PERTAMINA PHE ONWJ
CONTRACTOR HEALTH, SAFETY AND ENVIRONMENT MANAGEMENT SYSTEM (CSMS) QUESTIONNAIRE SECTION 1 LEDERSHIP AND TOP MANAGEMENT COMMITMENT 1. Commitment to HSE through leadership a) How a! a! "!#$o %a#a&!" $" 'o %a#a&!%!#' !"o#a* $#+o+! $#+o+! $# HSE HSE %a#a&!%!#'
-) Po+$! Po+$! !+$!#! o/ o%%$'%!#' o%%$'%!#' a' a !+!" o/ '0! '0! o&a#$a'$o# o&a#$a'$o# -* 2
(I) S'a'$#& '0$" *!a3" o%a#* 'a&!'" 'a&!'" /o HSE !/o%a#! !/o%a#! 2
(II) D!"$-$#& 0ow *o4 !#"4! '0a' *o4 o&a#$a'$o# 4#!"'a# a# $" o%%$''! 'o !$+! *o4 o%a#* HSE 'a&!'"
) How o *o4 o%o'! o%o'! a o"$'$+! 4'4! 4'4! /owa" /owa" HSE %a''!"5 %a''!"5
SECTION 6 7 POLICY AND STRATEGIC O8JECTIVES P!9:4a$;a'$o# Page 1
PERTAMINA PHE ONWJ
2.1. HSE Policy & Documents a) Do!" *o4 o%a#* 0a+! o# HSE o$* o4%!#' '0a' $" a$! $# '0$" !&$o# (Y!" < No) $/ *!", !a"! a''0.
-) W0o 0a" o+!a a# ;#a !"o#"$-$$'* /o HSE $# *o4 o&a#$a'$o# 5
) How o *o4 !#"4! HSE Po$* o%$a#! a# o%%4#$a'$o# a' "$'!5
2.2 Availability o Policy Statement to Employees How o *o4 o%%4#$a'! *o4 o%a#*3" o$* 'o *o4 !%o*!!" $#4$#& a#* 0a#&!" 5
STANDARDS AND DOCUMENTATION !.1. "rgani#ations $ Commitment and Comunication P!9:4a$;a'$o# Page 2
PERTAMINA PHE ONWJ
a) How %a#a&!%!#' I#+o+! $# HSE A'$+$'$!", o-=!'$+! "!''$#& a# %o#$'o$#& 5
-) W0a' o+$"$o# o!" *o4 o%a#* %a>! /o HSE o%%4#$a'$o# a# %!!'$#&5
!.2 Competence and %raining o anager 'Supervisor'Senior Site Sta( 'HSE Advisor Ha+! '0! %a#a&!" a# "4!+$"o" a' a !+!" '0a' w$ a#, %o#$'o, o+!"!! a# a* o4' '0! wo> !!$+! /o%a HSE 'a$#$#& $# '0!$ !"o#"$-$$'$!" w$'0 !"!' 'o o#4'$#& wo> 'o HSE !:4$!%!#'" 5 (Y!"
!.!. Competence and )eneral HSE %raining a) W0a' aa#&!%!#'" o!" *o4 o%a#* 0a+! 'o !#"4! !%o*!!" 0a+! >#ow!&! o/ -a"$ $#4"'$a HSE, a# 'o >!! '0$" >#ow!&! 'o a'! 5
SECTION 3: ORGANIZATION, RESPONSIBILITY, RESOURCES, P!9:4a$;a'$o# Page 3
PERTAMINA PHE ONWJ
STANDARDS AND DOCUMENTATION !.*. Speciali#ed %raining How 0a+! *o4 $!#'$;! a!a" o/ *o4 o%a#*3" o!a'$o#" w0!! "!$a$! 'a$#$#& $" !:4$! 'o !a w$'0 o'!#'$a 0aa"5 P!a"! $'!%$! a# o+$! !'a$" o/ 'a$#$#& &$+!#5
!.+. HSE ,uali-ed Sta( $ Additional %raining Do!" *o4 o%a#* 0a+! HSE "!$a$"' (!a'! 'o *o4 o%a#*3" "!+$!") w0o a# o+$! 'a$#$#& /o o'0! !%o*!!" 5 (Y!"
I/ Y!", !a"! a''a0 '0! 4$44% +$'a!
!.. Assessment o Suitability o Subcontractors Do *o4 !%o* "4-9o#'a'(S) /o '0! $#'!#! "!+$! 5 (Y!"
I/ No, !a"! &o 'o '0! :4!"'$o# ?.@. Do *o4 0a+! "4-9o#'a'o (") "!!'$o# o!4! $# '!% o/ HSE5
-) How o *o4 a""!" *o4 "4-9o#'a'o(") 'o !#"4! '0!* o%* w$'0 *o4 o%a#*3" HSE o$* a# "'a#a"5
SECTION 3: ORGANIZATION, RESPONSIBILITY, RESOURCES, P!9:4a$;a'$o# Page 4
PERTAMINA PHE ONWJ
STANDARDS AND DOCUMENTATION !./. Standards a) W0a' >$# o/ HSE !&4a'o* o $#4"'$a "'a#a" '0a' *o4 o%a#* !/! 'o /o '0! I#'!#! "!+$! 5
-) w0o o *o4 !#"4! '0!"! a! %!' a# +!$;! 5
SECTION 4: HAZARD AND EFFECT MANAGEMENT Do!" *o4 o%a#* 0a+! o!4! /o '0! I!#'$;a'$o#, a""!""%!#', o#'o a# %$'$&a'$o# o/ Haa" a# !!'" 5 (Y!"
I/ Y!", !a"! a''a0 '0! $#!B<'a-! o/ o#'!#' $#4$#& '0! "4-9I#!B
*.2.E0posures o the orace W0a' "*"'!%" a! $# a! 'o %o#$'o 'o 0aa3" !Bo"4! o/ *o4 wo>/a! !.&. 0!%$a o/ 0*"$a a&!#'" 5
*.!. Handling o Potential Ha#ards How $" *o4 wo>/a! a+$"! o# o'!#'$a 0aa", !.&. 0!%$a #o"!, a$a'$o#, !',, !#o4#'!! $# '0! o4"! o/ '0!$ wo> 5
SECTION 4: HAZARD AND EFFECT MANAGEMENT 4.4. Personnal Protective Equipment P!9:4a$;a'$o# Page 5
PERTAMINA PHE ONWJ
a) W0a' aa#&!%!#'" o!" *o4 o%a#* 0a+! /o o+$"$o# a# 4#>!! o/ o'!'$+! !:4$%!#' a# o'0$#&, -o'0 "'a#a" $""4!, a# '0a' !:4$! /o "!$a$! a'$+$'$!" 5
-) Do *o4 o+$! ao$a'! !"o#a o'!'$+! !:4$%!#' (PPE) /o *o4 !%o*!!"5 (Y!"
P!a"! o+$! a $"'$#& o/ '0! PPE /o '0! "o! o/ '0$" wo>. ) Do *o4 o+$! 'a$#$#& o# 0ow 'o 4"! PPE 5 (Y!"
-) P!a"! o+$! '0! #4%-! o/ a$!#'" !"4'$#& $# !#+$o#%!#'a a%a&! $# '0! a%o4#' &!a'! '0a# , /o '0! a"' 6 %o#'0". A''a0 o$!" o/ a#* &o+!#%!#'a !o'" "4-%$''! 5
) Do *o4 0a+! o!4!" /o wa"'! $"o"a5 (Y!" < No)
) Do *o4 0a+! o!4!" /o "$ !o'$#& 5 (Y!" < No)
!) Do *o4 0a+! o!4!" /o "$ !a# 4 5 (Y!" < No)
/) P!a"! o+$! !'a$" a' a#* o/ *o4 !:4$%!#' !a'! 'o !#+$o#%!#'a %a''!".
P!9:4a$;a'$o# Page 6
PERTAMINA PHE ONWJ
SECTION 2 HAARDS AND EFFECT AMANAGEMENT *.. 3ndustrial Hygiene a) Do *o4 0a+! a# I#4"'$a 0*&$!#! o&a% 5 (Y!"
P!a"! !"$-! '0$" o!"", $/ Y!", !a"! o+$! '0! $"'. *./. Druge and Alcohol Do *o4 0a+! a 4&" a# ao0o o$* $# *o4 o&a#$a'$o#5 (Y!"
SECTION 2 PLANNING AND PROCEDURES +.1. HSE or "perations anuals a) Do *o4 0a+! HSE o!4!" %a#4a" 5 (Y!" < No) I/ Y!", !a"! a''a0 '0! $"' o/ o#'!#'
-) How o *o4 !#"4! '0a' '0! wo>$#& a'$!" a# o!4!" 4"! -* *o4 !%o*!!" o#9"$'! a! o#"$"'!#'* $# aoa#! w$'0 *o4 HSE o$* o-=!'$+!" a# aa#&!%!#'"5 +.2. E4uipment Control and aintenance How o *o4 !#"4! '0a' a#' a# !:4$%!#' 4"! w$'0$# *o4 !%$"!", o#9"$'!, o a' o'0! oa'$o#" -* *o4 !%o*!!" a! o!'* !&$"'!!, !'$;! w$'0 !&4a'o* !:4$!%!#', $#"!'!, o#'o! a# %a$#'a$#! $# a "a/! wo>$#& o#$'$o#5 +.!. %ransport Saety anagement and aintenance W0a' aa#&!%!#' o!" *o4 o%a#* 0a+! /o +!0$! $#$!#'" !+!#'$o#5
+.* 5iting "peration Procedure 6i applicable7 Do *o4 0a+! a#* o!4!" 'o o#'o '0! wo> I#+o+! $# L$/'$#& o!a'$o#5 +.+. aintenance Schedule o 5iting "peration E4uipment 63 applicable7 Do *o4 0a+! a#* I#"!'$o#, '!"'$#&, %a$#'!#a#! a# !'$;a'$o# o&a%" a# "0!4! /o $/'$#& !:4$%!#' !.&. a#!, /o>$/' a# $&&$#& !:4$%!#' 5
P!9:4a$;a'$o# Page 7
PERTAMINA PHE ONWJ
+. Competency o 5iting "peration Personnel 6i applicable7 Do *o4 0a+! "*"'!% 'o !#"4! '0a' '0! $/'$#& '!a%, !.&. $/'$#& !:4$%!#' o!a'o", -a#>"%!# ("$&#a%!#) a# $&&$#& !"o##! a! o%!'!#' 5
SECTION 2 IMPLEMENTATION AND PERFORMANCE MONITORING .1. HSE anagement and Perormance onitoring o or Activities a) W0a' aa#&!%!#'(") o!" *o4 o%a#* 0a+! /o "4!+$"$o# a# %o#$'o$#& o/ HSE !/o%a#!5
-) W0a' aa#&!%!#'" o!" *o4 o%a#* 0a+! /o a""$#& o# a#* !"4'" a# ;#$#&" o/ '0$" "4!+$"$o# a# %o#$'o$#& 'o *o42 (I)
8a"! Ma#a&!%!#'
(II)
S$'! E%o*!!"
) Ha" *o4 o%a#* !!$+! a#* awa /o HSE !/o%a#! a0$!+!%!#'5 (Y!"
.2. Statutory 8oti-able 3ncidents'Dangerous "ccurrences9 3mprovement :e4uirement and Prohibition 8otices Ha" *o4 o%a#* "4!! a#* $%o+!%!#' !:4$!%!#' o o0$-$'$o# #o'$!" o# "'a'4'o* #o'$;a-! $#$!#'"<a#&!o4" o4!#!" -* '0! !!+a#' #a'$o#a -o*, !&4a'o* -o* /o HSE o o'0! !#/o$#& a4'0o$'* o -!!# o"!4'! 4#! a#* HSE !&$"a'$o# $# '0! a"' ;+! *!a"5 I/ *!", !a"! &$+! '0! #4%-! o/ o4!#!" a# $'" "0o' !"$'$o#. .!. HSE Perormance :ecords a) P!a"! o+$! "'a'$"'$a !'a$" o/ *o4 HSE !/o%a#! o+! '0! a"' ? *!a" ($/ No' !o!
N
• • •
To'a N4%-!
F!:4!#*
( I#. A o#'a' "4- o#'a' !"o##!)
( -a"! o# OSHA)
Fa'a$'$!" Da* Awa* Fo% Wo> Ca"!" (DAFWC) o LT" To'a R!oa-! Ca"!" (!.&. M!$a T!a'%!#', R!"'$'! Wo>, Ta#"/! 'o A#o'0! Jo-, U#o#"$o4"#!"")
P!9:4a$;a'$o# Page 8
PERTAMINA PHE ONWJ
-) How $" 0!a'0 !/o%! !o! 55 ) How $" E#+$o#%!#'a !/o%a#! !o! 5
SECTION 2 IMPLEMENTATION AND PERFORMANCE MONITORING .*.3ncident 3nvestigation and :eporting a) Do *o4 0a+! a o!4! /o '0! $#+!"'$&a'$o#, !o'$#& a# /oow94 o/ a$!#', a#&!o4" a4a#!" o o4a'$o#a $#!"a"" 5 (Y!"
-)
How a! '0! F$#$#&" /oow$#& o# $#+!"'$&a'$o#, a a !!+a#' $#$!#' a4$#& !"!w0!!, o%%4#$a'! 'o *o4 !%o*!!" 5
P!a"! a''a0 o# !Ba%! o/ $#+!"'$&a'$o# !o'" 4$#& '0! a"' 16 %o#'0".
SECTION @2 AUDIT AND REVIEW a) Do *o4 0a+! a w$''!# o$* o# HSE a4$'$#& 5 (Y!"
SECTION 8 : EMERGENCY RESPONSE PROCEDURE Do *o4 o# !%!&!#* !"o#"! a# 5 ( Y!"
SECTION 9: HSE MANAGEMENT ADDITIONAL FEATURES a) Do *o4 o%a#* 0o a""o$a'$o# (") %!%-!"0$ 5 (Y!"
P!9:4a$;a'$o# Page 9
