Global Upstream CHESM Interim and Post-Job Evaluation Form

1. General

Contractor Company Name: Contract/Project Name or Number: Chevron Contract Owner: Number of employees supporting the contract/operations: Contractor Key Personnel:

PT. ALSSA Corporindo Lease of Trunking Radio System M. Arie Nugraha 7 pax

Company Manager: Dani Rahayu Phone: 021 8010035 Email/Fax: 021 8010033 0812 5420077 dani.rahayu@alssacorp.com Site Supervisor: Putra Agung Noviardhy Phone: 0542 7020883 Email/Fax: 0542 760077 0856 52009247 noviardhy@alssacorp.com HES Representative: Wendra Gusti Nova Phone: 0542 7020883 Email/ Fax: 0542 760077 082157009990 wendra @alssacorp.co.id

Evaluation Completed by: Date Submitted: 27 April 2011

M Husein B, Emil Habli HN, Rivai Aris, M. Sadikin.

2. HES Performance Data

Provide HES performance data specific to the Chevron project/contract, not to exceed 3 years Total number of employee hours worked Number of work-related fatalities Number of injuries that resulted in restricted work activity Number of injuries that resulted in one or more days away from work Number of injuries and illnesses involving medical treatment Number of motor vehicle accidents Number of oil and chemical spills

Year 2008

Year 2009

Year 2010

5920
0 0 0 0 0 N/A 0 0 0 0 0

5936
0 0 0 0 0

6238

N/A

N/A

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GU CHESM Interim and Post-Job Evaluation Form

2. HES Performance Data

Provide HES performance data specific to the Chevron project/contract, not to exceed 3 years Annual percent (%) employee turnover rate

Year 2008 0%

Year 2009 0% Yes

Year 2010 0% No

Have you received any regulatory citation or been involved in any court litigation in the last three years?
3. HES Management Systems

Acceptable HES Performance 1. 2. 3. 4. Safety/Health performance Environmental performance Significant events Annual percent (%) employee turnover rate Regulatory or court litigation

Improvement Needed

Comments _____ of 25 pts

5.

HES Management 1. HES organization

_____ of 41 pts HES Organization exists. HES Chairman reports directly to Director JAMSOSTEK insurance for employees covers JHT, medical & death insurance HES Target 2011 available, but Lagging indicator should change to numeral Annual HES program exists, by attached HSE PERFORMANCE APPRAISAL WORKSHEET All employees shall sign Perjanjian Kerja Selamat act that covers safety actions should be performed as ALSSA employee and sanction for doing violations.

2.

Employee benefits

3.

HES targets

4.

HES written programs

5.

Employee engagement

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GU CHESM Interim and Post-Job Evaluation Form

3. HES Management Systems

Acceptable 6. Safety meetings

Improvement Needed

Comments Safety meetings were conducted in monthly basis. Meeting minutes are available. Policy for subcontractor management is available. But it has not been implemented since ALSSA has no subcontractor to support Chevron contract. Inspection and audit policy exists. Regular inspections were performed and proofed by evidences. Internal audits were performed. Policy for hazard identification is available. Proofed by evidence Form Risk Register Procedure is available in HES manual. Employees were trained for doing incident investigation & reporting, its proofed by Certificates. For accident in Pancur site should to reported by using ALSSA Investigation Form. Procedure is available. Conducted through Mailing List, Posters at Bulletin Board Policy is available. Proofed by BBS Reports and HSE Performance Appraisal PPE lists are available and checked in regular basis. Documents are available. All Regulation are met. Currently ALSSA in progress for certification ISO & OHSAS

7.

Subcontractor management

8.

Inspections and audits

9.

Hazard identification and control

10.

Incident investigation and reporting

11. 12.

Incident corrective action Sharing of incident learning

13.

Behavior-based safety

14.

Personal protective equipment

15.

Regulatory compliance

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GU CHESM Interim and Post-Job Evaluation Form

3. HES Management Systems

Acceptable 16. Pollution prevention

Improvement Needed

Comments Waste management procedure is available in HES manual. Has a waste management contract with a vendor to handle unused batteries Procedure is available in HES manual. ALSSA building equips with some facilities to support emergency condition, e.g. fire extinguisher, muster point, contact info, medical evacuation procedure, etc. For Emergency schedule recommended conducted just once a year (Office). Evidence of Emergency Drill 2010 was found. _____ of 19 pts Handover/on boarding training is available for new employees and employees worked in new position. Checklist for on boarding training is available. Found employees certificates for attending some training, e.g. climbing, rigging, working at height, radio related training Proofed by Document Induksi Karyawan Refer to ISO & OSHAS requirements, e.g. incident management, fire fighting, BBS etc. Record of executed training program is available. Yearly training matrix plan is available. _____ of 11 pts

17.

Emergency preparedness

Fitness for Duty: Skills, Knowledge and Training 1. Short -service employees

2.

Craft training

3. 4.

HES orientation HES training (content)

5.

Training records

Fitness for Duty (Medical and Industrial Hygiene)

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GU CHESM Interim and Post-Job Evaluation Form

3. HES Management Systems

Acceptable 1. 2. Medical services Medical examinations

Improvement Needed

Comments Covered by insurance (JAMSOSTEK) Conducted annually. MCU records proofs are available N/A N/A Policy exists. Policy exists. _____ of 4 pts Critical equipment is recertify in regular basis, e.g. lifting equipment. Lifting Equipment ( Snatch Block & Rope) checked and inpected in 6 Month by BKI.

3. 4.

Substance abuse Industrial hygiene

Equipment and Materials 1. 2. General Equipment

Total Points

______ of 100 pts

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GU CHESM Interim and Post-Job Evaluation Form

4. Action Items

Needs Improvement/Not Acceptable Subject 1. 2. 3. 4. 5. Attach additional sheet if needed. Contract Owner: Muhammad Arie Nugraha Corrective actions to be completed by: Contract firm informed of results? Yes

Corrective Action Required

Target Date

Actual Completion

Date reviewed with Contract Owner:

No

Name informed: Yes No

Date: Date:

Contract firm to remain on re-selection bid list?

Version 1.0. Revised 23 May 2007. Printed 22 July 2012. Uncontrolled when printed. Document1

GU CHESM Interim and Post-Job Evaluation Form

Scoring Guidelines
The scoring process is consistent with the HES rating evaluation for the TRIR data and qualification questionnaire. Acceptable and N/A evaluation shall receive full points. Improvement Needed shall receive no points. Corrective actions may be suggested to a contract firm, even if an acceptable rating is given. Each section is scored by totaling the acceptable and N/A answers and then dividing by the total number of points available in the section. The resulting number is then multiplied by the weighting percentage of the section. For example:
Section Points/Points Available Weighting Score

HES Performance HES Management Fitness for Duty (Skills, Knowledge and Training) Fitness for Duty (Medical and Industrial Hygiene) Equipment and Materials Total score 87 pts.

Version 1.0. Revised 23 May 2007. Printed 22 July 2012. Uncontrolled when printed. Document1