: Inspection Form
TSC9608-SHE-FR-031 SCAFFOLDING INSPECTION
Project / Site Date Of Inspection
Contractor Last Inspection Date
Current Activity
Model/Type
Condition
No Description NR
Good Bad
GUARD RAILS
1 Securely Fastened / Terpasang kuat
2 90 cm to 120 cm high
3
Gap between toe board and first rail not more or <76 cm / Jarak
antara toe board dengan first rail tidak lebih <76 cm
TOE BOARDS
All rounds protection against objects falling / Perlindungan
1 terhadap benda jatuh dipasang seputaran(keliling)
2 Minimum high 15 cm
Decking / Boards
1
Close boarded to prevent toes /
2 Tied down against wind /
3 Not split or cracked / Tidak retak
4 Free from knots /
5 Minimum thickness 2 cm for hard wooden (ulin) / Ketebalan kayu
minimal 2 cm untuk kayu ( ulin )
6 Pengukur (Gauges) Oli mesin
Tubular / Pipes
1 No Distotion
2 No cuts or holes / Tidak boleh ada lubang
3 No bents or flattening / tidak boleh ada peralatan
4 No sharp object / Tidak boleh ada benda tajam
Supports
1 Upright position / Posisi tegak
2
Distance each supports
- Max 2,4 m ( man working )
- Max 1,2 m ( load bearing )
Foundations
1
Prepared & Level foundation / Persiapan & level pondasi
2
Sole plates, covering two supports on soft grounding
Access Ladder
1 Seat at 750 approx (1 in 4) / Kedudukan sekitar 750
Additional horizontal pipe if no ladder available / Tambahkan pipa
2 horizontal jika tidak ada tangga yang available
3
Is the proper access for ladders ? Are ladders secure at least at
the top ? / Tepatkah Akses tangga ? Apakah tangga aman digunakan
sampai ke atas?
Are scaffolds constructed by competent personnel ? / Apakah
4 scaffolding dibangun oleh orang yang berkompeten ?
For process sites are no light alloy or alumuniums ladders used
5 on site ? /
6 Scaffolder Inspector certified ?
7 Scaffolder certified ?
Landing
1
Ladder at least 1m (5 rungs ) above landing place / Tangga
seharusnya 1 m (5 anak tangga ) diatas tempat pendaratan
2 Ladder lashed to stiles not rungs
Transomes as Decking Supports
1 Each board must rest on at least 3 supports
2
Decking board ends not to extend over support more than 15 cm
Others
1 Are safety harnesses use when required ?
2
Are scaffold inspections performed after each modification & at
least weekly ? Are proper records kept ?
3 Are proper scaffold entry tag used to inform personnel when it is
safe ( or not safe ) to use a scaffold ?
Comments :
: Inspected by : Acknowledge by
: Name : Name
: Position : Position
Remark
Acknowledge by
Name
Position
Inspection SCAFFOLDING INSPECTION
Date of Inspection 15-02-2015 Contractor PT PANUTAN SEJATI
Type of Scaffolding Combination Current Activity Acses Ladder
Duties of Scaffolding Location
Purpose of Scaffolding Dimention
Condition
No Description N/A PICTURE
Yes No
Ladder Access ( Secure and Clear from Material )
ok
Base Plate ( Is base plate necessary )
ok
Working Floor ( Minimum 2 boards and Lashed )
ok
Hand Rails ( 1 m above work floor )
ok
Mid Rails ( 0,5 m above work floor )
ok
Toe Boards
ok
Bracing ( Diagonal / Cross / Vertical )
ok
Tied In
ok
Strenght Constructed ?
ok
Barricade ( If barricade necessary )
Scaffolding ranks, Metal Scaffolding platform
ok
Clamp ( Swivel / Rigid )
ok
Tube Schedule 40 ( 1 1/2 inch. 1 1/4 Inch )
ok
Safety Recommendation : Unsafe Condition Stop work No Taging : 002/21 TDU
Scaffolder Supervisor Scaffolder Inspector
