No. Dekumen | Rev. ACCIDENT/INCIDENT INVESTIGATION REPORT tH LAPORAN INVESTIGAS! KECELAKAAN 008 Use this Form (Gunskan Format inj)! FOR INCIDENTS THAT DID OR COULD HAVE RESULTED IN INJURY OR LOSS LUN TUN RECELAKAAU VAN TERIADY ATAU DABAT NEVVEBABRAN LURALUKG ATAU KEHIANGAN T. BASIC DETAILS PLEASE PRINT ‘Team Leader / Supervisor: Time: wis | CLEARLY/ Harap tuis yang Tim PimpinervPengenes «Rs Adji Rupiyanto elas dengan huruf Cetak ment | Departemen > onsite al evan Deportment/ ‘cep ca! Leper Tocation of Incident] Tenet toractrve kecotkan Tienes WB | Moe deck Ure Gn (Did this Incident resultin = NEAR MISS Praose tik the box Hava Apa Bates ini moury ee oe (ands yong topat lKotok) Injured Name | Nam Korte Property Damaged | Keniatan = ‘ree nce ret Part of Body Injured Boaien angpota tabu Nature of Damage / Rerusskan Abr (Nature of Injury OF Hness / Luka ika yang desbabkan ‘lsh Als» Eaimate of Coat (Property Demage)) Pervaan aye: (Object/Equipment/Substance Inflieting Harm / Aavaistan,/ Kelengkapon / yang ‘Object/Equipment/Substance Infliting Damage or Lost / Objek/ perlengkapon| yang meninbultan kerusakan mencodera! ‘Occupation ¢ Age! Pokesjaan : Uinue : Experience | engateman : Ttis "Erwironment” Incident; YES/NO Injadalah bahaya lingkungan 2 Land Environment Damage ‘enusakan Lingkungwa deratan @ Water Environment Damage Kerusaitan Lingkungan Perairan 7, RISK POTENTIAL LOW POTENTIAL - POTENSIAL RENCAH MEDIUM POTENTIAL ‘This incident could have realistically resulted in (tick appropriate box) No incapacity to work Tidak mengurargy kelayatan kerja Property damage < US$ 1,000 ‘Kerusakan yang borniey Kurang dar! < US$ 1,000 ‘Phcy ot property arage ‘ras a per TS? aka aay tok atu keratin saunas eto? ‘Compete al evan Cit sermia yang eta ‘Sectonsaeqar is, Gre the YES or HO. TER YESthen px Tk one ot ‘hetones/ Harap ington poe Ya au TOK. Jie A, Harbord pad sol sate Rot ‘ven completing ts section ast yeast itt agpened again, what oat th worst exteeme the cai eu? ‘What was happening, what went wrong, what were the consequences? / ‘Apa yang ean 270, apakah kesatshan yang Lr, apkan LoMsOXLENP pO? Where did it happen? / Duman hai tol? When did it happen ? / kapsn iat in/ engi? OTENSEAL SEDLNG = A temporary incapacity to work (1 or more days absence from work) ra mabnptan ti wei sor eck name bate (to Lt | i at tec i = Apermanent partial incapacity to work ‘Sebagin sai yang bisa ker ~ Property damage between US$ 1.000 - 20,000 ‘eresakan let ri USS 1.000 = 20,000 HIGH POTENTIAL A fatality or total incapacity to work POTENSIAN TINGGI ——_Mennggat atau ornoseal tidak sa bokera = Property damages > US$ 20,000 Aerusatan fbn dr» US$ 20,000 [Chances oft happening again? (Tick appropriate tox) Often : |] Occasional are Yt ihe thon [peta acs petuong fir akon tract apy ‘sorng | |sokartas See anda pads hotak yang topat) Seon movin see FERS HST AT 3. INCIDENT STATEMENT / PERNYATAAN BAHAYA PF Spores offre Who was involved? / Sigar yg ferkbat ” Snot ea oe