IRIS Project

Method of Statement
Submission
SWITCH SOCKET
INSTALLATION
 REQUEST FOR
METHOD OF STATEMENT
APPROVAL

To : PT. SHIMIZU BANGUN CIPTA KONTRAKTOR Reference No. : IRIS-RFA-MOS-E-007

Revision : 0

Attn : Date Submitted : 16-Nov-22

Page (s) : Date Required : 23-Nov-22

Copy to :
SHIMIZU Others, pls specify
FOR
AURECON APPROVAL
Subject METHOD OF STATEMENT SWITCH SOCKET INSTALLATION

Location : General Drawings Specification

Documents Part Print Others

S/N ITEMS DESCRIPTION REFERENCE

1 Switch Socket Installation Submission for method of statement Switch Socket Installation

Note :

Requested By: Signature:

REPLY :

A: Approved C: Rejected

B: Approved with comments D: Not reviewed / not applicable

Comments :

Representative Signature Name / Date

TABLE OF CONTENT :
1.0 PURPOSE
2.0 SCOPE OF WORK
3.0 DEFINITIONS
4.0 PROCEDURE
4.1 Site Plan / Schematic Diagram
4.2 Preparatory Work
4.3 Use of Special Equipment / Machine
4.4 Lifting Plan
4.5 Equipment / Machine Certification Requirements & Technical Specifications
4.6 Mode of Transportation & Routing Plan
4.7 List of Manpower
4.8 Competency Level of Personnel Executing The Job
4.9 List of Approved Material
4.10 Safety Data Sheet (SDS) of Chemical / Hazardous Substances Used
4.11 Job Safety Analysis
4.12 Risk Assesment
4.13 Emergency Rescue / Contingency Plan
4.14 Mitigating Measures
4.15 Applicable Safe Work Procedures
4.16 Sequence of Work
4.17 Communication, Inspection & Supervision Methodology
5.0 ASSOCIATED DOCUMENTS
5.1 Layout Installation
5.2 Job Safety Analysis
5.3 Risk Assesment
5.4 Inspection Test Report
1.0 PURPOSE
The purpose of this statement is to ensure that the Switch Socket Installation to
be carried out following the correct procedure with specified requirements for
IRIS project.
2.0 SCOPE OF WORK
This method statement is the necessary measures to ensure that all installation
activities to be identified and established and approved by the Employer’s
representative. The scope of this plan is to provide a guideline for the
implementation of quality assurance on installation works.
3.0 DEFINITIONS
Terms Definition
Project IRIS
GC PT. Shimizu Bangun Cipta Kontraktor
MOS Method of Statement
MAT Material Approval Submission
Table 1 : Definitions
4.0 PROCEDURE
4.1 Site Plan / Schematic Diagram (Phase 1)

Picture 1 : Site Layout of Switch Socket Installation

4.2 Preparatory Work
a. All related documents and approval required to perform work are to be
prepared and complete and confirm with approved documents by
consultant engineers including and not limited to required submittals
listed in specifications, Shop Drawings, RFI and Material Approval.
b. Secure all the necessary reference drawing layout and determine the
actual position to commence installation with the mobilization of
required work force, tools and equipment.
c. Prepare confirmation of conformance between temporary storage and
vendor storage requirement/standard.
d. Ensure all approval required to perform work are obtained and conform
with approved documents by Consultant Engineers and Architect.
4.3 Use of Special Equipment / Machine
No. Descriptions Purpose
General Tool Box
1 Carrying installation tools.

Measuring Tape
2 Measurement tool.

Screwdriver
3 Turning screws.

Continuity Test Tool

4 Continuity testing tools.

Electrical Cable Cutter

5 Material lifting.

Drill Machine
6 Drilling for support.

ELCB / GFCI Box Socket

Electrical shock prevention caused by
7
short circuit from electrical tools used.

Table 2 : List of Equipment, Tools, & Machinery

4.4 Lifting Plan
N/A.
4.5 Equipment / Machine Certification Requirements & Technical Specifications
N/A.
4.6 Mode of Transportation & Routing Plan

Picture 2 : Site Mobilization Traffic Route

4.7 List of Manpower
No. Designation Qty Responsibility
Responsible for overall commercial,
contractual & technical performances
1 Project Manager 1
associated with specific project &
reporting to the Project Director.
Planning and supervising work
2 M&E Engineer 1
activities.
Inspect, verify, and prepare work
3 QA / QC Engineer 1
method of statement for work quality.
To provide toolbox and guidance to
4 Safety Officer 1 work and ensure that work is carried
out in a safely manner.
Obtain permit to work, control the
sequence according to MOS,
Approved Shop Drawings, and MAT,
ensure mechanical aspects of the
5 Supervisor 1
work are according to the
specifications, ensure safe practices
are followed and ensure quality of
workmanships during execution.
To carry out all the technical aspects of
6 General Workers 1-5
installation process.
Table 3 : List of Manpower Responsibilities
4.8 Competency Level of Personel Executing The Job
N/A.
4.9 List of Approved Material
No. Descriptions Purpose
Socket Power Outlet
1 Electrical small power material.

Lighting Switch
2 Electrical small power material.

Outbow Box
Outbow box for switch/socket wiring
3
cable installation.

Inbow Box
Inbow box for switch/socket wiring
4
cable installation.

GI Conduit Electrical small power exposed

5
conduit.

GI Junction Box
6 Enclose wire connections.

PVC Conduit Electrical small power concealed

7
conduit.

PVC Junction Box

8 Enclose wire connections.

SUS Mesh
9 To protect concealed PVC conduit.

NYY 3 x 2.5mm Cable

10 Electrical small power cable.

Table 4 : List of Material Used

4.10 Safety Data Sheet (SDS) of Chemical / Hazardous Substances Used
N/A.
 4.11 Job Safety Analysis
Refer to attached Job Safety Analysis sheet.
4.12 Risk Assesment
Refer to attached Risk Assesment sheet.
4.13 Emergency Rescue / Contingency Plan

Picture 3 : SECM Emergency Response Chart

Picture 4 : Emergency Rescue / Contingency Plan Layout
4.14 Mitigating Measures
4.15 Applicable Safe Work Procedures
a. The actual manpower of each type of installation may vary according to
the site condition and requirement. All workers shall wear appropriate
Safety PPE (Safety Helmet, Protective Safety Glasses, Safety Gloves, Safety
Shoes, Safety Mask, High Visibility Vest). Body harness is required when
working above 1.8 meter in height.

Picture 5 : Standard Safety PPE

b. Obtain a permit to work for safety review (fabrication / installation).
c. Machineries / tools equipment for supporting installation should have
inspection and valid certification before use.
d. Ensure proper training has been provided to workers prior to commencing
work (e.g. safe work procedures, use of equipment or tools, PPE
requirements, identifying and reporting hazards, etc.).
 Picture 6 : Safety Induction Before Start Work Activity
e. Educate workers on emergency procedures, contacts and numbers. If
emergency contact information is not posted at the workplace, provide the
worker with a copy to carry with them. The worker compulsory know what
to do during emergency/injury.
f. Site-based office facilities must be equipped with adequate lighting,
ventilation, heating/cooling or air conditioning where conditions demand,
and cleaned and maintained daily. Office furniture is to be provided that
meets the ergonomic requirements prescribed by any applicable office
codes of practice.
g. ELCB / GFCI Box Socket is required as electrical power source usage to
prevent injury to human beings from electrical shocks and prevent
electrical fires that are caused by Short Circuit from electrical tools usage.
4.16 Sequence of Work
a. Ensure finishing works in all related areas are completed for the area of
installation and clearance released / cleared by civil section to proceed on
with the installation of switch socket.
b. Ensure that the location, type aid rating of socket outlets will be in
accordance with technical specification, approved architectural plans and
shop drawings.
c. Outlet boxes where mounted in walls will be located with the center line at
elevation above the finished floor level (AFFL), as specified on the shop
drawings.
d. Back box for socket outlet in kitchen or other areas where water used
must be positioned at least 300mm away from source of water i.e. sinks,
basins, filter units and supply taps.
e. The requirements & specification detail of switch socket installation are
comply according to the material approval and shop drawings.
f. Reference datum line (AFFL + 1M) is marked by surveyor on the wall of
each specific area. Identify, mark and locate concern G.I back boxes as per
approved shop drawings. Careful attention must be given to ensure that all
the G.I. back boxes are mounted at the correct height from AFFL as per
below requirements on spec:

Picture 7 : 520121-0000-DRG-EE-00002 – Electrical General Notes

g. Wiring will be pulled as per approved load schedule. Extra care must be
given to identify the phase color, number and size of the wire.
h. Earth wire shall be first terminated on the accessories and will loop to the
back box earth stud. The back box depth shall be suited the requirements
of the wiring accessories installed. Proper wire end termination will be
maintained and neutral wiring will be provided for each circuit.

Picture 8 : Detail Wiring of Switch Socket Installation

i. All wiring devices and switches will be installed levelled and plumb. All
wiring devices will be install flush mounted on the wall. All switches shall
be fixed 50mm away from door edge and placed such that it is
immediately accessible to a person entering the room.

Picture 9 : Switch Socket Installation

j. Switches shall be installed in such a way that toggle action is vertical and
ON position at the bottom.

Picture 10 : Typical Switch Socket Installation

k. All the wiring devices and switches shall be covered properly during
installation to protect it from moisture, dust or other type of
contaminants. Align accessories horizontally and vertically as indicated
where accessories are grouped, mounted horizontally in line and parallel
to each other and equidistant.
l. Floor outlets and floor boxes will be installed flush on the floor.

Picture 11 : Typical Floor Outlet Socket Installation

m. Tag / label will be provided for each wiring devices and switches as per
approved tagging system to indicate service / source from.

Picture 11 : Switch Socket Tagging Installation

4.17 Communication, Inspection & Supervision Methodology
5.0 ASSOCIATED DOCUMENTS
5.1 Layout Installation
5.2 Job Safety Analysis
5.3 Risk Assesment
5.4 Inspection Test Report
5.4.1 RFSI – Request for Site Inspection
5.4.2 Site General Inspection Report
5.4.3 Site Defect Inspection Report
5.4.4 Cable Support, Conduit Inspection Test Report
5.4.5 Illumination Level Inspection Test Report
 LAYOUT
INSTALLATION
 ID-JKT1-01-GF-DB-544-A (OG BOX) ID-JKT1-01-GF-DB-642-B (OG BOX)

POWER LAYOUT SYSTEM

SYMBOL DESCRIPTION

PANEL

2U
13A DOUBLE SSO UNDER RAISED FLOOR

2
13A DOUBLE SSO @ 400mm ABOVE RAISED FLOOR
HL WP
13A SINGLE WEATHERPROOF SSO AT HIGH LEVEL
WP
13A SINGLE WEATHERPROOF SSO @ 400mm AFFL

13A SINGLE METALCLAD SSO @ 400mm ABOVE RAISED FLOOR

2
13A DOUBLE METALCLAD SSO @ 400mm ABOVE RAISED FLOOR
ID-JKT1-01-GF-
F1 F2 F3 1 F4 2 2A 3 3A 4 4A 5 5A 6 6A 7 8 8A 9 9A 10 10A 11 11A 12 13 13A 14 14A 15 15A 16 16A 17 17A 18 18A 19 19A 20 20A 21 21A 22 23
DB-551-A
32A 3 PIN CEEFORM @ BENCH HEIGHT
32A SPN
HL
32A 3 PIN CEEFORM @ BENCH HEIGHT ID-JKT1-01-GF-DB-541-A ID-JKT1-01-GF-DB-542-A (OG BOX) ID-JKT1-01-GF-DB-642-B (OG BOX) ID-JKT1-01-GF-DB-641-B (OG BOX)

16A SPN (OG BOX)

16A 3 PIN CEEFORM @ BENCH HEIGHT

16A TPN
16A 5 PIN CEEFORM @ BENCH HEIGHT

ISOLATOR ( RATING AS INDICATED)

ID-JKT1-01-GF-DB-512-A ID-JKT1-01-GF-DB-508-A ID-JKT1-01-GF-DB-509-A ID-JKT1-01-GF-DB-608-B ID-JKT1-01-GF-DB-609-B

SOB EACH SOB TO COMES WITH 2 NOS OF POWER POINT ID-JKT1-01-GF- ID-JKT1-01-GF-DB-631-B
AND 2 NOS OF RJ45 DATA PORT DB-551-A

LOAD BANK
BIN CENTER 1

STAIR GF_01
PERMANENT CONNECTION - NON ESSENTIAL ID-JKT1-01-GF-DB-531-A
MALE PRAYER ROOM
FIRE COMMAND CENTRE (FCC)

1 PHASE
3 PHASE

PERMANENT CONNECTION - ESSENTIAL

DB-PLNA
A BREAKOUT AREA

ADMIN BLOCK SECURITY OFFICE

1 PHASE
RECEIVING AREA
3 PHASE MEETING 1

ID-JKT1-01-GF-DB-632-B
UNPACKING ROOM
FBX FLOOR BOX
X = FIXTURE TYPE. REFER TO SPECIFICATION FOR A1 ADMIN BLOCK LOBBY
STAGING ROOM

DETAILS. ID-JKT1-01-GF-

OB

OB

DH CORRIDOR 2
OBS

OBS
DB-643-B

DH CORRIDOR 3
SOB SOB SOB SOBS

SOB SOB SOB SOBS

2P-20A ISOLATOR - 2 POLE - 20A TECHNICAL ASSISTANCE CENTRE (TAC) ROOM
CUSTOMER STORE OPS STORE ROOM

ADMIN BLOCK CORRIDOR GF_01

GAS SUPPRESSION
ID-JKT1-01-GF-DB-533-A
3P-20A ISOLATOR - 3 POLE - 20A
SO

SO
STAIR GF_02
PASSENGER LIFT 02
B
PASSENGER LIFT 01

BSO
ELV ROOM 1D
IT ELECTRICAL ROOM - A1 IT ELECTRICAL ROOM - C1 IT ELECTRICAL ROOM - B1 IT ELECTRICAL ROOM - D1 IT ELECTRICAL ROOM - A2 IT ELECTRICAL ROOM - C2 IT ELECTRICAL ROOM - B2 IT ELECTRICAL ROOM - D2 IT ELECTRICAL ROOM - A3 IT ELECTRICAL ROOM - C3 IT ELECTRICAL ROOM - B3 IT ELECTRICAL ROOM - D3 IT ELECTRICAL ROOM - A4 IT ELECTRICAL ROOM - C4 IT ELECTRICAL ROOM - B4 IT ELECTRICAL ROOM - D4

B
4P-20A ISOLATOR - 4 POLE - 20A ID-JKT1-01-GF-DB-543-A
A2 (OG BOX)
DH CORRIDOR 1

5P-20A ISOLATOR - 5 POLE - 20A B FAN WALL GF-01

FAN WALL GF-03 FAN WALL GF-05B
FAN WALL GF-07
SERVER ROOM - A

SERVER ROOM - B

ID-JKT1-01-GF-DB-501-A ID-JKT1-01-GF-DB-503-A ID-JKT1-01-GF-DB-601-B ID-JKT1-01-GF-DB-602-B ID-JKT1-01-GF-DB-605-B ID-JKT1-01-GF-

DB-607-B
SERVICES POLE/UMBILICAL/BLADE B1 DH MAN TRAP MDF 1B

ID-JKT1-01-GF-DB-506-A
SERVICES CORE HOLE ID-JKT1-01-GF-DB-505-A
XX XX = DIAMETER B2 DOMESTIC WATER FILTRATION AND PUMP ROOM

DATA HALL GF-03

SERVICES PENETRATION MMR 1B

(DIMENSIONS AS INDICATED) B3 DATA HALL GF-01

CUSTOMER OFFICE / STORE DATA HALL GF-05A

DATA HALL GF-07

CIRCUIT REFERENCE TAG ID-JKT1-01-GF-

B4 DB-506-A
DENOTES CIRCUIT SOB SOB SOB SOB
BACKUP TAC 1
DENOTES NUMBERING MDF 1A SOB SOB
C
C1 ID-JKT1-01-GF-DB-502-A ID-JKT1-01-GF-DB-504-A ID-JKT1-01-GF-DB-603-B ID-JKT1-01-GF-DB-604-B ID-JKT1-01-GF-DB-606-B
ELV ROOM 1B

C1 FIRE PUMPS AND FUEL TANK ROOM

MMR 1A

DATA HALL GF-04

C2 DATA HALL GF-02

DATA HALL GF-06A
DATA HALL GF-08 GENERAL ELECTRICAL ROOM B

STAIR GF_03

C3

C4 FAN WALL GF-02

FAN WALL GF-04 FAN WALL GF-08
FAN WALL GF-06A

D GENERAL ELECTRICAL ROOM A

ID-JKT1-01-GF-DB-507-A

D1 ELV ROOM 1C

D2
MMR 1C

MDF 1C

ID-JKT1-01-GF-DB-545-A
(OG BOX)
ID-JKT1-01-GF-DB-510-A ID-JKT1-01-GF-DB-511-A ID-JKT1-01-GF-DB-610-B ID-JKT1-01-GF-DB-611-B
D3
ID-JKT1-01-GF-DB-645-B (OG BOX) ID-JKT1-01-GF-DB-644-B (OG BOX)

This Review is only for general conformance with the design concept of the project and general compliance with the
information given in the contract documents. Any action shown is subject to the requirements of the contract
[Link] works are not under Aurecon's scope of works for this project, and our review of temporary works
drawings will be limited to its impact/compatibility to Aurecon's and their sub-consultants ’ design. It is the contractor's
ID-JKT1-01-GF-
responsibility to ensure that the temporary works are correctly designed for construction and site safe [Link] review
does not relieve the Contractor of this Contractual obligations nor of his responsibilities of ensuring the work is complete, DB-651-B
accurate & [Link] amendment does not constitute an order or authority for a price variation to the contract. DB-PLNB

Accepted with no comment Not Reviewed

Accepted with comment Not Accepted

Reviewed
ELECTRICAL SEVICES - FINAL DAY - POWER LAYOUT GROUND FLOOR PLAN - OVERALL
1 : 400
CLIENT ENGINEER ARCHITECTURAL NOTES REVISION APPROVED BY :
PROJECT NAME F-SHIMS-SD-P01/1/01-08-2011
PROJECT IRIS REFERENCE DRAWING : FOR APPROVAL NO DATE REVISION DESCRIPTION APPROVAL DRAWING NUMBER
BEKASI, INDONESIA 1. ARCHITECTURAL DRAWING : 01 07/07/22 RENAME PANEL NAME DATE ID-JKT1-SHZ-01-GF-SD-E-62201
PROJECT MANAGEMENT MAIN CONTRACTOR
TITLE
11/07/22 SIGNATURE
SCALE : 1:400
2. STRUCTURAL DRAWING : A1
ELECTRICAL SEVICES - FINAL DAY - POWER LAYOUT GROUND FLOOR PLAN - OVERALL CHECK BY Andi Setiawan
PT. SHIMIZU BANGUN CIPTA KONTRAKTOR 3. MEP DRAWING : 520121-0000-DRG-EE-30100-0
DRAWN BY Ivan SHOP DRAWING
JOB SAFETY ANALYSIS
 JOB SAFETY ANALYSIS (JSA)
Job Description : Conduit Installation
Contractor : PT. SECM Tech Indonesia
No. Description of Task / Step Potential Hazards Control and / or Recovery Measures Action / Responsible Person

1. Wearing PPE based on standard requirements. Especially using the

Exposed to sharp objects. proper handgloves to protect the skin from direct contact to sharp Worker / site supervisor.
object.

1. Obtain a permit to work for grinding activities.

2. Inspect the grinding disc / complete tool prior starting works.
3. Make sure the grinding disc is compatible with the grinding
machine.
Worker / site supervisor /
Exposed to blade fracture of 4. Ensure the grinder have a protection cover to prevent the fire
site safety supervisor / safety
grinder machine. spark hit to personnel body.
officer.
5. Wearing PPE based on standard requirements. Especially using the
handgloves to protect the skin from direct contact to sharp object
and full body covered to prevent the fire spark hit to personnel body.
6. Wise in using the tools properly.
Fabrication Work of
1 Conduit Support 1. Obtain a permit to work for use electrical tool activities.
(Grinding, Threading, Bending) 2. Ensure the power source come from proper panel installation.
3. Ensure power connection is using ELCB based on site standard. Worker / site supervisor /
Electric shock. 4. Always set the switch off when the electrical tool is no longer in site safety supervisor / safety
order to use. officer.
5. Give more isolation / repair the cable when found the eletrical
power cabling of tool has been damaged before use it.

1. Obtain a permit to work for welding / fire activities.

2. Ensure the welder are certified and inducted by safety team.
3. Maintain a clean working area before proceeding to weld and
Worker / site supervisor /
provide fire extinguisher near the welding point.
Fire, explosion, fumes and gas. site safety supervisor / safety
4. Provide adequate ventilation and local exhaust to keep fumes and
officer.
gases from the breathing zone and the general area.
5. Ensure the welder is using spark containment such as a welding
hood / fire blanket and welding goggles.

1. Obtain a permit to work for cable containment installation.

Worker / site supervisor /
2. Conduct a safety induction for worker for installation work.
Improperguidance work. site safety supervisor / safety
3. Brief / training the working for proper installation work.
officer.
4. Make the mockup installation before further progress.

1. Ensure the quality of material/equipment is not damaged and

Worker / site supervisor /
have conducted the inspection earlier before start to install.
Material rejection. site safety supervisor / safety
2. Ensure the proper mobilization method from storage thru site.
officer.
3. Proceed temporary material protection before to install.

1. Barricade working area in purposes to avoid clashing with other

2 Conduit Installation activities. Worker / site supervisor /
Material / object falling from a
2. Coordination for material lifting / mobilization to height area site safety supervisor / safety
height.
usage with proper method. officer.
3. Ensure the material support is already installed properly earlier.
1. Ensure the worker have conducted the safety induction for
purpose they have explanation about working at height.
2. Body harness is required when working at height above 1.8m. Worker / site supervisor /
Fallen from height. 3. Hook the body harness into steel safe structure. site safety supervisor / safety
4. Do not using the straight ladder. Any installation at height officer.
should be using scissor lift / catwalk.
5. Ensure the catwalk have safety tagging before stand at there.
RISK ASSESMENT
 RISK ASSESMENT (RA)
Company & Package No : PT. SECM Tech Indonesia
Hirarc/JSA No
Process/ Location :
Prepared by: Reviewed by:
(Names, designations) (Names, designations)
Last Review Date: Next Review Date Rev
Date of preparation :

Hazard / Aspect Identification Initial Risk/ Risk / Impact Controls Residual Risk/ Additional Risk / Impact Controls Responsible Person

Occurrence

Occurrence
Potential EHS Hazards /

Severity

Severity
S/N Activities EHS Risks / Impacts Existing Control Measures References Additional Control Measures Action By
Aspects

RPN

RPN
1. To ensure worker have been indcuted prior start work.
1. Working without
2. To brief on TBM/ PTP upon job start. Worker selection must be review by HSE
induction Fail to comply with project rules
1 Mobilisation of the manpower 3 4 12 3. Development of competent/skill workers. 3 2 6 Officer prior to induction and ensure there are Operation Executive
2. Not fit to work and requirement
4. All worker must have covid-19 vaccine certificate before entering site. no critical illness history.
(health issue)
5. PPE shall to comply before enter in site.

1. Prior communication with related personnel.

1. Body injury (scratched, bruise, 2. Site inspection shall be carried-out to ensure the ground condition of the machineries UU RI No. 1/ 1970 Keselamatan
1. Fall from height etc.) mobilisation routing. Kerja, Permenakertrans No. 1/
Coordination about plannig machineries
2 Material handling mobilisation 2. Falling object 2. Property damage 4 2 8 3. To ensure all designated plates are used to support protection pathways. 1980 K3 Konstruksi Bangunan, 4 1 4 Operation Executive
mobilisation usage.
3. Hit by machinery 3. Respiratory tract infection by 4. Machineries with valid certificate and visually inspoection prior job start. Permenakertrans No. PER
dust 5. Walkie-talkie / HT as method of communication way. 04/MEN/1980
6. Spotter to guide the machineries mobilisation.

1. Routh path access for truck to be examined and ensure the path is clear and good to use to
Truck deliver the material to 1. Traffic incident 1. Property damage drive the truck carrying the chiller. UU RI No. 1/ 1970 Keselamatan
3 designated 2. Uncertified driver 2. Body injury (scratched, bruise, 3 2 6 2. Competent truck operator with valid license. (SIA/SIO) Kerja, Permenakertrans No. 1/ 3 1 3 Arrange escort truck during transport. Operation Executive
installation/parking area 3. Hit on structure etc.) 3. Spotter to guide the truck to designated installation/parking area especially when 1980 K3 Konstruksi Bangunan
reversing.

1. To ensure to have proper area to reach the material from hoisting/lifting process.
UU RI No. 1/ 1970 Keselamatan
1. Slip and fall 2. Signal man to giving instruction and communication with operator by radio (walkie-talkie)
Kerja, Permenakertrans No. 1/
2. Miss communicate 3. Lifting supervisor shall check the material center of gravity and the balance.
1980 K3 Konstruksi Bangunan,
3. Overloaded/ 4. Pre-test to slowly lift the precast manhole, placing back the material if any abnormal
Kep Men No. Kep.
suspended load condition found. This process shall continue the lift upon necessary action taken in place.
1. Body injury 174/MEN/1986, No. Additional checks done by Operation
4 Hoisting/lifting activities 4. Fall from height 3 2 6 5. To comply with critical lifting plan and safety factor calculation to ensure the capacity of 3 1 3 Operation Executive
2. Property damage 104/KPTS/198 Executive.
5. Struck by moving usage is safe to hoist.
equipment 6. Ensure the lift plan critical lifting plan (CLP) is correctly done and checked against the
Permenakertrans No. 1/ 1980
6. Property damaged relevant load chart (if applicable).
K3 Konstruksi Bangunan dan
7. Physical injuries 7. No one to be below the suspended load.
No. 9/ 2010 APD Pasal 2
8. Lifting supervisor shall brief on lifting plan during safe plan action (SPA).

1. Slip and fall 1. Signal man to giving instruction and communication with operator by radio (walkie-talkie). UU RI No. 1/ 1970 Keselamatan
2. Miss communicate 2. To comply with critical lifting plan and safety factor calculation to ensure the capacity of Kerja, Permenakertrans No. 1/
Positioning activities installing 3. Struck by moving 1. Body injury usage is safe to hoist. 1980 K3 Konstruksi Bangunan, Additional supervision done by Operation
5 4 2 8 4 1 4 Operation Executive
the material at placed. equipment 2. Property damage 3. Ensure the lift plan (CLP) is correctly done and checked against the relevant load chart. Kep Men No. Kep. Executive.
4. Property damaged, 4. No one to be below the suspended load and on the unloading area. 174/MEN/1986, No.
5. Physical injuries 5. Lifting supervisor shall brief on positioning plan during SPA. 104/KPTS/198

Additional supervision done by Operation

6 Housekeeping 1. Slip Body injury 2 2 4 1. The debris and tools equipment shall be proper keeping once the activities complete. 2 1 2 Operation Executive
Executive.
 RISK ASSESMENT (RA)
Company & Package No : PT. SECM Tech Indonesia
Hirarc/JSA No
Process/ Location :
Prepared by: Reviewed by:
(Names, designations) (Names, designations)
Last Review Date: Next Review Date Rev
Date of preparation :

Hazard / Aspect Identification Initial Risk/ Risk / Impact Controls Residual Risk/ Additional Risk / Impact Controls Responsible Person

Occurrence

Occurrence
Potential EHS Hazards /

Severity

Severity
S/N Activities EHS Risks / Impacts Existing Control Measures References Additional Control Measures Action By
Aspects

RPN

RPN
UU RI No. 1/ 1970 Keselamatan
Kerja, Permenakertrans No. 1/
1980 K3 Konstruksi Bangunan,
Kep Men No. Kep.
174/MEN/1986, No.
1. Accidents during 1. Standby better lighting to ensure the workers able to see and work clearly.
104/KPTS/198
working area due to 2. Provide adequate lighting. 1. Additional supervision done by Operation
fatigue 3. Have to establish 2 shift schdeule to avoid fatiguiness. Executive.
7 Night-Shift work Body injury 2 2 4 UU RI No. 1/ 1970 Keselamatan 2 1 2 Operation Executive
2. Lack of lighting 4. Provide proper working platform . 2. Every worker must wear appropriate PPE,
Kerja, Permenakertrans No. 1/
3. Limited vision 5. There are facilities/rest areas, smoking areas with fire extinguishers, toilets/bathrooms and especially safety belts, helmets, gloves, etc.
1980 K3 Konstruksi Bangunan,
4. Fall from height pray area.
Permenakertrans No. PER
04/MEN/1980

PermenKes-48-2016
Perkantoran

UU RI No. 1/ 1970 Keselamatan

Kerja, Permenakertrans No. 1/ 1. Additional supervision done by Operation
1. Fall from height
Installation of work must be carried out by competent people, scaffolding (if applicable) must 1980 K3 Konstruksi Bangunan, Executive.
8 Material installation 2. Stuck in confined Body injury 2 2 4 2 1 2 Operation Executive
be in accordance with established standards. Kep Men No. Kep. 2. Every worker must wear appropriate PPE,
space
174/MEN/1986, No. especially safety belts, helmets, gloves, etc.
104/KPTS/198

1. Wear raincoat and proper glassess to improve better vision (outdoor). UU RI No. 1/ 1970 Keselamatan 1. Additional supervision done by Operation
2. Standby proper lighting to ensure the workers able to see and work clearly. Kerja, Permenakertrans No. 1/ Executive.
1. Lack of lighting
3. Provide adequate lighting. 1980 K3 Konstruksi Bangunan, 2. Every worker must wear appropriate PPE,
9 Working during rainy season 2. Limited vision Body injury 2 2 4 2 1 2 Operation Executive
4. To provide a temporary tent/roof (using bluesheet) for ingress protection (indoor) where it Kep Men No. Kep. especially safety belts, helmets, gloves, etc.
3. Limited hearing
necessary. 174/MEN/1986, No. 3. To weather forecast by referring to current
5. To standby submersible pump to drain out water immediately. 104/KPTS/198 information/condition.

UU RI No. 1/ 1970 Keselamatan

Kerja, Permenakertrans No. 1/ 1. Additional supervision done by Operation
1. Fall from height Installation of work must be carried out by competent people, scaffolding (if applicable) must 1980 K3 Konstruksi Bangunan, Executive .
10 Dismantling installation Body injury 2 2 4 2 1 2 Operation Executive
2. Stuck in formwork be in accordance with established standards. Kep Men No. Kep. 2. Every worker must wear appropriate PPE,
174/MEN/1986, No. especially safety belts, helmets, gloves, etc.
104/KPTS/198

1. Provide adequate lighting

2. To ensure lighting lux is above than 200
1. Slip, trip and fall 3. Provide proper ventilation equipment UU RI No. 13/ 2003 1. HSE Officer to keep reminding during
2. Lack of lighting 1. Personnel injury (fatal) 4. Provide proper maintenance access for workers to go in-out Ketenagakerjaan, toolbox.
11 Working in confined space 4 2 8 3 2 6 Operation Executive
3. Lack of oxygen 2. May harm the environment 5. Use respirator if necessary Permenakertrans No. 2. To barricade the area from any unauthorised
4. Poisonous gas 6. Use proper ladder safety (3 points of contact) 326/MEN/XII/2011 personnel to go in
7. Authorised AGT to check the working area prior start work (if required)
8. To ensure standby person is ready at entrance in case of emergency
 RISK ASSESMENT (RA)
Company & Package No : PT. SECM Tech Indonesia
Hirarc/JSA No
Process/ Location :
Prepared by: Reviewed by:
(Names, designations) (Names, designations)
Last Review Date: Next Review Date Rev
Date of preparation :

Hazard / Aspect Identification Initial Risk/ Risk / Impact Controls Residual Risk/ Additional Risk / Impact Controls Responsible Person

Occurrence

Occurrence
Potential EHS Hazards /

Severity

Severity
S/N Activities EHS Risks / Impacts Existing Control Measures References Additional Control Measures Action By
Aspects

RPN

RPN
OCCURRENCE CRITERIA
Occurrence Rating Description Frequency
5 Most Likely. Daily occurrence.
4 Likely Weekly occurrence.
3 Possible Monthly occurrence.
2 Conceivable Yearly occurrence.
1 Remote Less than once in three years.
SEVERITY CRITERIA
Severity Rating Description People Company Environment
Major pollution affecting the public and
5 Catastrophic Any event that leads to eventual death. Shut down of Head Office/Projects
neighbours
Epidemic, serious injury result permanent Major legal non-compliance.
4 Major Closure of essential services and departments/affected area of projects.
disability Departmental/Project & surrounding area
Hospitalisation (>24hrs) without any disability. Closure of non- essential services and departments/ affected area of projects. Departmental/Project pollution
3 Serious
>3 days of medical leave. Disruption of utility supply. Significant depletion of natural resources
Light injury, requiring outpatient treatment with
2 Minor Momentarily minor interruption. Pollution limited to localised area or rooms.
<3 days of medical leave.
Superficial injury, no medication required.
1 Negligible No disruption No significant pollution.
First Aid Injury.
Risk Priority Number, RPN Action and Timescale
Negligible (1) No action is required and no documentary records need to be kept.
Trivial (2) No additional controls are required. Documentary records should be kept.
No additional controls are required. Monitoring required for ensuring that controls are maintained.
Acceptable (3/4)
However, where the tolerable risk/impact is associated with extremely harmful consequences, further assessment may be necessary to establish a precise likelihood of harm as a basis for determining the need for improved
Moderate (6) Efforts should be made to reduce the risk/impact but the costs of prevention should be carefully measured and limited. Risk/Impact reduction measures should be implemented within a 6-months period.
Substantial (8/9) Efforts should be made to reduce the risk/impact and considerable resources may be allocated to reduce the risk/impact. Risk reduction measures should be implemented within a 6-months period.
High (12) Efforts shall be made to reduce the risk/impact and considerable resources shall be allocated to reduce the risk. Risk/Impact reduction measures shall be implemented within a 3-month period. If the measures are not
Extreme (16) Work shall not be started or continued until the risk/impact has been eliminated or reduced. If it is not possible to reduce risk/impact even with unlimited resources, work has to remain prohibited.
INSPECTION TEST
REPORT
 Project :

Jakarta Office, 6Fl. Setiabudi Atrium Building suite 601, Jl. HR Rasuna Said Kav 62
REQUEST FOR SITE INSPECTION ( RFSI )
Report No. : SHIMS-RFSI-Project-Number-Year
Sub-Contractor :

Services :

The following works / tests are ready for inspection / will be conducted
at _____________(time) on __________________(date)

DESCRIPTION OF WORKS

Location :

Nature of Work :

Drawing / Sketches No. :

Attach Checklist No. :

(Note: Where required, include details of products, labour and equipment to be used)

Submitted by Received by

Signature : Signature :
Name : Name :
Time / Date : Time / Date :

INSPECTION / TEST RESPONSE

Inspection acceptable / test passed*, with / without* comment. Works are allowed to proceed

Inspection unacceptable / test failed*. Contractor to carry out remedial works

Re-inspection is required / Re-Testing is required

Signature : Shimizu Corporation Date:

Name :

FORM NO.: F-SHIMS-QCME-PO5-RFSI REV.0 ISSUED DATE: 5-09-12

 Project :

Jakarta Office, 6Fl. Setiabudi Atrium Building suite 601, Jl. HR Rasuna Said Kav 62
SITE GENERAL REPORT
Inspection Date : Report No. : SHIMS-M.03-Project-number-year
Location : Inspected By :
No. PICTURE INSPECTION ACTIVITY No. PICTURE INSPECTION ACTIVITY
1 2
Comfirmed by Comfirmed by
Shimizu Shimizu

ADD PHOTO ADD PHOTO

(Sign) (Sign)

3 4
Comfirmed by Comfirmed by
Shimizu Shimizu

ADD PHOTO ADD PHOTO

(Sign) (Sign)

5 6
Comfirmed by Comfirmed by
Shimizu Shimizu

ADD PHOTO ADD PHOTO

(Sign) (Sign)

7 8
Comfirmed by Comfirmed by
Shimizu Shimizu

ADD PHOTO ADD PHOTO

(Sign) (Sign)

FORM NO.: F-SHIMS-QCME-PO5-M.03 REV.0 ISSUED DATE: 05-09-12

 Project :

Jakarta Office, 6Fl. Setiabudi Atrium Building suite 601, Jl. HR Rasuna Said Kav 62
SITE DEFECT INSPECTION REPORT
Inspection Date : Report No. : SHIMS-M.04-Project-number-year
Location : Inspected By :
Action / Rectification Work Done
No. Defect / Comment Verification
Due Date (attach photo)
1
Comfirmed by Verify By
Client Shimizu

ADD PHOTO ADD PHOTO

(Sign) (Sign)

Due Date : Client

(Sign)

Comment :- Comment :-

2
Comfirmed by Verify By
Client Shimizu

ADD PHOTO ADD PHOTO

(Sign) (Sign)

Due Date : Client

(Sign)

Comment :- Comment :-

3
Comfirmed by Verify By
Client Shimizu

ADD PHOTO ADD PHOTO

(Sign) (Sign)

Due Date : Client

(Sign)

Comment :- Comment :-

4
Comfirmed by Verify By
Client Shimizu

ADD PHOTO ADD PHOTO

(Sign) (Sign)

Due Date : Client

(Sign)

Comment :- Comment :-

FORM NO.: F-SHIMS-QCME-PO5-M.04 REV.0 ISSUED DATE: 05-09-12

 Project :

Jakarta Office, 6Fl. Setiabudi Atrium Building suite 601, Jl. HR Rasuna Said Kav 62
CABLE SUPPORT, CONDUIT INSPECTION TEST REPORT
Date : Report No. : SHIMS-E.08-Project-Number-Year
Location : Drwg Ref. :

From Panel Cable ladder Cable Tray / Trunking Flexible Conduit Acceptability Remark / Non-
Conduit Size
Service Name Size / Raceway Size Length (Max - 2m) YES / NO Conformance

CHECKLIST
ACCEPTABILITY

1). Check material type & brand according to requirement Yes / No / NA

2). Check size & type of conduit are according to approved drawing Yes / No / NA
3). Check conduit installed are properly painted & installed according to Yes / No / NA
approved drawing
4). Check conduit joint boxes & outlet are properly tightened. If UPVC Yes / No / NA
conduit system,adhesive shall be applied.
5). Check flexible conduit are properly fixed. Length of flexible conduit Yes / No / NA
are according to requirements.
6). For cast in UPVC conduit, ensure all conduit are tied to rebar, boxes are Yes / No / NA
fully stuffed and check for conduit damage
7). Ensure conduits are installed between 1st & 2nd layer of slab rebar, Yes / No / NA
only bend down to formwork at junction box location.

REMARK / NON-CONFORMANCE

SUB CONTRACTOR SHIMIZU CORPORATION OWNER/CLIENT'S REP. (If Necessary) :

Tested by : Inspected by : Reviewed by : Witnessed by :

1) Name : 1) Name : 2) Name : Name :

Position : ME Engineer Position : ME Engineer Position : Sr. ME Engineer (QAQC)
Date : Date : Date : Position :
Reviewed by :
2) Name : 3) Name : Date :
Position : Project Manager Position : Site ME Manager

FORM NO.: F-SHIMS-QCME-PO5-E.08 REV.0 ISSUED DATE: 05-09-12