MONTHLY HSE PERFORMANCE

Manhours
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

No Nama Karyawan ID / Badge Manhours Manhours This

Jabatan Month
1 Adil Simatipang SPV 12 204
2 Bertha SPV 12 372
3 Eko Pujiono SPV 12 252
4 Jumansyah Storeman 12 204
5 Mayang Site Admin 8 184
6 Andi Santi indriani Safety 12 204
7 Hadi Waluyo Chife Cook 12 288
8 Sadikin Cook 12 204
9 Saipul Anwar Cook 12 252
10 Nor aini Help Cok 12 348
11 Mahmud Help Cok 12 204
12 Samsul Arifin Help Cok 12 240
13 Abdul Wahab Sahrani Cook 12 132
14 Rahmat Yudha Driver 8 56
15 Sandi Fadillah Driver 8 136
16 Arwan Driver 8 128
17 Nuryana Sari Waitress 8 216
18 Fitriani Waitress 8 0
19 rafidah Waitress 8 216
20 norliana Waitress 8 200
21 Radha W Waitress 8 216
22 Nur Hikmah Waitress 8 216
23 Hendra Room Boy 8 112
24 Yitro Room Boy 8 128
25 M Zaki Room Boy 8 208
26 Sudillah Room Boy 8 216
27 Rahmat Hidayat Room Boy 8 216
28 Tomi. A Room Boy 8 216
29 Jefri Can Oping Room Boy 8 216
30 Evi Kembar Laundry 8 216
31 Mariati Laundri 8 216
TOTAL MANHOURS THIS MONTH 296 6212
 MONTHLY HSE PERFORMANCE
Illness & Medical Treatment
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

Jenis Medical Lama Illness & Penanganan

No Tanggal Nama Karyawan ID Badge Posisi Treatment Medis (Hari) Penyebab Tindak Lanjut

1 - -
2
3
4
5
6
7
8
9
10

TOTAL OF MEDICAL TREATMENT THIS MONTH Cases

 MONTHLY HSE PERFORMANCE
FIRST AID & RESTRICTED WORK CASE
LOCATION Pama BBSO
PERIOD Nov-16
WORKING DAY 30
RWD CASE
No Tanggal Nama Karyawan ID Badge Posisi Jenis Kecelakaan First Aid Case Penyebab Tindak Lanjut
Dialihkan Ke Posisi Lama RWD
teriris pinggiran
1 29-Nov-16 Abdul Wahab Syahrani Cook I Teriris Bioplacento &Hansaplast - - -
baskom
2
3
4
5
6
7
8

TOTAL OF RESTRICTED WORK CASE THIS MONTH 1 Cases

TOTAL OF FIRST AID CASE THIS MONTH 1 Cases
 MONTHLY HSE PERFORMANCE
Accident & LTI Record
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

Jenis Accident

Lama Kehilangan
Lokasi
No Tanggal Nama Karyawan ID Badge Posisi Kejadian Jam Hari Kerja Serious/ Major Fatality Penyebab Langsung Penyebab Dasar Tindak Lanjut
(LTI) Minor Injure (1-21 Injure (lebih dari 21 (MENINGGAL dalam
hari)
hari ) waktu 1 X 24 Jam)

1 - - - - -
2
3
4
5
6
7
8
9
10

TOTAL OF ACCIDENT THIS MONTH Cases

Note : INCIDENT REPORT and INVESTIGATION INCIDENT must be Attached

 MONTHLY HSE PERFORMANCE
Property Damage
LOCATION Pama BBSO
PERIOD Nov-16
WORKING DAY 30

No Nomor Asset Nama Alat Komponen yang Rusak Penyebab Lama Kerusakan Supervisor In Charge

1 Genset Mesin tidak berfungsi Pemakaian sudah lama 1 Tahun Adil Simatupang
2 Engsel pintu mesin pengering Pintu Mesin pengering terlepas Pemakaian sudah lama 2 Hari Eko Pujiono
3 Saringan Saringan patah Pemakaian sudah lama 8 Hari Adil Simatupang
4
5
6
7
8
9
10
 KONDISI

Rusak
Patah ( Masih berfungsi)
Rusak
 MONTHLY HSE PERFORMANCE
HAZOB Record
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

No Tanggal Nama Pelapor ID Badge Posisi Lokasi Kejadian Bahaya Tindakan Perbaikan Ditindaklanjuti Oleh Status

1 -
2
3
4
5
6
7
8
9
10

TOTAL OF HAZOB THIS MONTH : Cases

Note : Form HAZOB must be Attached

 MONTHLY HSE PERFORMANCE
Induction
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

No Tanggal Nama Karyawan ID Badge Posisi Diinduksi Oleh Tempat Induksi Durasi (jam)
Induksi
1 11/16/2016 Abdul Wahab Sahrani Cook PAMA OTD LAMA 1 Jam

TOTAL OF INDUCTION THIS MONTH 1 Person

Note : Copy of List Attendence must be Attached

 MONTHLY HSE PERFORMANCE
Safety Meeting
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30
Date Of Total of Attendant
No Descibtion Of Meeting Place Of Meeting Duration (Jam)
Meeting (Person)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

TOTAL OF SAFETY MEETING THIS MONTH Times

Note : Copy of List Attendence and Minutes Of Meeting must be Attached

 MONTHLY HSE PERFORMANCE
Safety Talk
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

No Date Topic Of Safety Talk Place Of Safety Talk Total of Attendant Conducted By Position
(Person)
1 12 Nov 2016 Housekeeping ( 5R ) Housekeeping 11 A.Santi Indriani Safety Officer
2 19 Nov 2016 Manual Heandling Housekeeping 12 A.Santi Indriani Safety Officer
3 28 Nov 2016 MSDS Housekeeping 12 A.Santi Indriani Safety Officer
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

TOTAL OF SAFETY TALK THIS MONTH :4 Times

Note : Copy of List Attendence must be Attached

 MONTHLY HSE PERFORMANCE
Training
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

No Date Type Of Training Place Of Training Total of Attendant Conducted By Position Duration (Jam)
(Person)
1 -
2
3
4

5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Duration Of Training This Month 0

TOTAL OF TRAINING THIS MONTH 1 Times

Note : Copy of List Attendence must be Attached

 MONTHLY HSE PERFORMANCE
Inspection Record
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

No Date Type Of Inspection Location Of Inspection Inspected By Position

1 11/11/2016 personal hygine Dapur Andi Santi , Eko Pujiono Safety & SPV
2 11/12/2016 Sanitasi Tempat Kerja Pack Meal Andi Santi & Eko pujiono Safety & SPV

3 11/13/2016 Peralatan & Kebersihan Sarana Driver Andi Santi & Eko pujiono Safety ,SPV & Driver

4 11/16/2016 Sistem Penyimpanan Barang ( Vegetable ) Store Andi Santi & Adil Simatupang Safety,Store & SM
Acuk. W , Dian Wahyu Sulistya, Andi
5 11/17/2016 Inspeksi Food Index Kitchen dan Store Santi , Adil Simatupang
GS Dept,Safety,SPV

6 11/18/2016
7 11/19/2016
8 11/27/2016
Sanitasi tempat kerja Laundry Andi Santi & Adil Simatupang Safety & SPV
Sanitasi tempat kerja Kantin Andi Santi & Bertha Safety,SPV
Andi Santi , Jumansyah , Adil
Sanitasi tempat kerja Store Safety,Store &SPV
Simatupang

TOTAL OF INTERNAL INSPECTION / AUDIT THIS MONTH 7 Times

TOTAL OF EXTERNAL INSPECTION / AUDIT THIS MONTH 0 Times
TOTAL OF CLIENT INSPECTION THIS MONTH 1 Times
TOTAL OF LIGHT VEHICLE INSPECTION THIS MONTH 8 Times

Note : Copy of Inspection Form must be Attached

 MONTHLY HSE PERFORMANCE
Emergency Drill
LOCATION PAMA BBSO
PERIOD Nov-16
WORKING DAY 30

No Date Location Of Emergency Total Of Attendant Duration (Jam)

Drill (Person)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

TOTAL OF EMERGENCY DRILL THIS MONTH : Times

Note : Documentation of Emergency Drill and List Attendance must be Attached

Keterangan :
- FREQUENCI RATE (FR) = Jumlah Kecelakaan (Incident / Accident) X 1 Juta
Jumlah Jam Kerja (Man Hours)

- SEVERITY RATE (SR) = Jumlah Hari Hilang Akibat Kecelakaan (Lost Day Injury /LDI) X 1
Jumlah Jam Kerja (Man Hours)

- FIRST AID : Kecelakaan Yang TIDAK menyebabkan Kehilangan hari kerja dan tidak a
MEDICAL TREATMENT : Kecelakaan Yang TIDAK menyebabkan Kehilangan hari kerja tetapi mem
- MINOR INJURY : Kecelakaan Menyebabkan Kehilangan hari kerja 1-21 hari ( Kurang darii 3
- MAJOR INJURY : Kecelakaan Menyebabkan Kehilangan hari kerja lebih dari 21 hari ( Lebih
FATALITY /
- : Kecelakaan Yang Menyebabkan Korban MATI / MENINGGAL dalam wakt
MATI
ENVIRON
- : kerusakan lingkungan yang bisa meneyebabkan kerusakan komunitas dis
DAMAGE
QUALITY
- : suatu peristiwa yang menyebabkan kerusakan mutu / penurunan mutu ba
CASE
 ccident) X 1 Juta
Man Hours)

akaan (Lost Day Injury /LDI) X 1 Juta

am Kerja (Man Hours)

ehilangan hari kerja dan tidak ada perawatan medis

ehilangan hari kerja tetapi memerlukan perawatan medis
i kerja 1-21 hari ( Kurang darii 3 Minggu)
i kerja lebih dari 21 hari ( Lebih dari 3 Minggu)

MATI / MENINGGAL dalam waktu 1 X 24 Jam

abkan kerusakan komunitas disekitarnya

kan mutu / penurunan mutu baik berupa services Quality maupun mutu bahan baku atau produksi