KIE SAFETY AUDIT ( NEB INSTALLATION )

Daftar Cek Pemeriksaan Keselamatan ( Instalasi untuk NEB )

Site Audited by
Lokasi Diperiksa oleh
Date Accompanied by
Tanggal Diikuti oleh
RR = Risk Rating
Score Rating Action
4 Safety Critical STOP WORKING and Immediate A
3 Urgent Attention Required Set - Up action to ensure risk managed o
2 Attention Advised Set - Up action to ensure risk managed o
1 Satisfactory Good
Please follow Instructions for filling up : √
SAFE UNSAVE No.
No. ITEM
1 2 3 4
1 Mandotary Documents & Others (Dokumen wajib & lainnya) Open pit/no barrier
5.2
Risk assessment are available on site (Pit terbuka/tidak ada hamb
1.1
(Penilaian resiko tersedia di lokasi) Housekeeping
5.3
Kone Pasport issued to worker (Housekeeping)
1.2
(Kone Pasport sudah diterbitkan untuk pekerja) Lighting provided
5.4
KONE Assembly Manual (AM) available on site (Tersedianya pencahayaan)
1.3
(Petunjuk perakitan KONE tersedia di lokasi) Pit is dry, no water
5.5
5 minutes safety discussions/toolbox (Pit dalam kondisi kering, tid
1.4
(Diskusi keselamatan selama 5 (lima) menit/kotak alat) Debris in pit
5.6
Hot works (welding,grinding,etc.) procedure followed (Puing-puing di dalam pit)
1.5
(Prosedur pekerjaan panas (las,gerinda,dll diikuti) Accessibility to work area
5.7
2 Mandotary Observation (Tirak in Use) (Pengamatan wajib (Tirak digunakan)) (Area bekerja yang mudah d
Tested test plate place in lift pit 6 Liftin
2.1
(Tempat test plate diuji di pit lift) Certified an Tagged (Tiraq
6.1
Buffer Installed (Bersertifikat dan beretiket (
2.2
(Buffer terpasang) Storage in good and acce
6.2
ASGT/Blockstop Installed and working (demonstrate by fitter) (Penyimpanan dalam kondis
2.3
(ASGT/Blockstop terpasang dan bekerja (ditunjukkan oleh fitter)) 7 Pe
Tirak "Inspection for installation use" done Helmet - no evidence of d
2.4 7.1
(Tirak"Pemeriksaan untuk digunakan instalasi" sudah dilakukan) (Helm proyek - Tidak dalam
Tirak "Daily/Weekly Safety Checklist" done Safety goggles - free from
2.5 7.2
(Tirak"Daftar cek pemeriksaan Harian/Mingguan" sudah dilakukan) (Kacamata Pengaman - Beb
OSG, Safety Gear, Safety Rope, Parking chain attach corrrectly Safety gloves - not dama
2.6 7.3
(OSG, Safety Gear, Safety Rope, Parking chain terpasang dengan benar) (Sarung tangan keselamata
3 Lift Motor Room ( Ruang Motor lift ) Safety boots - grip on sol
7.4
Lighting provided (Sepatu keselamatan - sol s
3.1
(Tersedianya pencahayaan) Safety harness in good c
7.5
Housekeeping acceptable (Safety Harness dalam kond
3.2
Page 1 of 14 KIE/FO/ST/04/R01
 KIE SAFETY AUDIT ( NEB INSTALLATION )
Daftar Cek Pemeriksaan Keselamatan ( Instalasi untuk NEB )
3.2
(Housekeeping sesuai) 8 Mandotary Obse

Safe access Lifeline/rope grib provide

3.3 8.1
(Akses yang aman) (Lifeline/rope grib disediaka
Fire extinguishers available and valid on site Condition of scaffolding a
3.4 8.2
(Alat Pemadam kebakaran tersedia dan benar di lokasi) (Kondisi peerancah dan lant
Warning signs on LMR doors Available balustrades at w
3.5 8.3
(Tanda-tanda peringatan pada pintu LMR) (Tersedia pengaman pagar
Guarding/covers in place for expose opening 9
3.6
(Guarding/covers di tempat untuk mengekspos pembukaan) First aid kit available on s
9.1
4 Lift Shaft and Car Top (Pertolongan pertama pada
Lighting provided Available Incident flow inf
4.1 9.2
(Tersedianya pencahayaan) (Tersedia alur informasi keja
Balustrades/kickboards in place Available emergency rou
4.2 9.3
(Balustrades/kickboards di tempat) (Tersedia jalur keadaan daru
Guarding covers in place 10
4.3
(Guarding/covers di tempat) Storage/disposed of woo
10.1
Debris on lift car top, tools, etc (Penyimpanan/ Peti kayu da
4.4
(Puing-puing pada car top lift, tools, dan lain sebagainya) Storage/disposed of lubri
10.2
Clear access to Shaft and top (Penyimpanan/minyak/oli di
4.5
(Akses yang mudah menuju shaft dan puncak) General noise in lift shaft
10.3
Entrance Protection (Kebisingan di shaft lift)
4.6
(Perlindungan masuk) 11
5 PIT LIFT Earth available and used
11.1
Pit ladder access (Grounding tersedia dan dig
5.1
(Akses tangga pit) Cables and plugs in good
11.2
(Kabel dan colokan dalam k

Final Inspection Score :

Note: It item not observed or not applicable subtract from " possible " score and mark item N/A

Page 2 of 14 KIE/FO/ST/04/R01
 KIE SAFETY AUDIT ( NEB INSTALLATION )
Daftar Cek Pemeriksaan Keselamatan ( Instalasi untuk NEB )

Inspector/Auditor allocates corrective actions (if any) and upload the form into ACAS

Pemeriksaan/audit

Actions Taken for conformance/Tindakan yang diambil

No Non-conformance/ Ketidaksesuaian
untuk kesesuaian

This Report to be distributed to / Laporan ini harus didistribusikan ke :

1 PM or Supervisor at the site
2 Safety Manager
3 Installation Manager or Project Director

Page 3 of 14 KIE/FO/ST/04/R01
ION )
EB )

(Name/sign)
(Nama/ttd)
(Name/sign)
(Nama/ttd)

Time Frame
mediate Action Immediate
anaged or eliminated 1 Week
anaged or eliminated 2 Week

ITEM SAFE UNSAVE

1 2 3 4
arrier
ak ada hambatan)
g
)
ded
encahayaan)
water
disi kering, tidak ada air)

dalam pit)
o work area
ang mudah dijangkau)
Lifting Equipment (Peralatan Lifting)
agged (Tiraq & Winch)
an beretiket (Tirak & winch))
od and acceptable condition
dalam kondisi baik dan dapat diterima)
Personal Protective Equipment ( Alat Pelindung Diri )
vidence of damage & worn
Tidak dalam kondisi rusak dan dikenakan)
s - free from scratches & worn
gaman - Bebas dari goresan dan dikenakan)
- not damaged & worn (spares)
n keselamatan - tidak rusak dan dikenakan (ada cadangan))
grip on soles, no tears & worn
matan - sol sepatu kuat, tidak sobek dan dikenakan)
s in good condition-sign of torn/wearing
s dalam kondisi baik - Tanda sobek/ memakai)

Page 4 of 14 KIE/FO/ST/04/R01
ION )
EB )

dotary Observation (Scafold in Use) (Pengamatan wajib (Perancah digunakan))

grib provided for each fitter&helper when scaffold in use

rib disediakan untuk setiap fitter&helper saat perancah digunakan)
caffolding and working platform
ncah dan lantai kerja)
ustrades at working platform
aman pagar bekerja diatas papan kerja)
Site Package (Paket Lokasi)
ailable on site
ertama pada kecelakaan tersedia di lokasi)
dent flow information - Emergency contact number
nformasi kejadian )
ergency route
keadaan darurat)
Environmental (lingkungan)
sed of wooden crates and cardboards
Peti kayu dan kardus dirapikan)
sed of lubrican/oil
minyak/oli dibersihkan)
e in lift shaft
shaft lift)
Electrical ( listrik )
e and used
sedia dan digunakan)
ugs in good condition
okan dalam kondisi baik)

TOTAL :

Page 5 of 14 KIE/FO/ST/04/R01
ION )
EB )

Responsible Completed Checked by safety

Due Date Status
for action on (if closed)

Page 6 of 14 KIE/FO/ST/04/R01
 KIE SAFETY AUDIT ( NEB INSTALLATION )
Site Audited by
Date Accompanied by
RR = Risk Rating
Score Rating Action
4 Safety Critical STOP WORKING and Immediate Action
3 Urgent Attention Required Set - Up action to ensure risk managed or elim
2 Attention Advised Set - Up action to ensure risk managed or elim
1 Satisfactory Good
Please follow Instructions for filling up : √
SAFE UNSAVE No.
No. ITEM
1 2 3 4
1 Mandotary Documents & Others 5.3 Housekeeping
1.1 Risk assessment are available on site 5.4 Lighting provided
1.2 Kone Pasport issued to worker 5.5 Pit is dry, no water
1.3 KONE Assembly Manual (AM) available on site 5.6 Debris in pit
1.4 5 minutes safety discussions/toolbox 5.7 Accessibility to work area
1.5 Hot works (welding,grinding,etc.) procedure followed 6 Lifting Equipment
2 Mandotary Observation (Tirak in Use) 6.1 Certified an Tagged (Tiraq & W
2.1 Tested test plate place in lift pit 6.2 Storage in good and acceptab
2.2 Buffer Installed 7 Personal Protective Equipm
2.3 ASGT/Blockstop Installed and working (demonstrate by fitter) 7.1 Helmet - no evidence of dama
2.4 Tirak "Inspection for installation use" done 7.2 Safety goggles - free from scra
2.5 Tirak "Daily/Weekly Safety Checklist" done 7.3 Safety gloves - not damaged &
2.6 OSG, Safety Gear, Safety Rope, Parking chain attach corrrectly 7.4 Safety boots - grip on soles, n
3 Lift Motor Room 7.5 Safety harness in good condit
3.1 Lighting provided 8 Mandotary Observation (Sca
3.2 Housekeeping acceptable 8.1 Lifeline/rope grib provided for
3.3 Safe access 8.2 Condition of scaffolding and w
3.4 Fire extinguishers available and valid on site 8.3 Available balustrades at worki
3.5 Warning signs on LMR doors 9 Site Package
3.6 Guarding/covers in place for expose opening 9.1 First aid kit available on site
4 Lift Shaft and Car Top 9.2 Available Incident flow informa
4.1 Lighting provided 9.3 Available emergency route
4.2 Balustrades/kickboards in place 10 Environmental
4.3 Guarding covers in place 10.1 Storage/disposed of wooden c
4.4 Debris on lift car top, tools, etc 10.2 Storage/disposed of lubrican/o
4.5 Clear access to Shaft and top 10.3 General noise in lift shaft
4.6 Entrance Protection 11 Electrical
5 PIT LIFT 11.1 Earthing available and used
5.1 Pit ladder access 11.2 Cables and plugs in good con
5.2 Open pit/no barrier

Final Inspection Score :

Note: It item not observed or not applicable subtract from " possible " score and mark item N/A
Inspector/Auditor allocates corrective actions (if any) and upload the form into ACAS
No Non-conformance Actions Taken for conformance
This Report to be distributed to :
1 PM or Supervisor at the site
2 Safety Manager
3 Installation Manager or Project Director
LLATION )
(Name/sign)
(Name/sign)

on Time Frame
d Immediate Action Immediate
sk managed or eliminated 1 Week
sk managed or eliminated 2 Week
od

ITEM SAFE UNSAVE

1 2 3 4
keeping
g provided
ry, no water
in pit
sibility to work area
g Equipment
ed an Tagged (Tiraq & Winch)
e in good and acceptable condition
nal Protective Equipment
t - no evidence of damage & worn
goggles - free from scratches & worn
gloves - not damaged & worn (spares)
boots - grip on soles, no tears & worn
harness in good condition-sign of torn/wearing
otary Observation (Scafold in Use)
e/rope grib provided for each fitter&helper when scaffold in use
ion of scaffolding and working platform
ble balustrades at working platform
ackage
d kit available on site
ble Incident flow information - Emergency contact number
ble emergency route
onmental
e/disposed of wooden crates and cardboards
e/disposed of lubrican/oil
al noise in lift shaft
ical
ng available and used
s and plugs in good condition
TOTAL :

Responsible Completed
for action Due Date on Status Checked by safety (if closed)
 Quality Document Audit
Lokasi
Tanggal

Please follow Instructions for filling up : √

No. ITEM OK NO

1 Safety

1.1 Form diisi

1.2 Form diverivikasi dan ditandatangani oleh fitter/foreman/spv

1.3 Kelengkapan Safety tersedia (prosedur, p3k, APD dan nomor darurat)

1.4 5s Tercapai

1 Plumbing

1.1 Data Plumbing diisi dengan benar dan sesuai

1.2 Form diverivikasi dan ditandatangani oleh fitter/foreman/spv

1.3 Plumbing di posisikan sesuai dengan tabel plumbing dan gambar

1.4 Tools pemasangan dan pengecekan sudah sesuai

2 Rel Pemandu Pertama

2.1 Data Pemandu Rel pertama diisi benar dan sesuai

2.2 Form diverivikasi dan ditandatangani oleh fitter/foreman/spv

2.3 Rel Pemandu Pertama diposisikan sesuai dengan gambar dan data

2.4 Tools pemasangan dan pengecekan sudah sesuai

3 Sling sangkar, sangkar dan bobot imbang (counterweight)

3.1 Data diisi dengan benar dan sesuai

3.2 Form diverivikasi dan ditandatangani oleh fitter/foreman/spv

3.3 Material diposisikan sesuai dengan gambar dan data

3.4 Tools pemasangan dan pengecekan sudah sesuai

4 Sisa Pemandu Rel

4.1 Data diisi dengan benar dan sesuai

4.2 Form diverivikasi dan ditandatangani oleh fitter/foreman/spv

4.3 Material diposisikan sesuai dengan gambar dan data

4.4 Tools pemasangan dan pengecekan sudah sesuai
Pintu pendaratan (landing door), pintu
5
sangkar dan curtain of light
5.1 Data diisi dengan benar dan sesuai

5.2 Form diverivikasi dan ditandatangani oleh fitter/foreman/spv

5.3 Material diposisikan sesuai dengan gambar dan data

6 Sebelum Commisioning

6.1 Data diisi dengan benar dan sesuai

6.2

6.3 Material diposisikan sesuai dengan gambar dan data

7 Commisioning

7.1 Data diisi dengan benar dan sesuai

7.2 Form diverivikasi dan ditandatangani oleh fitter/foreman/spv

7.3 Material diposisikan sesuai dengan gambar dan data

8 Kenyamanan berkendara (Ride Comfort)

8.1 Data diisi dengan benar dan sesuai

8.2 Form diverivikasi dan ditandatangani oleh fitter/foreman/spv

8.3 Material diposisikan sesuai dengan gambar dan data

8.4 Parameter Ride Comfort Tercapai

Final Inspection Score : OK

OK+NO
ment Audit
Diperiksa oleh (Nama/ttd)
(Nama/ttd)
Diikuti oleh (Nama/ttd)
(Nama/ttd)

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