Doc.

No: GC-SHE-F-24
SHE DEPARTMENT Page: Page 1 of 2
Version: 0.0
Author: Mgr SHE
Approval:
Preliminary Incident Report

PRELIMINARY SHE INCIDENT REPORT

Important Notes:
1. This is a preliminary report! Report any relevant data as a result of your best observation relevant to the occurrence. Be factual.
2. This for shall be completed by Immediate Supervisor and/or Supervisor of the work area where incident occurred, and/or Responder(s).
3. Submit the completed form immediately or at the first chance (normally less than 2 hours) to BU Head. PTFI Safety and Industrial Health Department, and
other relevant parties.
4. Use the Supervisor’s SHE Incident Investigation Report for investigating the occurrence. Refer to PTFI SHE Standard No. 4.12 – Internal SHE Incident
Investigation.
5. You may expand this form or attach any additional documents as required in order to provide more factual information.

Incident Injury Property Equipment Fire Spillage Other:_______

Type Damage Incident

Equipment Involved Bending Eqp No. -

Estimated Quantity of Spill Possible Source of Spill -

- Ltrs

Day & Date Tuesday, 27 Oct 2015

Time 14.10
Scene (in detail) Workshop Iron (solar Side)

Name(s) of Injured 1 Mr. Duyeh ID MB-1035 Title Iron Workers DOH

Person 2 ID Title DOH
3 ID Title DOH
Accountability/ ID Title DOH
Operator/ Driver
PTFI License Issued on Within Area of Certification? Yes No
GOI License Issued on Valid Until

Witness(es) 1 Mr. Ages ID Title Iron Workers (Rebar)

2 ID Title
3 ID Title

Supervision of the 1 Immediate Foreman Mr. Yin

Occurrence 2 General Foreman Mr. Anda
3 Superintendent Mr. Andri
4 Manager Mr. Gao Feng

Organization 1 Section Operator Bending

2 Department Iron
3 Division Iron
4 Company PT. Mutiara Indah Anugerah (CHI/China Harbour Indonesia Dept.)

Possible Injury Fatality LTA RAC NDL FAC

Classification

Description of
Incident: There was an accident on a finger left on behalf of Mr. Duyeh (43 years old, 2 years working and iron
th
worker on the 27 of October 2015 02.00pm with foreman Mr. Yin. Chronology incident to when Mr.
Duyeh do to bend iron used a bending, when the device working (to bend iron involuntary forefinger the
left mr. Duyeh holding implements. So when bending turning automatically worker conditions dreamy
until about forefinger to was broke one finger.

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 Doc. No: GC-SHE-F-24
SHE DEPARTMENT Page: Page 2 of 2
Version: 0.0
Author: Mgr SHE
Approval:
Preliminary Incident Report

Reported by 1 Mr. Lukman Contact No. 0857 2735 4112

2 Mr. Benny. A Contact No. 0812 3440 0033
3 Mr. Li Bifa Contact No. 0859 4518 1975

DOCUMENTATIONS

THIS DOCUMENT IS UNCONTROLLED IN HARD COPY FORMAT