Diisi oleh Superintenden K3LL dan RSES (Filled by HSE Superintendent & RSES) Foto / Sketsa jika ada

Foto / Sketsa jika ada (Photo or sketch, if any)

CeRMAT [ ] For Statistic Purpose [ ] Register in Synergi No: ___________________
Diisi oleh pelapor (Filled by reporter) [ ] Anomaly [ ] Incident
Uraian (Details) : Potensi Risiko Awal (Initial Potential Risk)

Found the walkway behind HLB Manifold -02 was obstructed by 6 inci Tingkat Keparahan/ Severity Real Severity Potential Likelihood
pipe that crossing the walkway. In case of lack concentration, the Level (1-6) Severity (1-6) (1-6)

worker's head may exposed to risk of being hit by the 6 inchi pipe Cedera Manusia / Human Injury
while moving or threspassing. Extra vigilant needed, Kerusakan Lingkungan/Environment Damage
Kerusakan Finansial/ Financial Loss:
[ ] Production Loss [ ] Material Loss
Media

Tindakan Perbaikan Jangka Pendek (Short Term Mitigation):

Lokasi (Site): CPA - Field Daerah (Area): HLB cluster, M3
Tanggal (Date): 30 September 2017 Jam (Time): 16.00 Close-out Acknowledgement / Pengakuan Penutupan
Tindakan langsung yang dilakukan (Immediate action taken): Description of Action Implemented /
- Issued CERMAT Deskripsi Tindakan yang Dilaksanakan
- Report to hierarcy •
- Take picture for documentation

Risiko Sisa (Residual Risk) •

Tingkat Keparahan/ Severity Severity Likelihood
Level (1-6) (1-6)
STOP Card Issued? [ ] Ya/Yes [ ] Tidak/No Cedera Manusia / Human Injury
Penyebab langsung (Immediate causes): Kerusakan Lingkungan/Environment Damage

Kerusakan Finansial/ Financial Loss:

- Lack of safety awareness [ ] Production Loss [ ] Material Loss
Date / Tanggal :

Media Name of Performing / Nama Pelaksana :

Service / Dinas :
Date: Signature&Name: Signature / Td. Tangan :
RSES recommendations/actions:
*Action Description - Responsible for Action (By) - Target Date :
Saran pencegahan&perbaikan (Suggestion for prevention&improvement): Close-out Acceptance / Penerima Penutupan
l Line supervisor / Penyelia Lini
Date / Tanggal :

- Apply coating or painting at 6 inci pipe by colourful paint, make it

eye catching and visible from the distance Name / Nama :

l Signature / Td. Tangan :

l
Pelapor - Diisi jika diperlukan (Filled if required) RSES - CSR
Nama (Name): Gede Andi Dipayadnya l Date / Tanggal :
Bagian (Entity): CST/OPB Perusahaan (Co.): INCONIS Name / Nama :
Signature / Td. Tangan :
Atasan Pelapor (Line Supervisor) ; M. Sigalingging *Internal Deadline (Estimated date for the case to be closed) :
Bagian (Entity): CST/OPB Td. Tangan (Signature): Date: Signature&Name:

CeRMATi sekeliling anda untuk meningkatkan keselamatan. Do CeRMAT in your surrounding to improve safety. Use CR EP HSE 102 as reference to define severity level of the case