TEP Self Verification Record Sheet Rev.

Date: Purpose
Location:

Task / Activity / aktivitas / Area

The purpose of this Self Verification is to ensure that Work
Permit Number / Nomor Permit Activity at the Tangguh Greenfield Site is executed in line with
Name of Verifiers / Pemeriksa the Transportation Safety and associated relevant
documentation under the CSTS Management System.
Persons Interviewed or Supervisor:

Sub-Contractor:

Process, Plan or Procedure to be Verified Doc. Compliance

Comments / Remarks
Traffic and Journey Management (TEP-930-PLA-HS-BP4-0025) Reference YES / NO / NA

DOCUMENTS/ADMINISTRATION /POLICY/ PROCEDURE

Is there a validated risk assessment available at the verified road? Is it regularly reviewed?
Apakah telah terdapat dokumen penilaian risiko pada jalan yang diverifikasi? Apakah direview
1
secara rutin
No. Reference : (…………………………………………………………………..)

Are all other supplementary certificates referenced in the above documents available for
review? E.g Driving License, SIMPER, Vehicle License, Vehicle permit, etc
2
Apakah semua sertifikat tambahan lainnya dirujuk dalam dokumen di atas tersedia untuk
ditinjau? Seperti SIM, SIMPER, dokumen kendaraan, ijin kendaraan, dsb

Has daily preinspection performed by the driver and properly documented?

3 Apakah pemeriksaan harian dilakukan oleh driver dan didokumentasikan dengan baik dan
benar?

Has journey management plan been prepared for specific transportation?

4
Apakah perencanaan perjalanan dibuat untuk transportasi khusus?

Pre Start Communication to the Workers (Sometimes referred to as the TBT)

Was a STARRT meeting held with the workforce prior to the work starting?
1 CoW Procedure
Apakah diskusi STARRT diadakan dengan pekerja sebelum pekerjaan dimulai?

Has the STARRT Card been signed by all relevant personel? (Workers/Supervision)
2 Apakah Kartu STARRT telah ditandatangani oleh semua personel yang relevan? (Pekerja / CoW Procedure
Pengawasan)

Has the STARRT Card been filled correctly and verified all requirement in place?
3 CoW Procedure
Sudahkah Kartu STARRT diisi dengan benar dan diverifikasi semua persyaratan?

Does the Description of the STARRT adequately reflect the work being carried out
4 CoW Procedure
Apakah Deskripsi STARRT cukup mencerminkan pekerjaan yang dilakukan

Do the Hazards and Controls identified on the STARRT sheet adequately reflect the task?
5 Apakah Bahaya dan Kontrol yang diidentifikasi pada lembar STARRT cukup mencerminkan CoW Procedure
tugas?

Has the person who held the STARRT meeting received training?
6 CoW Procedure
Apakah orang yang mengadakan pertemuan STARRT menerima pelatihan?

Are at least 2 members of the work force able to identify at least 50% of the hazards and
controls on the STARRT sheet? (Not counting the Supv) when INDEPENDANTLY questioned?
7 Apakah setidaknya 2 anggota angkatan kerja dapat mengidentifikasi setidaknya 50% dari CoW Procedure
bahaya dan kontrol pada lembar STARRT (Tidak termasuk Supv) ketika dipertanyakan secara
INDEPENDEN?

WORK EXECUTION - TRAFFIC & JOURNEY MANAGEMENT

Are the traffic area equipped with designated pedestrian access? If not, is there prohibition
sign posted?
1
Apakah area jalan lalu lintar dilengkapi dengan akses pejalan kaki? Bila tidak, apakah rambu
larangan telah terpasang?

Are the pedestrian access segregated from the main road or properly barricaded / guarded?
2
Apakah jalur pejalan kaki terpisah dengan jalur kendaraan dan telah dibarikade / dilindungi?

Are there pedestrian access sign and crossing point sign posted on dedicated crossing point?
3 Apakah rambu akses pejalan kaki dan penyebrangan telah terpasang pada tempat
penyebrangan yang telah ditentukan?

Have traffic marshal assigned on the crossing point if needed based on the risk assessment?
4 Apakah petugas lalu lintas telah ditugaskan di titik perlintasan / penyebrangan bila diperlukan
berdasarkan hasil penilaian risiko?

Are traffic marshal equipped with reflective vest, whistle and flags?
5
Apakah petugas lalu lintas telah dilengkapi dengan rompi reflektif, peluit dan bendera?

Have all signed been installed on the area:

6
Apakah seluruh rambu telah terpasang di areai?

Speed limit
- Construction and Laydown area : 20km/hn?
- Office and camp area : 10km/h?
7
Batas kecepatan
- Area konstruksi dan laydown : 20 km/jam
- Camp dan kantor : 10 km/jam

Stop sign at all road crossing

8
Rambu berhenti di setiap simpang jalan

Parking sign at parking area

9
Rambu parkir di setiap area parkir
Priority sign
10
Rambu prioritas

Are the road condition mantained in clean (less dust) and compacted condition?
11
Apakah area jalan raya dijaga agar bersih (kurang debu) dan padat?

Has clear road delimination marking available at road?

12
Apakah tanda batas jalan dapat terlihat jelas di jalan?
 Are the road equipped with sufficient lighting?
13
Apakah jalan telah diberikan cukup penerangan?

Has the traffic arranged on one-way system to minimize the reversing operation?
14
Apakah jalur jalan telah diatur dengan sistem satu arah untuk meminimalisir operasi memutar?

Has designated turning point clearly difine and provided as per risk assessment?
15
Apakah area memutar telah disediakan dan ditentukan sesuai dengan hasil penilaian risiko?

Have the parking area clearly defined?

16
Apakah area parkir telah ditentukan?
Are the parking area have adequate room for vehicle movement?
17
Apakah area parkir memiliki cukup ruang untuk pergerakan kendaraan?

Have the parking area equipped with wheel stopper or other means to secured the parked
vehicle?
18
Apakah area parkir dilengkapi dengan penghenti roda atau cara lain untuk mengamankan
kendaraan yang sedang parkir?

Are the parking area not blocking the other vehicle access, pedestrian access or access to
emergency equipment?
19
Apakah area parkir tidak menghalangi akses kendaraan, pejalan kaki dan akses ke peralatan
darurat?

Have the passenger loading unloading area clearly defined?

20
Apakah area naik turun penumpang telah ditentukan?

EMERGENCY PREPAREDNESS/WORKER PROTECTION

Is all emergency equipment identified and required for the specific task avaialble, in cetification
and ready for use? e.g Spill Kit, Fire extinguisher. Eye Wash , First Aid Kit, Stretcher etc
Actual Check
1 Apakah semua peralatan darurat diidentifikasi dan diperlukan untuk tugas khusus yang
on-site
tersedia, dalam sertifikasi dan siap digunakan? Contoh Spill Kit, Fire extinguisher. Eye Wash ,
First Aid Kit, Stretcher dan sebagainya

Have persons received adequate training or familiarisation in the use of any specificed
emergency equipment or duties for the task. Actual Check
2
Sudahkah personel menerima pelatihan atau pengenalan yang memadai tentang penggunaan on-site
peralatan darurat atau tugas tertentu untuk tugas tersebut?

Do workers know what to do in the event of an emergency? - Ask at least 2 person (1) how to
raise the alarm/notify emergency (2) the emergency contact number, (3) where their muster
point is. Put "Yes" only if the all of the answers are correct)
Actual Check
3 Apakah pekerja tahu apa yang harus dilakukan jika terjadi keadaan darurat? - Tanyakan pada
on-site
2 orang (1) bagaimana cara meningkatkan alarm / memberitahukan darurat (2) nomor kontak
darurat, (3) di mana titik keramaian mereka. Masukkan "Ya" hanya jika semua jawaban sudah
benar)

Is all PPE stated on the Permit or JSA being worn? Worn correctly? And in good condition
(Worker can explain and show how to wear and use full body harness properly)
Actual Check
4 Apakah semua APD yang tercantum pada Izin atau JSA dikenakan? Apakah benar? Dan
on-site
dalam kondisi baik (Pekerja dapat menjelaskan dan menunjukkan cara memakai dan
menggunakan seluruh tubuh dengan benar)

Percentage of Implementaion #DIV/0!

RECOMMENDATION
NO ACTION RESPONSIBLE PERSON TARGET DATE
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