: CSCODS-LIMND-00-HS-SFT-03-

No. Doc INVESTIGASI

SAFETY, HEALTH & ENVIRONMENT
Rev :0
PRELIMINARY INCIDENT REPORT (LAPORAN INSIDEN AWAL) Date : 12 September 2022

SITE NAME : DATE OF OCCURRENCE :

LAMIPAK New Plan Project 27-Feb-23
NAMA LOKASI TANGGAL KEJADIAN
AREA OF INCIDENT : DATE REPORTED :
LAMIPAK New Plan Project 27-Feb-23
TEMPAT KEJADIAN TANGGAL LAPORAN
INCIDENT CATEGORY PERSON INJURED/ PROPERTY DAMAGED
KATEGORI INSIDEN CIDERA ORANG/ KERUSAKAN PROPERTY
INCIDENT NAME :
Fatality Property Damaged NAMA KEJADIAN Eye exposed to iron fillings

LTI Environmental Damage ESTIMATED COST & PROPERTY LOSS :

PERKIRAAN BIAYA & KERUGIAN Rp200,000
Rawat Medis Near Miss PROPERTI
MCB Tertabrak VICTIM & OCCUPATION :
√ P3K Fire KORBAN & PEKERJAAN Asep Dede
Explosio
Others ................... Electrical Short Circuit WITNESS & OCCUPATION :
(Jelaskan) Collaps of Scaffolding SAKSI & PEKERJAAN Dadang As Foreman
Object Falling from Height
Lifting Equipment Failure
Lift Failure
Landslide Incident
Release of Haarmful Substance
Pressure System Failure
Others ...................
(Jelaskan)

DESCRIBE CLEARLY THE OCCURRENCE

DESKRIPSIKAN DENGAN JELAS TENTANG KEJADIAN

on Monday 27 February 2023 at 15.00 Mr. Asep was ordered by his foreman to do the job using a
welding machine, PPE was provided by the foreman Mr. Dadang. Because he felt uncomfortable using
the face shield, Mr. Asep took off and did not use PPE, so Mr. Asep's right eye was splashed with iron
filings and had to be cleaned immediately. at 16.00 Mr. Asep was delivered to the Gandi clinic to get first
aid.

ISSUED BY : REVIEWED BY : APPROVED BY :

DIBUAT OLEH : DIPERIKSA OLEH : DISETUJUI OLEH :

SPV / SM / CM EHS Project Manager / Director

Laporan lengkap berdasarkan hasil investigasi kecelakaan akan dikeluarkan terpisah, setelah selesainya investigasi kecelakaan.
Seluruh kategori insiden (termasuk nearmiss) harus dilakukan investigasi.
Laporan investigasi harus dikirimkan ke SHE HO dengan batas waktu maksimal :
Fatality : H+3
LTI : H+3
Rawat Medis : H+2
P3K : H+1
Others : H+2
Property Damaged : H+2
Environmental Damage : H+2
Near Miss : H+1

Laporan insiden awal (Preliminary Report Form) ini harus dikirimkan ke SHE HO di hari yang sama dengan kejadian (H+0).