Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)

Supplier / Contractor A.N. Other plc

Date of Assessment Friday, September 10, 2010
Completed By John Smith

Required KPIs are listed on the 2nd tab

HSSE stands for Health, Safety, Security & Environment

Please cover all aspects in your responses to the questions
PT DJOERIWANDHAWA INDONESIA
Keyword Question Document

1 Leadership & HSSE Culture

Committment to How are senior managers personally involved in HSE management for
a) example objective-setting and monitoring? By regular meeting, periodically safety meeting, briefing
HSE aspects
1.1
through
leadership b) Provide evidence of commitment at all levels of the organisation? Attached YES
c) How do you promote a positive culture towards HSE matters? Attached By regular meeting, periodically safety meeting, briefing
2 HSSE Policy & Strategic Objectives

Does your company have an HSE policy document?

a) If the answer is YES please attach a copy. Attached HSSE Policy

Structure and Job

b) Who has overall and final responsibility for HSE in your organisation? Top Management
Responsibility
HSE Policy Documents

Who is the most senior person in the organisation responsible for this
Structure and Job
2.1 c) policy being carried out at the premises and on site where his employees Top Management
are working? Provide name and title. Responsibility

Itemise the methods by which you have drawn your policy statements to
d) the Attached Attached
attention of all your employees?

What are your arrangements for advising employees of changes in the

e) policy? Attached By regular meeting, periodically safety meeting, briefing
HSE contract strategic

Does your company have strategic HSE objectives?

a) If the answer is YES please attach a copy. Attached HSE Objectives
objectives

2.2

Itemise the methods by which you have communicated your strategic HSE
b) objectives to the attention of all your employees? Attached Attached

3 Organisation, responsibilities, resources, standards and documentation Attached

Organisational structure for HSE management

How is your organisation structured to manage and communicate HSE

a) effectively? Attached To Manage and communicate HSE effectively by Periodically Meeting, From Top to Operator,

b) Do HSE meetings promote HSE awareness? Attached Yes

3.1
Do client and contractor meet regularly to discuss and action any interface
c) situations? Attached Yes

What provision does your company make for HSE communication

d) meetings? Attached Organisation chart
Please provide an organisation chart
HSE training of managers, supervisors and HSE critical

Have the managers and supervisors at all levels who will plan, monitor,
a) oversee and carry out the work received formal HSE training in their Attached Attached
responsibilities with respect to conducting work to HSE requirements?

If YES please give details. Where the training is given in-house please
b) describe the content and duration of courses. Please provide an example Attached Training matrix
of training matrix.
positions

How have you identified areas of your company’s operations where

3.2 c) specialised training is required, for instance training related to health Attached Safety Inspection and Job Safety Observation
hazard such as radiation, asbestos and chemicals?

d) What specialist HSE resources does your organisation have available? Attached Attached

e) How does your company provide HSE specialised training for HSE staff? Attached HSE specialised training conduct regularly inhouse and public training

What arrangements does your company have to ensure new employees

a) have knowledge of basic industrial HSE, and to keep this knowledge up to Attached Details of content
date?
General HSE training

What arrangements does your company have to ensure new employees

3.3 b) also have knowledge of your HSE policies, practices and company Attached Attached
requirements?

What arrangements does your company have to ensure new employees

c) have been instructed and have received information on any specific Attached Details of content
hazards arising out of the nature of the activities?
Cometence assurance

Does your organisation have a competence system in place?

a) If YES, please describe the scope and content of your competence Attached Yes, stated on documented human resource development
system.

3.4

What arrangements does your company have to ensure existing staff HSE
b) knowledge is up to date? Attached Attached

Does your company have a contractor management process or system?

a) If yes, provide an outline of the process. Attached Contractor management process outline
Contractor management process

b) How do you assess contractors, HSE competence or HSE performance? Attached Provide Contractors selection, evaluation and re-evaluation programme

3.5

Where do you define the company standards you require your contractors
c) to meet? Attached Attached

d) How do you ensure these standards are met and verified? Attached By regular meeting, periodically safety meeting, briefing

How do you identify new industry or regulatory standards that may be To identify new industry or regulatory standards that may applicable in activities by linked to
a) applicable to your activities? Attached Authorized Provider Network
HSE standards

3.6
Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)

Supplier / Contractor A.N. Other plc

Date of Assessment Friday, September 10, 2010
Completed By John Smith

Required KPIs are listed on the 2nd tab

HSSE stands for Health, Safety, Security & Environment

Please cover all aspects in your responses to the questions
PT DJOERIWANDHAWA INDONESIA
Keyword Question Document
HSE standards

Is there an overall structure for producing, updating and disseminating

3.6 b) standards? Attached Attached

Are your company standards aligned with OGP/industry guidelines or

c) recommended practices? If yes state which one. Attached Yes

4 Risk Management Attached

Risk How does your company identify hazards, assess risk, control and
Assessment & 4.1 a) mitigation Attached Stated documented for identifiy hazards, assess risk, control and mitigation
Control consequences, to a level as low as reasonably practicable?

Do you have specific policies and programmes on specific health hazards

a) e.g. substance abuse, blood borne thogens, malaria pandemic diseases Attached
etc.
Health Hazards

What type of health hazards (chemical, vibration, noise, radiation, etc) are
associated with the scope of your services? Explain how occupational
4.2 b) health Attached
hazards are identified, assessed and controlled.

What systems are in place to control these hazards and monitor the
c) effectiveness of these controls? Is worker’s regular exposure monitoring Attached Regular meeting, Induction Periodically, Briefing Morning Talk
part of these systems?

What type of safety hazards (mechanical guarding, work at height, lifting

Safety hazards

a) and hoisting, confined space entry, explosive atmospheres etc.) are Attached
associated with the scope of your services?

4.3

What systems are in place to control these hazards and monitor the
b) effectiveness of these controls? Attached
Logistics hazards

What type of logistics hazards (land transport, air transport, marine

a) transport, materials handling etc.)are associated with the scope of your Attached logistic hazards associated: Slip trip, Car crash, Unauthorized operator,
services?

4.4

What systems are in place to control these hazards and monitor the
b) effectiveness of these controls? Attached Inspection, Audit, Schedule, Safety regular evaluation

What type of environmental hazards (chemical spill, atmospheric

Environmental

a) emissions, waste disposal etc.) are associated with the scope of your Attached Environmental hazard associated: Chemical spills. Athmospheric emission, Waste disposal
services?
hazards

4.5

What systems are in place to control these hazards and monitor the
b) effectiveness of these controls? Attached Inspection, Audit, Schedule, Safety regular evaluation
Security hazards

What type of security hazards (terrorism, hostage taking, robbery, hostile

a) local population etc.) are associated with the scope of your services? Attached Security hazards associated: Hostile local population

4.6

What systems are in place to control these hazards and monitor the
b) effectiveness of these controls? Attached Inspection, Audit, Schedule, Safety regular evaluation
Social responsibility

What type of social hazards are associated with the scope of your
a) services? Attached Social hazards associated: Welfare, public relationship
hazards

4.7

What systems are in place to control these hazards and impacts and
b) monitor the effectiveness of these controls? Attached Regular meeting, Induction Periodically, Briefing Morning Talk

5 Planning & Procedures Attached

Do you have a company HSE-MS manual (or operations manual with
integrated HSE requirements) which describes in detail your company
HSE operations
5.1 a) approved HSE working practices relating to your work activities? Attached HSSE-MS manual index & supporting information
manual If the answer is YES please attach a copy of an index and relevant
supporting documentation.

Infrastructure How do you ensure that infrastructure, plant and equipment used within
your operations (own premises, client site, or at other locations) are Periodically controlled and review of certification, registration and maintained of safe working
and equipment 5.2 a) correctly certified, registered, controlled and maintained in a safe working Attached condition
integrity condition?

Management of How do you manage changes and assess associated risks e.g. personnel,
5.3 a) equipment, processes, documentation? Attached Evaluation and Asses the Personnel, equipment, process and documentation regularly
change
Emergency planning

What arrangements does your company have for emergency planning and
a) response? Attached
and response

By regular meeting, periodically safety meeting, briefing

5.4

b) Which emergency situations are included? Attached Fire, Earthquake, Floods, Riots,

6 Implementation and performance monitoring Attached

HSE-MS implementation and active performance monitoring of work

What arrangements does your organisation have for monitoring the

a) implementation of your HSE-MS? Attached By regular meeting, periodically safety meeting, briefing

How does your company assure the implementation of work procedures

b) within your work-site operations e.g. compliance with procedures, toolbox Attached By regular meeting, periodically safety meeting, briefing
talks, safety meetings, supervision, job observations?

How do you monitor employee HSE performance e.g. hazard identification

c) systems, HSE participation? Attached Regular meeting, Induction Periodically, Briefing Morning Talk
activities

6.1

What active HSE monitoring is performed (i.e. where no incident has

d) occurred)? Attached Regular meeting, Induction Periodically, Briefing Morning Talk

Report and correct deficiencies identified on document and government regulation if accident
e) How do you report and correct deficiencies identified? Attached occurred

How do you communicate the results of active performance monitoring to

f) relevant personnel? Attached Regular meeting, Induction Periodically, Briefing Morning Talk
Supplier / Contractor Pre-Award HSSE Questionnaire (Version 1 - 1 June 2011)

Supplier / Contractor A.N. Other plc

Date of Assessment Friday, September 10, 2010
Completed By John Smith

Required KPIs are listed on the 2nd tab

HSSE stands for Health, Safety, Security & Environment

Please cover all aspects in your responses to the questions
PT DJOERIWANDHAWA INDONESIA
Keyword Question Document

Safety
performance 6.2 a) See separate spreadsheet called Contractor Assessment KPI Data Attached Yes
indicators

a) How is health performance monitored and recorded? Attached HSE and HRD GA monitored and recorded Health Performance

b) How is environmental performance monitored and recorded? Attached HSE and HRD GA monitored and recorded Health Performance
HSE performance monitoring

c) How is security performance monitored and recorded? Attached HRD GA monitored and recorded security performance

6.3 d) How and what near miss incidents are reported? Attached By regular meeting, periodically safety meeting, briefing

e) How often is HSE performance reviewed? By whom? Attached Weekly, Monthly by HSE

f) How is logistics performance monitored and reported? Attached Weekly, Monthly by Logistic

g) Do you record vehicle incidents? Attached Yes

a) What types of HSE incident are investigated? Attached Stated documented for identifiy hazards, assess risk, control and mitigation
HSE incident and investigation follow-up

b) What process is used to investigate HSE incidents? Attached SCAT,

6.4 c) Who conducts HSE incident investigations? Attached HSE

How are the findings of an incident investigation followed up to ensure

d) effective prevention of recurrence? Attached By regular meeting, periodically safety meeting, briefing

e) How is incident learning communicated to all relevant personnel? Attached By regular meeting, periodically safety meeting, briefing

Statutory
notifiable Has your company suffered any statutory notifiable incidents in the last five
years (safety, occupational health and environmental)?
incidents or non 6.5 a) Answers with details including dates, country and location, summary of Attached Details of statutory notifiable incidents or non compliance notices
compliance incident and follow-up preventative measures taken.
notices
7 HSE auditing and management review of HSE-MS Attached

Do you have a written procedure for HSE auditing?

a) If yes, please attach a copy. Attached Audit procedure

Who is involved in conducting HSE audits? How are audit team members
selected to have specific expertise and be independent from the activities
b) being audited? Attached HSE and Team Auditors have trained, certified, re-trained regualrly
What are the qualifications required for auditors?
Audits

7.1
How does your company schedule HSE audit and what scope of auditing
c) is covered? e.g. internal, regulatory compliance, supplier/contractor, HSE Attached Monthly, Yearly audit scheme covered HO and Sites, contractors by HSE CSMS
management system implementation.

How does management follow up on audit findings and ensure effective

d) close out of action items? Attached By regular meeting, periodically safety meeting, briefing
Management review and follow-up

Do you have a written procedure for management review of the HSE-MS?

a) If yes, please attach a copy Attached Management review procedure for HSE-MS

How often are HSE-MS reviews conducted and who is involved in the
7.2 b) process? Attached Monthly, Yearly audit scheme covered HO and Sites, contractors by HSE CSMS

How are identified actions and improvement efforts recorded and tracked
c) to effective completion? Attached By regular meeting, periodically safety meeting, briefing

8 HSE management - additional features Attached

Certification of Please provide information on any certification which you have received
8.1 Attached Yes, stated on documented human resource development
your HSE-MS from certification bodies

Membership of Describe the nature and extent of your company’s participation in relevant
8.2 Attached Yes, stated on documented human resource development
associations industry, trade, and governmental organisations

Additional Does your organisation (globally, regionally or locally) have any HSE
features of your 8.3 features or arrangements not described elsewhere in your response to the Attached Yes, stated on documented human resource development
HSE-MS questionnaire?

9 Company specific information Attached

Attached

Attached

END
Supplier pre-qualification Questionnaire - HSSE Data
See Glossary of terms for definition of each item

Current
EXPOSURE Year -1 Year -2 Year -3
Year
Total Manhours worked
Exposure - Driving (km)
Exposure - Site Work (hours)

Current
SAFETY Year -1 Year -2 Year -3
Year
Fatalities FAT
Lost Time Incidents LTI
Lost Workday Cases LWC
Restricted Workday Cases RWC
Medical Treatment Cases MTC
First Aid Cases
Total Recordable Cases (sum FAT, LWC,
TRCMTC, or RWC)

Near Miss Incidents

Fatal Accident Rate (per 108 hours) FAR

Lost Time Injury Frequency (per 106 LTIF
hours)
Total Recordable Case Frequency (per
TRCF106 hours)

Current
Year -1 Year -2 Year -3
ENVIRONMENT Year
Loss of Primary Containment (re LOPC
Year -4

Year -4

Year -4