LAPORAN INSIDEN NOMOR LAPORAN INSIDEN

INCIDENT REPORT INC/02/09/KS/01

1). DILAPORKAN OLEH (REPORTED BY) - MOHON DIISI DENGAN HURUF BESAR SEMUA (BLOCK LETTERS PLEASE)
Nama Lengkap (Full Name) Tanggal Lahir (Birth Date) Jenis Kelamin (Sex)
WILSON MALE
Tanggal Kejadian (Incident Date) Waktu Kejadian (Incident Time) Pekerjaan (Occupation) Negara (Country)
14/09/01 11.50 OPERATOR INDONESIA
Karyawan PETROSEA (PETROSEA Employee) Nama Perusahaan (Employer's Name) Nama dan Nomor Proyek (Project Name & No.)

_ Ya (Yes) PT. Petrosea Tbk 33321C / 3338C

Lokasi Kejadian (Injury Location) Nama Pengawas Kerja (Supervisor's Full Name)
Jam Kerja Mulai Jam Kerja Akhir
= 06.00AM/Pagi =18:00 PM/Sore
Starting Time Finishing Time LOWER NAKAN MARTHEN L.W

Kepada Pengawas Anda

(To Your Supervisor)

2). URAIAN KEJADIAN (DESCRIPTION OF INCIDENT)

WILSON AND HEWI WERE MAKING AN ACCESS ROAD AROUND THE POLISHING POND WITH (J 103) D6H. UNIT BECOME BOGGED AFTER GETTING

TO CLOSE TO THE EDGE OF THE POND.

BOTH OPERATOR AND SPOTTER WERE OBSERVED TO BE ATTEMPTING TO PLACE TIMBER UNDER TRACKS .

BY CLIMBING UNDERGATH THE UNIT WHILE IT WAS IN SOFT GROUND.

3). RINCIAN KEJADIAN (INCIDENT DETAILS)

Hampir Celaka (Near Miss) Kerusakan Peralatan/Barang (Property Damage) Kerusakan Kendaraan Ringan (Light Vehicle Damage)
Kelas Kejadian
=
(Incident Class)
Kebakaran (Fire) Kerusakan Lingkungan (Environemetal Damage) Kerusakan Kendaraan Berat (Heavy Vehicle Damage)

Kerugian (Cost) = < AS$ 5,000 AS$5,001 - AS$10,000 AS$10,001 - AS$20,000 AS$20,001 - AS$100,000 > AS$100,001

Ya / Yes Kepada Siapa (To Whom) Oleh Siapa (By Whom) Tanggal/Jam (Date/Time)
Pemberitahuan Kepada Badan Pemerintahan
Notifiable to Statutory Authorities
Tidak / No

4). TINDAKAN PERBAIKAN / PENCEGAHAN (REMEDIAL / PREVENTIVE ACTION)

Uraian Tindakan-Tindakan (Description of Actions) Yang Bertanggung Jawab (Person Responsible) Selesai (Completion)

SAFETY / FOREMAN 9/17/2001

1. TALK TO ALL OPERATOR THAT THEY HAVE TO RECOGNIZE THE ENVIRONMENT
BEFORE CONTINUE THE WORK.

5). KATEGORI TINGKAT PENYELIDIKAN (INVESTIGATION LEVEL CATEGORY)

Berat Sekali (Catasthropic) Berat (Major) Sedang (Moderate) Ringan (Minor) Ringan Sekali (Insignificant)
Nama Pengawas (Supervisor's Name) Tanda Tangan (Signature) Tanggal dan Waktu (Date and Time)

Kepada Departemen Keselamatan Kerja Lapangan

(To Site Safety Department)

6). PENGKAJIAN ULANG (REVIEW)

1. Apakah semua tindakan perbaikan / pencegahan sudah dilaksanakan? (All items closed out?) Ya (Yes) Tidak (No)

2. Apakah tindakan peningkatan keselamatan kerja disarankan untuk dilakukan? (Safety alert recommended?) Ya (Yes) Tidak (No)

3. Apakah informasi ini perlu dibicarakan dalam pertemuan keselamatan kerja? (Information for safety meetings?) Ya (Yes) Tidak (No)
Nama Pengawas Keselamatan Kerja (Site Safety Supervisor's Name) Tanda Tangan (Signature) Tanggal dan Waktu (Date and Time)

Nama Pimpinan Proyek (Project Manager's Name) Tanda Tangan (Signature) Tanggal dan Waktu (Date and Time)

SAFE521aP
 REPORTABLE EVENT NOTIFICATION
PEMBERITAHUAN KEJADIAN
YANG HARUS DILAPORKAN
TO : Rob Jewkes Fax : 61 89 481 7371 Date
Tim Humphry Fax : 61 89 481 7371 Tanggal
Tony Speechley Fax : 62 21 718 4251
Irrawardy Manany Fax : 62 21 718 3266
Ron Smith Fax : 61 89 281 9423

LOCATION
PROJECT PROJECT NO.
KELIAN PROJECT EQUIPMENT RENTAL 33321C / 3338C KELIAN SITE
PROYEK NO PROYEK
LOKASI

Project Manager BRIEF DETAIL OF INJURY

Manager Proyek KETERANGAN SIFAT KECELAKAAN/CIDERA
Date & time of event
L.T.I
Tanggal / Waktu -
Hilang hari kerja
Kejadian
Persons Injuried Yes No M.T.I
-
Karyawan mengalami cidera Ya Tidak Per Med.
Name(s) of Injuried First Aid
-
Nama Korban P3K

Incident
-
Insiden
No If so, who advised
Advice to Authorities Yes Date
Jika ya, siapa
Dilaporkan ke yang berwenang Ya Tanggal
Tidak yang melapor
Method of advice Phone Fax Personal Date & Time
E-Mail
Cara melapor Telepon Facs Pribadi Tanggal & Waktu
Authorities Visiting Site Yes No When
Pihak berwenang mengunjungi lokasi Ya Tidak Kapan

SUMMARY OF EVENT
URAIAN KEJADIAN

RATING NOMINATED INVESTIGATION TEAM

TINGKATAN TEAM INVESTIGASI YANG DITUNJUK

5 SIGNIFICANT
KURANG Supervisor Place names in boxes of team personnel
Pengawas Tulis nama anggota team dalam kotak

4 MINOR
KECIL Superintendent
Superintenden

- - -
3 MODERAT
MENENGAH Project Manager
- - -
Manager Proyek

- - -
2 MAJOR
BESAR Divisional Manager
- - -
Manager Divisi

- - -
1 CATASTROPHIC
BENCANA BESAR
CEO

SAFE518bP
CIDERA

-
 INCIDENT / INJURY INVESTIGATION REPORT EXECUTIVE SUMMARY
RINGKASAN LAPORAN PENYELIDIKAN KECELAKAAN DAN INSIDEN
PART 1 - INCIDENT/INJURY DETAILS (Team Leader) PART 4 - MANAGEMENT OF WORK (Team Leader) PART 7 - REMEDIAL / REPRESENTATIVE ACTIONS
BAGIAN 1 - RINCIAN KECELAKAAN / INSIDEN (Pimpinan Team) BAGIAN 4 - PEKERJAAN MANAGEMENT BAGIAN 7 - TINDAKAN PENCEGAHAN KEJADIAN
Work System
Project No. Incident Date Required Used Adequate Description of Action /Task Person By When
Sistem
No. Proyek Tanggal Kejadian Diperlukan Digunakan Cukup Perincian Tindakan Responsible Kapan dilakukan
Kerja
Site Work Permit
Yes No Yes No Yes No
Lapangan Izin Kerja
Incident Location
JSA Yes No Yes No Yes No
Lokasi Kejadian
PART 2 - INVESTIGATION DETAILS (Team Leader) Work Proc.
Yes No Yes No Yes No
BAGIAN 2 - RINCIAN PENYELIDIKAN (Pimpinan Team) Proc. Kerja
Team Appointed by: Investigation finish date PART 5 - IMMEDIATE CAUSES (Team Leader)
Team diangkat oleh BAGIAN 5 - PENYEBAB LANGSUNG
Team Member 1 Cause Code
Investigation leaders name : EXPLANATION OF IMMEDIATE CAUSES
Kode
Nama pimpinan penyelidikan PENJELASAN TENTANG PENYEBAB LANGSUNG
Penyebab
Team Member 2 Team Member 3

Circle Specific Category

1 2 3 4
Lingkari Kategorinya
Reason for category selection PART 8 - TEAM LEADER'S COMMENTS
Alasan pilihan kategori BAGIAN 8 - KOMENTAR PIMPINAN TEAM

PART 6 - UNDERLYING CAUSES (Team Leader)

BAGIAN 6 - PENYEBAB DASAR
Cause Code
EXPLANATION OF UNDERLYING CAUSES
Kode
PENJELASAN TENTANG PENYEBAB DASAR
Penyebab
PART 3 - SEQUENCE OF EVENTS (Team Leader)
BAGIAN 3 - URUTAN KEJADIAN (Pimpinan Team)

PART 9 - INVESTIGATION CLOSE OUT

BAGIAN 9- PENYELIDIKAN TELAH DILAKSANAKAN
Signature Date
Tanda tangan Tanggal
Team Leader
Pimpinan Team
Project Manager
Manajer Proyek

SAFE519aP
 PT. PETROSEA Tbk.

INCIDENT / INJURY INVESTIGATION REPORT

PROJECT NAME KELIAN PROJECT EQUIPMENT RENTAL

REFERENCE NUMBER INC/INJ -

DATE OF INCIDENT / INJURY / /

INVESTIGATION LEVEL 1 2 3 4

INVESTIGATION COORDINATION YOHANES LAWING

MANAGEMENT COMMENTS ON INCIDENT AND CORRECTIVE ACTION

1 : .
SUPERINTENDENT'S


SIGN DATE

2 : .
PROJECT MANAGER


SIGN DATE

3 : .
OPERATION MANAGER



SIGN DATE

4 : .
SAFETY MANAGER/SUPT.


SIGN DATE

5 PRESIDENT DIRECTOR :
.
.
.
SIGN DATE
Prepared by : ___________________________________________________ Date : ___________________________________
SAFE059aP