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LAPORAN INSPEKSI FORKLIFT
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
1 dari 7
Lokasi / Tempat Pemeriksaan : ……………........................ Tanggal Pemeriksaan : ……………………................ I . DATA FORKLIFT : DATA UMUM
Nama Equipment
Tipe / Kapitas Maks
Pemilik Equipment
Brand / Manufacturer
No. Item
Dimension (Fork)
Tahun Pembuatan
Forklift Class
Tahun Perakitan. DOKUMEN NAMA DOKUMEN
ADA
TIDAK ADA
KETERANGAN
BPKB STNK Sertifikat Forklift (Migas) Sertifikat Operator (Migas) Manual Book Operasional Laporan inspeksi sebelumnya ENGINE
Brand / Manufacturer
Jumlah Silinder
Model No.
Voltage / Current
Serial No
Freq./Phase
LAPORAN INSPEKSI FORKLIFT
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
2 dari 7
II. PEMERIKSAAN FORKLIFT CHECK FISIK NO.
PERALATAN
INSPEKSI
1. LOAD LIFTING MECHANISM 1.1. Mast Kepala Tiang (Upright)
Korosi, retak, bengkok
Batang Utama (Mast)
Korosi, retak, bengkok
Rangka Penguat (Stiffener)
Korosi, retak, bengkok
Sambungan (Splices)
Aus, retak, bengkok
1.2. Carrier Batang Utama (main Frame)
Korosi, retak, bengkok
Rangka Penguat (Stiffener)
Korosi, retak, bengkok
Rantai (Chain)
Longgar, retak, bengkok
Sproket (Sprocket)
Longgar, aus, bengkok
Engsel, Pin (Hinge / Pin)
Longgar, retak, bengkok
1.3. Lift Cylinder Lengan Mendatar (Horizontal arm) Selongsong Lengan (Arm Box)
Korosi, retak, bengkok
Pendongkrak Hidrolik (Hyd. Jack)
Aus, bengkok, adjust
Alas (Shoe / Pad)
Aus, bengkok, adjust
Korosi, retak, bengkok
1.4. Counterweght Beban (Counter Weight)
Tersedia
Penyangga (Support)
Korosi, retak, bengkok
Pengikatan (Bolting)
Aus, longgar
1.5. Fork Garpu (Fork)
Korosi, retak, bengkok
Sambungan Pengikat (Bracket)
Korosi, retak, bengkok
Sambungan Las (Welding)
Korosi, retak, bengkok
Pengunci (Lock)
Longgar, retak, bengkok
2. TRAVELLING MECANISM Chasis (Chassis / Car Body)
Korosi, retak, bengkok
Roda Depan (Front Wheel)
Aus, tekanan, adjust
Roda Pengikut / tengah (Non Drive Wheel)
Aus, tekanan, adjust
Roda Belakang (Drive Wheel)
Aus, tekanan, adjust
Gardan (Differential)
Korosi, retak, bengkok
Sambungan Pengikat, baut (bracket , Bolt)
Longgar, retak, bengkok
Rem (travelling Brake)
Aus, adjust
ADA
TIDAK ADA
KONDISI BAIK
TIDAK BAIK
KETERANGAN
LAPORAN INSPEKSI FORKLIFT
CHECK FISIK NO.
PERALATAN
INSPEKSI
3. PRIME MOVER 3.1. Engine Rumah Mesin (Engine Housing)
Korosi, bengkok, layak
Badan Mesin (engine Block)
Kotor, bocor, bengkok
Dudukkan Mesin (Engine Mounting)
Layak, aus, longgar
Pembautan (Bolting)
Korosi, longgar
3.2. Cooling / Lubrication Radiator (Radiator)
Level, Kontaminasi
Pelindung (Safety Guard)
Fit, bengkok, safety
Kipas & Tali (Fan & Belt)
Tension, aus, safety
Selang Air (Water Hose)
Kontaminasi, safety
Tutup Pengisi (Cap)
Fit, kebocoran
Pelumasan (Lubrication)
Level, kontaminasi
3.3. Fuel System Bahan Bakar (Fuel)
Kontaminasi
Tangki B. Bakar (Fuel Tank)
Penyok, bocor
Pompa B. Bakar (Fuel Pump)
Kotor, bocor, aus
Saluran B. Bakar (Fuel Line)
Buntu, bocor, aus
Pembersih udara (Air Cleaner)
Buntu, bocor, aus
Manifold
Bocor, aus, safety
Knalpot, anti api (Muffler, Spark Arrestor)
Bocor, aus, safety
4. ELECTRICAL SYSTEM 1
Sistem Kabel Kabin (Cabin Wiring System)
Buruk, function
Sistem Kabel Lampu (Lighting System)
Buruk, function
Sistem Kabel Aki (Battery Wiring System)
Buruk, function
Sistem Kabel Mesin (Engine Wiring System)
Buruk, function
Saklar / Kontraktor (Switch / Contactor)
Buruk, function
Sistem Pengaman (Main Breaker)
Buruk, function
Sistem Pembumian (Grounding System)
Buruk, function
Baterai (Battery)
Level, sambungan, ujung hub
ADA
TIDAK ADA
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
3 dari 7
KONDISI BAIK
TIDAK BAIK
KETERANGAN
LAPORAN INSPEKSI FORKLIFT
Stater Listrik (Motor Stater)
PERALATAN
INSPEKSI
5. HYDRAULIC SYSTEM Pompa (Hydraulic Pump)
Kebocoran, function
Pengumpul (Hydraulic Accumulator)
Kontaminasi, kebocoran
Katub kendali (Control Valve)
Bocor, Function
Katub pembagi (Three Way Valve)
Bocor, Function
Swievel Pusat (center Valve
Bocor, Function
Saluran Hidrolik - Mengangkat
Gompal, aus, bocor
- Membalik
Gompal, aus, bocor
Katub - katub - Mengangkat
Gompal, aus, bocor
- Membalik
Gompal, aus, bocor
Silinder Hidrolik - Mengangkat
Gompal, aus, bocor
- Membalik
Gompal, aus, bocor
6. AIR / PNEUMATIC SYSTEM 1
Kompressor (Compessor Unit)
Kontaminasi, bocor
Saluran Udara (Air line)
Koyak, aus, bocor
Fiting (Fitting)
Bengkok, aus, bocor
Katup Kendali (Control Valve)
Bengkok, bocor
Tangki Penimbun (Air Receiver Tank)
Kontaminasi, bocor
Katup Pengaman (Pressure Safety Valve)
Adjust, fuction
Tangki Udara (Accumulator)
Bocor, safety
Pompa (Charging Pump)
Function
7. DRIVING CABIN 7.1. Structure Rangka Dinding (Cabin Wall Frame)
Korosi, retak, penyok
Kursi, penguat (Seat, Bracket)
Korosi, retak, koyak, layak
Lantai (Platform, Floor)
Korosi, retak, koyak, layak
Tangga (Ladder)
Korosi, retak, koyak, layak
7.2. Control Unit Kemudi (Wheel)
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
4 dari 7
Layak, sambungan, function
CHECK FISIK NO.
No. Dokumen
Function, Layak
ADA
TIDAK ADA
KONDISI BAIK
TIDAK BAIK
KETERANGAN
LAPORAN INSPEKSI FORKLIFT
Tuas, Pedal, Kenop (joystik, pedal, Push Button)
Function, Layak
- Memutar (Slewing)
Function, Layak
- Gas (Throtle)
Function, Layak
- Rem (Brake)
Function, Layak
- Rem parkir (Parking brake)
Function, Layak
- Pasneling (Transmission)
Function, Layak
- Kopling (Coupling)
Function, Layak
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
5 dari 7
LAPORAN INSPEKSI FORKLIFT
CHECK FISIK NO.
PERALATAN
INSPEKSI
Tek. Pelumas (lubrication gauge)
Function
Tek. Udara (Air Pressure Gauge)
Function
Amper, Tegangan (Ampere, Volt Meter)
Function
Suhu Mesin (Engine Temperature gauge)
Function
Putaran Mesin (Tachometer)
Function
Kecepatan Jalan (Speedometer)
Function
Tek. Hidrolik (Hydraulic Pressure Gauge)
Function
ADA
TIDAK ADA
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
6 dari 7
KONDISI BAIK
TIDAK BAIK
KETERANGAN
SAFETY DEVICE Indikator Level (Level Gauge)
Function
Indikator Sudut (Angle Indicator)
Function
Tek. Hidrolik (Hydraulic Pressure Gauge)
Function
Tabel Beban (Laod Chart)
Tersedia
Penunjuk Beban (Load Indicator)
Function, akurat
Kunci Darurat (Emergency Shutdown)
Function
APAR (Portable Fire Extinguisher)
Kedaluarsa, Inspeksi
V. REKOMENDASI : ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................
LAPORAN INSPEKSI FORKLIFT
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
7 dari 7
VI. KESIMPULAN HASIL PEMERIKSAAN Dari hasil Pemeriksaan disimpulkan, bahwa sebagai berikut : *) 1. Forklift LAIK Operasi. 2. Forklift LAIK Operasi dengan ketentuan dilakukan perbaikan sesuai butir V di atas. 3. Forklift TIDAK LAIK Operasi. *) : Coret yang tidak perlu (X). Dibuat oleh, 1.
.............................. Nama & Jabatan
2.
............................. Nama & Jabatan
Disetujui oleh,
........................... Nama & Jabatan
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
1 dari 7
Lokasi / Tempat Pemeriksaan : ……………........................ Tanggal Pemeriksaan : ……………………................ I . DATA FORKLIFT : DATA UMUM
Nama Equipment
Tipe / Kapitas Maks
Pemilik Equipment
Brand / Manufacturer
No. Item
Dimension (Fork)
Tahun Pembuatan
Forklift Class
Tahun Perakitan. DOKUMEN NAMA DOKUMEN
ADA
TIDAK ADA
KETERANGAN
BPKB STNK Sertifikat Forklift (Migas) Sertifikat Operator (Migas) Manual Book Operasional Laporan inspeksi sebelumnya ENGINE
Brand / Manufacturer
Jumlah Silinder
Model No.
Voltage / Current
Serial No
Freq./Phase
LAPORAN INSPEKSI FORKLIFT
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
2 dari 7
II. PEMERIKSAAN FORKLIFT CHECK FISIK NO.
PERALATAN
INSPEKSI
1. LOAD LIFTING MECHANISM 1.1. Mast Kepala Tiang (Upright)
Korosi, retak, bengkok
Batang Utama (Mast)
Korosi, retak, bengkok
Rangka Penguat (Stiffener)
Korosi, retak, bengkok
Sambungan (Splices)
Aus, retak, bengkok
1.2. Carrier Batang Utama (main Frame)
Korosi, retak, bengkok
Rangka Penguat (Stiffener)
Korosi, retak, bengkok
Rantai (Chain)
Longgar, retak, bengkok
Sproket (Sprocket)
Longgar, aus, bengkok
Engsel, Pin (Hinge / Pin)
Longgar, retak, bengkok
1.3. Lift Cylinder Lengan Mendatar (Horizontal arm) Selongsong Lengan (Arm Box)
Korosi, retak, bengkok
Pendongkrak Hidrolik (Hyd. Jack)
Aus, bengkok, adjust
Alas (Shoe / Pad)
Aus, bengkok, adjust
Korosi, retak, bengkok
1.4. Counterweght Beban (Counter Weight)
Tersedia
Penyangga (Support)
Korosi, retak, bengkok
Pengikatan (Bolting)
Aus, longgar
1.5. Fork Garpu (Fork)
Korosi, retak, bengkok
Sambungan Pengikat (Bracket)
Korosi, retak, bengkok
Sambungan Las (Welding)
Korosi, retak, bengkok
Pengunci (Lock)
Longgar, retak, bengkok
2. TRAVELLING MECANISM Chasis (Chassis / Car Body)
Korosi, retak, bengkok
Roda Depan (Front Wheel)
Aus, tekanan, adjust
Roda Pengikut / tengah (Non Drive Wheel)
Aus, tekanan, adjust
Roda Belakang (Drive Wheel)
Aus, tekanan, adjust
Gardan (Differential)
Korosi, retak, bengkok
Sambungan Pengikat, baut (bracket , Bolt)
Longgar, retak, bengkok
Rem (travelling Brake)
Aus, adjust
ADA
TIDAK ADA
KONDISI BAIK
TIDAK BAIK
KETERANGAN
LAPORAN INSPEKSI FORKLIFT
CHECK FISIK NO.
PERALATAN
INSPEKSI
3. PRIME MOVER 3.1. Engine Rumah Mesin (Engine Housing)
Korosi, bengkok, layak
Badan Mesin (engine Block)
Kotor, bocor, bengkok
Dudukkan Mesin (Engine Mounting)
Layak, aus, longgar
Pembautan (Bolting)
Korosi, longgar
3.2. Cooling / Lubrication Radiator (Radiator)
Level, Kontaminasi
Pelindung (Safety Guard)
Fit, bengkok, safety
Kipas & Tali (Fan & Belt)
Tension, aus, safety
Selang Air (Water Hose)
Kontaminasi, safety
Tutup Pengisi (Cap)
Fit, kebocoran
Pelumasan (Lubrication)
Level, kontaminasi
3.3. Fuel System Bahan Bakar (Fuel)
Kontaminasi
Tangki B. Bakar (Fuel Tank)
Penyok, bocor
Pompa B. Bakar (Fuel Pump)
Kotor, bocor, aus
Saluran B. Bakar (Fuel Line)
Buntu, bocor, aus
Pembersih udara (Air Cleaner)
Buntu, bocor, aus
Manifold
Bocor, aus, safety
Knalpot, anti api (Muffler, Spark Arrestor)
Bocor, aus, safety
4. ELECTRICAL SYSTEM 1
Sistem Kabel Kabin (Cabin Wiring System)
Buruk, function
Sistem Kabel Lampu (Lighting System)
Buruk, function
Sistem Kabel Aki (Battery Wiring System)
Buruk, function
Sistem Kabel Mesin (Engine Wiring System)
Buruk, function
Saklar / Kontraktor (Switch / Contactor)
Buruk, function
Sistem Pengaman (Main Breaker)
Buruk, function
Sistem Pembumian (Grounding System)
Buruk, function
Baterai (Battery)
Level, sambungan, ujung hub
ADA
TIDAK ADA
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
3 dari 7
KONDISI BAIK
TIDAK BAIK
KETERANGAN
LAPORAN INSPEKSI FORKLIFT
Stater Listrik (Motor Stater)
PERALATAN
INSPEKSI
5. HYDRAULIC SYSTEM Pompa (Hydraulic Pump)
Kebocoran, function
Pengumpul (Hydraulic Accumulator)
Kontaminasi, kebocoran
Katub kendali (Control Valve)
Bocor, Function
Katub pembagi (Three Way Valve)
Bocor, Function
Swievel Pusat (center Valve
Bocor, Function
Saluran Hidrolik - Mengangkat
Gompal, aus, bocor
- Membalik
Gompal, aus, bocor
Katub - katub - Mengangkat
Gompal, aus, bocor
- Membalik
Gompal, aus, bocor
Silinder Hidrolik - Mengangkat
Gompal, aus, bocor
- Membalik
Gompal, aus, bocor
6. AIR / PNEUMATIC SYSTEM 1
Kompressor (Compessor Unit)
Kontaminasi, bocor
Saluran Udara (Air line)
Koyak, aus, bocor
Fiting (Fitting)
Bengkok, aus, bocor
Katup Kendali (Control Valve)
Bengkok, bocor
Tangki Penimbun (Air Receiver Tank)
Kontaminasi, bocor
Katup Pengaman (Pressure Safety Valve)
Adjust, fuction
Tangki Udara (Accumulator)
Bocor, safety
Pompa (Charging Pump)
Function
7. DRIVING CABIN 7.1. Structure Rangka Dinding (Cabin Wall Frame)
Korosi, retak, penyok
Kursi, penguat (Seat, Bracket)
Korosi, retak, koyak, layak
Lantai (Platform, Floor)
Korosi, retak, koyak, layak
Tangga (Ladder)
Korosi, retak, koyak, layak
7.2. Control Unit Kemudi (Wheel)
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
4 dari 7
Layak, sambungan, function
CHECK FISIK NO.
No. Dokumen
Function, Layak
ADA
TIDAK ADA
KONDISI BAIK
TIDAK BAIK
KETERANGAN
LAPORAN INSPEKSI FORKLIFT
Tuas, Pedal, Kenop (joystik, pedal, Push Button)
Function, Layak
- Memutar (Slewing)
Function, Layak
- Gas (Throtle)
Function, Layak
- Rem (Brake)
Function, Layak
- Rem parkir (Parking brake)
Function, Layak
- Pasneling (Transmission)
Function, Layak
- Kopling (Coupling)
Function, Layak
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
5 dari 7
LAPORAN INSPEKSI FORKLIFT
CHECK FISIK NO.
PERALATAN
INSPEKSI
Tek. Pelumas (lubrication gauge)
Function
Tek. Udara (Air Pressure Gauge)
Function
Amper, Tegangan (Ampere, Volt Meter)
Function
Suhu Mesin (Engine Temperature gauge)
Function
Putaran Mesin (Tachometer)
Function
Kecepatan Jalan (Speedometer)
Function
Tek. Hidrolik (Hydraulic Pressure Gauge)
Function
ADA
TIDAK ADA
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
6 dari 7
KONDISI BAIK
TIDAK BAIK
KETERANGAN
SAFETY DEVICE Indikator Level (Level Gauge)
Function
Indikator Sudut (Angle Indicator)
Function
Tek. Hidrolik (Hydraulic Pressure Gauge)
Function
Tabel Beban (Laod Chart)
Tersedia
Penunjuk Beban (Load Indicator)
Function, akurat
Kunci Darurat (Emergency Shutdown)
Function
APAR (Portable Fire Extinguisher)
Kedaluarsa, Inspeksi
V. REKOMENDASI : ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................
LAPORAN INSPEKSI FORKLIFT
No. Dokumen
Tgl. Terbit
F - 039
04.01.10
No. Revisi
Halaman
02
7 dari 7
VI. KESIMPULAN HASIL PEMERIKSAAN Dari hasil Pemeriksaan disimpulkan, bahwa sebagai berikut : *) 1. Forklift LAIK Operasi. 2. Forklift LAIK Operasi dengan ketentuan dilakukan perbaikan sesuai butir V di atas. 3. Forklift TIDAK LAIK Operasi. *) : Coret yang tidak perlu (X). Dibuat oleh, 1.
.............................. Nama & Jabatan
2.
............................. Nama & Jabatan
Disetujui oleh,
........................... Nama & Jabatan
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