Broken Incident Report

INSURANCE/NON INSURANCE
PLEASE REMARK IF Insurance claim

SITE JAW-JT-BNR-0208, 19 JAN, 2023

Document Version:
Date: 13 FEBRUARY 2023

[Type here]
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1. Incident Detail
Site ID JAW-JT-BTG 0230
Site Name MILINGAN
SITE INSURANCE/NO INSURANCE/ NO INSURANCE
Area Mgr / Region BATANG
Date/Time Stolen Or Broken 13 Februari 2023
Incident (Broken or Stolen) Broken
Broken Battery ;
Damaged/defect, Corroded, Bloated, Broken
Rusted, Conductor is broken, etc
Height Antenna Sector for
-
request Feeder (Mandatory)
Distance between tower with
-
shelter (Mandatory)
For request AC ; fill & share form
-
warranty
Tower property
TT / WO & Description :
Work order Installation
Item name /bom CODE VSWR Sector 1 Antenna Port R1 (+) ,Y2 (+), Sector 3
Antena Port R1 (+)
Quantity : 2 Pcs
Date evidence: 13 Feb , 2023
PR no/OWS Number

Requirement Detail mention On Incident report

No Material Remark
Antenna Sector
1 VSWR Sector 1 Antenna Port R1 (+), Y2 (+) Broken
Triple Band Broken
Antenna Sector
2 VSWR Sector 3 Antenna port R1 (+) Broken
Triple Band Broken
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2. Incident Chronology
(Describe chronology incident based on real condition)
Date & Time Description
9 Feb , 2023 Team Nokia check and troubleshoot VSWR alarm at site
13 Feb , 2023 08.35 AM Team Nokia additional give Dummy to AHEGC at Antenna Sector
13 Feb , 2023 15.00 Pm Team Nokia take evidence to complete request antenna sector
by IR

3. Impacted
(Describe impact of incident)
No Description
1 VSWR HIGH VALUE 1.4 (MINOR ALARM)
- Sector 1 Broken Port Anntena R1 (+) , Y2 (+)
- Sector 3 broken Port antenna R1 (+)

4. Detail Asset
(Describe detail of asset due incident)
After Recovery
Asset Stolen/Damage Price
(per Material
Impact NE Q Price
No Asset Name Material ID meter EWO EWO
System ty Total
/unit)

Sector 1 Broken
Port Anntena R1 Tipe :BA-
(+) G7W9W9X65V-
1 11
1
SN
(KA663418D19
Sector 1 Broken 00074)
antenna Y2 (+)
Tipe :BA-
G7W9W9X65V-
Sector 3 Broken 11
2 1
antenna R1 (+) SN
(KA663418D19
0047)
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5. Photo Documentation
BEFORE (Describe detail Photo base on incident related)

1.ANTENA SECTOR 1
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2.ANTENA SECTOR 3
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Remark (If
Photo not
complete)
 Incident Network
PT HUAWEI TECH INVESTMENT-XL MANAGE SERVICE PROJECT
1.
2
S*1. ANTENA SECTOR 1

2. ANTENA SECTOR 3
AFTER
TEST
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AFTER
TEST
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BRAND
INSTALLED -

SERIAL
NUMBER
-
INSTALLED
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PT HUAWEI TECH INVESTMENT-XL MANAGE SERVICE PROJECT
DATE OF
INSTALLATI -
ON

SIGNED BY PIC MS PARTNER, PIC FOP –

Manager
SPV/RTS

NOT ALLOWED ELECTRONIC SIGNATURE NOT ALLOWED ELECTRONIC SIGNATURE

Name/ID : Name/ID :
Date & time : Date & time :