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Video Display Glass Indonesia
Safety Environment Control Center

Factory Mgr Ass.Fact. Mgr Div/ Ass.Div.Mgr Dept.Head

Eng. / Formen Grp.Leader

President Director General Mgr SE Manager Safety Officer

Date Working In Normal shift Morning shift Day Off
When & Where Tanggal Bekerja pada Night shift Afternoon shift Hari Libur
Kapan & Dimana Time Place
Waktu Tempat
Employee Name Department Group Date of Birth Age Years Old
Nama karyawan Tanggal Lahir Usia Tahun

Date of Join Position Engineer Leader Operator Porter Other
NIK : Tgl.mulai bekerja Jabatan
What is injure
Apa yang cidera
How Serious Light ( unrest ) Serious ( rest ) Hospitalized Yes No
Seberapa parah Ringan Parah Rawat inap RS Ya Tidak
Injured by
Penyebab cidera
Lama penyembuhan
Evacuated by Security Guard Emergency Car On Foot Accompanied by
Pengangkutan korban Petugas Keamanan Mobil Emergensi Jalan Kaki Ditemani oleh
First Aid by Hospital Company Clinic Others
Pertolongan pertama Rumah Sakit Klinik Perusahaan Lain - lain

Explanation 1. Where did it happen ? ( Dimana kecelakaan terjadi ? )

2. What was he/she doing when the accident happened ( Apa yang sedang dilakukan ketika kecelakaan itu terjadi )

3. Under what situation did it happen ? ( Dalam situasi yang bagaimana kecelakaan itu kemudian terjadi ? )

4. What does injured ( Apa yang cidera ? )

Notes / Catatan :
1. This report must be made as soon as an accient happened and immediate hand it over to Adm.Division at the same day. But if it happen after
Business hour ,Overtime, Public holidays,etc. the report must be send at the next day of the week at 08.00 am
Laporan harus segera dibuat setelah terjadi kecelakaan dan dikirim ke Safety Officer pada hari yang sama. Jika kecelakaan terjadi setelah
jam 17.00, Overtime, Hari libur resmi,dll.maka laporan harus diserahkan pada hari kerja berikutnya pada kesempatan pertama (jam 08.00)
2. In case of serious accident when it happen in bussines hour (08.00 - 17.00), the responsible person must contact to Adm.Division immediately
by telephone. If the accident after business hour must contact to Security Guard immediately
Jika terjadi kecelakaan serius pada jam kerja normal,maka penanggung jawab harus melapor ke Divisi Adm via telepon, tetapi jika terjadi
setelah jam kerja normal maka penanggung jawab harus melapor ke Petugas Keamanan.
Ext. List / No.Telepon :
3. The classification will be judge and recorded by Safety Officer.
1. Security ……………100
Safety Officer akan menentukan tingkat kecelakaan dan mendokumentasikannya 2. Clinic ...…………….105
3. Safety Officer …518
4. Adm.Division 140
: fill in by " " / Isi dengan " "

Doc.No :IR-SEC-001/Rev.01

Telepon : 1.Division 140 Doc.……………. List / No. Clinic .. Adm..Video Display Glass Indonesia 2. Security ……………100 PT.01 .No :IR-SEC-001/Rev. Safety Officer …518 4. Ext.105 Safety Environment Control Center 3.

Remind All Mechanical Member regarding working with safety conditions 05 June 2006 Gatot Maladi Doc. PT. MANAGER SAFETY OFFICER 3. Factory FACTORY AREAS 1.9 Other 3. What action which has taken that cause the accident ? Position Operator Other : ~ accident ? Yes. there is No.1 Unclear order or procedure Very Serious Serious Fair Light Minor Recovering …………… days Hospitalized No 3. Place : FM-Meeting Room Production Office DIRECTOR MANAGER MANAGER SE MANAGER ADM. Under what situation did it happen ? 3. 1.8 Looks no good condition (since he/she start working) 3. What was he/she is doing when accident happened ? (Illustration) 3. Chairman : Gatot Maladi Office Clerk :~ 4.Mgr Dept.3 Health Condition 3.14.7 Work beyond the limit 3. what was that ? Shift & Work type Normal Morning Afternoon Night Regular Overtime that position for long time ? To shorten downtime without consider about working safely Where J11 .Video Display Glass Indonesia Safety Environment Control Center COUNTER MEASURE REPORT OF ON DUTY ACCIDENT * Counter measure meeting after theaccident happened FACTORY Ass. What action did he / she do ? COUNTER MEASURE Scheduled In Charge Retighten bolt of base Robot M/C Right hand crash to HUMAN FACTOR S bracket . What did it happen next ? F Extension pipe suddendly loosen out & his hand crash to bracket machine surround working area Standing position when tighten bolt 5. every one in this Department have to pay attention to : ………………………………… Y/N Y/N Y/N Y/N Y/N The suggestion of each Manager To avoid any equal potential accident occur in other department. Record 1st Date of last accident ~ Date and time Date : ……03………………. Others Degree of Injured Yes 3. The machine itself is the main cause ? 1. Why such unsafe condition remain stay in 2. please Safety First 05-June-06 Hadi S T C A 4.Don’t' working in hurry.30 Hours …….5 Operation organization 3.6 Operation scheduling 2.INS-Line #1 No. Time : …….Head Engineer 2.6 No authority to do this job 3.02 .8 Unsafe workpiece material 3.2 SOP . If it is yes.5 Lack or/and no signboard 3. Month : ……June……………….No :IR-SEC-002 /Rev.1 Less Experience 3. Others 3. Year : ………2006…………. Y……8……… M………5.Prepare specials tools extension bar join to Hexagonal Key wrench Y/N 06-June-06 Hadi/Supriyo The Manager suggestion To avoid this ame accident may happen again.14 Minutes 30……… 2.3 Training Replacement Robot M/C due to trouble happen Pipe not 3. is not Tools Acc. Is there any mismanagement that cause this 1.9 Other 3.DIVISION MAIN OFFICE AREA MANAGER Manager Div/Ass. there is not Used improper (pipe diameter Normal shift 3 shifts 2 shifts tool's to big) Type of work Others : ~ No.2 Operation Method 3. Date of meeting : 05 June 2006 PRESIDENT GENERAL ADM.3 Maintenance & Inspection 3.4 Advance Age 3.2 Operation environment 3. Why he/she took those unsafe action ? 2.7 Breaking the safety regulation Pushing extension pipe for hexagonal L key-wrench 3. What does injured ? Ring Finger & nail brush of Right hand EQUIPMENT Budget Scheduled In Charge FACTOR .4 Tools 3.5 Body position of work 3.1 Safety devices 3.6 Lay-Out 3.2 Robot Machine ~ ~ What Injured Ring Finger (Right Hand) Type of Injured Nail Brush 3. every one in related Department have to pay more attention to : ……………… Y/N MANAGEMENT Scheduled In Charge FACTOR . Others 3. Attendance Murain W ACTUAL SITUATION ROOT CAUSE ANALISYS Personal Data Date of brith Date ………14……… Month …………April Year ………1974… Age …………32… Years HUMAN FACTORS EQUIPMENT FACTORS MANAGEMENT FACTORS Joint Date Date 21 Month Jan Year 1998 Exp. anyone are informed 1.4 Man Power placement suitable 3.

PT.Video Display Glass Indonesia Safety Environment Control Center Doc.02 .No :IR-SEC-002 /Rev.

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