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O-006/0.

18/F01

FORMULIR RISK CONTAINMENT AUDIT

Date:

Description of Severity rating: Audit Team : Ir. Wibowo Budi Sulistyo


1 = Untidy area minor issues sets pool example
2 = Restricated access, unacceptable trash, disorderly
3 = Rule or procedure violation, potential injury
4 = Unsafe condition, serious injury potential
5 = Immediate serious injury potential, stop activity immediately and correct Audit Time : 28-Apr-14
Weather : Cerah

# People Violations Leading Indicator

Good Citizens

Number of

Violation x
Vlolations
Description

Vlolators

Severity

Severity

keeping
Process

House
4&5

PPE
NO

1 Kawat enamel menghalangi pejalan kaki 4 1 1 2 2 0 0 0 0


2

Sub Totals 4 1 1 2 2 0 0 0 0

% of observed people working safely/good citizen


No of violations 1
Average severity of violations. 2.00
Number of severity of 4 & 5 violations 0 0%
Approximate No of workers observed 5
Number of people on site 0
% of workers observed

Jakarta, 28 April 2014


PT. GAKA INDOINSPECTION
HSE Coordinator

Ir. Wibowo Budi Sulistyo

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