Hazard Observation Card

This card shall be used by Fugro employees,

contractors or visitors to report the following:

Unsafe act:
An act that could lead to an injury to personnel,
equipment or the environment.

Unsafe condition:
A physical situation or condition of equipment that
could lead to an injury to personnel, equipment or
the environment.

Safe act:
An act beyond normal expectations that displays
exceptional awareness or commitment.

Suggestion:
A suggestion for improvement to a condition
or a process that has the potential to improve
health and safety of personnel, environment or
equipment.

Safety
A lways
M atters

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 Fugro IMPACT HSE Reporting

Unsafe act: Unsafe condition: Safe act: Suggestion:

Cikande Project
Site/Vessel:
3 February 2017/09.00
Date/time:*
Project number: E160063

Responsible dept:* Land Division

(your department)

HOC coordinator: Adiwirabrata

(your direct supervisor)

Observers name: Hairul

Location of observation: Workshop

(e.g. drill deck, gun deck, car park, open field, construction site, etc.)

Observation:* Sling from Drilling machine used to lifting process because of chain block
not long enough to reach machine (mobilization) & Driller crew step up on the machine to drive

machine lifted to truck

Task stopped by: co-worker supervisor other

Immediate action taken:

Suggested further action: Replacement chain block with proper long enough chain block
so no need crew step up machine

IMPACT Nr:
* Required Field Issue number: 3 Date: 27 January 2011

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