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ACCIDENT INCIDENT INVESTIGATION REPORT

Internal Number contractor

Project Information
Date
Project Tanggal
Working area Time (Local Time)
Lokasi Kerja Pukul (Waktu Lokal)
Location / Dept. Work Orde r No.
Lokasi/Dept. No WSP
Subcontractor Contractor

Illumination
Natural/alami/baik Adequate/Memadai Inadequate/Tidak Memadai
Penerangan
Weather conditions Clear
Kondisi cuaca

Incident Classification
Risk Assessment Matrix High Risk Medium Risk Low Risk

Fatality LTI (Lost time Incident) MTC (Medical treatment case)

FAC (First aid case) Near Miss / Near Hit HIPO Near Miss / Near Hit

Security Incident Environmental Incident Loss of equipment

Vehicle Accident Equipment/ Property Damaged Other:

Incident occurred: In Company site Outside Company Site

Type of accident/Tipe kecelakaan:

Details of the accident/Detail Kecelakaan:

Immediate Action(s) taken/Tindakan yang segera diambil:

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ACCIDENT INCIDENT INVESTIGATION REPORT

Worker(s) Involved
List of Personnel Involved/Daftar personel yang terlibat:
Own Employee Contractor Third Party Visitor
Name, Surname, ID Card Number, Role/Nama, Nama Keluarga, No. ID, Peran

Preliminary report attached? Witness declaration attached? Other Reports attached?

Laporan Awal dilampirkan? Pernyataan saksi dilampirkan? Laporan lain dilampirkan?

Injured Person (IP) details(in case of Fatality, Lost Time Injury, Medical Treatment or First Aid Case)
Detail Orang yang Terluka (jika terjadi Kematian, Kehilangan Waktu Kerja, Perawatan Medis dan Pertolongan Pertama
Full Name Age Date of Birth
Nama Lengkap Umur Tanggal Lahir
Home Address &Telephone Number Local Address &Telephone Number
Alamat Rumah & Nomor Telepon Alamat setempat & Nomor Telepon

Occupation / Role Gender Male Female

Pekerjaan/Peran Jenis Kelamin Pria Wanita
How many years the IP is working in this role? (in years)
Berapa tahun Orang yang terluka/IP bekerja di peran ini ? (dalam tahun)
How many years the IP is working in the Company / Contractor? (in years)
Berapa tahun Orang yang terluka/IP bekerja dalam Perusahaan/Kontraktor? (dalam tahun)
When the IP had the last day off / holiday? (date)
Kapan Orang yang terluka/IP mendapatkan hari libur? (Tanggal)
What time the IP started working in the day of the accident? (time)
Pukul berapa Orang yang terluka/IP mulai bekerja di hari kecelakaan terjadi? (Waktu)

Injury Type/Tipe Cidera

Body part/Bagian Tubuh

Details of Injury/Detail cidera:

No Treatment Required First Aid in working place Medical Treatment Hospital

Tidak diperlukan perawatan Pertolongan Pertama di Tempat Kerja Perawatan Medis Rumah Sakit

Details of any Treatment given to the IP/Detail dari perawatan yang diberikan pada orang yang terluka/IP:

Permanent disability: Discharged from Hospital:

Cacat Permanen:
Yes No Keluar dari rumah sakit
Yes No
Report from Hospital attached Leave Sick Days from doctor:
Yes No Berapa hari Cuti Sakit dari dokter:
Laporan dari RS dilampirkan

Investigation

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ACCIDENT INCIDENT INVESTIGATION REPORT

Unsafe acts/Tidakan tidak Aman: Unsafe conditions/Kondisi Tidak Aman: Personal factors/Faktor Personal:

Root Cause Analysis/Analisa akar masalah

1. Organizational/Keorganisasian

2. Technical/Teknis

3. Personal/Pribadi

[Please, describe the incident including the details coming from investigation and attach pictures for explanation ]
[Tolong deskripsikan kecelakan termasuk detail dari investigasi dan lapiran foto/gambar untuk penjelasan]

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ACCIDENT INCIDENT INVESTIGATION REPORT

PART 5– Corrective Actions

Due Date
Corrective Action description Responsible
tanggal jatuh tempo/
Deskripsi tindakan perbaikan Bertanggung Jawab
batas tanggal

PART 6– Verification and Approval

Report issued by Verification by Authorization by Authorization by Approved
Client

Date

Role

Name

Signature

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FM-HSE-040 Rev.00