PetroChina International Companies in Indonesia PCID/J/F-1/HSE/EHSMS/4.5.

3/01
ENVIRONMENTAL, HEALTH & SAFETY MANAGEMENT SYSTEM
DATE ISSUED/ :
TGL DIKELUARKAN
REV. DATE/ :
TGL REVISI
NON-CONFORMANCE, INVESTIGATION AND CORRECTIVE ACTION
KE-TIDAK SESUAIAN, PENYELIDIKAN DAN TINDAKAN PERBAIKAN Page 1 of 3/
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Internal Incident Report Form/Formulir Laporan Kecelakaan Internal

General Information/Informasi Umum Incident Risk Ranking/Tingkat Resiko
File Number/Nomor File Likelihood/Kekerapan (1-4) :
Date of Incident/Tgl Kecelakaan : Potential Severi) :
Date of Report/Tgl Pelaporan : Suggestion WO Priorit :
Location/Lokasi :
Facilities/Facilities :
NEAR PERSONNEL PROCESS ENVIRONMENT MOTOR VEHICLE
MISSES INJURY FAILURES/UPSET IMPACT ACCIDENT

PERSONNEL INJURY / PROPERTY/EQUIPMENT

ENVIRONMENTAL BUSINESS INTERRUPTIONS
ILLNESS DAMAGE

PCI employee Equipment Loss - Damage Oil/Chemical Spills Operations process upset
Contractor employee Fire Gas Release Business process failure
Outsider Loss Value = US $ Volume release = bbls Loss Value = US $
First Aid (Reportable if > 10,000 US$) (Reportable if > 15 bbls) (Reportable if > 1 Million US$)
NON

Env. Infect. Disease Acts of terrorism

REPORTAB
Off-The-Job Case MVA Responsible Evacuations
Medical Treatment MVA Not Responsible Media attentions
Restricted Workday Fines/Penalties (>1K US$)
Lost Workday
REPORTABLE

Fatality

Multiple Injuries

Off-The-Job (PCI employee only)

Originator Name/Dept
Pembuat Laporan/Dept

Investigating members/Dept.
Anggota Investigasi/Dept.
Management Sponsor

Nature of loss (all actual and potential losses – personal injury/illness, property damage, environmental, business
interruptions)

Jenis Kerugian (Semua kerugian nyata dan potensi kerugian – cedera/luka, kerusakan harta benda, kerusakan lingkungan,
gangguan bisnis)
Actual Loss/
Kerugian nyata
Potential Loss/
Kerugian potensial
Description of events (describe in details what happened – contact with, fall to or on, struck against or by, poison, etc.)
Gambaran kejadian (jelaskan dengan detil apa yang terjadi - kontak dengan, jatuh ke atau pada, menabrak atau
ditabrak,keracunan, dll)

Direct Causes : (Symptom of real problem, unsafe act or condition – defective equipment or condition – insufficient PPE,
unsafe position, speed, practice, or action)

Penyebab langsung : (gejala dari masalah sebenarnya, tindakan atau kondisi tidak aman – kerusakan peralatan atau
kondisi – alat pelindung diri tidak memadai, posisi tidak aman, kecepatan, kebiasaan atau
tindakan)

Indirect Causes : (Personal related : fatigue, depression, motivation, lack of knowledge/skill)

(Job related : wear and tear, abuse, design, tools, equipment, weather, visibility)
Penyebab tidak langsung : (Perorangan : kelelahan, tekanan mental/depresi, motivasi, kurang
pengetahuan/ketrampilan)
(Pekerjaan : usang dan sobek, salah pakai, perencanaan, perkakas, peralatan, cuaca,
penglihatan/jarak pandang)

Root Causes : (The management practices that allowed the condition to exist – inadequate standards, lack of
procedure to follow, unclear policies or consequences)
Akar penyebab : (Praktek manajemen yang membiarkan kondisi itu terjadi – standar yang tidak memadai, kurangnya
prosedur yang harus diikuti, kebijaksanaan yang tidak jelas atau konsekuensinya )

Recommendations (to prevent repeated or similar occurrence)

Rekomendasi (untuk mencegah terulangnya kejadian yang sama atau mirip)
Recommendations follow-up
Tindak lanjut rekomendasi
Target
W/O Prove
Accountable Description Completion W/O No. RCI Crew
Priority Completeness
Person Date
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