TRAFFIC ACCIDENT REPORT

PT ASTRA DAIHATSU MOTOR

Page : 1 Revision No. : 1

Form No. : 024/Form/Safety Issue Date : 20-Sep-21
Title of the incident Traffic Accident Logistic Assy 1 Member 2021
Date Monday Time 6:00 Location Cakung, DKI Jakarta
Time Category Going Home Going Work Weekend Long Holiday Shutdown Mudik Lebaran
Permanent Empl.
Employment pattern Contract Employee Temporary Empl. Others ( )
( )
Name ALIF RIZKY NPK 66805 Safety Dojo Date Nov 11-15, '19 Safety Riding Date -
Victim's detail Age 20 th Sex Male Female Length of experience 1 years 11 moth
Employee Level Team Member Dept./Div. Logistic Assy / PAD Plant SAP
Vehicle Motorcycle Car Bus Train Bicycle Others

License NG OK SIM STNK Sticker

PPE Not Use OK Helm Not Clicked Helmet Shoes Jacket Gloves

OK Main Lamp Signal Lamp Brake Lamp Brake Mirror

Vehicle NG
Tire Other

Head Face Neck Left Hand Right Hand Body

Site Of Injury
Left Foot Right Foot

Severity Death Lost Work Day Scratch-Non LWD

Cost Impact -

Description Sketch
Saturday-Sept, 18th 2021 Kondisi Jalan
● 20.00, finish at work, and directly go to Cikarang for visiting friend
● 22.00, ETA Cikarang
Sunday-Sept, 19th 2021
● 02.00, returning home (kost) at semper, north Jakarta
● 19.30, go to work (holiday over time), MP fit with prefect condition
Monday-Sept, 20th 2021
● 05.15, absent out after asking permission for leaving overtime early to
Leader (Mr. Nuryanto)
● Mr. Alif only told his leader that he has necessary activity at Cikarang
● 07.10, received info from another Logistic MP (Mr. Aji) that Mr. Alif SIM YBS --> Status OK
having an accident at Cakung Cilincing artery road
Note:
● Estimation Tira (motorcycle) parking to accident spot :
1. Leaving Tira on 05.30
ADM Accident spot
2. Distance estimation from tira to accident spot is 11km
3. Timing estimation from tira to accident spot is 20 minute
4. Accident happened estimated on 05.50
● Gap time between 05.50 until 07.10 :
1. Resident nearby found Mr. Alif already on the midside of the street Destination
2. Moving to roadside and try to communicate someone on contact
Road Map
<Causes of incident> 4M 1E + 1 Direct Cause
Hit by Other Violation Traffic
Overtaking Road Condition Unfit Rider Overspeed
Vehicle Rules
Direct Cause
Vehicle NG

Main Problem Break The Rule Poor KY Poor Environment Fatigue

Analysis :
1. Still continue to Cikarang (47Km) with sleepy and fatigue condition (after work).
2. Single accident
3. With no witnesses, possibility accident caused by "Micro sleep", "Avoid something", or "Hit by something"

<Countermeasures> <Due Date> <PIC> <Status>

1. Quick Action
● Sounding to all member about traffic accident of Logistic Member Sept 20th, 2021 MNU / NRI
● Broadcast warning to avoid motorcycle riding if improper condition Sept 20th, 2021 MNU / NRI
2. Anticipate Action
● Briefing all Logistic Member and refreshing Safety Riding rule Sept 20th, 2021 SRI / MWI
● Individual KY related to mapping Traffic Domicile each man power who used motorcycle to go to work, Sept 22th, 2021 SRI / MWI
main target to knowing potential hazard/danger with route condition and also for anticipation
● Speedup Safety Riding training Committee
● Special control by Leader if any case to those (member) leaving early from reguler or over time working All Leader
hour, incase for reminder potential hazard if riding motorcycle.

Setelah Laporan Selesai Harap Merubah Risk Management Max. 3x24 Jam.
Jakarta, 20 September 2021

Verified Approved Checked Safety Officer Prepared

Bayu Ranu W Paulus Ardi Eko S SRI / MWI

EHS Div. Head Dept. Head Saf. Officer Leader Area