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No : FM-00-PLT-080

Warranty Claim Form Tgl terbit : 01-12-09


Revisi : 00

Issued To Vendor/Dealer:
(Company Name, Address & Person Contacted) Claimer :
PT. CIPTA KRIDATAMA
Garden Center Building #7 Suite 1
Cilandak KKO Raya - Cilandak
PT. CHAKRA JAWARA
Jakarta Selatan - 12560
Tel +622178846887
Fax +622178846855

Equipment
Brand : IVECO Date Delivered : 31/05/2018
Model/Type : AD410T44 Date Received : 15/06/2018
Serial No/Arrangement No : WJMJ4CSS5JC389314 Document References :
SMU ( HRS,MIL,KM ) : 3538,49999999998
Failure/Problem Cause

2X sample X eval code reported gear box high fe(iron) & PQ(Particle quantifier) and indication probably gear/bearing
wear.

Document Attachment :
Guarantee Letter Failue Analysis Report X Photo

Component
Part No : 41288086 Date Delivered
Part Description : GEAR BOX Z.F. Date Received :
Install Date / SMU : - /SMU : 3538,49999999998 Document References :
Remove Date / SMU :0
Failure/Problem Cause

2X sample X eval code reported gear box high fe(iron) & PQ(Particle quantifier) and indication probably gear/bearing
wear.

Document Attachment :
Guarantee Letter Failue Analysis Report Photo

Vendor / Dealer Signatures Claimer


Accept
Reject Location : CK MIFA MEULABOH
(………………………………………..) Department : Plant Operation
Vendor / Dealer Approval Reason :
Prepared By : Syahrul
Approved By : SUDIYONO
No : FM-00-PLT-026
Tgl terbit : 16-11-2010
Revisi : 01

FAILURE ANALYSIS REPORT


LAPORAN ANALISA KERUSAKAN
PROJECT : PT.CK MIFA UNIT ID : WT 2171
Proyek Unit ID
LOCATION : ACEH BARAT MODEL : ACTROS 3939
Lokasi Model
DATE REPORTED : 10-Feb-21 SERIAL NO. : WDB9321632L532684
Tgl Dilaporkan Serial No.
REPORTED BY : ARIS FAUZI ENGINE MODEL :
Dilaporkan Oleh Model Engine
DEALER NAME : PT.CIPTA KRIDATAMA ENGINE SERIAL NO. :
Nama Dealer Serial No. Engine
DATE OF FAILURE : 10-Feb-21 SMU : 23759 DEALER NAME :
Tgl Saat Komp Rusak SMU Saat Komp Rusak Nama Dealer

COMPONENT FAILURE LAST COMPONENT INSTALLED


Komponen Yang Rusak Terakhir Komponen Dipasang

COMPONENT PART NO : DATE : NEW


Part No Komponen Tgl Pemasangan
COMPONENT DESCRIPTION : PROPELER SHAFT SMU : 0
Nama Komponen SMU Saat Pemasangan
PART NO. CAUSING FAILURE : WORN OUT HOURS OF COMPONENT : 23759
Part No. Yang Menyebabkan Kerusakan Umur Komponen

LAST OIL SAMPLED - IF AVAILABLE


Sampel Oli Terakhir - Jika Ada

DATE LAST TAKEN : DATE LAST REPORT RECEIVED :


Terakhir Diambil Terakhir Laporan Diterima
DATE LAST SENT : LAST REPORT EVALUATION*) : A B C X
Terakhir Dikirim Evaluasi Laporan Terakhir

FAILURE OUTLINE - Please Show The P/N That Damage As Facts


Ringkasan Kerusakan - Sebutkan Part No Yang Mengalami Kerusakan

PROPELER SHAFT PN :

BACKGROUND - Please Describe Background Of Failures


Alasan Kerusakan - Jelaskan Alasan Kerusakan
PROPELER SHAFT LOSE DI SEBABKAN SLIP JOINT SPLINE WORN OUT

FAILURE ANALYSIS
Analisa Kerusakan
SLIP JOINT SPLINE WORN OUT DI SEBABKAN KARENA METERIAL WORN OUT

CONCLUSION
Kesimpulan
KERUSAKAN ATAU KEAUSAN PADA SLIP JOINT SPLINE DI SEBABKAN USIA PEMAKAIN KOMPONEN

REPAIR
Perbaikan
PART HARUS DI GANTI

*) Please Thick The Box with √, As Per Facts

ATTACHMENT PHOTOS / SKETCHES


COMPONENT OBSERVATIONS
Sebutkan Part No. Komponen, Nama Komponen, Serta Letak Dan Posisi Komponen (Atas, Bawah, Kanan Untuk Menjelaskan Proses Tahapan Kerusakan, Maka Gunakan Catatan, Sketsa, Foto Atau Ilustrasi Dari Part
Atau Kiri) Book

Sebutkan Type, Jumlah, Partikel Yang Ditemukan, Lokasi Yang Mengalami Keausan, Kerusakan Atau Patah, Dsb

SLIP JOINT SPLINE

Prepared By, Approved By,

Sudiyono
Plant Supt
Date : 3-Oct-22 Date:

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