Ref. No.

:
Action Request SWO_JLKBKostrad_15082016

Improvement Notice / Non-Conforming Works Date Recorded:

Asia-Pac Region Non-compliance / Accident or Incident August 15th 2016
1. FINDING(what went wrong? what is the problem? what could be improved?)
Class: Non-Conforming System Accident or Preventive / STOP WORKS(until
Works Non-Compliance Incident Recommendation approval to proceed received)
Source: Inspection or Feedback or Document Project: Ref.:
Audit Complaint Review
Location: Region Profit Centre: Department: Supplier / Other:
JLKB Kostrad Subcontractor
Type: Quality Health & Safety Environment Sustainable Other:
Development
Activity: Stressing PT
Details: (what are the details of the finding? be specific and provide enough detail in the supporting evidence to allow re-examination)
Unsafe condition on P40 Access and platform, design must be fixed for secure access
(Support platform and Falling object preventions) until it get submitted and approved

Attachment-Photos

Issuer: Name: Mulyo Santoso Position: Safety Officer Signature Date:15 August 2016

2. INVESTIGATION (why has the finding occurred? why is the finding recommended?) Deadline: 15 August 2016
Standard: (what should have happened? what is the standard or requirement that should have been followed? what could go wrong?)
Ensure work platform support strength enough for 7 person above work platform minimum, including falling object installed correctly

Follow-up Complete Cause Provide Reason Reason:

Decision: Y and Section 3 N (subject to approval)

Cause(s): (List all the causes that resulted in the finding. We need to get to the root cause, a useful tool is to ask ‘Why?’ 7 times. The effort required
should be appropriate to the seriousness of the finding. Attach additional information if required)
Attachment

Definer: Name: Stefan Carlo Position: Site Engineer Signature: Date: 15 August 2016
Approve Name: Yudi WGumilar Position: Project Manager Signature: Date: 15 August 2016
(2 & 3):
3. ACTION(what remedial action is recommended to fix the finding? what preventive action is recommended to fix the cause?)
A1) Proposed Action: Remedial Preventive Responsibility Target
Date
Provides the materials (Toeboards and plywood) To Action To Close 15 August
Fix the support platform
Provides Netting for anticipate falling object may occures YGW FA 2016

A2) Actual Action Implemented (including reference to supporting evidence) Closure Comments and Sign-off
Toeboards, safety net and rails installed I had close the findings because of
retrifications is already submitted and
Forbidden access is blocked with rails approved as a secure working platform
Minimized falling possibility with lifeline installed to gantry structure (note: as long as lanyard (Mulyo Santoso)
hooked to the lifeline)
B1) Proposed Action: Remedial Preventive Responsibility Target
Date
To Action To Close

B2) Actual Action Implemented (including reference to supporting evidence) Closure Comments and Sign-off

C1) Proposed Action: Remedial Preventive Responsibility Target

Date
To Action To Close

C2) Actual Action Implemented (including reference to supporting evidence) Closure Comments and Sign-off

VI-AP-Form 001 Rev. B (03-04-2014)