Contractor Safety, Health and Environmental Management System

(CSMS) Guidelines

Pre-Qualification Forms

Pre-Qualification
New Contracts
Qualification Phase: Select A Qualified Contractor

Risk Assessment
Pre-Qualification
Selection CSMS

Contract Award
Data Bank
Contract Implementation Phase: Ensure Field Safe Work

Pre-Job Activity Work In Progress Final Evaluation

 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

Form CSMS/PQ/01

PRE-QUALIFICATION

Date : 29 April 2013

Project Period : ------

Job Title : INTEGRITY MANAGEMENT & CORROSION SERVICES

Contract No : ------

Work Location : Company & Contractor Jakarta Office and Company

Offshore

Contractor Name : PT. KARYA SEJAHTERA PRATAMA

Address : Graha Mobisel Lt.3

Jl. Warung Buncit Raya No.139 Jakarta Selatan 12740

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

Form CSMS/PQ/02: Contractor HSE MS Questionnaires

Company Name : PT. KARYA SEJAHTERA PRATAMA

Work Subject : Personnel Services Contract for Operational and

Project Activities Support Services

SECTION 1 :
LEADERSHIP AND TOP MANAGEMENT COMMITMENT
1. Commitment to HSE through leadership

a) How are senior managers is top management personally involved in HSE

management?

Keterlibatan Manager Senior (Top Management) PT.KSP dilakukan melalui penandatanganan Kebijakan
HSE dan Larangan penggunaan Obat-obatan terlarang. Kemudian kunjungan kelapangan (Management
Walktrough) setiap 3 bulan serta rapat HSE yang dilaksanakan setiap bulannya yang semua itu masuk
menjadi KPI (Key Performance Indicator) PT.KSP

b) Provide evidence of commitment at all levels of the organization by:·

(i) Stating this year's company targets for HSE performance·

Pernyataan tentang target kinerja HSE perusahaan dituliskankan melalui HSE MOM dan participants list

(ii) Describing how you ensure that your organization understands and is
committed to deliver your company HSE targets

Komitmen HSE untuk setiap jenjang organisasi yang ditandatangani setiap level jabatan yang ada
dikantor dan juga level manajemen melalui HSE meeting setiap bulan.

c) How do you promote a positive culture towards HSE matters?

Promosi budaya positif masalah HSE dilakukan melalui penerbitan bulletin HSE bulanan, dan Safety Alert.

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

d) Provide your current Organization chart

Terlampir bagan organisasi PT.KSP

SECTION 2 :
POLICY AND STRATEGIC OBJECTIVES
2.1. HSE Policy & Documents

a) Does your company have an HSE policy document that is applied?

(Yes/No) If yes, please attach.

Yes, PT.KSP memiliki kebijakan HSE, mutu dan larangan pemakaian narkoba, minuman keras dan merokok
yang sudah ditandatangani oleh Direktur Utama

b) Who has overall and final responsibility for HSE in your organization?

Pengaturan untuk memberitahukan karyawan mengenai perubahan kebijakan dengan cara membuat
dokumen distribusi untuk masing-masing fungsi dan membuat berita acara penyerahan dokumen
kebijakan revisi terbaru

c) How do you ensure HSE Policy compliance and communication at site?

Cara memastikan kepatuhan akan kebijakan dan komunikasi HSE yaitu dengan menjelaskan HSE function
dan responsibilites

2.2. Availability of Policy Statements to Employees

How do you communicate your company's policy to your employees including any
changes?
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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

Cara mengkomunikasikan kepada karyawan mengenai perubahan kebijakan perusahaan dengan cara
membuat dokumen distribusi untuk masing-masing fungsi dan membuat berita acara penyerahan
dokumen kebijakan revisi terbaru.

SECTION 3:
ORGANIZATION, RESPONSIBILITY, RESOURCES, STANDARDS AND DOCUMENTATION
3.1. Organizations - Commitment and Communication
a) How is management involved in HSE activities, objective setting and monitoring?

Keterlibatan Top Manajemen (BOD) dalam penetapan sasaran dan pemantauan HSE melalui sasaran
ukuran kinerja terpilih pada KPI (Key Performance Indicator) yang dibuat setiap awal tahun.

b) What provision does your company make for HSE communication and meetings?

Ketentuan yang perusahaan buat untuk mengkomunikasikan masalah HSE yaitu dengan cara membuat
jadwal meeting setiap bulannya dan mendokumentasikan hasil dari penyelenggaraan komunikasi
tersebut.

3.2. Competence and Training of Manager/Supervisors/Senior Site Staff/HSE Advisor

Have the managers and supervisors at all levels that will plan, monitor, oversee and
carry out the work received formal HSE training in their responsibilities with respect to
conducting work to HSE requirements? (Yes/No)

Yes,

If yes, please attach the training matrix.

PT.KSP sudah melakukan inhouse training dengan materi Building Emergency Respon Plan & Evacuation
Course dengan lama waktu 1 hari

3.3. Competence and General HSE Training

a) What arrangements does your company have to ensure employees have
knowledge of basic industrial HSE, and to keep this knowledge up to date?

Untuk memastikan bahwa karyawan mempunyai pengetahuan tentang HSE dasar dalam industri maka
PT.KSP melakukan inhouse training untuk Crew untuk menjaga agar pengetahuan mengenai HSE mereka
tetap update.

b) What arrangements does your company have to ensure ALL employees, including
sub contractors, also have knowledge of your HSE policies and practices?
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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

Seluruh karyawan diberikan Safety Induction sebelum memulai bekerja dan informasi mengenai bahaya
khusus yang timbul dari sifat pekerjaan dilakukan pada saat Pre Job Meeting dengan membahas JSA
untuk pekerjaan yang akan dilakukan.

3.4. Specialized Training

Have you identified areas of your company's operations where specialized training is
required to deal with potential hazards? (Yes/No)

PT.KSP telah mengidentifikasikan lokasi operasi yang membutuhkan pelatihan khusus melalui Prosedur
Identifikasi Bahaya, Penilaian Resiko, dan Penentuan Kontrol.
Sebagai penjabaran maka dilakukan : Fire Drill, Evacuation Drill, dll

If Yes, please provide the list (e.g. radioactive, asbestos, explosive, diving, etc).

Identifikasi terhadap bahaya baik terhadap manusia maupun peralatan dinilai dan diatasi melalui
pembuatan JSA untuk masing-masing proses kegiatan yang ada di Rig. Kegiatan ini diatur dalam Prosedur
Identifikasi Bahaya, Penilaian Resiko, dan Penentuan Kontrol.

3.5. HSE Qualified Staff - Additional Training

Does your company have HSE specialist (related to your company's services) who can
provide training for other employees? (Yes/No)

Yes, PT.KSP memiliki kualifikasi HSE yang mampu memberikan pelatihan dasar

If Yes, please attach the curriculum vitae

Terlampir CV dari pekarya PT.KSP

3.6. Assessment of Suitability of Subcontractors

a) Do you employ sub-contractor(s) for the intended service? (Yes/No)

No, PT.KSP tidak memiliki subkontraktor

If No, please go to the question 3.7.

Do you have sub-contractor(s) selection procedure in term of HSE?

b) How do you assess your sub-contractor(s) to ensure they comply with your
company's HSE policy and standards?

PT.KSP tidak memiliki subkontraktor

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

3.7. Standards
a) What kind of HSE regulatory or industrial standards that your company refer to for the
intended service?

PT.KSP mengenali standar-standar industri baru yang mungkin berlaku dengan menggunakan Daftar
Peraturan Perundangan yang terkait dengan HSE yang berasal dari Ditjen Migas, API, & SNI

b) How do you ensure these are met and verified?

Standar-standar ini dipenuhi dan diperiksa melalui berbagai macam kegiatan inspeksi.
Seperti : Inspeksi kendaraan, checklist sebelum tanjak, pemeliharaan HSE umum dan laporan inspeksi yang
dilakukan oleh PJIT.

SECTION 4:
HAZARDS AND EFFECT MANAGEMENT
4.1. Hazards and Effect Management
Does your company have procedure for the identification, assessment, control and
mitigation of hazards and effects? (Yes/No)

Yes,

If Yes, please attach the index/table of content including the sub-index.

Dalam mengidentifikasi, menilai, mengurangi bahaya dampak yang ada di PT.KSP menggunakan general
risk assesment yang menggunakan teknik atau metode FMEA untuk mengukur Probaility dan Consequnce.

4.2. Exposures of the Workforce

What systems are in place to monitor the hazard's exposure of your workforce e.g.
chemical or physical agents?

Untuk memantau paparan pekerja terhadap bahan kimia atau unsur fisika yang diakibatkan oleh bahan-
bahan material atau kimia yang digunakan PT.KSP yaitu dengan cara menempelkan MSDS disekitaran
gedung inventory kerja dan tempat yang dekat dengan lokasi penggunaan bahan kimia tersebut.
Disamping itu penjelasan MSDS juga dijelaskan ke Crew melalui Tail Gate Meeting.

4.3. Handling of Potential Hazards

How is your workforce advised on potential hazards, e.g. chemicals, noise, radiation,
etc., encountered in the course of their work?

PT.KSP memberitahukan bahaya yang mungkin timbul seperti bahan kimia, kebisingan melalui prosedur
Pengelolaan Bahan-bahan Berbahaya dan Komunikasi Informasi HSE. Kemudian pekerja tersebut
mengkomunikasikan pada saat Tail Gate Meeting

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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

4.4. Personnel Protective Equipment

a) What arrangements does your company have for provision and unkeep of
protective equipment and clothing, both standards issue, and that required for
specialized activities?

PT.KSP membuat prosedur P-012 Alat Pelindung Diri untuk pengadaan dan pemberian alat pelindung diri
dan dipakai kerja baik untuk yang standar maupun yang diperlukan untuk kegiatan-kegiatan khusus.

b) Do you provide appropriate personal protective equipment (PPE) for your

employees? (Yes/No)

Yes,

Please provide a listing of the PPE for the scope of this work.

PT.KSP menyediakan PPE yang sesuai untuk karyawan, daftar PPE untuk pekerjaan yang ada dilokasi kerja
juga sudah dibuat. Disamping itu distribusi PPE ke masing-masing Area kerja juga sudah dibuat

c) Do you provide training on how to use PPE? (Yes/No)

Yes,

Explain the content of the training and any follow-up

PT.KSP sudah memberikan pelatihan tentang cara penggunaan PPE kepada karyawan yang baru masuk
dan tamu yang berkunjung kelokasi pengeboran melalui Safety Induction.

d) Do you have a program to ensure that PPE is impacted and maintained?

PT.KSP membuat program dan data base PPE yang ada disetiap Area Kerja untuk memastikan
penggunaan dan jumlah PPE yang dibutuhkan dimasing-masing Area Kerja. Inspeksi dilakukan oleh HSE
Officer dengan menggunakan General HSE Inspeksi.

4.5. Waste Management

a) What systems are place for identification, classification, minimization and
management of waste?

PT.KSP membuat prosedur P-010 (Pengelolaan Limbah dan Pemantauan Lingkungan) untuk
mengidentifikasi, klasifikasi, pengurangan dan penanganan limbah.

b) Please provide the number of accidents resulting in environmental damage in the

amount greater than $50,000 for the last 24 months. Attach copies of any
governmental reports submitted.

Dalam 24 bulan terakhir PT.KSP tidak pernah mengalami kecelakaan yang menyebabkan kerusakan
lingkungan dalam jumlah melebihi $50.000,-
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 Contractor Safety, Health and Environmental Management System
(CSMS) Guidelines
Form CSMS/PQ/02

c) Do you have procedures for waste disposal? (Yes/No)

Yes, PT.KSP membuat prosedur P-010 (Pengelolaan Limbah dan Pemantauan Lingkungan) untuk
pembuangan limbah

d) Do you have procedures for spill reporting? (Yes/No)

Yes, PT.KSP membuat prosedur P-010 (Pengelolaan Limbah dan Pemantauan Lingkungan) untuk pelaporan
tumpahan minyak (oil spill) yang diakibatkan oleh peralatan PT.KSP

e) Do you have procedures for spill clean up?(Yes/No)

Yes, PT.KSP membuat prosedur P-010 (Pengelolaan Limbah dan Pemantauan Lingkungan)

f) Please provide details at any of your equipment related to environmental matters.

PT.KSP memiliki peralatan yang berkaitan dengan masalah lingkungan yang telah diuji coba
(commisioning) yang dapat dilihat pada lampiran.

4.6. Industrial Hygiene

Do you have an industrial hygiene program? (Yes/No)

Yes,

Please describe this process. If Yes, please provide the list.

PT.KSP memiliki program kesehatan yang dijelaskan pada P-007 (Kesehatan Kerja) seluruh crew setiap awal
kontrak wajib melakukan MCU sedangkan asuransi untuk crew menggunakan Jamsostek.

4.7. Drugs and Alcohol

Do you have a drugs and alcohol policy in your organization? (Yes/No) If yes, please
attach

Yes, PT.KSP memiliki Kebijakan Larangan Pemakaian Narkoba, Minuman Keras, dan Merokok

SECTION 5:
PLANNING AND PROCEDURES
5.1. HSE or Operations Manuals
a) Do you have HSE procedures? (Yes/No) If Yes, please attach the list of content

Yes, PT.KSP memiliki buku prosedur HSE yang dijelaskan secara rinci, dapat dilihat pada daftar prosedur HSE

b) How do you ensure that the working practices and procedures used by your
employees on-site are consistently in accordance with your HSE policy objectives and
arrangements?

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 Contractor Safety, Health and Environmental Management System
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Form CSMS/PQ/02

Untuk memastikan cara kerja dan prosedur yang digunakan oleh karyawan dilapangan konsisten dengan
tujuan dan kebijakan HSE maka dilakukan penetapan prosedur Ijin Kerja untuk pekerjaan berbahaya.

5.2. Equipment Control and Maintenance

How do you ensure that plant and equipment used within your work environment, on-
site, or at other locations by your employees are correctly registered, certified with
regulatory requirement, inspected, controlled and maintained in a safe working
condition?

PT.KSP membuat maintenance schedule dan maintenance record untuk masing-masing peralatan.
Disamping itu untuk mempermudah pekerjaan maka dibuat Tata Kerja Individu (Work Instruction) untuk
masing-masing pekerjaan pemeliharaan.

5.3. Transport Safety Management and Maintenance

What arrangement does your company have for vehicle incidents prevention?

PT.KSP menetapkan prosedur P-025 untuk Keselamatan Berkendaraan di Darat.

5.4. Lifting Operation Procedure (if applicable)

Do you have any procedures to control the work involved in lifting operation?

5.5. Maintenance Schedule of Lifting Operation Equipments (if applicable)

Do you have any inspection, testing, maintenance and certification programs and
schedule for lifting equipments e.g. crane, forklift and rigging equipment?

5.6. Competency of Lifting Operation Personnel (if applicable)

Do you have any system to ensure that the lifting teams e.g. lifting equipment operators,
signalmen and rigging personnel are competent?

SECTION 6:
IMPLEMENTATION AND PERFORMANCE MONITORING
6.1. HSE Management and Performance Monitoring of Work Activities
a) What arrangement(s) does your company have for supervision and monitoring of HSE
performance?

Pengawasan dan pemantauan kinerja HSE dilakukan setiap bulannya oleh Top Manajemen melalui HSE
meeting.

b) What arrangements does your company have for passing on any results and findings
of this supervision and monitoring to your:

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Form CSMS/PQ/02

(i) Top/Base management

Melalui laporan management walktrough yang dilakukan BOD dan HSE Manager

(ii) Site employees

Melaksanakan hasil temuan & melakukan tindakan pencegahan melalui komunikasi dan informasi yang
dilakukan oleh seluruh karyawan dilapangan.

c) Has your company received any award for HSE performance achievement?
(Yes/No)

PT.KSP belum memiliki penghargaan atas prestasi kerja.

6.2. Statutory Notifiable Incidents/Dangerous Occurrences, Improvement Requirement and

Prohibition Notices
Has your company suffered any improvement requirement or prohibition notices on
statutory notifiable incidents/dangerous occurrences by the relevant national body,
regulatory body for HSE or other enforcing authority or been prosecuted under any HSE
legislation in the last five years? (Yes/No)

PT.KSP tidak pernah mengalami insiden berbahaya

If yes, please give the number of occurrences and its short description.

6.3. HSE Performance Records

a) Please provide statistical details of your HSE performance over the past 3 years (if not
recorded/applicable please mark N/R or N/A) Total Number Frequency
(incl. All contract & sub contract personnel) (based on OSHA)
 Fatalities
 Days Away From Work Cases (DAFWC) or Loss Time Incidents (LTI)
 Total Recordable Cases (e.g. Medical Treatment, Restricted Work, Transfer to
Another Job, Unconsciousness)

b) How is health performance recorded?

Dokumentasi kinerja kesehatan didokumentasikan sesuai P-007 (Kesehatan Kerja) dan kemudian dibuat
rekap Medical Check Up untuk seluruh karyawan yang sudah melaksanakan Medical Check Up dan
dilakukan analisa terhadap medical tersebut.

c) How is environmental performance recorded?

Kinerja lingkungan didokumentasikan kedalam berita acara, dan kemudian dirangkum dalam laporan
bulanan HSE.

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 Contractor Safety, Health and Environmental Management System
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Form CSMS/PQ/02

6.4. Incident Investigation and Reporting

a) Do you have a procedure for the investigation, reporting and follow-up of accidents,
dangerous occurrences or occupational illnesses? (Yes/No) If yes, please attach

Yes, PT.KSP memiliki prosedur P-011 (Penyelidikan dan Pelaporan Kecelakaan dan Pencemaran
Lingkungan) untuk melakukan investigasi, pelaporan dan tindak lanjut insiden.

b) How are the findings following an investigation, or a relevant incident occurring

elsewhere, communicated to your employees?

Melalui safety alert dan bulletin HSE PT.KSP

Please attach an example of investigation reports during the last 12 months.

Yes, kami laporkan investigasi untuk 12 bulan terakhir.

SECTION 7:
AUDIT AND REVIEW
a) Do you have a written procedure on HSE auditing? (Yes/No)

Yes, PT.KSP memiliki prosedur Internal Audit

b) How does this procedure specify the standards for auditing, including schedule,
coverage and the qualifications for auditors?

Prosedur Internal Audit menjelaskan standar pelaksanaan Internal Audit, ketidaksesuaian dan kualifikasi
Auditor serta hasil yang sudah dilaksanakan.

c) How is the effectiveness of audit verified and how does management report and
follow up audits?

Efektifitas audit diperiksa, direkapitulasi dan dianalisa yang kemudian disajikan kedalam rapat
management review yang dilakukan setiap 6 bulan.

SECTION 8:
EMERGENCY RESPONSE PROCEDURE
Do you have an emergency response plan? (Yes/No) If yes, please attach

Yes, PT.KSP menjaga kesiapan Tanggap Darurat melalui prosedur P-013 (Tanggap Darurat) yang
didalamnya dijelaskan struktur komando dan tanggung jawab masing-masing tim/fungsi dalam
menghadapi keadaan darurat.

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 Contractor Safety, Health and Environmental Management System
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Form CSMS/PQ/02

SECTION 9:
HSE MANAGEMENT - ADDITIONAL FEATURES
Does your company hold association(s) membership? (Yes/No)

Yes,

If yes, please provide the list

PT.KSP memiliki sertifikat keanggotaan dari GAPENSI, KADIN, APMI,

PT.KSP juga memiliki sertifikat CSMS dari Chevron, EMP Malacca Strait S.A, Tately N.V, CNOOC

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