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  • FR-K3L-027 Rev.0 Incident Investigation Report Form

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    Ogi Staplez Band Official
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    This incident investigation report details an incident that occurred at a project or plant site. The incident involved property damage and injuries to employees. The investigation team gathered details of the incident including time, people and equipment involved, witness statements, and injury details. They identified contributing factors and corrective actions to prevent future incidents. Photographs were also included to document the incident scene.

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    This incident investigation report details an incident that occurred at a project or plant site. The incident involved property damage and injuries to employees. The investigation team gathered details of the incident including time, people and equipment involved, witness statements, and injury details. They identified contributing factors and corrective actions to prevent future incidents. Photographs were also included to document the incident scene.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    16 views5 pages

    FR-K3L-027 Rev.0 Incident Investigation Report Form

    Uploaded by

    Ogi Staplez Band Official
    This incident investigation report details an incident that occurred at a project or plant site. The incident involved property damage and injuries to employees. The investigation team gathered details of the incident including time, people and equipment involved, witness statements, and injury details. They identified contributing factors and corrective actions to prevent future incidents. Photographs were also included to document the incident scene.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 5

    FR-K3L-027

    INCIDENT INVESTIGATION REPORT


    Rev. 0

    PROJECT / PLANT SITE: :


    Notification Details / Pemberitahuan
    1. Exact Location / Lokasi Insiden :
    2. Incident Title / Judul Insiden :
    3. Incident classification/ klasifikasi insiden: () 4. PHOTO (Incident Scene) / FOTO (lokasi insiden):
     Property Damage Injury
     Near Hit  Environmental
    Other (Describe)

    Type Injury/Jenis Cidera Description of Type Injury / Deskripsi Jenis Cidera:


     FAI  MTI
     RWI  LTI
    5. People, Plant or Equipment Affected / Orang, fasilitas atau peralatan yang terlibat
    (State name, employee number, company, position, role performed during in this activity)
    (Beri nama, momor pegawai, perusahaan, posisi, peran yang dilakukan dalam aktivitas ini)

    6. Incident Details including timings, names of people, plant and equipment affected and any witnesses / Rincian Kejadian
    termasuk; waktu, nama orang, lokasi facility, peralatan dan saksi

    7. Injury Details/ Rincian Cidera


    Employee Injury Type/ Classification/ Mechanism/
    Name - Nama Body Part / Lokasi cidera
    No. Cidera Klasifikasi Mekanisme

    8. Property Damage/ Kerusakan Peralatan


    Code / Kode Unit Description / Nama Unit Damage / Kerusakan Estimate Cost/ Estimasi biaya

    Author: HSE Dept. Page 1 of 5

    This controlled copy document will be uncontrolled when printed. If you need controlled copy document, please contact document controller.
    FR-K3L-027
    INCIDENT INVESTIGATION REPORT
    Rev. 0

    9. Direct Supervision Details / Detail Pengawas Langsung (Level up of people involved/ Di atas orang yang terlibat)
    Location/ Lokasi
    Name / Nama Company / Perusahaan Department Position / Posisi
    (at the time of incident)

    10. Investigation Team / Tim Investigasi


    Investigation Team Role /
    Name / Nama Company / Perusahaan Department Position / Posisi
    Peran dalam investigasi

    11. Investigation – Investigasi (Description of Investigation)


    People, Plant, Equipment, Environment, Management Systems and Procedures, Training. / Orang, fasilitas, peralatan,
    lingkungan, system manajemen dan prosedur , pelatihan

    12. Contributing Factors / Faktor Pendukung

    Author: HSE Dept. Page 2 of 5

    This controlled copy document will be uncontrolled when printed. If you need controlled copy document, please contact document controller.
    FR-K3L-027
    INCIDENT INVESTIGATION REPORT
    Rev. 0

    13. Corrective Action Monitoring/ Monitor Tindakan Perbaikan


    Actual Date / Tgl
    Required Action / Tindakan yang diperlukan By who / oleh When / Kapan:
    Aktual
    1.
    2.
    3.
    4.
    5.
    6.

    Author: HSE Dept. Page 3 of 5

    This controlled copy document will be uncontrolled when printed. If you need controlled copy document, please contact document controller.
    FR-K3L-027
    INCIDENT INVESTIGATION REPORT
    Rev. 0

    14. Additional Photos or Sketch / Foto tambahan atau sketsa:

    1. 2. 3.

    4. 5. 6.

    7. 8. 9.

    10. 11. 12.

    Author: HSE Dept. Page 4 of 5

    This controlled copy document will be uncontrolled when printed. If you need controlled copy document, please contact document controller.
    FR-K3L-027
    INCIDENT INVESTIGATION REPORT
    Rev. 0

    Report Prepared By / Laporan disiapkan oleh (HSE) Authorized By / Disahkan oleh (Director)

    Name / Nama : Name / Nama :

    Sign /
    : Sign :
    Tanda angan

    Date / Tanggal Date / Tanggal :

    Position / Posisi : Position :

    Author: HSE Dept. Page 5 of 5

    This controlled copy document will be uncontrolled when printed. If you need controlled copy document, please contact document controller.

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