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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 volume bottle of instrument gas supply, V-3253, at HT-01 Tingkat Keparahan/ Severity Real Severity Potential Likelihood
MAN without name plate. Level (1-6) Severity (1-6) (1-6)
Cedera Manusia / Human Injury
Kerusakan Lingkungan/Environment Damage
Kerusakan Finansial/ Financial Loss:
[ ] Production Loss [ ] Material Loss
Media

Tindakan Perbaikan Jangka Pendek (Short Term Mitigation):


Lokasi (Site): Handil Field Daerah (Area): HT, M3 area
Tanggal (Date): 20 January 2017 Jam (Time): 09.00 LT 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 :

- Wear and tear 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
- Install name plate, as per ASME standard Date / Tanggal :

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) ; SRI widadi *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