Health, Safety and Environment Management System

Incident Investigation Report

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Record No.
INCIDENT INVESTIGATION REPORT/ LAPORAN INVESTIGASI KEJADIAN

1 General Information / Informasi Umum Business Unit (Unit Bisnis) : ###

Incident Type (Jenis Kejadian) ###
Injury / Illness (Cedera / Property Damage Near Hit / Miss (Hampir ###
Sakit) (Kerusakan Alat) Celaka)
Fatality (Mati) Violation (Pelanggaran) Pot. Class I ###
LTI (Lost Time Injury) (Kehilangan
Environmental Risk (Dampak Pot. Class II ###
jam
RWI kerja)
(Restrict Working Injury)(Kerja
MTI (Medical Treatment Injury) Lingkungan) ###
Terbatas) Fire (Kebakaran)
(Perawatan
FAI (First Aid Medis)
Injury) Hazardous Spill ###
(Pertolongan P3K) (Tumpahan B3)
###
Class I (Kelas Class II Class III (Kelas ###
Incident Class (Tingkat Kejadian)
I) (Kelas II) III)
2 Incident Details (Rincian Kejadian) ###
Department Involved (Departemen Terlibat) Incident happen (Kejadian terjadi) Time (Waktu) ###
Production Date (Tanggal) Month (Bulan) Year (Tahun) Time ###
Exploration Incident Reported (Kejadian Dilaporkan) ###
Hauling /
Transportation Date (Tanggal) Month (Bulan) Year (Tahun) Time ###
HRGA
Incident Location (Lokasi Kejadian) ###
Finance
###
Port Marine Operations
Shift Schedule (Jadwal Kerja) % Shift Worked (% Waktu Kerja) ###
HSE
50 100 ###
Workshop 25% 75% Day Shift / Siang ✘
Site Journey % %
Over Time (Jam Night Shift / Malam ###
Operation : (Perjalanan) Lembur)
3 Personal Involved (Orang Yang Terlibat) Direct Supervisor (Pengawas) ###
Subject 1 (Pelaku 1) ###
Name (Nama) : Department Experience(s) Year(s) ###

ID No. (NIK) : Occupation Sex Age ###

Employment (Pegawai) : Outsider / Contract ###

BIB
Public or ###
Personal Involved (Orang Yang Terlibat) Direct Supervisor (Pengawas) ###
Subject 2 (Pelaku 2) ###
Name (Nama) : Department Experience(s) Year(s) ###

ID No. (NIK) : Occupation Sex Age ###

Employment (Pegawai) : Outsider / Contract ###

BIB
Public or ###
Injured Person (Korban Cidera) ###
Action Be Taken
Sex Age Involvement Consequences Employment
Name (Nama)
Jenis Kelamin Umur Keterlibatan Akibat Tindakan yang diambil Karyawan

###
Incident Short Description (Penjelasan Ringkas Kejadian) ###
###
###
###
###
###
###
###
###
4 Injury Details (Rincian Cidera) ###
###
Agency of Injury Location Injured ###

Mechanism Cause ###

Injury Impact ###

###
5 Analysis of Fire (Analisa Kebakaran) ###
Ignation Sources Electrical Hot Surfaces Static Electricity Open Fire ###
(Sumber Pemicu) Lightning Cutting/Welding ###
Phyroporic Material Unknown
Fired Equipment Friction Other ###
Auto Ignition
: ###

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6 Analysis of Environment Impact (Analisa Pengaruh Lingkungan) ###
Source(s) of Pollution: Process/Pumping ###
Stack / Flare Shipping Line Drum/Container
(Sumber Polusi) Tank Above Equipment Produced Water ###
Tank/Truck/Vehicle Production Line
Ground Line/Canal ###
Tank Under Ground Pit Vessel Other :
###
7 Plant/Property Damage (Kerusakan Peralatan/Properti Perusahaan) ###
Unit No.
Description/ Expected Cost
Penjelasan (Perkiraan Biaya)
(No Unit)
Unit No.
Description/ Expected Cost
Penjelasan (Perkiraan Biaya)
(No Unit)
Description
Expected Cost (Perkiraan
8 Environmental Damage (Gambaran)
Biaya) ###
Statutory Notification (Perlu pemberitahuan ke pemerintah/ yang berwajib?) Yes / Ya No / Tidak Other : ###
Police / Polisi Government Body ###
###
9 Causal Factors (After Investigated) / Faktor Penyebab (Setelah Di Investigasi) ###
###
Basic Cause - Work System ###
Inadequate environmental control
Failure to secure Inadequate training ###
program
Inadequate job planning
Improper engineering Working on moving equipment Improper layout or design of work
methods
###
Improper position / worn-out and threadbare
Inadequate hiring / placement area ###
posture Inadequate supervision
Improper tools / equipment Inadequate preventive
practices ###
Improper or inadequate Inadequate medical monitoring
procedure Inadequate safety management
maintenance Unsafe design or construction of ###
Inadequate maintenance activities Inadequate hazard analysis or
tools/equipment ###
Inadequate Inadequate job instruction
Inadequate purchase
or lack Inadequate enforcement of prevention act ###
Other :
supervision work rules and procedures ###
Unsafe Condition(s) ###
Inadequate guards or barriers Noise exposure Congested work area/roadways ###
Improper safety Unsafe floors, ramps, stairways,
Radiation exposure platforms
###
Defective equipment &
protection Hazardous chemicals/substances
High or low or
Inadequate temperature
excess ###
tools Limited visibility
Inadequate working space ###
illumination Adverse weather
Inadequate warning system Inadequate Ventilation ###
Explosive and fire hazard Lack of supervision Poor road conditions
Defective tools, equipment, machine or
Improper material
Environment hazardstorage
condition; gas, smog, dust, Poor housekeeping
vehicle
fume, vapor Inadequate guards or protection Other :
Unsafe Practice(s)
Failure to use PPE properly Removing safety devices Operating without authority
Failure to follow procedure Using defective equipment Unsafe lifting,
Improper loading
lifting, or placing
lowering, or carrying
Under influence of alcohol and /
Failure to obey safety rules
or drugs words
Improper technique
Taking unsafe position
Failure to secure
Failure to warn Inattention Influence of alcohol or drugs
Horseplay Lack of skill or knowledge Physical or mental limitation
Improper loading / unloading Operating at improper speed Unaware of hazard
Failure to use proper tools or Servicing equipment in
Improper lifting
Improper placement equipment operation
Using known defective equipment
Failure to use guards provided
Improper position for task Failure to use personal protective Operating equipment without authority /
Making safety device equipment training
Making safety devices inoperable Other :
inoperable
Failure to follow procedures or Operating mobile equipment in unsafe
methods manner or speed
10 Corrective Action Taken & to prevent recurrence/ Tindakan perbaikan yang diambil untuk mencegah terulangnya kejadian By Whom (Oleh By When (Kapan) Sign & Date on Completion
Siapa) (Tandatangan dan Tanggal Saat
serupa Penyelesaian)

Basic Cause - Work System

1
2

Unsafe Condition
1
2
3

Unsafe Act
1

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11 Action and Effectivess of Corrective Actions (Tindakan dan Keefektifan Tindakan Perbaikan)
Direct Supervisor Action & Comment (Tindakan dan Komentar Pengawas Langsung) Sign (TTD) Date/ Tgl

Departmental Manager / Head Action & Comment (Tindakan dan Komentar Manager / Pimpinan Departemen) Sign (TTD) Date/ Tgl

Workplace HSE Department Action & Comment (Tindakan & Komentar Departemen K3L di Tempat Kerja) Sign (TTD) Date/ Tgl

Actual Days Lost Actual Cost (Biaya yang dikeluarkan) Is Attachment Other Investigation Report Available? (Adakah Laporan Investigasi Lain Tersedia?)
(Hari Kerja yang Hilang) Rp. - Yes / Ya No / Tidak
No /
Has short-term corrective action been implemented?(Sudahkah tindakan perbaikan jangka pendek dilakukan?) Yes / Ya
Tidak
Has report been discussed with General Manager?(Sudahkah laporan ini didiskusikan dengan General Manager?) No /
Has long-term corrective action been planned? (Apakah tindakan perbaikan jangka panjang sudah direncanakan?) Yes / Ya
Tidak
No /
Yes / Ya
Tidak
12 Close Out (Penutupan Laporan Kejadian)

General Manager-KTT / Representative Comments of The Follow Up Action(s) If Required / (Komentar GM-KTT / Perwakilannya Tentang Langkah Tindak Lanjut Jika Dibutuhkan)

Sign (TTD) Date/ Tgl

Head Office HSE Manager / Representative Comments of The Follow Up Action(s) (Komentar Manajer K3L Pusat / Perwakilannya Tentang Langkah Tindak Lanjut)

Sign (TTD) Date/ Tgl

Documents attached to this report (interviews, monitoring results, photographs, competency assessments etc):
Lampiran Untuk Laporan ini (Hasil Wawancara, hasil monitor, photo, penilaian kemampuan, dll)

Incident Interview Form Incident Sketch

Photograph Attachment Loss Insurance Form
Cause Analysis
Assessment
Others Result
Form
:

Close out of Incident report ( Penutupan laporan insiden )

(To be completed once all relevant sections have been completed). This incident report, including investigation and corrective actions, has been adequately closed out. The effectiveness of the corrective actions has been evaluated.

(Kolom ini hanya diisi bila semua tindakan yang terkait sudah dilakukan. Laporan insiden ini, termasuk penyelidikan dan tindakan perbaikan telah sepenuhnya dilaksanakan. Keefektifan dari tindakan perbaikan telah dievaluasi.)

Incident Report Status : Completed / Telah Diselesaikan Not Yet Completed/ Belum Diselesaikan

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