F.120-Rev.

04/03
HAZARD OBSERVATION REPORT Report No:
GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:

CPI NDD Project Zul Bakri

Business Partner
4. Observation Type: 5. Date of Observation: 6. Time of Observation:

Unsafe Acts 0 3 - 0 2 - 2 0 1 0 [dd-mm-yyyy] 0 9 - 3 0 [hh-mm]

At Risk Behavior 7. Observation Location or Area:

Hazard Identification Hauling Road to simpang Bangko
8. Observation Identified by:
Name of Identifier: Badge No.: Team of Identifier (or name of Company):
Muhammad Isnaini #027 EII HES Compliance Coordinator

OBSERVATION DETAIL INFORMATION

9. Job Purpose: 10. Equipment Used:
Specific Task: Specific Equipment:

Loading Sub base material Dump Truck

11. Observation Short Description:

Loading sub base material crew not wear PPE

OBSERVATION ANALYSIS
12. Investigation and Root Cause Analysis Result (for Significant Hazard Observed):
Sub base material supply by vendor (out sider)

13. OE Tenets Evaluation (check the OE tenets that were violated which caused of the incident)

Always operate within design or environmental limits Always maintain integrity of dedicated system
Always operate in a safe and controlled condition Always comply with all applicable rules and regulations
Always ensure safety devices are in place and functioning Always address abnormal conditions
Always follow safe work practices and procedures Always follow written procedures for high risk or unusual situation
Always meet or exceed customer's requirements Always involve the right people in decision that affect procedures and equip.

RECOMMENDATIONS
14. In order to prevent recurrence:
a. Call TJE representative
b. Corrective coaching for crew
c. If the crew not have PPE, all of them must be in cabin

15. Identifier's Signature 16. Leader Acknowledge 17. HES Committee Chairman
date date date
Muhammad Isnaini#027

18. HES Team Acknowledge 19. Manager Acknowledge 20. VP/GM Acknowledge
[for Significant Hazard Observation] [for Significant Hazard Observation]
date date date

THIS REPORT TO BE USED ONLY FOR PT Caltex Pacific Indonesia INTERNAL BUSINESS PURPOSE. PT Caltex Pacific Indonesia WILL DISCLAIM ANY LIABILITY ARISING FROM ANY
INFORMATION ON THE REPORT THAT USED TO AGAINST PT Caltex Pacific Indonesia OR PT Caltex Pacific Indonesia EMPLOYEE.

Distribution : Team Concern

Corporate HES