responkuesioner pt pdsi

PRA-KUALIFIKASI HSE UNTUK KONTRAKTOR

No. Dokumen Tgl. Terbit

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1. GENERAL INFORMATION /KETERANGAN UMUM

1. Company Name PT. WIDODO LINTAS SAMUDRA

Phone

Nama Perusahaan TeleponStreet Address Mailing AddressAlamat Jalan Alamat Surat-Menyurat

2. Officers Name Years with companyPejabat Nama Lama bekerja di perusahaanPresident (General Manager)PimpinanVice President (Director)Wakil PimpinanTreasurerBendaharawan

3. How many years has your organisation been in business under your present firm name?Berapa tahun organisasi Anda telah berusaha menggunakan nama perusahaan yang sekarang?

4. A. Parent Company Name Nama Perusahaan IndukCity State I Zip Code Kota Negara Kode Zip

Subsidiaries -Anak-anak perusahaan

B. Principal Company Name -Nama Perusahaan PrinsipalCity - State - Zip Code - Kota Negara Kode Zip

5. Under Current Management since (date) Di bawah Manajemen Sekarang sejak (tanggal)

6. Contact for Insurance InformationKontak untuk keterangan asuransiTitle Phone FaxJabatan Telepon Fax

7. Insurance Carrier(s) Penanggung Asuransi

Name Type of Coverage PhoneNama Jenis Asuransi Telephone

PT. JAMSOSTEKPersonel Accident and Medical Care/Hospitalization 021. 788 47212-5

8. Are you self insured for Worker’s Compensation Insurance? Yes NoApakah Anda menanggung sendiri risiko untuk Asuransi Kecelakaan Kerja Bagi Karyawan Anda? Ya Tidak

9. Contact for Requesting BidsKontak untuk Permintaan PenawaranTitleJabatan Telepon Fax

10. PQF completed and signed by NameFPK diisi dan ditandatangani oleh Nama

*) This Pre-Qualification Questionnaire must be completed and signed by the Company’s authorised first level ManagementDaftar Pertanyaan Pra-kualifikasiini harus diisi dan diketahui oleh Pimpinan Perusahaan yang berwenang.

Signature

Title PhoneJabatan Telephone Fax

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ORGANISATION / ORGANISASI

11.Form of BusinessBentuk Usaha

Firma/CV Perseroan Terbatas Others/Lain-lain ______________

12.List other types of work within the services yhou normally perform that you sub-contract to othersUraikan jenis pekerjaan lain dalam kelompok jasa yang biasa Anda lakukan yang Anda sub-kontrakkan kepada pihak lain:

COMPANY WORK HISTORY / RIWAYAT PEKERJAAN PERUSAHAAN

13.Major jobs in progress (use additional papers as necessary)Pekerjaan-pekerjaan besar yang sedang dikerjakan (pakai kertas tambahan bila perlu)

Customer / LocationPelanggan / Lokasi

Type of WorkJenis Pekerjaan

Size (in US$ M)Nilai (US$ Juta)

Customer ContactKontak Pelanggan

PhoneTelepon

14.Major Jobs in the past 3 yearsPekerjaan besar yang diselesaikan dalam tiga tahun terakhir

Customer/locationPelanggan/Lokasi

Type of WorkJenis Pekerjaan

Size (in US$ M)Nilai (US$ Juta)

Customer ContactKontak Pelanggan

PhoneTelepon

15.Are there any judgements, claims or suits pending or outstanding against your company?Apakah perusahaan Anda sedang menghadapi masalah, klaim atau tuntutan yang belum tuntas?

If Yes, please attach the detailsJika Ya, harap lampirkan rincian

Yes No

Ya Tidak

16. Are you now (or have you ever been) involved in any bankruptcy or re-organisation proceedings?Apakah Anda sedang (atau pernah) mengalami pailit atau perombakan organisasi karena tuntutan hukum?

If Yes, please attach the detailsJika Ya, harap lampirkan rincian

Yes No

Ya Tidak

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2. HSE MANAGEMENT SYSTEMSISTEM MANAJEMEN K3LL

ReferenceAcuan

2.1 POLICY STATEMENT/ PERNYATAAN KEBIJAKAN2.1.1 Has a HSE Policy Statement been developed for the Company?

Please provide copy (ies)Apakah Pernyataan Kebijakan K3LL sudah dibuat untuk Perusahaan?Harap melampirkan salinannya.

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has HSE Policy and Other company Policies. Please refer to attachment 1:PT. WIDODO LINTAS SAMUDR’ HSE Policy Statement & Drugs and Alcohol Policy and other policies related HSE

2.1.2 Define who is responsible for monitoring HSE activities? Menjelaskan siapa yang bertanggung jawab untuk memantau aktivitas K3LL?

Answer:

The President Director assumes overall responsibility for Health, Safety & Environment (HSE) for PT. WIDODO LINTAS SAMUDRA operations. Operations Manager is accountable to the President Director for all matters related to HSE.

Line Manager has overall responsibility for HSE for individual PT. WIDODO LINTAS SAMUDRA operations. They are accountable to the Operations Manager for all matters related to HSE on the Project / services.

Line Supervision: PT. WIDODO LINTAS SAMUDRA line supervision has direct responsibility for HSE for individual tasks under their supervision. They are accountable to their Managers for all matters related to HSE under their supervision.

Attachment 1:PT. WIDODO LINTAS SAMUDRA’ HSE Policy Statements & Drugs and Alcohol Policy and other policies related HSE.

Attachment 2:PT. WIDODO LINTAS SAMUDRA’ HSE Roles and Responsibilities.



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2.1.3 Has the HSE Policy Statement been communicated to the workforce, and if yes, how? Please provide evidences of policy communication.

Apakah Pernyataan Kebijakan tersebut telah dikomunikasikan kepada para pekerja, jika ya, dengan cara bagaimana?Lampirkan bukti pelaksanaanya

Answer:

Yes, Methods of communication:

All PT. WIDODO LINTAS SAMUDRA offices display policy statements on their notice boards and other prominent places e.g.: Jakarta and site offices, etc.

PT. WIDODO LINTAS SAMUDRA President Director issues policies to be applied on PT. WIDODO LINTAS SAMUDRA projects

HSE Coordinator introduces, discusses and explains HSE policy statements to the PT. WIDODO LINTAS SAMUDRA management team, local offices and employees.

This is routinely carried out during:

(1) Operations Meetings (Management)

(2) Supervisor Safety Meeting

(3) Pre Task Briefing/Toolbox Safety Meeting

Attachment 3: Evidence of PT. WIDODO LINTAS SAMUDRA’s HSE Policy Display at the prominent places

Attachment 4: PT. WIDODO LINTAS SAMUDRA’s Minutes of Meeting discuss HSE Policy

Attachment 5: PT. WIDODO LINTAS SAMUDRA’ HSE Hand Book. In the HSE Hand Book is explained PT. WIDODO LINTAS SAMUDRA’ HSE Policy.

Attachment 6:PT. WIDODO LINTAS SAMUDRA’ Intern Memo with subject PT. WIDODO LINTAS SAMUDRA’ HSE Policy



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2.2. HSE OBJECTIVES/ SASARAN K3LL

2.2.1 Has an HSE Objective been established, and does it include HSE targets?Apakah Sasaran K3LL telah dibuat, dan apakah juga termasuk target-targetnya?

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been HSE Objective established and include HSE targets.

ReferenceAcuan

Attachment 7:PT. WIDODO LINTAS SAMUDRA’ HSE Objectives and Programs 2010

2.3 HSE STRUCTURE/ STRUKTUR ORGANISASI K3LL

2.3.1 Has a clear HSE structure been established in the Company?If yes, provide copy of organization and Job Description.

Apakah struktur organisasi K3LL yang jelas telah dibuat dalam Perusahaan?Jika ya, harap berikan salinan Uraian Tugas.

Answer:Yes. PT. WIDODO LINTAS SAMUDRA’ HSE Structure has been establish. Please refer to attachment 2 and attachment 6.

ReferenceAcuan


Attachment 8:PT. WIDODO LINTAS SAMUDRA’ Organization Chart.



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2.4 HSE RESPONSIBILITIES/ TANGGUNG JAWAB K3LL

2.4.1 Senior Management,Does Senior Management Job Description include clear statements with regards to HSE responsibilities? Please submit copy, including description of roles and responsibilities.Manajemen Senior,Apakah Uraian Tugas Manajemen Senior ada menjelaskan tanggung jawab terhadap K3LL? Harap lampirkan salinannya beserta penjabaran wewenang dan tanggung jawab.

Answer:Yes. PT. WIDODO LINTAS SAMUDRA,s Senior Management Job Description include clear statements with regards to HSE responsibilities. Please refer to attachment 2.

2.4.2 Employee Responsibility,How is the individual employee HSE responsibility communicated to them? (Please give evidences in details how this is practiced)Tanggung Jawab Karyawan, Bagaimana cara memberi tahu tentang tanggung jawab pribadi karyawan kepada mereka? (Lampirkan bukti rincian praktek pelaksanaannya)

Answer:President Director, Manager, Supervisor and HSE Coordinator introduces, discusses and explains employee HSE responsibility.This is routinely carried out during:1. Operations Meetings (Management)2. Supervisor Safety Meeting3. Pre Task Briefing/Toolbox Safety Meeting

ReferenceAcuan


Attachment 2:PT. WIDODO LINTAS SAMUDRA’ HSE Roles and Responsibilities.Attachment 5: PT. WIDODO LINTAS SAMUDRA’s HSE Hand Book. In the HSE Hand Book is explained PT. WIDODO LINTAS SAMUDRA’s Employee Responsibility.Attachment 9: PT. WIDODO LINTAS SAMUDRA’ Employee HSE Orientation ProgramAttachment 10: PT. WIDODO LINTAS SAMUDRA’s HSE Memo that show employee HSE responsibility



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2.4.3 HSE Staff,Is there a job Description for the HSE staff members? (Please provide a copy)Staf K3LLApakah Uraian Tugas anggota staf K3LL tersedia? (Harap lampirkan salinannya)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA have job description for the HSE staff members. Please refer to attachment 2.

2.4.4 Who is the most senior person for coordinating HSE matters and what is his experience?Siapa posisi paling senior untuk mengkoordinir masalah K3LL dan apakah pengalamannya?

Answer:HSE Coordinator has responsibilities in managing of safety matters.Our HSE Coordinator qualifications are: 5 years experience in HSE practical for oil and gas operations Capable to conduct training course Have good communication and leadership


Attachment 11: Resume of PT. WIDODO LINTAS SAMUDRA’ HSE Coordinator

2.5 HSE PROGRAM/ PROGRAM K3LL

2.5.1 Has a HSE program been developed for the Company?Apakah K3LL program untuk Perusahaan telah dibuat?

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been developed HSE Manual and ProceduresPlease refer to Attachment 12 and complete HSE Manual and Procedures in the separate attach. And please refer to attachment 7

ReferenceAcuan

Attachment 7:PT. WIDODO LINTAS SAMUDRA’ HSE Objectives and Programs 2010



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Attachment 12:List of PT. WIDODO LINTAS SAMUDRA’ HSE Manual and Procedures. and 5 Sample PT. WIDODO LINTAS SAMUDRA’ HSE Procedure.Complete HSE Manual and Procedure please refer to separated attachment.

2.6 HAZARD IDENTIFICATION AND RISK ASSESSMENTS/ IDENTIFIKASI BAHAYA DAN PENILAIAN RESIKO

2.6.1 Has procedures and requirements for Hazard Identification and Risk Assessments been established in the Company? (Please prive copis)Apakah prosedur dan persyaratan Pengidentifikasian Bahaya dan Penilaian Resiko telah dibuat pada Perusahaan? (harap melampirkan salinannya)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been developed procedures and requirements for Hazard Identification and Risk Assessment. Please refer to Attachment 13.

2.6.2 Does this procedure include guidelines for control or elimination of the Hazard or Risk? (Please provide copies)Apakah prosedur tersebut telah mencakup petunjuk untuk mengendalikan atau menghilangkan Bahaya atau Resiko? (harap melampirkan salinannya)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been developed procedures and requirements for Hazard Identification and Risk Assessment include guidelines for control or elimination of Hazard or Risk. Please refer to Attachment 13.

ReferenceAcuan

Attachment 13:PT. WIDODO LINTAS SAMUDRA’ Hazard Identification and Risk Assessment Procedure

Attachment 13:PT. WIDODO LINTAS SAMUDRA’ Hazard Identification and Risk Assessment Procedure



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2.6.3 Is regular review carried out? (If, yes. Please provide evidences in detail how this practiced)Apakah persyaratan ini dilakukan secara reguler?m (Jika ya, lampirkan bukti rincian praktek pelaksanaannya)

Answer: Yes. PT. WIDODO LINTAS SAMUDRA applies Hazard Identification and Risk Assessment, which equipped with Job Safety Analysis (JSA) and its follow up.

Attachment 14:Sample of PT. WIDODO LINTAS SAMUDRA’ Hazard Identification and Risk Assessment.

Attachment 15:Sample of PT. WIDODO LINTAS SAMUDRA’ Job Safety Analysis.

2.7 PERMIT TO WORK SYSTEM / SISTEM IJIN KERJA

2.7.1 Does the Company operates a Work Permit System for critical activities, and has critical activities in the Company been defined and identified? (Please provide copy of Permit to work Procedure and give evidences in details how this practiced).

Apakah Perusahaan menjalankan Sistem Ijin Kerja untuk aktivitas yang kritikal, dan apakah aktivitas kritikal tersebut telah ditentukan dan didentifikasi? (Harap melampirkan salinan prosedur dan bukti rincian praktek pelaksanaanya)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA operates a Permit To Work System for critical activities.Please refer to attachment 16 and attachment 17.

ReferenceAcuan

Attachment 16:PT. WIDODO LINTAS SAMUDRA’ Work Permit System

Attachment 17: Sample of Implementation Permit To Work System



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2.8 PERSONNEL PROTECTIVE EQUIPMENT (PPE)/ ALAT PELINDUNG DIRI (APD)

2.8.1 Has procedure for the provision and use of PPE been established for the Company? (Please provide copies)

Apakah prosedur untuk penyediaan dan penggunaan APD telah dibuat oleh Perusahaan? (Harap lampirkan salinannya)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been established procedure for the provision and use of PPE. Please refer to attachment 18.

2.8.2 What PPE’s are provided? (Please provide a list of the PPE for the scope of this work)

Apakah macam APD yang disediakan? Harap berikan daftar PPE sesuai lingkup pekerjaan ini.

Answer:During the work on site personnel will be equipped with appropriate PPEs, including not limited to: Gloves, Coverall, Safety helmet, Safety boots, Protection glasses/full face visors where required, Work vests (when required), Safety harshness (when required), Protective apron (for arc welding and sand blasting operations), Gloves (for handling hard or sharp objectives, irritant or dirty products and for hot work), Acid-resistant overall (when applicable), Anti noise helmets or earplugs for use in noisy areas, Respiratory protection (when applicable), Any other protective equipment identified during the Hazard

Identification and Risk Assessment.

Note: The use of safety boots and hard hats is mandatory on site, at all time.

ReferenceAcuan

Attachment 18:PT. WIDODO LINTAS SAMUDRA’ Personal Protective Equipment Procedure

Attachment 18:PT. WIDODO LINTAS SAMUDRA’ Personal Protective Equipment Procedure.

Attachment 18a.:Evidence of PT. WIDODO LINTAS SAMUDRA’ Distribution of Personal Protective Equipment to Employee.



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2.9 PLANNED MAINTENANCE/ PEMELIHARAAN YANG TERENCANA

2.9.1 Have the Company established systems for planned maintenance, examination and routine testing of rig or equipment? (Please provide copies and give evidences in details how this practiced).

Apakah Perusahaan telah membuat system untuk pemeliharaan, pengujian dan pemeriksaan rig atau peralatan? (Harap melampirkan salinannya dan bukti rincian praktek pelaksanaanya)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been established systems for planned maintenance, examination and routine testing of equipment.Please refer to attachment 19 and Attachment 20.

2.9.2 Have procedures for such activities been developed, including the requirements for Quality Records, certification/test certificates and documentation that the equipment is “fit for purpose”. (Please provide copies and give evidences in details how this practiced).

Apakah prosedur untuk semacam aktivitas tersebut telah dibuat, termasuk persyaratan tentang Catatan Kualitasnya, sertifikasi, sertifikat pengujian dan dokumentasi bahwa peralatan tersebut “layak digunakan”. (Harap melampirkan salinannya dan bukti rincian praktek pelaksanaanya)

Answer:Yes. Please refer to attachment 19 , 20 & 20a.

ReferenceAcuan

Attachment 19:PT. WIDODO LINTAS SAMUDRA’ HSE Inspection, and Observation Procedure

Attachment 20:PT. WIDODO LINTAS SAMUDRA’ Equipment Management Procedure

Attachment 19:PT. WIDODO LINTAS SAMUDRA’ HSE Inspection, and Observation Procedure

Attachment 20:PT. WIDODO LINTAS SAMUDRA’ Equipment Management Procedure

Attachment 20a:Sample of PT. WIDODO LINTAS SAMUDRA’ Equipment Certificate



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2.10 COMPETENCY AND TRAINING/ KOMPETENSI DAN PELATIHAN

2.10.1 Has the Company established a training procedure and plans? (Please provide copies and give evidences in details how this practiced).

Apakah Perusahaan telah menetapkan prosedur mengenai pelatihan dan perencanaannya? (Harap melampirkan salinannya dan bukti rincian praktek pelaksanaanya)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been established a training procedure and plans.Please refer to attachment 21.

2.10.2 Does this Training Procedure include requirements for:Apakah Prosedur mengenai Pelatihan termasuk persyaratan-persyaratan:

a. Induction? Yes/NoInduction?Answer: Yes

b. Training in Emergency response, for relevant personnel? Yes/NoPelatihan Tanggap Darurat untuk personil yang relevan?Answer: Yes

c. Emergency response drills? Yes/NoLatihan gladi keadaan darurat?Answer: Yes

ReferenceAcuan

Attachment 21:PT. WIDODO LINTAS SAMUDRA’ Training and Competencies Procedure.

Attachment 21:PT. WIDODO LINTAS SAMUDRA’ Training and Competencies Procedure.

Attachment 22: PT. WIDODO LINTAS SAMUDRA’ HSE Training Need Analysis/ Training Matrix

Attachment 23: Photos as evidence that PT. WIDODO LINTAS SAMUDRA’s employee given HSE Induction

Attachment 24: Sample Statement Letter from PT. WIDODO LINTAS SAMUDRA’ Employee after given HSE Induction.

2.11 COMMUNICATION/ KOMUNIKASI Reference



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2.11.1 Have routines for communicating HSE issues within the Company been established? (Please provide copies and give evidences in details how this practiced).

Apakah bentuk-bentuk komunikasi tentang K3LL di Perusahaan telah dibuat? (Harap melampirkan salinannya dan bukti rincian praktek pelaksanaanya)

Answer:Yes. Please refer to attachment 25, 26, 27, 28, 29 and 6

2.11.2 Does this HSE Communication include requirements for:Apakah komunikasi K3LL mencakup persyaratan tentang:

Acuan

Attachment 25:PT. WIDODO LINTAS SAMUDRA’ Group Meeting Procedure

Attachment 26:PT. WIDODO LINTAS SAMUDRA’ HSE Communication and Information

Attachment 27:Sample of PT. WIDODO LINTAS SAMUDRA’ HSE Poster

Attachment 28:Sample of PT. WIDODO LINTAS SAMUDRA’ Buletin

Attachment 29:Sample of PT. WIDODO LINTAS SAMUDRA’ Safety Alert

Attachment 30:Sample of Minutes of Meeting conducted by PT. WIDODO LINTAS SAMUDRA

Attachment 6:PT. WIDODO LINTAS SAMUDRA’ Intern Memo with subject PT. WIDODO LINTAS SAMUDRA’ HSE Policy



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a. Pre-task briefing? Briefing awalan kerja?Yes/NoAnswer: Yes

b. Tool box talks? Yes/NoAnswer: Yes

c. Information notice boards? Yes/NoInformasi yang diperoleh melalui papan pengumunan?Answer: Yes

Please refer to attachment 25, 26, 27, 28, 29 and 6

Attachment 25:PT. WIDODO LINTAS SAMUDRA’ Group Meeting Procedure

Attachment 26:PT. WIDODO LINTAS SAMUDRA’ HSE Communication and Information Procedure

Attachment 27:Sample of PT. WIDODO LINTAS SAMUDRA’ Poster

Attachment 28:Sample of PT. WIDODO LINTAS SAMUDRA’s Bulletin

Attachment 29:Sample of PT. WIDODO LINTAS SAMUDRA’ Safety Alert

Attachment 30:Sample of Minutes of Meeting conducted by PT. WIDODO LINTAS SAMUDRA

Attachment 6:PT. WIDODO LINTAS SAMUDRA’s Intern Memo with subject PT. WIDODO LINTAS SAMUDRA’ HSE Policy

2.12 INSPECTION AND CHECKLIST/ INSPEKSI DAN CHECKLIST Reference



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2.12.1 Has requirements for regular inspection, checklist etc. been established including but not limited to the following been established:

Apakah persyaratan-persyaratan untuk inspeksi, pemeriksaan dengan sistem checklist, dll. telah dibuat termasuk hal-hal berikut, walau tidak terbatas:

Answer:Yes. Please refer to attachment 19 & attachment 31.

a. HSE Management inspections?: Yes/NoInspeksi Oleh Manajemen K3LL?

Answer: Yes

b. Safety Monitoring? Yes/NoPantauan K3LL?

Answer: Yes

c. Operations checklist(s)?: Yes/NoChecklist operasi?

Answer: Yes

(Please provide copies and give evidences in details how this practiced).

(Harap melampirkan salinannya dan bukti rincian praktek pelaksanaanya)

Acuan

Attachment 19:PT. WIDODO LINTAS SAMUDRA’ HSE Inspection, and Observation.Procedure

Attachment 31:Sample HSE Inspection Report



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2.13 HSE OBSERVATION/ OBSERVASI K3LL

2.13.1 What arrangement(s) does your company have for supervision and monitoring of HSE performance in line with safe behaviour? (Please provide copies and give evidences in details how this practiced).

Program apa yang diterapkan oleh perusahaan anda untuk pengawasan dan pemantauan kinerja K3LL berdasarkan prilaku aman? (Harap melampirkan salinannya dan bukti rincian praktek pelaksanaanya)

Answer:PT. WIDODO LINTAS SAMUDRA applies unsafe acts and condition management program, which are basic safety behaviors standard to improve safety performance in our operations. We also encourage a free open dialogue with employees on all safety matters through daily pre-task briefing, HSE meeting and Management/ Operation meeting.

Please refer to attachment 31.a. Sample of HSE Observation Report.

ReferenceAcuan

Attachment 19:PT. WIDODO LINTAS SAMUDRA’ HSE Inspection, Audit and Observation.

Attachment 31.a:Sample of HSE Observation Report

2.14 ACCIDENT, INCIDENT AND NEAR MISS INVESTIGATION AND REPORTING/ INVESTIGASI KECELAKAAN DAN NYARIS CELAKA

2.14.1 Have routines and standard reporting formats been established? If so, please provide copy procedure. ? If so, please provide copy procedure.

Apakah formulir-formulir laporan rutin dan standar telah dibuat? Jika ya, harap lampirkan salinan procedure.

Answer:Yes. PT. WIDODO LINTAS SAMUDRA have been established routines and standard reporting formats. Please refer to attachment 32 and attachment 33.

2.14.2 Please provide copies of investigation reports for the last 12

ReferenceAcuan

Attachment 32:PT. WIDODO LINTAS SAMUDRA’ Standards Accident/Incident reporting and Investigation formats.

Attachment 33: PT. WIDODO LINTAS SAMUDRA’ Accident/Incident Reporting and Investigation Procedure



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(twelve) months.Harap lampirkan salinan semua laporan penyelidikan kecelakaan dalam 12(duabelas) bulan terakhir.

Are the result of accident investigations communicated to the employees? Please give examples.

Apakah hasil penyelidikan kecelakaan dikomunikasikan kepada pekerja? Harap lampirkan contoh cara komunikasinya.

Answer:Yes. PT. WIDODO LINTAS SAMUDRA, zero accident for the last 12 month. If any accident, PT. WIDODO LINTAS SAMUDRA have accident reporting and investigation procedure, result of investigation ( root cause) communicated to all employee through safety memo, safety alert and safety meeting.

Please refer to attachment 33, 25, 26, 27, 28,29 and 30.

Attachment 33: PT. WIDODO LINTAS SAMUDRA’ Accident/Incident Reporting and Investigation ProcedureAttachment 25:PT. WIDODO LINTAS SAMUDRA’ Group Meeting ProcedureAttachment 26:PT. WIDODO LINTAS SAMUDRA’ HSE Communication and Information Procedure

Attachment 27:Sample of PT. WIDODO LINTAS SAMUDRA’ Poster

Attachment 28:Sample of PT. WIDODO LINTAS SAMUDRA’s BulletinAttachment 29:Sample of PT. WIDODO LINTAS SAMUDRA’ Safety AlertAttachment 30:Sample of Minutes of Meeting conducted by PT. WIDODO LINTAS SAMUDRA



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2.15 STATISTICAL DATA/ DATA STATISTIK

2.15.1 What type of safet HSE records do you maintain e.g.Macam-macam pencatatan K3LL apa saja yang anda buat & pelihara?

1. Facilities (Kematian)2. Injuries (Cedera)3. Dangerous occurrences (Near Miss,

Anomaly) - (Kejadian Berbahaya (Nyaris, Penyimpangan)4. Environmental damaged costs (Biaya

kerugian pencemaran lingkungan)5. Property and or vehicle damaged costs

(Biaya kasus kerusakan barang dan/ atau kerusakan kendaraan)

Answer:The following Safety Records are maintained; Fatality Reports & Investigation Lost Time Injury Reports & Investigation Restricted Work Case Medical Treatment Case First Aid Near Miss (Dangerous Occurrence) Reports Material Damage Reports Environmental Pollution Reports

Please refer to attachment 34.

ReferenceAcuan

Attachment 34: PT. WIDODO LINTAS SAMUDRA’ HSE record Keeping and Performance Reporting Procedure



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2.15.2 Please show the details of your annual safety record for the last three (3) years

Mohon lihatkan rincian statistic/ catatan K3 untuk 3 tahun terakhir?

1. Number of facilities (Jumlah kasus

kematian)2. Number of lost work day case injuries

(Jumlah Kasus hilang hari kerja)3. Number of total recordable injuries (Lost

Work Day Case, Restricted Work Day Case, Medical Treatment Case) (Jumlah kasus kecederaan yang masuk pencatatan – Kasus Kec. Hilang Hari Kerja, Kasus Kec. Berakibat Kerja Ringan, Kasus Kec. Memerlukan Perawatan Medis)

4. Number of days lost (Jumlah hari kerja yang hilang)

5. Number of relevant exposure hours (Jumlah jam kerja)

Answer:Please refer to attachment 35: Statistical Safety Performance 2007- Nov. 2010.

Attachment 35: PT. WIDODO LINTAS SAMUDRA’ Statistical Safety Performance

2.16 HSE DOCUMENTS, PROCEDURES AND HAND BOOKS/ DOKUMEN, PROSEDUR DAN BUKU SAKU

2.16.1 Has related HSE Procedures (Safe Working and Administration) for the Company developed? If yes, list applicable procedures and attach at least the existing 5 procedures.Apakah Prosedur K3LL (Prosedur Kerja Aman dan Adminstrasi) sudah dibuat untuk Perusahaan? Jika, ya buat daftar prosedur yang ada dan lampirkan minimal 5 prosedur kerja aman.

Answer: PT. WIDODO LINTAS SAMUDRA has HSE Manual and Procedures and HSE Hand Book.Please refer to attachment 12 and 46.

ReferenceAcuan

.Attachment 12:List of PT. WIDODO LINTAS SAMUDRA’ HSE Manual and Procedures. And 5 Sample PT. WIDODO LINTAS SAMUDRA’ HSE Procedure.Complete HSE Manual and Procedure please refer to separated attachment.



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2.16.2 Have personal safety handbooks been developed and issued to all personnel?Apakah buku pegangan untuk perorangan telah dibuat dan dibagikan kepada semua personil?.

Answer:Yes. PT. WIDODO LINTAS SAMUDRA have been developed personal safety handbooks and issued to all personnel. Please refer to attachment 46.

Attachment 46: PT. WIDODO LINTAS SAMUDRA’s HSE Hand Book.

Attachment 46: PT. WIDODO LINTAS SAMUDRA’s HSE Hand Book. .

2.17 SUBCONTRACTORS/ SUBKONTRAKTOR

2.17.1 Do you have procedure to control the HSE performance of your (sub) contractors? (Please provide copy if any)

Apakah Anda mempunyai prosedur untuk mengawasi kinerja HSE (sub)-kontraktor Anda sendiri? (Harap lampirkan salinan, jika ada)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA have been established HSE requirements for Subcontractor. Subcontractor carrying out PT. WIDODO LINTAS SAMUDRA works will ensure that PT. WIDODO LINTAS SAMUDRA standards and requirements are complied with. Operations Director will ensure that prior to contract award, any subcontractor being considered are included in the “Acceptable Subcontractor List”. Please refer to attachment 36.

ReferenceAcuan

Attachment 36: PT. WIDODO LINTAS SAMUDRA’ Subcontractor and supplier HSE Control Procedure



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2.18 EMERGENCY RESPONSE/ TANGGAP DARURAT

2.18.1 Has a Contingency or Emergency response plan been established? (Please provide copies and give evidences in details how this practiced (drill schedule, result etc.).

Apakah Kontigensi atau Rencana Tanggap Darurat telah dibuat oleh Perusahaan? (Harap lampirkan salinannya dan bukti pelaksanaanya (jadual latihan, hasil dll))

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been established contingency or Emergency response plan. Please refer to attachment 37 and 38

ReferenceAcuan

Attachment 37: PT. WIDODO LINTAS SAMUDRA’ Emergency Response Plan Procedure

Attachment 38: PT. WIDODO LINTAS SAMUDRA’ Emergency Response Drill Report

2.19 CONTROL OF HAZARDOUS SUBSTANCES/ PENGENDALIAN BAHAN-BAHAN BERBAHAYA2.19.1.Have procedures been developed for identifying hazardous

substances, and are procedures in place for limiting and controlling such substances? (Please provide copies and give evidences in details how this practiced

Apakah prosedur untuk mengidentifikasi bahan-bahan berbahaya telah dibuat dan dilaksanakan untuk membatasi pengendalian bahan-bahan tersebut? (Harap lampirkan salinannya dan bukti pelaksanaanya)

Answer:Yes. PT. WIDODO LINTAS SAMUDRA have developed Hazardous Substances Control Procedure. Please refer to attachment 39 and 40.

ReferenceAcuan

Attachment 39: PT. WIDODO LINTAS SAMUDRA’ Hazardous Substances Control Procedure

Attachment 40: Sample of PT. WIDODO LINTAS SAMUDRA’ Material Safety Data Sheet



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2.20 OCCUPATIONAL HEALTH / KESEHATAN KERJA

2.20.1 Has a Medical Advisor/ Paramedic been appointed? Apakah ada Dokter Penasehat Medis/ Paramedik yang ditunjuk?Yes/No

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been appointed Paramedic. The Paramedic are employed as a contract basis. Please refer to attachment 41, attachment 42 and attachment 1.

2.20.2 Is pre-employment medical performed for Company personnel?Apakah pemeriksaan kesehatan untuk karyawan baru masuk kerja dilakukan?

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been performanced pre employment medical. Please refer to attachment 41.

ReferenceAcuan

Attachment 41: PT. WIDODO LINTAS SAMUDRA’ Occupational Health Procedure

Attachment 42: PT. WIDODO LINTAS SAMUDRA’ Medical Check Up Policy and Medical Check Up Report.

Attachment 1: PT. WIDODO LINTAS SAMUDRA, Drug and Alcohol Policy Statement.


Attachment 42: PT. WIDODO LINTAS SAMUDRA’ Medical Check Up Policy and Medical Check Up Report.




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2.20.3 Are the Company facilities regularly reviewed for suitability (hygiene, food and water control, cleanliness etc.)?Apakah fasilitas Perusahaan secara reguler ditinjau ulang untuk kesesuiannya (hygiene, pengendalian makanan dan pengendalian air, kebersihan, dll.?

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been reviewed facilities regularly for suitability (hygiene, food and water control, cleanliness etc.). Please refer to attachment 41 and attachment 41.a

2.20.4 Has a policy for use and abuse of alcohol and drugs been established? If yes, please provide copy of the policy.Apakah kebijakan tentang konsumsi minuman keras dan obat-obatan telah ditetapkan? Jika ya, harap lampirkan salinannya.

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been established policy for use and abuse of alcohol and drugs. Please refer to attachment 1.


Attachment 41a.: PT. WIDODO LINTAS SAMUDRA’ House keeping and Higienes Inspection report.




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2.21 ENVIRONMENT/ LINGKUNGAN HIDUP

2.21.1 Have a policy and procedures for environmental control been established? If yes, please provide copy of the policy.Apakah kebijakan dan prosedur tentang pengendalian lingkungan telah dibuat? Jika ya, harap lampirkan salinannya.

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been established a policy and procedure for environmental control. Please refer to attachment 1 and attachment 43.

ReferenceAcuan

Attachment 43:PT. WIDODO LINTAS SAMUDRA’ Waste Management and Environment Monitoring Procedure

Attachment 1: PT. WIDODO LINTAS SAMUDRA’ HSE and Drug & Alcohol Policy Statement

2.22 INTERNAL HSE AUDITS/ AUDIT K3LL INTERNAL

2.22.1 Has a program for HSE Audits been established? ? (Please provide copy of program for HSE Audit)

Apakah program Audit K3LL ditetapkan? (Harap lampirkan salinannya)

Answer :Yes. PT. WIDODO LINTAS SAMUDRA has been established a program for HSE Audits.Please refer to attachment 44 and 44.a.

ReferenceAcuan

Attachment 44:PT. WIDODO LINTAS SAMUDRA’ HSE Management System Audit

Attachment 44a:

PT. WIDODO LINTAS SAMUDRA’ HSE Internal Audit Report



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2.22.2 Have routines for control and close out of such reports been established? (Please provide copy of implementation)Apakah secara rutin pengendalian dan penutupan laporan tersebut ditetapkan? (Harap lampirkan bukti pelaksanaannya)

2.22.3 Have routines for control and close out of such reports been established?Apakah secara rutin pengendalian dan penutupan laporan tersebut ditetapkan?

Answer:Yes. PT. WIDODO LINTAS SAMUDRA,s procedure for HSE Audits has been established routines for control and close out of reports.Please refer to attachment 44 and 44.a.

Attachment 44:PT. WIDODO LINTAS SAMUDRA’ HSE Management System Audit Procedure

Attachment 44a:

PT. WIDODO LINTAS SAMUDRA’ HSE Internal Audit Report

2.23 MANAGEMENT REVIEWS/ TINJAUAN ULANG OLEH MANAJEMEN

2.23.1 Has requirements for, and is regular review of HSE matters carried out in the Company?Apakah persyaratan untuk peninjauan ulang secara tetap terhadap masalah K3LL dilaksanakan di Perusahaan?

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been carried out requirement for, and is regular review of HSE matters.Please refer to attachment 44 & 45

ReferenceAcuan

Attachment 44:PT. WIDODO LINTAS SAMUDRA’ HSE Management System Audit ProcedureAttachment 45:PT. WIDODO LINTAS SAMUDRA’ HSE Management Review ProcedureAttachment 45a:Attendance List & Minutes of Meeting of Management Review.



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2.23.2 Have requirements and routine follow up procedures been established?Apakah persyaratan dan prosedur untuk peninjauan ulang secara tetap terhadap masalah K3LL dilaksanakan di Perusahaan?

Answer:Yes. PT. WIDODO LINTAS SAMUDRA has been established requirements and routine follow up procedures.Please refer to attachment 44, 45 & 45a..

Attachment 44:PT. WIDODO LINTAS SAMUDRA’ HSE Management System Audit Procedure

Attachment 45:PT. WIDODO LINTAS SAMUDRA’ HSE Management Review Procedure

Attachment 45a:Attendance List & Minutes of Meeting of Management Review.

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