SAFE WORK METHOD STATEMENT

Property Name : Google Indonesia Address : PCP bld 45 fl, SCBD lot 10, Jl. Jend Sudirman no. 52-53,
Jakarta Selatan

Company Name : PT. EPCON GRAHA GUNA Activity/Trade : Replacement of light bulbs
Address: Jl. Arjuna Selatan No : 35 Jakarta Barat Office Contact No : (021) 532 2101 (H)
Supervisor Name : Wilson Susanto Contact No : 0899-8311-171

Person who
Procedure (in steps) Possible Hazards Risk Control Measures will ensure
Rating (Describe what action or procedure will be taken to eliminate or this
(Break the job down into steps. Each (Identify the hazards associated with
step should accomplish some major each step. Examine each to find (See minimise the risk of injury or damage. Use the Hierarchy of happens
task and be in logical sequence.) possibilities that could lead to an accident below) Controls below as a guide
or potential harm arising.) 1. Eliminate the Hazard
2. Substitute the material or equipment
3. Isolate the hazard
4. Implement Engineering control
5. Implement Administrative control
6. PPE
Administration miss
Preparation Low Make sure the permit is ready Technician
Cannot work
• Prepare work permit spare part &
tools

Electrical Shock
Isolate the hazard
Bolt and or Nut Lost
Replacement of light bulbs Medium PPE Technician
Property damaged
Secure small items such as bolts
Body injur
• Preparation the necessary
equipment and coordinating with
relevant parties to turn off the
lamp
 SAFE WORK METHOD STATEMENT
• Remove the light bulbs existing
• Do replace the bulbs and make
sure right installation
• Do test of motor unit and make sure
the bulbs / lamp function in normal
condition

Personnel Summary

SUPERVISOR’S DETAILS
Supervisors Name & Qualifications: Name: Bpk. Wilson Susanto
Experience: Maintenance
Qualifications: Engineer
Supervisor’s Responsibilities: Dita Widhi Pangesti

In addition to the above, the supervisor is to provide training in the use of this SWMS, issue PPE and provide training in the
same, supervise the work, ensure conformity with this SWMS, amend the SWMS when additional hazards are found (and if
applicable, ensure all workers receive a tool-box talk to discuss the control measures for the additional hazards).

DESCRIPTION OF TRAINING THAT HAS BEEN GIVEN TO PEOPLE INVOLVED WITH THE WORK
H&S GENERAL INDUCTION: All workers must have successfully completed industry induction training
WORK ACTIVITY TRAINING: All workers need to have been trained in the activities outlined in this safe work method statement.
SITE INDUCTION: All workers are to be site inducted by the Principal Contractor, prior to commencing work on site.
OTHER: (List other training undertaken by workers): (eg: Confined Space, Manual Handling, Traffic Control etc)
TICKETS, PERMITS or LICENCES REQUIRED to undertake this work (ie. Certificates of Competency, Confined Spaces etc):

N.B. - Copies of the above must be shown to the Principal Contractor during site induction.
LEGISLATION, CODES OF PRACTICE and GUIDELINES applicable to this work
All work to comply with the location HS Acts and Regulations and amendments, Workplace Injury Management & Workers Compensation Acts
Additional Codes and Standards applicable to this trade:
 SAFE WORK METHOD STATEMENT

Equipment & Material Summary

PLANT and EQUIPMENT USED and MAINTENANCE FREQUENCY:

Serial Plant/Equipment Contractor Registration No (if Plant Hazards Maintenance/service records and log books sighted
applicable) identified and by Principle Contractor prior to equipment being used
controlled within on site?
SWMS?
Yes No Sign Date
1 Tang Ampere PT. Epcon Graha Guna
Tool kits (Wrench, L Key, Ring
2 PT. Epcon Graha Guna
Pass)
3 Bulbs Lamp PT. Epcon Graha Guna
ELECTRICAL EQUIPMENT USED DURING THE WORKS (Attach Electrical Equipment Register if applicable):
Item Tag/Item Testers Name & Signature License Number Test Date Result Test Date Result
Number
/ / / /

/ / / /
HAZARDOUS SUBSTANCES or DANGEROUS GOODS USED IN THE WORKS and anticipated volumes (Attach SAFETY DATA SHEET if applicable):
Purpos Controls S
te on Site te Left Site Product Name on & Volume Used on (& PPE to be DS Date
e Attached
(ie. Application on Site worn) (Y/N)
site)
/ / / / / /
N.B. - All workers must be trained in the safe use of all chemicals and provided with the PPE required when using and storing these chemicals. Disposal is to be as per the waste
disposal methods in the SDS. Spillage and leaks are to be cleaned up as per the spill/leak procedures identified in the SDS.

We agree that we have been consulted in the hazards and control measures and agree to complete the work in accordance with our Safe Work Method Statement
(SWMS).
We have been provided with training in all tasks outlined in our SWMS and in the Codes of Practice applicable to our work.
 SAFE WORK METHOD STATEMENT

Employee / Worker Signature Date Employee / Worker Signature Date

1. Nursalim 02/11/2023

2. Sutejo 02/11/2023

3. Rio 02/11/2023

Reviewed by: Wilson Susanto Signature: Date: 01/11/2023

(Principal Contractor’s Representative)

Any changes, additions or deletions made to this SWMS are to be covered with the above personnel and the Principal Contractors representative at a Toolbox meeting (Record date
and time of Toolbox meeting below):

Date: 01/11/2023 Time: 3.26 PM

Comments:
A copy of the Toolbox Meeting must be attached to this SWMS
SAFE WORK METHOD STATEMENT