CAUSAL FACTOR OUTLINE

WORKSHEET

Loss/near-miss

Tangan putus

Event
Terjepit mesin pengginggiling daging

Immediate Cause
1. Unsafe Conditions
Peralatan yg digunakan tidak dilengkapi dengan safety device khususnya di bagian extension,
dimana baut muncul di permukaan dan tidak di tutup.

Basic Cause
Perubahan design dari peralatan handrill belum dilakukan analisa risiko dan evaluasi dan
persetujuan dari perubahan belum dilakukan oleh HSE dan Operation Manager, dimana hal
tersebut melanggar prosedur perubahan design dari perusahaan.

Recommended Corrective & Preventive Action Approved by

1. Melakukan sosialisasi prosedur Perubahan design kepada Mgmt
semua karyawan, khususnya supervisor melalui Safety meeting

Recommended Corrective & Preventive Action Approved by

Mgmt

Basic Cause
1.

Recommended Corrective & Preventive Action Approved by

Mgmt

Recommended Corrective & Preventive Action Approved by

Mgmt
 CAUSAL FACTOR OUTLINE
WORKSHEET

Immediate Cause

Basic Cause

Recommended Corrective & Preventive Action Approved by

Mgmt

Recommended Corrective & Preventive Action Approved by

Mgmt

Basic Cause
2.

Recommended Corrective & Preventive Action Approved by

Mgmt

Recommended Corrective & Preventive Action Approved by

Mgmt