PTVI Safety Observation-Inspection

Manager Area : Date & Time :

Observer : Observer 1 Observer 2 Observer 3 Departement :

Name : Location :

Badge Number : Event description :

Sign : Type Of Observation : ¨ Scheduled ¨ Unscheduled

Performed On : ¨ PT Vale Employee ¨ Contractor

Company name of
:
person observed

HPL = High Potencial Losses NA -Not Applicable Reportable? ¨ Production Time Lost? ¨

Personal Protective Equipment

Head ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Comments of behavioral Observation
Eyes ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Respiratory ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Ears ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Hands and Arm ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Feet and Legs ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Risk Agent

Dust, Gas, & Vapors ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Noise & Vibration ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Temperature ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Illumination ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Action Taken

Ergonomics

Adequate Position ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Critical Movement ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Fatigue ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Workplace

Clean & Organized Place ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Movement Posibility ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Lock Out & Tag Out ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Condition Inspection – Hazard Description
Barricade and Signage ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Fall Risk ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Procedures

Procedures Available ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Knew & Understood ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Followed ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Job Safety Analysis Performed ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Action Taken
Tool & Equipment

Appropriated for the Task ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

In Good Condition ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Correct Utilization ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Safety Devices ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

General Evaluation

Risk Perception ¨ Un acceptable ¨ Acceptable

¨ Tolerable ¨ Best Practice

Safety Behavior ¨ Un acceptable ¨ Acceptable

¨ Tolerable ¨ Best Practice

PT Vale Indonesia Audit & Inspection Subcommitee

 PTVI Safety Observation-Inspection

Manager Area : Date & Time :

Observer : Observer 1 Observer 2 Observer 3 Departement :

Name : Lokasi :

Badge Number : Deskripsi Kegiatan :

Sign : Tipe Observation : ¨ Terencana x Tidak Terencana

Dilakukan Pada : ¨ Karyawan PT Vale ¨ Contractor

Nama perusahaan
:
kontraktor yang diawasi

HPL = High Potencial Losses NA -Not Applicable Harus Dilaporkan? ¨ Hilang waktu produksi? ¨

Alat Pelindung Diri

Kepala ¨ Safe ¨ Unsafe ¨ HPL x N/A

Komentar tentang tindakan tidak aman
Mata ¨ Safe ¨ Unsafe ¨ HPL x N/A

Respirator ¨ Safe ¨ Unsafe ¨ HPL x N/A

Telinga ¨ Safe ¨ Unsafe ¨ HPL x N/A

Tangan dan Lengan ¨ Safe ¨ Unsafe ¨ HPL x N/A

Kaki ¨ Safe ¨ Unsafe ¨ HPL x N/A

Agen Resiko `

Debu, Gas & Uap ¨ Safe ¨ Unsafe ¨ HPL x N/A

Kebisingan & Getaran ¨ Safe ¨ Unsafe ¨ HPL x N/A

Suhu ¨ Safe ¨ Unsafe ¨ HPL x N/A

Pencahayaan ¨ Safe ¨ Unsafe ¨ HPL x N/A

Action yang dilakukan

Ergonomi

Posisi ¨ Safe ¨ Unsafe ¨ HPL x N/A

Pergerakan ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Kelelahan ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Area kerja

Bersih & Rapi ¨ Safe ¨ Unsafe ¨ HPL x N/A

Access ¨ Safe ¨ Unsafe ¨ HPL x N/A

Lock Out & Tag Out ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Kondisi Tidak aman - Deskripsi
Barikade dan rambu keselamatan¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Resiko Jatuh ¨ Safe ¨ Unsafe ¨ HPL ¨ N/A

Prosedur

Procedures Tersedia ¨ Safe x Unsafe HPL x N/A

Diketahui dan Dipahami ¨ Safe x Unsafe ¨ HPL ¨ N/A

Dilakukan ¨ Safe x Unsafe ¨ HPL ¨ N/A

JSA dilakukan ¨ Safe x Unsafe ¨ HPL ¨ N/A

Action yang dilakukan
Perlengkapan & Peralatan

Tepat sesuai pekerjaan ¨ Safe ¨ Unsafe ¨ HPL x N/A

Dalam kondisi baik ¨ Safe ¨ Unsafe ¨ HPL x N/A

Digunakan dengan benar ¨ Safe ¨ Unsafe ¨ HPL x N/A

Alat pengaman ¨ Safe ¨ Unsafe ¨ HPL x N/A

Evaluasi Umum

Persepsi anda tentang resiko ¨ Un acceptable x Acceptable

¨ Tolerable x Best Practice

Perilaku Safety ¨ Un acceptable x Acceptable

¨ Tolerable Best Practice

PT Vale Indonesia Audit & Inspection Subcommitee