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SDO Scaffolding Inspection Form.

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arindalestari301
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7 views

SDO Scaffolding Inspection Form.

Uploaded by

arindalestari301
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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DAILY PRE-USE SCAFFOLDING INSPECTION FORM

Date : ____________________________________________

Contractor : ____________________________________________

Job Description : ____________________________________________

Loc. : ____________________________________________

Scaffolder/Inspector : ____________________________________________

Jumlah bay dan lift : ____________________________________________

No. Pertanyaan C N.C Keterangan


1 Apakah konstruksi scaffolding masih sesuai dengan kebutuhan kerja
hari ini?

- Luas lantai kerja


- Ketinggian lantai kerja

2 Apakah access menuju tangga dan access tangga scaffolding masih


dalam kondisi normal dan sesuai standard?

- Kemiringan tangga (1:4)


- Ikatan tangga ke scaffolding
- Kedudukan tangga/landasan tangga
- Access gate menuju lantai scaffolding
- Bebas dari penghalang

3 Apakah system pencegah orang dan benda Jatuh Masih terpasang dan
berfungsi?
- Top Rail (ketinggian 90Cm - 110Cmm dari lantai kerja)
- Midrail (ketinggian 45Cm - 55Cmm dari lantai kerja)
- Toe board (ketinggian 6" atau 15Cmm dari lantai kerja)

3 Apakah terjadi perubahan cuaca yang cukup ekstrim sebelumnya, yang


mengakibatkan terjadinya perubahan terhadap landasan dan konstruksi
scaffolding?

- Hujan deras/Angin kencang


- Pergeseran permukaan tanah landasan
- Pergeseran sole plate/base plate
- Posisi scaffolding (bergeser, miring, dsb.)

4 Apakah ditemukan Kuncian dari bagian struktur utama dan pendukung


scaffolding yang longgar, terbuka atau lepas?
- Sole Plate
- Base Plate
- Tiang
- Ledger
- Transom
- Putlog
- Bracing
- Plank/Papan Lantai
- Ties/Achor
- Castor/Roda Scaffolding
- Out Rigger (jika diperlukan

5 Apakah ditemukan material dan fitting scaffolding yang rusak/tidak


berfungsi?

6 Apakah ikatan/clamp pada plank dan toe board ada yang


terlepas/longgar?

7 Apakah batasan area Berbahaya, Waspada dan Aman masih sesuai dan
terpasang?

8 Apakah tanda peringatan bekerja pada scaffolding masih terpasang


pada tempat yang benar?

9 Apakah tag scaffolding (Green) sudah di update dan terpasang pada


temapt yang benar?

Yang melakukan Inspection: Diketahui Oleh:


SCAFFOLDING INSPECTION CHECKLIST
Before Installing Green Tag

Inspection date

Contractor & Team

Project title

Location

Class of scaffolding 1. Light Duty 2. Medium Duty 3. Heavy Duty


Standby Person
1. 3.
Name of scaffolder
2. 4.

Condition
No Inspection Items Specification Remarks
Good Poor
1 Base Ground
Concrete
Plate
2 Sole plate Condition
3 Base plate 150X150X6mm (made by metal)
4 Standard Diameter 48mm
Thickness 4mm
Length
Leveling (vertical)
Couplers
Pins/sprockets/sleeves
5 Ledger Diameter 48mm
Thickness 4mm
Length
Leveling (horizontal)
Couplers
sleeves coupler
6 Transom Diameter (48mm)
Thickness (4mm)
Length
Leveling (horizontal)
Couplers
sleeves coupler
7 Putlog Diameter (48mm)
Thickness (4mm)
Length
Leveling (horizontal)
Couplers
8 Bracing Diameter (48mm)
Thickness (4mm)
Length
Pins/sprockets/sleeves
Couplers
9 Mid rail Diameter (48mm)
Thickness (4mm)
Length
Leveling (horizontal)
9 Mid rail

High from plarform (450mm-550mm)


Couplers
Sleeve coupler
10 Top Rail Diameter (48mm)
Thickness (4mm)
Length
Leveling (horizontal)
High from plarform (90mm-110mm)
Couplers
Sleeve coupler
11 Platform Planks 38mm thick
Length
Wide
Space plank to plank (max. 10mm)
Lashing (Wire dia. 4mm)
Deflection (max. 16mm)
12 Toeboard/kickboard Planks (25mm thickness)
Length
Wide (min. 150mm)
Space toeboard to platform plank
Lashing (Wire dia. 4mm)
13 Ladder (aluminium) Post
Rung
Anti slip (rubber)
Angle (formula 1:4)
Length
Ties/lock
14 Stairway Wide (min 76.2cm)
Raise (20cm - 30cm)
Angle (30o - 45o)
Handrail (mid & top)
15 Gin Wheel Tie in Point condition
(for material)
Safe Working Load (max. 50 Kg)
Hoist line/manila rope(min 12mm)
Safety catch
safety clamp
ties
16 Ties in Condition and strenght
Pipe & putlog end
Position of ties
17 Access to ladder Kedudukan tangga/landasan tangga
Kemiringan tangga (1:4)
Ikatan tangga ke scaffolding
Access gate menuju lantai scaffolding
Bebas dari penghalang
18 Rescue access & Tools Evacuation line
Tools Installation
19 Anchorage Point Condition
Withstand a force 22.2KN/worker
20 Static line/life line Condition
Min dia. 10mm wire rope
Min wide 45mm webbing
21 Scaffolding Work Zone Barricade
Warning sign
safe distance (Dangerious zone, Alert
Zone, Safe Zone)

Inspected by: Knowledged by:


Scaffolding Inspector Site supervisor
SCAFFOLDING INSPECTION & ASSESSMENT FORM

Scope of Work: Location

Scaffolder/Inspector: Assessor:

Percentage: Score: Scaffolding Status NO ITEMS


8 Platform

NO ITEMS SPECIFICATION C N.C REMARKS

1 Base Ground
Concrete
Sole Plate 9 Toe Board
Base Plate
Adjustable Base Plate

2 Standard Pipe Diameter


Thickness
Leveling (Vertical) 10 Aluminium Ladder
Couplers
Pins/Sprockets/Sleeves

3 Ledger Pipe Diameter


Thickness
Leveling (Horizontal) Gin Wheel
Couplers
Sleeve Couplers

4 Transom Pipe Diameter


Thickness
Leveling (Horizontal) 11 Access Ladder
Couplers
Sleeve Couplers

5 Putlog Pipe Diameter 12 Castor/ Scaffolding


Thickness Wheel
Leveling
Couplers

6 Bracing Pipe Diameter


Thickness 13 General
Pins/Sprockets/Sleeves
Spur (cantilever)
7 Guardrail/ Pipe Diameter
Handrail Thickness
Leveling (horizontal) 14 Administration &
Couplers Permiting
Leeve Coupler
Contractor: Area:

Date:

SPECIFICATION C N.C REMARKS


Plank Condition
Thickness/width of plank
Clearence Plan to Plank
Lashing Plank
Deflection

Plank Condition
Length of Plank
Height
Clearenece to Platform
Lashing Plank

Condition
Length of Plank
Height
Putlog/Ties
Angle (75o/1:4)

Condition
S.W.L
Hoist/Rope
Safety Cath
Safety Clamp

Ladder Access
Landing Platform
Access Condition

Condition
S.W.L
Lock
Brake Pad
Bearing

Safety Tools
Scaffolding Installation
Ties in Strength
Material Storage
Applicated Plan

Scaffolding Plan
GPTW,SOP,JSA,ERP,ETC.
Certificate

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