INDODRILL GROUP F050

HAZARD REPORT FORM

INSTRUCTIONS
PART A: To be completed by the PERSON identifying the Hazard.
Complete the following -
 Date and time the Hazard was  How did you control the Hazard?
spotted?  What control measures were taken?
 Your name?  Does the Hazard require further action?
 Location of Hazard?
 Description of Hazard?
PART B To be completed by the Supervisor and the PERSON identifying the Hazard
 Actions taken to control the  What further action do you
Hazard? recommend?
 Level of Priority? (Refer to table  Sign and date the form.
below)  Forward to the Department
 Has the Hazard been eliminated? Superintendent.
YES or No
LEVEL OF RISK

HIGH / SIGNIFICANT MODERATE LOW / ACCEPTABLE

UNACCEPTABLE
Stop work, reassess Task has minor Manage by JSA or
Stop work the Hazard. Reduce hazards. Identify and Standard Operating
immediately, secure the risk rating to as control all hazard Procedures.
area and report low as reasonably prior to starting Control all identified
hazard to the practical. Approval work. hazards.
supervisor from the department
immediately. Manager is required
before restarting
work.
HIERARCHY OF CONTROL
ELIMINATE SUBSTITITE ENGINEER ADMIN PPE
ISOLATE OUT CONTROLS
 INDODRILL GROUP F050
SPOT THE HAZARD
Department Indodrill

Reported by: Olive / Ridwan

Location: busa ID 350 D

What Hazard Exists:

- Slippery work floor

How did you immediately control the

Hazard:
- Clean the floor while drilling

Can we remove the Hazard using the

Hierarchy of Control?  Control used
Eliminate Substitute/Isolate Engineer Out Admin controls

PPE

Does this Hazard require further action? Yes No

PLEASE GIVE THIS REPORT TO YOUR SUPERVISOR

 INDODRILL GROUP F050

Consequence
Likelihood
Catastrophic 5 High 4 Medium 3 Low 2 Insignificant 1

Almost Certain 5 25 20 15 10 5

Likely 4 20 16 12 8 4

Possible 3 15 12 9 6 3

Unlikely 2 10 8 6 4 2

Rare 1 5 4 3 2 1

Consequence:       Likelihood:       Risk Rating:      

Part B Completed by Supervisor

What actions have been taken to address underlying cause?

- Inform the crew to always clean the work floor

Level of Priority? Low Moderate High

Has the Hazard been eliminated? Yes No

If NO What further actions do you recommend to control the Hazard?

Supervisor Date

Please send feedback to the originator as to actions taken.

This form is to be handed to the Department Superintendent.