Diisi oleh Superintenden K3LL dan RSES (Filled by HSE Superintendent & RSES) Foto / Sketsa jika ada

to / Sketsa jika ada (Photo or sketch, if any)

CeRMAT [ ] For Statistic Purpose [ ] Register in Synergi No: ___________________
Diisi oleh pelapor (Filled by reporter) [ ] Anomaly [ ] Incident
Uraian (Details) : Potensi Risiko Awal ( Initial Potential Risk )

Tingkat Keparahan/ Real Severity Potential Likelihood

Found pipe 2 1/2" for Overboat was leaking
Severity Level (1-6) Severity (1-6) (1-6)
Status : Closed by Change with new one Cedera Manusia / Human Injury
Kerusakan Lingkungan/Environment Damage
Kerusakan Finansial/ Financial Loss:
[ ] Production Loss [ ] Material Loss
Media

Tindakan Perbaikan Jangka Pendek (Short Term Mitigation):

Lokasi (Site): ELSA-3 Daerah (Area): TN-C444 Safe Area
Tanggal (Date): 26 July 2015 Jam (Time) : 23.:00:00 Close-out Acknowledgement / Pengakuan Penutupan
Tindakan langsung yang dilakukan (Immediate action ) : Description of Action Implemented / Deskripsi Tindakan yang Dilaksanakan

Inform to C/O

Report trough Cermat Paint the expired date tag to the tank

Risiko Sisa (Residual Risk)

Tingkat Keparahan/ Severity Likelihood
Severity Level (1-6) (1-6)
STOP Card Issued? [ ] Ya/Yes [ ] Tidak/No Cedera Manusia / Human Injury
Penyebab langsung (Immediate causes): Kerusakan Lingkungan/Environment Damage
Kerusakan Finansial/ Financial Loss:
Envirotment Date / Tanggal : 26 July 2015
[ ] Production Loss [ ] Material Loss

Media Name of Performing / Nama Pelaksana : Budi Harmono

Service / Dinas : Well Testing
Date: Signature&Name: Signature / Td. Tangan :
RSES recommendations/actions:
*Action Description - Responsible for Action (By) - Target Date:
Saran pencegahan&perbaikan (Suggestion for prevention&improvement): Close-out Acceptance / Penerima Penutupan
l Line supervisor / Penyelia Lini
Date / Tanggal :
Name / Nama :
l Signature / Td. Tangan :

l
Pelapor - Diisi jika diperlukan (Filled if required) RSES - CSR
Nama (Name) : Budi Harmono l Date / Tanggal :
Bagian (Entity): Operator Perusahaan (Co.): Elnusa Name / Nama :
Signature / Td. Tangan :
Atasan Pelapor (Line Supervisor) : *Internal Deadline (Estimated date for the case to be closed) :
Bagian (Entity): Td. Tangan (Signature): Date: Signature&Name:

CeRMATi sekeliling anda untuk meningkatkan keselamatan. Do CeRMAT in your surrounding to improve safety. Use CR EP HSE 102 as reference to define severity level of the case