Doc No :

Date :
MANAGEMENT OF CHANGE ASSESMENT
Revision :
DIRGANTARA INDONESIA
INDONESIAN AEROSPACE (IAe)
Page : Of
Facility : Departement : Originator : Permanent

Temporary
Description of proposed Change / Modification

Otrganization

Personeel

Place relocation

Procedure/regulation

Machine/tools/method

Schedule

Other……………………………………..

Technical basis for the changes :

Essential & Immediate Construction Need Safety Need Environmental Need Desirable

Change reason :

ASSESMENT REVIEW
Is the Management of Change can lead to :

Incident/Accident YES NO The Validity of the procedure/regulation YES NO

Change of environment YES NO Extra man power/hour YES NO

Lower productivity YES NO Impairment of corporate assets YES NO

Mental Changes Employee YES NO modification toos and facilities YES NO

Waste of Resources YES NO procurement of new training YES NO

Defect / disturbance to equipment YES NO procurement of PPE YES NO

Impact to the occupational diseases YES NO Other …………………………………………………………………….. YES NO

MITIGATION
HIRA No. (If any ) : Safety Engineer: Safety Manager :
 Doc No : 1

MANAGEMENT OF CHANGE Date : 2

ASSESMENT Revision : 3
DIRGANTARA INDONESIA
INDONESIAN AEROSPACE (IAe)
Page : Of 4
Facility : Departement : Originator : Permanent
5 6 7 8
Temporary
Description of proposed Change / Modification

Organization

Personeel

Place relocation
9
10
Procedure/regulation

Machine/tools/method

Schedule

Other……………………………………..

Technical basis for the changes : 11

Essential & Immediate Construction Need Safety Need Environmental Need Desirable

Change reason :

12

ASSESMENT REVIEW
13
Is the Management of Change can lead to :

Hazard YES NO The Validity of the procedure/regulation YES NO

Environment Changes YES NO Disposals of man hour YES NO

Decline in productivity YES NO Impairment of corporate assets YES NO

Employee mentality Changes YES NO Modification toos and facilities YES NO

Waste of Resources YES NO Procurement of new training YES NO

Defect / disturbance to equipment YES NO Procurement of PPE YES NO

Impact to the occupational diseases YES NO Other …………………………………………………………………….. YES NO

MITIGATION

14

HIRA No. (If any ) : Safety Engineer: Safety Manager :

15 16 17
15 16 17