PT.
AKURA BINA CITRA
CORRECTIVE AND PREVENTIVE ACTION REQUEST FORM
CPAR No. #013/2018
Date Issued:
November 10, 2018
Affected Department /
Person In Charge
Problem Description
Reference Detail
(Fill where applicable)
Reference Standard /
Procedure
Cause of Problem
Action Needed
Corrective / Preventive
Action
(Use other paper if it is not
sufficient)
Action to prevent
recurrence / occurrence
of problem
(Use other paper if it is not
sufficient)
Proposed by,
Name: Asep Sudrajat
Position: Deputy
Date: December 08, 2018
Management of Change :
Reviewing the
effectiveness of corrective
/ preventive action
Additional Notes
Form No.: 6.4
SPK No. #
Requested Company/ by: Issued to (company or title): Target of Response Time:
QHSE FS December 10, 2018
Field Service
Acceptance criteria during inspection top drive system in Nabors Drilling
Technology Balikpapan using procedures and acceptance criteria on DS1 Volume 3
instead DS1 Volume 4
v Service System Part / Equipment
Internal Audit:
Customer Complaint:
Contract / Work Order No:
Purchase Order No.:
Inspection Report No.:
Part/Equipment No.:
Other:
Some of criteria DS1 volume 3 same with DS1 volume 4 especially for sub
inspection
Corrective Action Preventive Action
Completion Date:
Revise inspection report and affected inspection
Evidence Document:
procedures
Completion Date:
Training and indoctrination Evidence Document:
Reviewed and Approved by, Closing Out Verified by,
Name: Andi Setyo Budianto Name: Andi Setyo Budianto
Position: QHSE Manager Position: QHSE Manager
Date: January 11, 2019 Date:
Yes No Effective Date :
Verified by
Date Verification
Remarks Effective / Not Effective / Repetitive
Rev. No.: 01 Date Issued : 05/01/2015