INCIDENT/ACCIDENT INVESTIGATION REPORT

LAPORAN INVESTIGASI INSIDEN/KECELAKAAN

Serial No. : 016/HSE/VIII/2022

COMPANY / PERUSAHAAN:
PT. Pertama Pacific Shipyard
☒ Accident / Kecelakaan
☐ Fire / Kebakaran
DATE OF OCCURRENCE / TANGGAL KEJADIAN:
Wednesday, 11th August 2022
NAME / NAMA:
Eriadi
DEPARTMENT / DEPARTEMENT:
Production
CAUSES OF PERSONNEL INCIDENT
PENYEBAB INSIDEN PERSONIL:
☒ Injury (Cedera / Luka )
☐ Health problems (Gangguan Kesehatan )
☐ Others (Lain) Sore eyes (Mata perih)
SENT TO HOSPITAL
DIKIRIM KE RUMAH SAKIT:
☒ Yes ☐ No
COMPANY ADDRESS/ ALAMAT PERUSAHAAN: DATE REPORTED / TANGGAL DILAPORKAN:
Kavling Sei Lekop – Sagulung – Batam – Kepulauan Riau – Indonesia 11th August 2022
29439
TYPE OF INCIDENT / JENIS INSIDEN
(Tick a box/Tandai kotak)
☒ First Aid / Pertolongan Pertama ☐ Near Miss / Nyaris Celaka
☐ Property Damage / Kerusakan Properti ☐ Environment Case / Kasus Lingkungan
PARTICULAR OF INJURED PERSON / KHUSUS ORANG CEDERA
TIME / WAKTU: LOCATION OF OCCURRENCE / LOKASI KEJADIAN:
17:30 AM Assembly Workshop
SEX/JENIS KELAMIN: OCCUPATION/JABATAN:
☒ MALE / PRIA Fitter
☐ FEMALE / WANITA
No. KPJ: No. KTP / No. ID Card:
INJURY DETAILS / RINCIAN CEDERA
THE INJURED LIMBS CLASSIFICATION OF CASE / KLASIFIKASI KASUS:
ANGGOTA TUBUH YANG MENGALAMI ☐ Fatality
CEDERA: ☐ Major
☐ Head (Kepala) ☒ Fingers (Jari Tangan ) ☒ Minor
☐ Eyes (Mata) ☐ Thigh ( Paha )
☐ Ears (Telinga) ☐ Feet (Kaki )
☐ Fingers Feet (Jari kaki)
☐ Body (Badan)
☐ Inside Organs (Organ
☐ Arms (Lengan)
tubuh dalam) Lainnya
☐ Hands (Tangan)
……………………………………
COMMENTS / KOMENTAR:
He Immediately met the HSE personnel and take him to the hospital to get first aid.
Beliau segera menemui HSE Personel dan membawanya ke rumah sakit untuk diberikan
pertolongan pertama.

INCIDENT/ACCIDENT CAUSATION
PENYEBAB INSIDEN/KECELAKAAN
IMMEDIATE CAUSE / PENYEBAB LANGSUNG:
Hammer hit his finger (tumb)
Ibu jari tangan terkena palu
BASIC CAUSE / PENYEBAB DASAR:
Lack of concentration
Kurang konsentrasi
BRIEF DESCRIPTION OF INCIDENT/ACCIDENT
DESKRIPSI SINGKAT INSIDEN/KECELAKAAN
Mr. Eriadi hit his finger (thumb) with hammer while his join the foundation top flange 20mm and flange 50mm

Pak Eriadi memukul ibu jari tangannya sendiri dengan palu ketika dia merapatkan flange atas 20mm dan flange 50mm

IMMEDIATE ACTION / TINDAKAN LANGSUNG:

Immediately take him to hospital to get first aid.
Segera membawanya ke rumah sakit untuk diberikan pertolongan pertama.

CM-FM-HSE-04-01 Rev.01 Page 1 of 2 Issued 26th March 2020

 INCIDENT/ACCIDENT INVESTIGATION REPORT
LAPORAN INVESTIGASI INSIDEN/KECELAKAAN
Serial No. : 016/HSE/VIII/2022

CORRECTIVE / PREVENTIVE ACTION

TINDAKAN KOREKTIF / PENCEGAHAN
 Always plan before start work/ selalu merencanakan sebelum memulai kerja.
 Always keep concentration while working / Selalu konsentrasi ketika bekerja
SKETCH / DIAGRAM / PICTURE
SKETSA / DIAGRAM / GAMBAR

Reported by, Acknowledge by,

Petrus Sare Wolo _______________________

HSE Coordinator

CM-FM-HSE-04-01 Rev.01 Page 2 of 2 Issued 26th March 2020