Rec.

No _____________________
Date: _________ Time: _______

PRELIMINARY INTERNAL SHE INCIDENT REPORT FORM

Important Notes:
1. This is a preliminary report! Report all relevant data based on your best observation in the incident scene. Be factual.
2. This form must be completed by Assigned Responder and submitted or sent to concerned BU Head, PTFI DG-GRS-OH&S-Services@fmi.com, and other
relevant parties as soon as possible (+/- 2 hours).
EVENT DATA & FACTS
Incident Type: ☒ Fatal/Injury ☐ Property Damage Date of Report:15 June 2023
☐ No Loss
Day & Date of Incident: Thursday 15 June 2023 Time of Incident: 15:10 pm (use 24 hours
format)
Exact Location of Incident SAG3, North Annex
(detail):
Organization Section & Crew Structure Department Mechanical
Division MOC Company FPJO
Brief Description of Incident: At 15:10 located at SAG3 North Annex when injured person checking the checker
(Use “What, Why, How” principle) plate with his supervisor.
When supervisor push the checker plate out, a 6 inch pipe elbow fell about 5cm height
and pinch his right little finger causing open wound and bleeding. IP's transported to
RC Clinic and referred to be examined by a surgeon at 68 Hospital.
Name(s) of Injured Person(s) (Use additional sheet if numbers of injured person more than 3)
No Name ID No. Title Organization
1 Edi Widodo Subroto 80032961 Structure fitter Lead hand FPJO
2                        
3                        
Property Involved (Equipment/ Material/ Facility/ etc.)
Description of Damage
No Property Type & No Operator Name & ID Organization
(if equipment damaged)
1 N/A                  
2                        
3                        
Spill
Type of Spill: N/A Estimated Non-Significant Possible      
Quantity: Significant source:
Direct Witness(s) (If applicable)
No Name ID No. Title Organization
1 Budi Haryanto 80030553 Mechanical & Piping FPJO
Supervisor
2                        
3                        
Direct Supervisor(s) who supervise task resulting incident:
No Name ID No. Title Organization
1 Budi Haryanto 80030553 Mechanical & Piping FPJO
Supervisor
Fact(s) Finding on 1. Injured person worn resistan cut
Scene: 2.      
3.      
Immediate Action(s) 1. IP and Supervisor report to Safety by Budi Haryanto and Edi Widodo
Taken 2. Apply First Aid treatment by Dita Purnamasari
3. Contact ERT by Dita Purnamasari
Reported by: 1 Ben Abram Contact No. 081393314330
2            

Form No. FRM-5.04-PTFI-001 Page 1 of 3

 Rec. No _____________________
Date: _________ Time: _______

ADDITIONAL INFORMATION
Additional Information Insert additional information/pictures here
/Pictures

ACCIDENT BRIEF ANALYSIS

RISK ASSESSMENT
Consequence Potential Minor (1) Recurrence Potential Mungkin (2)
POTENTIAL FATAL EVENT QUESTIONNAIRE
If the answer is YES, continue to the next question, if the answer is NO, ignore the next question and stop, this is Not Potential Fatal Event (PFE). If all
answers are YES, this is a Potential Fatal Event (PFE).
2. Fatal energy type &
1. Unplanned event? ☒ YES ☐ NO ☐ YES ☒ NO
magnitude?
4. Failure or lack of
3. Person exposed? ☒ YES ☐ NO ☒ YES ☐ NO
control?
Main Fatal Risk (Look at the event, not the whole job / task / activity)

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Contact with Aircraft interaction Blasting Confined Space Contact with Falling Object Vehicle Impact on Vehicle collision or
electricity molten material Person rollover

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Fall from Heights Uncontrolled Hazardous Hazardous Entanglement Drowning Fire Ground Failure
Release of Energy Substance - Acute Substance - Chronic and Crushing

☐ ☐ ☐ ☐ ☐ ☐ ☐
Lifting Operations Personnel Rail Collision Rail Impact on Underground Underground Underground Hazardous Atmosphere
Hoisting Person Rock Fall Inrush

HUMAN FACTOR (This section is filled in for accidents that result in property damage only. If there is an unsafe action or the cause of unsafe
condition from human factors)
☐ Violation ☒ Error ☐ No Human Factor
(Deviation from rule/procedure) (Deviation made because of not
knowing / being disturbed/

Form No. FRM-5.04-PTFI-001 Page 2 of 3

 Rec. No _____________________
Date: _________ Time: _______

distracted/ not intended)

ANALYZE BY
Name & ID No ID No Title Organization

Ben Abram 903273 HSE Supervisor FPJO

                       
                       

Reference Table – Risk Matrix:

Consequence Explanation Recurrence Potential Explanation
Potential
Minor (1) Minimal injury or first aid Unlikely (1) Highly unlikely to occur during the lifetime of
an operation / project.
Moderate (2) Medical treatment or restricted duty or lost time injury, Possible (2) Event that may occur during the lifetime of an
or reversible health effects, or hearing loss operation / project.
Significant (3) One or more fatalities, permanent disabilities, or Likely (3) Peristiwa yang mungkin terjadi (
isolated cancers or terminal/disabling disease
Catastrophic (4) Multiple fatalities which may result from a physical Almost Certain (4) Recurring event during the lifetime of the
event (slope failure, personnel transport accident), operation/ project or >once per year.
chemical release event, or clusters of cancer or
terminal disease

Form No. FRM-5.04-PTFI-001 Page 3 of 3