinder storage areas should be kept away from general traffic paths and must not be adjacent to vehicle paths.

- Flammable gases and oxygen cylinders must not be stored in close proximity unless separated by a non-combustible wall.

- Cylinder may only be hoisted when enclosed in an approved box or cradle within which they are securely fastened.

- Cylinders must be identified by a color code in accordance with respective national standards.

- Gas welding cylinders shall have hose check valve (non-return valves), which allow gases to the blowpipe, but not back from it. Flashback arrestors shall be installed to quench flashback flames and cut off the gas flow automatically, in both oxygen and fuel gas outlet lines.

XX. ELECTRICAL SAFETY / POWER LINES

All electrical receptacles shall be of industrial grade and comply with area classification requirement.

No part of any lifting devices or any equipment operated around power lines is closer than below:

Power Line Min. Lifting Clearance

150 – 750kV 2.0 m

750 - 50kV 3.0 m

50k – 250kV 4.5 m

Over 250kV 6.0 m

The above clearance applies in all directions. All overhead lines shall be identified with a highly visible sign

placed 7 m from both sides of the lines, 1.8m above ground. A restriction guard pole connected with ropes shall be installing to restrict clearance close to power lines.

XXI. HSE BRIEFING / TOOLBOX MEETING

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Sub-contractor shall ensure that his appointed Work Supervisors hold tool box meeting for about 5 – 10 minutes daily or prior to commencement of work. Specific topics shall include hazards identified in the Job Safety Analysis relevant to the current work, Permit to Work requirements, and review of accidents, near misses and any new equipment or machinery. Sub-contractor shall maintain record of attendances and submit to CONTRACTOR as daily basis.

XXII. USE OF PUBLIC ROAD

contractor shall keep public road free from its debris due to vehicle movement to and from site. Sub-contractor shall provide tyre-washing facilities at site. In the event of spillage onto the road,

sub-contractor shall undertake the cleaning activities at sub-sub-contractor cost.

XXIII. HSE AWARENESS

Sub-contractor shall at its own expense provide continuous HSE awareness to their employee through but not limited to the following:

- HSE Bulletin Board, which located at strategic location of site and updated regularly.

- HSE Banners, which strung at entrance and strategic location at site and changed periodically. - HSE Sign Board, which located at strategic location at site and updated regularly.

XXIV.RADIOGRAPHY

Sub-contractor shall ensure that all radiographic, sub-contractor be appointed is in possession of valid operating license issued by Nuclear Energy Regulatory Agency (BAPETEN).

Sub-contractor shall obtain a permit to work for radiography work. Extra precaution shall be taken to keep away all non relevant personnel from the area. The area shall be isolated by visible barricades, signs, warning lights etc. The source shall be stored according to approved procedure. Sub-contractor shall employ only qualified radiography operators for the job. Properly calibrated radiation survey must be available.

Each radiography technician shall be supplied with a personal beeper.

XXV. AIR HOSE

Air hose connection shall be equipped with anti whipping device to prevent accidental disconnection. Air hose should not be used to clean any part of the body or clothing or use to blow off dirt on the floor.

Compressor supplying air shall posses a valid certificate of fitness and equipped with automatic relief valve. The relief valve must carry a current calibration tag.

XXVI. WORKING AT HEIGHT

All work at elevated areas in the excess of six (6) meters shall require the use of full body harness.

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ATTACHMENT 5

FABRICATOR'S SAFETY, HEALTH AND ENVIRONMENT (HSE) PRE-QUALIFICATION / ASESSMENT QUESTIONNAIRE

Project :

2. Does your company have an HSE policy document ?

Yes No

Siapa senior staff di perusahaan anda yang bertanggung jawab dalam implementasi kebijakan ini di tempat anda bekerja?

S

Name: Job Title:

Yes No

6. Does a full time HSE Department exist in your organisation? Apakah Departement K3 tersedia di perusahaan anda?

Yes No

7. If answer to 6 above is yes, do you have job descriptions for the person(s) employed in your HSE Department?

Jika jawaban no 6 Ya, Apakah perusahaan anda mempunyai job description terhadap karyawan di Departement K3.

Yes No

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Jika Ya, silahkan lampirkan detail dari posisi masing-masing karyawan dan responsibilitinya.

8. If the answer to item 7 above is no, who is responsible for providing safety advice and monitoring the implementation of HSE Management System at your work sites and what is their qualification? Jika jawaban no.7 Tidak ada, siapa yang bertanggung jawab dalam memberikan arahan K3 dan melakukan monitoring terhadap implementasi K3 management system ditempat perusahaan anda bekerja dan apa kualifikasi orang tersebut?

Person Responsible :

___________________________________________________________________ Qualification :

S

ection III Organising for HSE - HSE P lanning

9. Do you produce an HSE Plan in your workplace?

Apakah anda menyiapkan rencana pelaksanaa K3 dan Lindungan Lingkungan di tempat anda bekerja?

10. If answer to Question 9 above was no, briefly describe how you ensure that the required HSE Systems

are communicated and implemented on time.

Jika jawaban anda Tidak, Jelaskan bagaimana anda memastikan K3 dan Lindungan Lingkungan yang disyaratkan dapat terkomunikasi dan dilaksanakan dengan baik.

S

11. Do you have a HSE Training Matrix for your employees?

Apakah perusahaan anda mempunyai rencana training K3 dan Lindungan Lingkungan untuk karyawan anda? Please attach the HSE training matrix / Silahkan lampirkan HSE training matrux

Yes No

12. If the answer to Question 11 above was no, briefly describe how you identify and implement HSE Training for your staff.

Jika jawaban no 11 Tidak ada, Jelaskan bagaimana anda mengidentifikasi dan mengimplementasi kebutuhan trainining K3 dan Lindungan Lingkungan untuk karyawan anda.

13. Do you have a formal training program(s) for Supervisors their responsibilities in HSE Management as Supervisors?

Apakah perusahaan anda mempunyai program training untuk safety suprvisor ?

Yes No

14. If the answer to item 13 above is yes, briefly describe this program and who conducts this training. Jika jawaban no 13 Ya, Jelaskan bagaimana program ini berjalan dan siapa yang melakukan training tersebut.

15. Do you have a formal HSE Orientation Programme for new employees?

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Apakah perusahaan anda mempunyai Program Safety Orientation untuk karyawan baru? If Yes, Please attach / Jika ya, silahkan lampirkan

Yes No

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16. Does your Company have written HSE procedures?

Apakah perusahaan anda mempunyai procedure K3 dan Lindungan Lingkungan?

Yes No

17. If answer to Question 16 was yes, please attach HSE Procedure that you have.

Jika jawaban no.16 Ya, Silahkan lampirkan procedure K3 dan Lindungan Lingkungan yang perusahaan anda punyai.

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18. Do you measure environmental performance?

Apakah perusahaan anda mengukur performance lingkungan?

Yes No

How?

Apakah perusahaan anda menyimpan statistic kecelakaan terhadap karyawan anda?

Yes No

S

22. Do your Senior Management conduct regular HSE Audit and Inspection?

Apakah senior management anda melakukan audit K3 dan Lingkungan dan melakukan inspeksi Secara regular? If yes, please attach sample / Jika ya silahkan lampirkan bukit dari pelaksanaan

Yes No

Section VIII Current HSE Statistical Information

23 Please provide the following information:

(A) Please provide your statistical HSE Performance for 3 last years:

(19)

24. Do you provide appropriate personal protective equipment (PPE) for your employees? Please provide a listing of the PPE for the scope of this work ?

27. Who is the person in charge for coordinating environment matter and what is he/she experience? Siapa yang bertanggung jawab dalam menghandle untuk melakukan perlindungan lingkungan diperusahaan anda dan apa pengalaman orang tersebut?

(20)

ATTACHMENT 6

FABRICATOR HSE BID EVALUTION

3 5 7

1.1 HSE Policy

Total

2.3 HSE Department

2.4 Job Description in HSE Department 2.5 Responsible for safety advice & monitoring Sub Total

Total

3 HSE Planning

3.1 Produce HSE Plan 3.2 Implement plan for HSE Sub Total

Total

4 HSE Training

4.1 HSE Matrix Training

4.2 Identify and implement HSE Training 4.3 Training Program for Supervisor 4.4 Program & Conduct HSE Training 4.5 HSE Orientation

6.2 Keep of Accident Statistic of Employee 6.3 Describe of the Accident Statistic Sub Total

Total

7.1 Senior Management use of HSE Audit Inspection

(21)

Total

9 Personal Protective Equipment

9.1 List of PPE

Total

Recommendation:

Note : Score achievement:  50: Pass the HSE requirement

Criteria Score:

(22)

ATTACHMENT 8

FORWARDER'S SAFETY, HEALTH AND ENVIRONMENT (HSE) PRE-QUALIFICATION / ASESSMENT QUESTIONNAIRE

Project :

1. Does your company have an HSE policy document ?

Yes No

Siapa senior staff di perusahaan anda yang bertanggung jawab dalam implementasi kebijakan ini di tempat anda bekerja?

S

Name: Job Title:

Yes No

6. Please provide HSE Leader for this works / operation? (Just for Heavy Lift Transporter) Sebutkan siapa yg akan menjadi HSE Leader untuk kegiatan ini?

S

ection III Risk Identification

(23)

S

8. Do you have a HSE Training Matrix for your employees? (Just for head quarter International Transporter)

Apakah perusahaan anda mempunyai rencana training K3 dan Lindungan Lingkungan untuk karyawan anda? Please attach the HSE training matrix / Silahkan lampirkan HSE training matrux

Yes No

9. If the answer to question no.8 was no, briefly describe how you identify and implement HSE training for your staff?

Jika jawaban no.11 tidak ada, jelaskan bagaimana anda mengindentifikasi dan mengimplementasi kebutuhan training K3 dan lindungan lingkungan untuk karyawan anda.

10. Do you have a formal HSE Orientation Programme for new employees? (Just for head quarter International Transporter)

Apakah perusahaan anda mempunyai Program Safety Orientation untuk karyawan

baru? If Yes, Please attach / Jika ya, silahkan lampirkan

Yes No

S

11. Does your Company have written Safety procedures (Just for International Transporter and Local Transporter)and Environmental Procedure (Just for Intrainsular Transporter)?

Apakah perusahaan anda mempunyai procedure K3 (Untuk International Transporter dan Local Transporter) dan Lindungan Lingkungan (Untuk Intrainsular Transporter)?

Yes No

12. If answer to Question 16 was yes, please attach Safety and Environmental Procedure that you have. Jika jawaban no.16 Ya, Silahkan lampirkan procedure K3 dan Lindungan Lingkungan yang perusahaan anda punyai.

S

13. Do you measure environmental performance? (Just for Heavy Lift Transporter) Apakah perusahaan anda mengukur performance lingkungan?

(24)

How?

Apakah perusahaan anda menyimpan statistic kecelakaan terhadap karyawan anda?

Yes No

S

16. Do your Management conduct HSE Audit and Inspection at the work site? (Just for Heavy Lift Transporter)

Apakah senior management anda melakukan audit K3 dan Lingkungan dan melakukan inspeksi Secara regular? If yes, please attach sample / Jika ya silahkan lampirkan bukit dari pelaksanaan

Yes No

Section VIII Current HSE Statistical Information

17. Please provide the following information:

(A) Please provide your statistical HSE Performance for 3 last years: (Just for Heavy Lift Transporter)

Section IX Personnel Protective Equipment

18. Do you provide appropriate personal protective equipment (PPE) for your employees? Please provide a listing of the PPE for the scope of this work ?

21. Who is the person in charge for coordinating environment matter and what is he/she experience? (Just For International Transporter)

(25)

(26)

ATTACHMENT 9

FORWARDER HSE BID EVALUTION

3 5 7

1.1 HSE Policy

Total

4.2 Identify and implement HSE Training 4.5 HSE Orientation

Sub Total Total

5 HSE Procedure

5.1 Written Safety / Environmental Procedure 5.2 Attachment Safety & Environmental Procedure

Sub Total Total

6 Accident Performance Measurement

6.1 Measure Env. Performance

6.2 Keep of Accident Statistic of Employee 6.3 Describe of the Accident Statistic Sub Total

Total

7.1 Management use of HSE Audit & Inspection Sub Total

Total

(27)

9 Personal Protective Equipment 9.1 List of PPE

Total

Recommendation:

Note: Score achievement: > 50: Heavy Lift, Dangerous Cargo Transport, International Forwarder; 35 – 50: Local Transporterand General Cargo Transport.

Criteria Score: