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SAFETY OBSERVATION -I SPECTION

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Date &. TIme e-. 3n 13!5'"l-oV
Observer .i Observer L Observer 3 Departement ~ -l:·tM· -7.4
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Nama ..~V~ I Lokasj ~)~ '2-£

Bagde Number (.Ao~~ Desi:ripsj Kegiatan ~e.~\ ~\7or
Sign Tlpe Observation ~enca n a o TJdak Terenca na

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Dilakukan P<lda rl Kary Valf' D£i'lntractor
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K'T ~l~ ~ <ftt

Nama PiiJrusahiliil1
Kontraktor yang
diawasl
HPL = High Potensial Looses NA=Not Applicable ,IAarus Dllaporkah? alAilang Waktu _Produksi 0

Aiat Peiindung Din KOMENTAR PENGAMAiAN FERILAKU

Kepala ~fe o UnSafe l.J I;PL o NjA
Mata dfe r::; UnSafE l.J HPL o N/A ~\\.:
Respirator o5afe o UnSafe u HPL Q)d/A
Telinga n C;af~ r,llnS<lfe n HPJ cAQ/A
Tangel'l & L~ngdll
Kakf
:2!t afe
L:Ur)$aft:;
o UnSate
w HPl
n APL
o N/A
o N/A

~n Reslko
Oebu,G<ls & Uap fJ Safe n UnSafe Cl HPI ;vP4/A
~A

=
Keuisingljn & Gt,ldldll o Safe o UnSafe o Arl
Suhu o Safe o UnSafe c APl
Pcncnho';<lnn c: Safe - Un5afe o APl Acnor-~ YANG DILAKUKAN

Ergonoml \}\v
Posisj ~~fe [l UnSafe o HPL n NiA
Pergerakan 04afe L UnSafe o HPl N/A
Kolclahiln .,9'5afe " UI"'.5<lfe o APt .:l N/A

Ar~a I(~rja

Bersih & Rapi ~fe o UnSafe o HPL o N/A

Acces s \!,Sefe u UnSafe o HPl o N/A
Log Cut & Tag Out o Safe ~ UnS.1fe o APL ~A

~
8arlkade p Safe o UnSafe o HPl INSPEKST AREA KERlA URAIAN BAHAVA
Re.siko Jatuh o SafE> o UnSafe Q HPI.
•
~V
Prosedur
Prosedures r.ersedia ~re l.J UnSide u HPl u N/A
Dlketahui&dipahaml dafe Q UnSafe o APL oN/A
Dilakukan ~afe c UnSafe :J HPl o N/I\.
JSA dilakukan ~fe u UnSafe u HPl o N/A

.
Perlengl<Ci~ail & Pe,alatajl
Tepa ses.uaJ pekerjaan mafe D UnSafe o HPl rfN/A
DaJn~ koncis! ba k dafe h UnSafe r: HPL NIP. ACTION VANG OILAKUKAN
~ate o UnSate o HPL D N/A
DIKunakan dengan bellar
Afat Ppng<lman dafe c UnSafe o HPl c. N/A \J\ 'v-
Evafuasi Urnum /
P€lse-psi Anda Tentang Reslka o Un AcceptablE ;/ACceptable
o Tolerable o Best PractIce
Perilaku Saff'ty n lIn Acrpptahlp n Arrppt<lblp
o Tolerable c Best Practice
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AUDITAND INS.oEITtoN SJJSCOMMTTTEE
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