ConocoPhillips (Grissik) Ltd.

Long Term Liquid Transportation Project

Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007

HSE PRE-QUALIFICATION QUESTIONAIRES

Company Name : PT.Geoindo Girijaya

Work Subject : Long Term Liquid Transportation Project - Land Survey (CS13938047)

SECTION 1 – LEADERSHIP AND COMMITMENT

1. Commitment to HSE through leadership

a) How are senior managers is top management personally involved in HSE management ?
Bagaimana manajer senior yang merupakan manajemen atas secara pribadi terlibat dalam manajemen HSE ?
The Managing Director accepts the overall responsibility of the policy. The managing director delegates his responsibility to the
technical director who delegates to Head of Departments and the Supervisors in ensuring that the policy, together with the
Safety and Health procedural requirements and instruction are read and understood by all employees as well ass conductors
and their associates.

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

Sertakan bukti dari komitmen semua bagian organisasi dengan :
(i) Stating this year’s company targets for HSE performance
Sebutkan target kinerja HSE perusahaan tahun ini
The Company shall strive to obtain a zero defect target with the following principles:
 No accident, injury or fatality
 No operational downtime
 No loss to Company asset
 No health-related incidents or health hazards
 No damage to the environment
 No lapse in security of personnel, facilities or information
(Please See Attachment A – HSE Manual Page i regarding notification and circulation of Approval
Signatures and Circulation and Distribution Form)
(ii) Describing how you ensure that your organization understand and is committed to deliver your company HSE
targets
Jelaskan bagaimana anda memastikan organisasi saudara mengerti dan berkomitmen untuk mencapai target
HSE perusahaan anda
In order to achieve these principles, PT Geoindo Survey Services shall implement the following strategies, these
are:
 Create and provide a system that enhances the development, implementation and continuously improves
the quality standard of the HSE-MS in order to assure, an excellent business process that will provide
consistent value-added service to our client.
 Develop, communicate and align strategic intentions, policies and principles that are incorporated into
Company policies, objectives and procedures to enable and continually improve on performance.
 Encourage individuals and groups within the organization to understand and fulfil their roles in enhancing
teamwork spirit to achieve a first class rated HSE performance.
 Evaluate risks and opportunities associated with day-to-day activities and develop processes, plans and
procedures that may reduce uncertainty in the work area.
 Plan at all levels of the organization to ensure that resources required to meet all HSE objectives are
sufficient for each type of project undertaken.
 Evaluate individual and group performance against defined criteria in order to confirm that the HSE-MS is
being deployed, its policies and objectives fulfilled and to define areas of improvement that may be required
for similar situations in other areas.
 Ensure that the Company is able to demonstrate to the client of compliance with any special HSE
requirements that may be enforced at their facility or operational area.
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Long Term Liquid Transportation Project
Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007
c) How do you promote a positive culture towards HSE matters
Bagaimana saudara mempromosikan kebudayaan positif terhadap hal – hal yang berhubungan dengan HSE ?
- By distribution all HSE manual, HSE policies, HSE procedure and HSE issues
- By training to all employees
- Demonstrated on the wall

d) Provide your current Organization chart

Sertakan bagan organisasi saudara sekarang
Managing & Financial Director

Technical Director
HSE-Q Management
Representative

Support Services Technical Services

QA & HSE Finance HRD Secretarial Logistic IT Geotechnical / CAD/GIS Survey Laser
Rep. Rep. Rep. Rep. Rep. Rep. Construction Scanning

Doc Con Maintenance Driver Field Project Drafter Field Modeling Field
Rep. Rep. Rep. Team Rep. Surveyor Rep. Scanning
Rep. Rep. Rep.
Office Boy
Rep.

Note:
Rep. = Representative

SECTION 2 – POLICY AND STRATEGIC OBJECTIVES

2.1 HSE Policy & Documents

a) Does your company have an HSE policy document that is applied in this region ? (Yes/No)
If yes, please attach
Apakah perusahaan saudara mempunyai dokumen kebijakan HSE yang dapat diaplikasikan di region ini? (Ya/ Tidak) Jika
ya, tolong lampirkan
- Yes, there are PT. Geoindo Giri Jaya Policy, Drugs and Alcohol Policy, Smoking Policy, Health and Hygiene.
( Please See attachment B – HSE Policies)

b) Who has overall and final responsibility for HSE in your organization ?
Siapa yang mempunyai kewajiban keseluruhan dan final untuk HSE di organisasi saudara?
- All personnel have a responsibility for HSE. However overall and final responsibility for HSE are managing Director
and / or Technical Director. And if the Managing director / Technical Director is not on office, they delegate to HSE
Steering Committee Coordinator.

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

Bagaimana saudara meyakinkan kepatuhan dan komunikasi terhadap kebijakan HSE tersebut di lapangan ?
- By implementing inspection for site HSE implementation
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Long Term Liquid Transportation Project
Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007
2.2 Availability of Policy Statements to Employees
How do you communicate your company’s policy to your employees including any changes?
Bagaimana saudara mengkomunikasikan kebijakan perusahaan anda termasuk perubahannya kepada para pegawai?
Jika ada perubahan terhadap
The changes will be distributed and signed off when read by all employees. The list of names of employees who have read the
policy is shown by circulation list that attached to the current document and a signature of the individual is required on the list to
acknowledge that the document has been read and understood by the individual.

SECTION 3 – ORGANIZATION, RESPONSIBILITY, RESOURCES, STANDARDS AND DOCUMENTATION

3.1 Organization – Commitment and Communication

a) How is management involved in HSE activities, objective setting and monitoring?
Bagaimana manjemen terlibat dalam kegiatan, penetapan tujuan dan pengawasan HSE ?
Senior managers and staff are all personally involved in acheveing, developing and improving HSE. He is given the
authority and responsibility to ensure that the requirements of the HSE MS are implemented and maintained. He reports
directly to the Director and / or Managing Director. He / she responsible for checking, assessing, and approving the HSE
- MS. He / she also responsible forimplementing and reviewing the effectiveness of the HSE - MS
The responsibility for all personnel is described on HSE Steering Committee Organization chart and Responsibility
(Please attachment D – HSE Steering Committee Organization Chart)

a) What provision does your company make for HSE communication and meetings ?
Provisi apa yang perusahaan saudara buat untuk komunikasi dan pertemuan HSE?
The HSE communication and HSE meeting are essential part of the HSE process. The company’s HSE management
Committee is given the task to discuss and agree on methods of implementation of the Policy and monitoring the
effectiveness of the HSE-MS throughout the organization.
PT. Geoindo Giri Jaya holds HSE monthly meeting which attending by all Steering Committee Teams. All meetings are
recorded and an attendee list sign by all present. The minutes of the previous meeting will be mentioned at the start for
reference and up date of any action that has taken place on what was discuss.

3.2 Competence and Training of Managers / 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 format HSE
training in their responsibilities with respect to conducting work to HSE requirements ? (Yes/No)
Sudahkah para manajer dan supervisor di semua bagian yang akan merencanakan, mengawasi, melihat dan mengerjakan
pekerjaan menerima format pelatihan HSE yang menjadi kewajiban mereka untuk melaksanakan pekerjaan sesuai ketentuan
HSE? (Ya /Tidak)
Yes, Training is given to Managers, Supervisor (Field team leader) by external training and in house training. Example PPE
training (in-house training), Bosiet training (external training). (Please see attachment E – PT. Geoindo Training Matrix)

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?
Pengaturan apa yang dilakukan perusahaan saudara untuk memastikan para pegawai, mempunyai pengetahuan
terhadap HSE industrial dasar, dan untuk terus memperbarui pengetahuan ini ?
Giving HSE training to all employees regularly. Their knowledge is up-dated on a regular basis by regular meetings,
seminars and training. In addition, a start of fieldwork all field teams are given a safety briefing / safety induction
meeting on site.

b) What arrangements does your company have to ensure ALL employees, including sub contractors, also have
knowledge of your HSE policies and practices?
Pengaturan apa yang dilakukan perusahaan saudara untuk memastikan SEMUA pegawai, termasuk sub kontraktor,
juga mempunyai pengetahuan terhadap kebijakan dan implementasi HSE saudara?
All new employees and subcontractor employees are given HSE induction meeting/ HSE training before they start to
the fieldwork. Their knowledge is up-dated on a regular basis by regular meetings / safety induction meeting on site.
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Long Term Liquid Transportation Project
Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007
And all employees and subcontractor’s employees have a copy all HSE policies and signed off when they read the
policies.
Before go the site they have a copy of HSE document, there is:
- PT. Geoindo HSE Implementation Scheme for each project (example : see annex HSE Implementation Scheme
for Lombok Project)(Please see attachment F- HSE Implementation Scheme for Lombok Project)

3.4 Specialized Training

Have you identified areas of your company’s operations where specialized training is required deal with potential hazard?
(Yes/No) If yes, please provide the list (e.g. radioactive, asbestos, explosive, diving, etc.)
Sudahkah saudara mengidentifikasi operasi-operasi perusahaan saudara dimana pelatihan khusus diperlukan untuk menangani
bahaya potensial? (Ya/Tidak) Jika ya, tolong disediakan daftar (e.g. radioactive, asbestos, explosive, diving, etc.)
Directors and senior managers have >10 years experience operations. And they have identified potential hazards that are
generally common. However PT. Geoindo prepared the HSE / PRO /001 – Risk Management Procedure (Please see
attachment C No 01 – HSE Procedures) to ensure all employees are aware of onsite work risk and guide all employees on
do the safety jobs.
Specialised training to deal with potential hazards includes:
- First Aid training
- PPE Training
- Fire drill training
- Emergency Response Training (Earthquake, Tsunami, Flood and Fires)

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) If yes, please attach the curriculum vitae
Apakah perusahaan saudara mempunyai spesialis HSE (berhubungan dengan jasa perusahaan anda) yang dapat menyedikan
pelatihan kepada pegawai lain ? (Ya/Tidak) Jika ya, tolong disertakan curriculum vitae
Yes, Please see attachment G
3.6 Assessment of Suitability of Subcontractors
a) Do you employ sub-contractor(s) for the intended service? (Yes/No) If No, please go to the question 3.7
Apakah saudara memperkerjakan su-kontraktor untuk pekerjaan ini? (Ya/Tidak) Jika tidak, silahkan pergi ke
pertanyaan 3.7
No
b) How do you assess your sub-contractor(s) to ensure they comply with your company’s HSE plocy and standard?
Bagaimana saudara mengevaluasi sub-kontraktor anda untuk memastikan mereka mematuhi kebijakan dan standar HSE
perusahaan anda?
3.7 Standards
a) What kind of HSE regulatory or industrial standards that your company refers to for the intended service?
Peraturan HSE atau standar industrial apa yang dijadikan referensi perusahaan saudara untuk pekerjaan ini?
1. Level I Procedure : HSE Manual
2. Level II Procedure : HSE Procedures, these are:
- HSE / PRO / 001 – Risk Management
- HSE / PRO / 002 – Job Safety Analysis
- HSE / PRO / 003 – Hazards Assessment and PPE
- HSE / PRO / 004 – Hygiene and Housekeeping
- HSE / PRO / 005 – Permit to Work
- HSE / PRO / 006 – Safety Briefing
- HSE / PRO / 007 – Emergency Response
- HSE / PRO / 008 – Accident / Incident Reporting
- HSE / PRO / 009 – Safety Working Procedure
- HSE / PRO / 010 – Audit and Management Review
(Please see attachment C – HSE Procedures)
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Long Term Liquid Transportation Project
Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007

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

Bagaimana saudara memastikan ini sesuai dan terverifikasi?
Top Management of PT. Geoindo that delegate to the HSE Steering Committee is responsible for ensure that all HSE
activities within PT. Geoindo Giri Jaya are carried out the requirements, rules, and procedures provide in HSE Manual
and its associated HSE Procedures and HSE Plans by implementing HSE Inspection, Audit and Management Review.

c) How do you update the standard and its dissemination?

Bagaimana saudara memperbaharui standard an penyebarannya?
We have procedure for controlling the revision of document and the changes made for all PT.Geoindo’s documents, it is
Change Control Procedure that implemented change request form (Please see attachment N –QMS/PRO/016 -
Procedure Change Control )

SECTION 4 – HAZARDS AND EFFECT MANAGEMENT

4.1 Hazard and Effect Management

Does your company have procedure for the identification, assessment, control and mitigation of hazards and effects?
Apakah perusahaan saudara mempunyai prosedur untuk identifikasi, assessment, control, dan mitigasi dari bahaya dan
efeknya? (Please see attachment C No 1 - 3)
- HSE / PRO / 001 – Risk Management
- HSE / PRO / 002 – Job Safety Analysis
- HSE / PRO / 003 – Hazard Assessment and PPE

4.2 Exposure of the Workforce

What systems are in place to monitor the hazard’s exposure of your workforce e.g. chemical or physical agents?
Sistem apa yang sudah ada untuk memonitor ekspos bahaya di tempat kerja saudara seperti kimia atau agen fisik?
HSE / PRO / 002 – Job Safet Analysis - (Please see attachment C No 2)

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?
Bagaimana tempat kerja saudara dalam menangani bahaya potensial seperti kimia, bunyi, radiasi, dst., yang dihadapi selama
bekerja?

It is will be described in the Job Hazards Analysis Form (HSE/FOR/001) (Please see attachment C No 1)

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?
Pengaturan apa yang dipunyai perusahaan saudara untuk mengusahakan dan menjaga peralatan dan pakaian
keselamatan, dalam issue standar, dan yang dibutuhkan untuk aktivitas khusus?
- HSE / PRO / 003 – Hazard Assessment and PPE (Please see attachment C No 3)

)b Do you provide appropriate personal protective equipment (PPE) for you employees?
(Yes/No) Please provide a list of the PPE for the scope of work to be performed?
Apakah saudara menyediakan perlengkapan pelindung personil yang sesuai (PPE) untuk karyawan-karyawan
saudara? (Ya/Tidak) Mohon berikan daftar PPE untuk lingkup pekerjaan yang akan dilaksanakan?
(Please see attachment H – List of PPE )

)c Do you provide training on how to use PPE ? (Yes/No) Explain the content of the training and any follow up
Apakah saudara menyediakan pelatihan tentang bagaimana menggunakan PPE? (Ya/Tidak)
Jelaskan isi dari pelatihan dan setiap kegiatan kelanjutannya.
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Long Term Liquid Transportation Project
Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007
Training is provided on issue of PPE by discussion and demonstration by HSE Safety Oficer or project manager on
how to use. Case study relevant to each item is explained and during demonstration to ensure employee understands
why he needs to wear PPE and what possible consequences if not. Follow up is provided by monitoring use of PPE
on site by project manager and site supervisors. PPE is mandatory on site. (Please see attachment I – PPE
training Material )
)d Do you have a program to ensure that PPE is impacted and maintained?
Apakah saudara mempunyai program untuk menjamin bahwa PPE digunakan dan dirawat?
Yes, project managers and site supervisors ensure that PPE is used on site as appropriate by all staff (and sub
contractor staff, if relevant).

4.5 Waste Management

a) What systems are place for identification, classification, minimization and management of waste?
Sistem apa yang telah ada untuk identifikasi, klasifikasi, minimisasi dan manajemen limbah?
- HSE / PRO / 004 – Higyene and Housekeeping. (Please see attachment C no 4)

b) How do you ensure these are imcompliance with local regulation?

Bagaimana saudara memastikan sesuai dengan regulasi lokal?
By comparing our regulation to the local regulation, but in business that we adopt, that procedure are not too
detailed cause our company didn’t produce product with resulting danger waste such chemical or another
flammable material that significant to make a fire and destroying environmental.

c) Please provide the number of accidents resulting in environmental damage in the amount greater than US$50,000
for the last 24 months. Attach copies of any governmental reports submitted
Tolong sediakan jumlah kecelakaan dari hasil kerusakan lingkungan yang bernilai lebih dari US$ 50,000 dalam 24
bulan terakhir. Lampirkan semua copy dari laporan pemerintah yang diserahkan.
None.

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

Apakah saudara mempunyai prosedur – prosedur untuk pembuangan limbah? (Ya / Tidak)
HSE / PRO / 004 – Hygiene and Housekeeping. (Please see attachment C no 4)
e) Do you have procedures for spill reporting? (Yes/No)
Apakah saudara mempunyai prosedur – prosedur untuk pelaporan tumpahan? (Ya / Tidak)
HSE / FOR / 007 (Accident / Incident Reporting Form). (Please see attachment C no 7)

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

Apakah saudara mempunyai prosedur – prosedur untuk pembersihan tumpahan? (Ya / Tidak)
No. we don’t have spill clean up procedure
g) Please provide details at any of your equipment related to environmental matters.
Tolong sediakan detil peralatan saudara yang berhubungan dengan masalah lingkungan
Our work is survey and laser scanning which has minimal impact on environment. No specialized equipment is
required other than use of bin liners or waste containers and shovels for waste burial. We have laser scanner that
operated using x – ray, but it were guaranted by the laser scanner producer that it is not impacted to the
environmental matters. (Please see attachment J – Guarantee Letter for HDS 3000 Laser Scanning from
Leica)

h) Do you assign an expertise to coordinate the environmental and how to ensure his / her competencies?
Apakah saudara menugaskan seorang ahli untuk mengkoordinasikan lingkungan dan bagaimana memastikan
kapabilitasnya?
Yes, we assign an expertise to coordinate the environmental and we also ensure his/her competencies by
reviewing his/her skills and experiences
 ConocoPhillips (Grissik) Ltd.
Long Term Liquid Transportation Project
Land Survey
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Prequalification Documents CS13938047 18.10.2007

4.6 Industrial Hygiene

a) Do you have an industrial hygiene program? (Yes / No) Please describe this process. If yes, please provide the list.
Apakah saudara mempunyai program higienis industri? (Ya / Tidak) Tolong deskripsikan proses ini. Jika ya, tolong
sediakan daftarnya
- Health and Hygiene Statement . Please see attachment K – Health and Hygiene Statement

b) How do you identify industrial health / hygiene?

Bagaimana saudara mengidentifikasi kesehatan / higienis industri?
- By reviewing our environmental condition related to employee health
- Provide medical check up for all employee whose will be work at field
- Provide first aid box at every floor of our office and first aid kit for each field personnel

c) If you produce hazardous substances, please explain the process of documentation and its supervision
Jika saudara membeli substansi berbahaya, tolong jelaskan proses dokumentasi dan supervisinya
The dangerous substances will be kept in the storage with adhering dangerous label or the same thing like that to
inform all employees that the substances will give effect if treated wrong as explained in the label. The substances
shall completed by MSDS as the references how to treat its as like as the dangerous level of the substances.
4.7 Drugs and Alcohol
Do you have a drug and alcohol policy in your organization? (Yes / No) If yes, please attach
Apakah saudara mempunyai kebijakan obat-obatan dan alcohol dalam organisasi saudara?
(Ya / Tidak) Jika ya, tolong lampirkan
Yes, please see attachment B – HSE Policies

SECTION 5 – PLANNING AND PROCEDURES

5.1 HSE and Operations Manuals

a) Do you have HSE procedures manuals? (Yes / No) If yes, please attach the list of content
Apakah saudara mempunyai manual prosedur HSE ? (Ya / Tidak) Jika ya, tolong lampirkan daftar isinya
Yes, please attachment A – HSE Manual
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?
Bagaimana saudara memastikan bahwa praktek kerja dan prosedur yang dipakai pegawai saudara di lapangan secara
konsisten sesuai dengan tujuan dan pengaturan kebijakan HSE?
- by implementing HSE Inspection that conducted in every month or once of every project
5.2 Equipment Control and Maintenance
How do you ensure that plan and equipment used within your premises, on-site, or at other locations by your employees are
correctly registered, certified with regulatory requirement, inspected, controlled and maintained in a safe working conditions?
Bagaimana saudara memastikan bahwa pabrik dan peralatan yang digunakan dalam daerah, lapangan, atau lokasi lainnya oleh
pegawai saudara telah didaftarkan dengan benar, tersertifikasi dengan ketentuan regulasi, diinspeksi, diawasi dan dijaga
sehingga berada dalam kondisi yang aman untuk digunakan dalam bekerja?
All our equipment has auditable documentation from purchase, maintenance, calibration.
Equipment is inspected regularly and also at start/end of fieldworks. Calibration certificates are kept up to date and status of
equipment documented. Corrective action regarding equipment repair, replacement or other forms part of the inspection
procedure and documentation given to logistics dept. for action.

Third party equipment if used by our company is required to have documentation similar to our standards and is fully inspected
prior to use by our company. An inspection report is produced and acts as documentation/record which forms part of project file
documentation.
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Long Term Liquid Transportation Project
Land Survey
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Prequalification Documents CS13938047 18.10.2007
5.3 Transport Safety Management and Maintenance
What arrangement does your company have for vehicle incidents prevention?
Pengaturan apa yang digunakan perusahan saudara untuk mencegah kecelakaan kendaraan?
- HSE / PRO / 009 – Working safety Procedure. Please see attachment C

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? Please explain the
criteria
Pengaturan-pengaturan apa yang dilakukan perusahaan saudara untuk memsupervisi dan mengawasi kinerja HSE?
Tolong jelaskan kriterianya
Top Managements that delegate to HSE Steering Committee teams has responsibility for supervising and monitoring HSE
performance. He monitors on monthly basis as well as undertakes 6 monthly audits in the office. The findings and
recommendations including non compliances and corrective actions required are identified and raised in monthly, HSE
meetings which are then subsequently disseminated to all staff by HSE Steering Committee team and put into action and
implemented by all staff who are monitored by divisional heads and HSE Steering Committee teams
b) What arrangements does your company have for passing on any result and findings of this supervision and monitoring of
your :
(i) Base management
(ii) Site employees
Pengaturan apa yang dilakukan perusahaan saudara untuk meneruskan hasil dan temuan dari supervise dan pengawasan
dari :
(i) Manajemen dasar
(ii) Pegawai lapangan
i) Base Management :
- results and findings are compiled by HSE Manager for the company and division and this is reported and discussed to
divisional heads and directors at HSE monthly meetings.

ii) Site employees?

– these are passed onto site employees via memos sent by email to site team leader who will disseminate this to all site
employees via briefing meeting and/or written memo for all to read and sign off.
c) Has your company received and award for HSE performance achievement? (Yes / No)
Pernahkah perusahaan saudara menerima penghargaan atas keberhasilan kinerja HSE? (Ya / Tidak)
No. However, in our service industry this is rare given that our services are generally short term.

6.2 Statutory Notifiable Incidents. Dangerous Occurences, 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) If yes, please give the number of occurrences and its short description
Pernahkah perusahaan sauadra mengalami keperluan perbaikan atau peringatan pelarangan atas kecelakaan / kejadian
berbahaya menurut undang undang dari badan nasional yang berhubungan dengan HSE atau otoritas yang berwenang atau
telah dilarang berdasarkan legislasi HSE dalam lima tahun terakhir? (Ya / Tidak) Jika ya, tolong beriakn jumlah dan deskripsi
singkatnya
No, we haven’t 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
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Long Term Liquid Transportation Project
Land Survey
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Prequalification Documents CS13938047 18.10.2007

6.3 Transport Safety Management and Maintenance

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 & subcontract personnel) (based on OSHA)
 Fatalities
 Days Away from Work Cases (DAFWC) or LTIs
 Total Recordable Cases (e.g. Medical Treatment, Restricted Work, Transfer to Another Job, Uncosciousness)
Tolong sediakan detik statistic dari kinerja HSE saudara selama 3 tahun terakhir (jika tidak dicatat / tidak berlaku tolong
ditulis N/R atau N/A
Jumlah Total Frekuensi
(termasuk semua personnel kontrak & subkontrak) (berdasarkan OSHA)

 Kejadian Fatal
 Days Away from Work Case (DAFWC) atau LTIs
Total kasus yang dicatat (seperti Perlakuan medis, Pekerjaan yang dibatasi, transfer ke pekerjaan lainnya,
Ketidaksadaran
Please see attachment L – HSE Statistic

b) How is health performance recorded?

Bagaimana pencatatan kinerja kesehatan?
The health performance are recorded and monitored by HRD department, every PT.Geoindo’s personnel who will be sent
to the field shall conducting medical check up to ensure the personnel healthy is good to work at field.

c) How is environmental performance recorded?

Bagaimana pencatatn kinerja lingkungan?
The environmental performance are recorded in the HSE Statistic Report that reported in monthly and yearly basis. All
accident/incident that impacted to the environmental are recorded

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)
Apakah saudara mempunyai prosedur untuk investigasi, laporan dan tindak lanjut kecelakaan, kejadian berbahaya atau
penyakit? (Ya / Tidak)
- HSE / PRO / 008 – Accident / Incident Reporting. Please see attachment C No 6

b) How are the findings following an investigation, or arelevant incident occurring elsewhere, communicated to your
employees?
Bagaimana temuan sebagai tindak lanjut investigasi, atau yang berhubungan dengan kecelakaan di lain tempat
dikomunikasikan kepada pegawai saudara?
- HSE Monthly Meeting
- Informed to all personnel through Toolbox Meeting
- Demonstrated the accident/incident inestigation in the safety induction meeting HSE

c) Do you report lesson learn of any near miss?

Apakah saudara melaporkan pelajaran yang didapat dari near miss?
Yes
 ConocoPhillips (Grissik) Ltd.
Long Term Liquid Transportation Project
Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007

SECTION 7 – AUDIT AND REVIEW

7.1 HSE and Operations Manuals

a) Do you have a written policy on HSE auditing? (Yes / No)
Apakah saudara mempunyai kebijakan tertulis tentang audit HSE? (Ya / Tidak)
- HSE / PRO / 010 – Audit and Management Review. Please see attachment C no 10

b) How does this policy specify the standards for auditing, including schedule, coverage and the qualifications for auditor?
Bagaimana kebijakan ini menjelaskan standar untuk audit, termasuk jadwal, lingkup dan kualifikasi auditor?
HSE Manual specifies standard for auditing by use of standard forms.
The auditors (generally HSE Manger) are provided training both internally and externally on how to audit. External training
involves certification of auditors and are used as qualification documentation

c) How is the effectiveness of audit verified and how does management report and follow up audits?
Seberapa efektif verifikasi audit tersebut dan bagaimana laporan manajemen dan tindak lanjut audit?
The audit is undertaken by HSE manager who analyses records, interviews divisional heads looks at performance and
produces a report which is then discussed at HSE Management Review Meetings and then followed up by HSE Manager.
The audit is reviewed by all divisions. Discussions, briefings and updated procedures issued in order to implement
corrective actions and improvements within the system.

SECTION 8 – EMERGENCY RESPONSE PROCEDURE

Do you have an emergency response plan? (Yes/No) If yes, please attach. How do you maintain readiness of the plan? And
explain the command structure?
Apakah saudara memliki rencana tindakan darurat? (Ya / Tidak) Jika ya, tolong dilampirkan.
Bagaimana saudara memelihara kesiapan rencana tersebut? Dan jelaskan struktur perintahnya
HSE / PRO / 007 – Emergency Response Procedure. Please see attachment C No 7

SECTION 9 – HSE MANAGEMENT – ADDITIONAL FEATURES

a) Does your company hold association(s) membership? (Yes/No) If yes, please provide the list.
Apakah perusahaan saudara memiliki keanggotaan asosiasi? (Ya / Tidak) Jika ya, tolong sediakan daftarnya
Yes, there are KADIN and INKINDO. Please see attachment M – Company Association Membership

b) Is there any aspect of your HSE performance that you believe diffentiates yourself from your competitors that not
described elsewhere in your response to the questionnaire? If yes, please explain
Adakah aspek dari kinerja HSE saudara yang saudara percaya mendiferensiasikan perusahaan saudara dari
competitor yang ada yang tidak dijelaskan sebelumnya di tanggapan anda di kuesioner? Jika ya, tolong jelaskan.
No.
 ConocoPhillips (Grissik) Ltd.
Long Term Liquid Transportation Project
Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007
QUESTION YES NO

SECTION E – QUALITY SYSTEM

E1 Apakah Pendaftar membenarkan bahwa Does Registrant confirm that it has a

pendaftar memiliki Sistem Manajemen documented and fully implemented
Kualitas yang terdokumentasi dan Quality Management System which
diimplementasi sepenuhnya yang addresses onshore programs for the
menyangkut program Pekerjaan onshore subject Work, which is certified in Not Available
untuk Pekerjaan, yang disertifikasikan accordance with ISO 9001:2000 or
sesuai dengan standar ISO 9001:2000 similar?
atau sejenisnya?

Sudahkah Pendaftar mengajukan, Has Registrant submitted, as

sebagai Lampiran E1, deskripsi rinci Enclosure E1, a detailed description of
mengenai Sistem manajemen Kualitas the documented and fully implemented
yang terdokumentasi dan diimplementasi Quality Mangement System which
sepenuhnya yang menyangkut program addresses onshore programs for the
Not Available
Pekerjaan onshore untuk Pekerjaan, subject Work, which is certified in
yang disertifikasikan sesuai dengan accordance with ISO 9001:2000, or
standarISO 9001:2000 atau sejenisnya? similar standard? Registrant to provide
Pendaftar harus memberikan salinan a copy of its current QMS Certification?
Sertifikasi QMS nya yang masih berlaku?

E2 Sudahkah Pendaftar mengajukan, Has Registrant submitted, as

sebagai Lampiran E2, salinan halaman Enclosure E2 a copy of the front
depan dan daftar isis Quality Manual, page and table of contents from the Yes
yang baru diterbitkan, untuk setiap Quality Manual, as currently issued, for (see
perusahaan yang akan memiliki peran each company that would have a role attachment )
dalam manajemen kualitas kontraktor in the contractor’s quality management
untuk Pekerjaan? of the Work?

E3 Apakah pendaftar setuju untuk Does Registrant agree to allow

mengijinkan Perusahaan, dengan Company, by prior appointment, to
perjanjian sebelumnya, untuk melakukan carry out an assessment of the quality
penilaian terhadap system kualitas dan system and practices of each party that
pelaksanaannya untuk tiap pihak yang would be a signatory to a contract for
akan menjadi penandatangan kontrak the Work (as the prime contractor, or as Yes
Pekerjaan (sebagai kontraktor utama a participant in a consortium), by
atau sebagai peserta suatu konsorsium) inspecting premises / facilities and
dengan melakukan inspeksi ke tempat- interviewing relevant personnel?
tempat / lokasi-lokasi dan mewawancarai
personil-personil terkait?
 ConocoPhillips (Grissik) Ltd.
Long Term Liquid Transportation Project
Land Survey
TITLE DOCUMENT NUMBER REV DATE PAGE
Prequalification Documents CS13938047 18.10.2007
Bagian F – Informasi Lain (apabila diperlukan) Section F – Other Iinformation (if required)

Pendahuluan Introduction

Bagian F ini terutama dimaksudkan untuk memberikan This section F is primarily intended to give the Registrant the
kesempatan kepada Pendaftar agar dapat memberikan opportunity to provide any further details that it could be of interest
rincian – rincian lebih lanjut yang diyakini akan dapat to the Company in our assessment of you as a potential candidate
menjadi hal yang penting bagi Perusahaan di dalam for the Work. Registrants are asked not to provide general
penilaian terhadap saudara sebagai calon yang potensial marketing brochures and similar material not to provide general
untuk pekerjaan ini. Para Pendaftar diminta untuk tidak marketing brochures and similar material not directly and
memberikan brosur-brosur pemasaran umum dan bahan- specifically relevant to the Prequalification process.
bahan serupa lainnya yang tidak secara langsung dan
secara khusus terkait dengan proses Prakualifikasi.