Doc. No.

: HSE P-005
PROSEDUR
PREVENTIVE Date Issued: 19 Jan 2024

Unit Issuing: HSE Dept

MAINTENANCE Page 1 of 4 Rev.02

PROSEDUR

PREVENTIVE MAINTENANCE

Issued Signature Date

Prepared Heri Hendi Nofis 30 January 2024

Approved Bernhard Stanley 30 January 2024

Revisi 02

HSE-P-005 PROSEDUR PREVENTIVE MAINTENANCE

 Doc. No.: HSE P-005
PROSEDUR
PREVENTIVE Date Issued: 19 Jan 2024

Unit Issuing: HSE Dept

MAINTENANCE Page 2 of 4 Rev.02

1. TUJUAN

Untuk memastikan ketersediaan peralatan kerja maupun peralatan pendukung kerja agar
selalu siap pada saat akan digunakan

2. RUANG LINGKUP

Prosedur ini disusun untuk mengatur pelaksanaan training di PT. STANLEY CIPTA
MANDIRI

3. REFERENSI

Manual Book Peralatan

4. TANGGUNG JAWAB

4.1. Mechanic
Bertanggung jawab untuk membuat preventive maintenance program, Check List, dan melakukan
aktifitas perawatan (maintenance) terhadap peralatan kerja dan peralatan pendukung kerja

5. DEFINISI

6. DOKUMENTASI

Preventive Maintenance Schedule

Equipment List
Preventive Maintenance Record

HSE-P-005 PROSEDUR PREVENTIVE MAINTENANCE

 Doc. No.: HSE P-005
PROSEDUR
PREVENTIVE Date Issued: 19 Jan 2024

Unit Issuing: HSE Dept

MAINTENANCE Page 3 of 4 Rev.02

7. PROSEDUR

FLOW CHART DISKRIPSI

Mechanic department membuat List

MEMBUAT LIST PERALATAN peralatan, preventive maintenance program,
MAINTENANCE PROGRAM check list, dan analisa kebutuhan spare part.
SCHEDULE DAN ANALISA
KEBUTUHAN SPARE PART
Dalam maintenance program harus mencakup
schedule perawatan dan point-point yang
wajib dilakukan perawatan/cek.

DISTRIBUSI KE Agar tidak mengganggu operasional pekerjaan,

DEPARTEMEN TERKAIT
maka preventive maintenance
program/schedule harus didistribusikan
kepada department terkait dan mendapatkan
persetujuan Manager Operational
APPROVAL MANAGER
OPERASIONAL Preventive maintenance program ini bisa
mengacu pada manual book masing2
peralatan, sehinga acuan yang digunakan bisa
standar sesuai dengan standar pabrikan
PELAKSANAAN
peralatan tersebut.
PREVENTIVE
MAINTENANCE
Hasil dari pelaksanaan preventive maintenance
ini adalah berupa Maintenance Record,
sebagai bukti bahwa proses maintenance
sudah dilakukan sesuai yang di standarkan

PREVENTIVE Hanya pekerja yang mempunyai kompetensi

MAINTENANCE RECORD. yang boleh melakukan pekerjaan preventive
MONTHLY P.M. maintenance ini.
PERFORMANCE

Selama pelaksanaan proses pekerjaan, pekerja

(mechanic) wajib menggunakan alat pelindung
diri yang sudah ditetapkan.

HSE-P-005 PROSEDUR PREVENTIVE MAINTENANCE

 Doc. No.: HSE P-005
PROSEDUR
PREVENTIVE Date Issued: 19 Jan 2024

Unit Issuing: HSE Dept

MAINTENANCE Page 4 of 4 Rev.02

MAINTENANCE RECORD

Forklift

Equipment Forklift

YEAR:
POINT CHECK
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Oli
Filter Oli
Filter solar
Electricity
Rantai
Seal Hydraulic
Minyak rem
Filter Udara

CHECKED BY (SIGN)

REMARK

HSE-P-005 PROSEDUR PREVENTIVE MAINTENANCE

 MAINTENACE XCMG QUY 50 PERIODE JANUARI - DESEMBER 2023
PT. STANLEY CIPTA MANDIRI
NOMER SERI : QUY5021000011
TAHUN PEMBUATAN : 2013

TANGGAL PEKERJAAN PERGANTIAN PART DAN LAIN2

OIL FILTER FUEL AIR CLEANER WATER SEPARATOR SPARE PART KELISTRIKAN HIDROLIK
2-Jan-23 SERVICE BERKALA YA YA YA YA TIDAK ADA PENGECEKAN KELISTRIKAN UNIT PENGECEKAN HIDROLIK
1-Mar-23 SERVICE BERKALA YA YA YA YA TIDAK ADA PENGECEKAN KELISTRIKAN UNIT PENGECEKAN HIDROLIK
5-Sep-23 SERVICE BERKALA YA YA YA YA TIDAK ADA PENGECEKAN KELISTRIKAN UNIT PENGECEKAN HIDROLIK
4-OKT-23 SERVICE BERKALA YA YA YA YA TIDAK ADA PENGECEKAN KELISTRIKAN UNIT PENGECEKAN HIDROLIK
2-Nov-23 SERVICE BERKALA YA YA YA YA PERGANTIAN PULLY BOOM PENGECEKAN KELISTRIKAN UNIT PENGECEKAN HIDROLIK
12-Dec-23 SERVICE BERKALA YA YA YA YA 1. PERGANTIAN WIRE HOOK KECIL PERBAIKAN JALUR HIDROLIK FAN PENGECEKAN HIDROLIK
" " " " " " 2. PERGANTIAN WIRE HOOK BESAR PERBAIKAN JALUR LOAD CELL PENGECEKAN HIDROLIK
" " " " " " 3.PERGANTIAN MONITOR LMI PERBAIKAN JALUR ATB PENGECEKAN HIDROLIK

Jakarta, 22 Desember 2023

Steven
Senior Mekanik
 SAMPLE LOCKOUT/TAGOUT PROCEDURE

The following simple lockout procedure is provided to assist employers in developing

their procedures so they meet the requirements of OSHA standard 1910.147. When the
energy isolating devices are not lockable, tagout may be used, provided the employer
complies with the provisions of the standard which require additional training and
more rigorous periodic inspections. When tagout is used and the energy isolating
devices are lockable, the employer must provide full employee protection that is
specified in paragraph (c)(3) of the standard and additional training and more rigorous
periodic inspections are required. For more complex systems, more comprehensive
procedures may need to be developed, documented and utilized.

Lockout/Tagout procedure for (name of company) ___________________________

at (location)___________________ for (machine/type of machines) _____________

This procedure establishes the minimum requirements for the lockout of energy
isolating devices whenever maintenance or servicing is done on machines or
equipment. It shall be used to ensure that the machine or equipment is stopped and
isolated from all potentially hazardous energy sources and locked out before
employees perform any servicing or maintenance where the unexpected energization
or start-up of the machine or equipment or release of stored energy could cause injury.

Compliance with this procedure

All employees are required to comply with the restrictions and limitations imposed
upon them during the use of lockout. The authorized employees are required to
perform the lockout in accordance with this procedure. All employees, upon seeing
a machine or piece of equipment which is locked out to perform servicing or mainte-
nance shall not attempt to start, energize, or use that machine or equipment. (Insert
type of disciplinary action to be taken for violation of the above.) _______________
____________________________________________________________________ .

Sequence of lockout

(1) Notify all affected employees that servicing or maintenance is required on a

machine or equipment and that the machine or equipment must be shut down and
locked out to perform the servicing or maintenance.

1
 NAMES/ NAMES/ METHOD OF
JOB TITLES OF JOB TITLES OF NOTIFYING SPECIFIC OR TYPE
AUTHORIZED AFFECTED AFFECTED MACHINE/
_EMPLOYEES __EMPLOYEES_ EMPLOYEES ____EQUIPMENT___
_____________ _______________ ____________ ___________________
_____________ _______________ ____________ ___________________
_____________ _______________ ____________ ___________________
_____________ _______________ ____________ ___________________
_____________ _______________ ____________ ___________________

(2) The authorized employee shall refer to the company procedure to identify the
type and magnitude of the energy that the machine or equipment utilizes, and
shall understand the hazards of the energy and know how to control the energy.

SPECIFIC OR TYPE TYPE MAGNITUDE METHOD

MACHINE/ ENERGY OF ENERGY HAZARDS OF ENERGY
EQUIPMENT_ UTILIZED USED___ INVOLVED CONTROL
_______________ __________ ___________ ___________ __________
_______________ __________ ___________ ___________ __________
_______________ __________ ___________ ___________ __________
_______________ __________ ___________ ___________ __________
_______________ __________ ___________ ___________ __________

(3) If the machine or equipment is operating, shut it down by the normal stopping
procedure (depress the stop button, open switch, close valve, etc.).

SPECIFIC OR TYPE TYPE OF MACHINE/

MACHINE/ EQUIPMENT LOCATION OF MACHINE/
EQUIPMENT____ __CONTROLS___ _EQUIPMENT CONTROLS_
__________________ ________________ _________________________
__________________ ________________ _________________________
__________________ ________________ _________________________
__________________ ________________ _________________________
__________________ ________________ _________________________

(4) De-activate the energy isolating device(s) so that the machine or equipment is
isolated from the energy source.

2
 SPECIFIC OR TYPE LOCATION/IDENTITY
MACHINE/ TYPE OF ENERGY OF ENERGY
EQUIPMENT___ ISOLATING DEVICE _ISOLATING__DEVICE__
_________________ __________________ _______________________
_________________ __________________ _______________________
_________________ __________________ _______________________
_________________ __________________ _______________________
_________________ __________________ _______________________

(5) Lock out the energy isolating device(s) with assigned individual locks.

(6)Stored or residual energy (such as that in capacitors, springs, elevated machine

members, rotating flywheels, hydraulic systems, and air, gas, steam, or water
Pressure, etc.) Must be dissipated or restrained by methods such as grounding,
Repositioning, blocking, bleeding down, etc.

SPECIFIC OR TYPE TYPE OF METHODS TO

MACHINE/EQUIPMENT STORED_ENERGY DISSIPATE OR RESTRAIN
_____________________ _________________ ________________________
_____________________ _________________ ________________________
_____________________ _________________ ________________________
_____________________ _________________ ________________________
_____________________ _________________ ________________________

(7)Ensure that the equipment is disconnected form the energy source(s) by

first checking that no personnel are exposed, then verify the isolation of the
equipment by operating the push button or other normal operating control(s)
or by testing to make certain the equipment will not operate.
CAUTION: Return the operating control(s) to “neutral” or “off” position after
verifying the isolation of the machine or equipment.

SPECIFIC OR TYPE METHOD OF VERIFYING

MACHINE/EQUIPMENT _________ISOLATION OF EQUIPMENT___
______________________ ______________________________________
______________________ ______________________________________
______________________ ______________________________________
______________________ ______________________________________
______________________ ______________________________________

(8) The machine or equipment has now been locked out.

3
 Restoring Equipment to Service

When servicing or maintenance is completed and the machine or equipment is

ready to return to normal operating condition, the following steps must be taken.

(1) Check the machine or equipment and the immediate area around the machine
to ensure that nonessential items have been removed and that the machine or
equipment components are operationally intact.

(2) Check the work area to ensure that all employees have been safely positioned
or removed from the area.

(3) Verify that the controls are in neutral.

(4) Remove the lockout device(s) and re-energize the machine or equipment.
NOTE: The removal of some forms of blocking may require re-energizing
the machine before safe removal.

(5) Notify affected employees that the servicing or maintenance is completed and
the machine or equipment is ready for use.

Procedure Involving More than One Person

In the preceding steps, if more than one individual is required to lock out or tag out
equipment, each must place his/her own personal lockout device or tagout device on
the energy isolating device(s). When an energy isolating device cannot accept multiple
locks or tags, a multiple lockout or tag out device (hasp) may be used. If lockout is
used, a single lock may be used to lock out the machine or equipment with the key
being placed in a lockout box or cabinet which allows the use of multiple locks to
secure it. Each employee will then use his/her own lock to secure the box or cabinet. As
each person no longer needs to maintain his/her own lockout protection, that person will
remove his/her lock from the box or cabinet.
EMPLOYEES AUTHORIZED FOR GROUP LOCKOUT/TAGOUT
NAME JOB TITLE
___________________ ______________________
___________________ ______________________
___________________ ______________________
___________________ ______________________

4
5
Lockout - Tagout Implementation Flowchart (ID-G-BU-00000-00000-00404)
Note: you are required to see the Business Process Detail
Originator +
Issuer

(1)

Prepare
Isolation
Start
Certificate
Form
Authorizer

Closes out
4.3.c Equipment is ready
Isolation Certificate
(section 4 – right
End (5) to be returned to
Close out side and section 5)
Isolation
Service
Certificate (See
mechanical, process, system)

Conducts De- explanation 4.2.g)

Isolator (i.e. electrical,

Together with Work Fills in Isolation

Isolation and sign Leader conduct Re- Certificate Sect. 3
Sanction To Test Isolation and fill Column De-Isolated and
(2) C Sanction To Test conducts De-
Form Sec. 2
Column C Form Section 2 Isolation
Isolation
4.2.c 4.2.e 4.3.b

and No
Together with Informs Isolator Opens his lock at
LOTO (4)
Yes Person Responsible
Issuer

Equipment and Work Leader drawer/lock box and

for the test fill in
Test ? Sanction to Test to conduct submits all keys to
process Isolation relevant Isolator
Form Section 1 4.2.f
Responsible Permit Users Work Leader

4.2.a 4.2.b 4.3.a

(3) Informs 4.2.g

Issuer
4.2.d Fail
Equipment is
Equipment Test ?
being repaired

Success
For The Test

Together with
Person

Issuer close out

Sanction to Test
Form Section 3

LEGEND: Input / Output

Start/End Decision/
Document Status
Manual
Cont Process Number ID-G-BU-00000-00000-00404
rol
Activity/ Point Process Description LOTO implementation Flowchart
Manual Process Owner (by Title) HSE Dept
Revision Number 1
Decision/ Business
Activity/ Tech. Process Date of Issue Oct 2023
Technology
Document Links
ConocoPhillips Indonesia

BUSINESS PROCESS DETAIL DOCUMENTATION

Business Process Title LOTO Implementation

Effective Date Oct 2023

Business Process Team Lead Safety Engineer Offshore

Business Process Owner HSE Manager

Business Process Definition/Purpose:
This process provides a guideline for conducting hazardous energy Isolation to comply with
PT.SMC LOTO Standard

Output: -

Business Process Scope:

The implementation of hazardous energy Isolation including Lockout/Tagout.

Policies:
PT.SMC HSE LOTO Standard

Notes/Comments/Assumptions: -

Lockout/Tagout Implementation Page 1 of 4

October 2023
 REVISION CONTROL SHEET
LATEST
DATE ISSUED PREPARED REVIEWED APPROVED COMMENTS
REV
Initial Safety Engineer
24 Oct 2023 HSE Dept HSE Manager
(0)

Lockout/Tagout Implementation Page 2 of 4

October 2023
Activity Technology/
Descriptions/Instructions
No. Notes
1.0 The preparation of Isolation Certificate by Originator, Issuer, and
Authorizer.
1) Isolation Certificate Form section 1, 2, and 3 filled in by
Originator and Issuer as their proposal of hazardous energy
isolation.
2) Authorizer reviews and checks the proposed hazardous energy
isolation and sign section 4 of Isolation Certificate Form.
3) Authorizer signs section 4 (left side) of Isolation Certificate Form
to give authorization for conducting the Isolation.
2.0 Isolation and Lockout Tagout Process.
1) Isolator (i.e. electrical, mechanical, process, system) conducts
Isolation and Logout/Tagout as directed by Isolation Certificate
Form and sign the Isolation Certificate section No. 3.
2) Work Leader either along with Isolator (i.e. electrical, mechanical,
process, system) conduct Logout/Tagout as directed by Isolation
Certificate Form and sign the Isolation Certificate section No. 3 or
perform the lock on the drawer after 2.4 and 2.5 have been
completed.
3) Isolator with Work Leader (if necessary) examines residual
energy, release if any, and verifies the isolation.
4) Issuer ensures that the implementation of isolation (as listed in
Isolation Certificate Form) has been completely conducted.
5) Issuer collects all keys, fuses and Isolation Certificate, then puts
and secures them in Central Permit Control Point (e.g. drawer,
lock box, etc).
6) Work Leader ensures that he has performed the lock as directed in
2.2.
7) Issuer informs Work Leader that the equipment is ready to be
repaired.
3.0 Equipment repaired by Work Leader and Permit Users.
1) Work Leader performs equipment services
2) Work Leader informs Issuer that the services have been completed
4.0 Equipment Testing (as required) by Work Leader, Permit Users,
Issuer, Isolator, Responsible Person, and Authorizer
1) Issuer identifies the requirement of equipment testing.
2) If equipment testing is required, the following actions must be
completed:
a) Issuer and Person Responsible for the test fill Temporary De-
Isolation/Sanction to Test Form section 1.
b) Issuer informs Isolator and Work Leader to conduct Isolation.
c) Isolator and Work Leader conduct De-Isolation (Removal of
the lock) and sign Temporary De-Isolation/Sanction to Test
Form section 2 Column C.
Note: Column A describes the order of the test (1st test, 2nd test, and so on).
d) Work Leader and Permit Users conduct equipment test.
e) If the test failed, Isolator and Work Leader conduct re-isolation

Lockout/Tagout Implementation Page 3 of 4

October 2023
 (re-instate the lock) and fill column C of Temporary De-
Isolation/Sanction to Test Form section 2, then return to
Activity No. 3.0.
f) If test succeed, Work Leader informs Issuer.
g) Person Responsible for the test and Issuer close out Temporary
De-Isolation/Sanction to Test Form Section 3, Isolator and
Authorizer close out Isolation Certificate (Section 3 – De-
Isolated, Section 4 – right side, and Section 5).
3) If equipment testing is not required, the following actions must be
completed:
a) Issuer opens his lock at drawer/lock box and submits all keys
to relevant Isolator.
b) Isolator fills Isolation Certificate (Section 3 – De-Isolated) and
conducts De-Isolation.
c) Authorizer closes out Isolation Certificate (Section 4 – right
side, and Section 5).

5.0 Equipment is Ready to be Returned to Service (End)

Lockout/Tagout Implementation Page 4 of 4

October 2023