PT.

Video Display Glass Indonesia

Safety Environment Control Center

ACCIDENT REPORT
Factory Mgr Ass.Fact. Mgr Div/ Ass.Div.Mgr Dept.Head

Eng. / Formen Grp.Leader

President Director General Mgr SE Manager Safety Officer

Date Working In Normal shift Morning shift Day Off

When & Where Tanggal Bekerja pada Night shift Afternoon shift Hari Libur
Kapan & Dimana Time Place
Waktu Tempat
Employee Name Department Group Date of Birth Age Years Old
Nama karyawan Tanggal Lahir Usia Tahun

Date of Join Position Engineer Leader Operator Porter Other

NIK : Tgl.mulai bekerja Jabatan
What is injure
Apa yang cidera
How Serious Light ( unrest ) Serious ( rest ) Hospitalized Yes No
Seberapa parah Ringan Parah Rawat inap RS Ya Tidak
Injured by
Penyebab cidera
Recovering
Lama penyembuhan
Evacuated by Security Guard Emergency Car On Foot Accompanied by
Pengangkutan korban Petugas Keamanan Mobil Emergensi Jalan Kaki Ditemani oleh
First Aid by Hospital Company Clinic Others
Pertolongan pertama Rumah Sakit Klinik Perusahaan Lain - lain

Explanation 1. Where did it happen ? ( Dimana kecelakaan terjadi ? )

Penjelasan

2. What was he/she doing when the accident happened ( Apa yang sedang dilakukan ketika kecelakaan itu terjadi )

3. Under what situation did it happen ? ( Dalam situasi yang bagaimana kecelakaan itu kemudian terjadi ? )

4. What does injured ( Apa yang cidera ? )

Notes / Catatan :
1. This report must be made as soon as an accient happened and immediate hand it over to Adm.Division at the same day. But if it happen after
Business hour ,Overtime, Public holidays,etc. the report must be send at the next day of the week at 08.00 am
Laporan harus segera dibuat setelah terjadi kecelakaan dan dikirim ke Safety Officer pada hari yang sama. Jika kecelakaan terjadi setelah
jam 17.00, Overtime, Hari libur resmi,dll.maka laporan harus diserahkan pada hari kerja berikutnya pada kesempatan pertama (jam 08.00)
2. In case of serious accident when it happen in bussines hour (08.00 - 17.00), the responsible person must contact to Adm.Division immediately
by telephone. If the accident after business hour must contact to Security Guard immediately
Jika terjadi kecelakaan serius pada jam kerja normal,maka penanggung jawab harus melapor ke Divisi Adm via telepon, tetapi jika terjadi
setelah jam kerja normal maka penanggung jawab harus melapor ke Petugas Keamanan.
Ext. List / No.Telepon :
3. The classification will be judge and recorded by Safety Officer.
1. Security 100
Safety Officer akan menentukan tingkat kecelakaan dan mendokumentasikannya 2. Clinic ....105
3. Safety Officer 518
4. Adm.Division 140
: fill in by " " / Isi dengan " "

Doc.No :IR-SEC-001/Rev.01
 Ext. List / No.Telepon :

1. Security 100
PT.Video Display Glass Indonesia 2. Clinic ....105
Safety Environment Control Center 3. Safety Officer 518
4. Adm.Division 140

Doc.No :IR-SEC-001/Rev.01
 PT.Video Display Glass Indonesia
Safety Environment Control Center

COUNTER MEASURE REPORT OF ON DUTY ACCIDENT

* Counter measure meeting after theaccident happened

FACTORY Ass. Factory FACTORY AREAS 1. Date of meeting : 05 June 2006 PRESIDENT GENERAL ADM.DIVISION MAIN OFFICE AREA

MANAGER Manager Div/Ass.Mgr Dept.Head Engineer 2. Place : FM-Meeting Room Production Office DIRECTOR MANAGER MANAGER SE MANAGER ADM. MANAGER SAFETY OFFICER

3. Chairman : Gatot Maladi Office Clerk :~

4. Attendance
Murain W
ACTUAL SITUATION ROOT CAUSE ANALISYS
Personal Data Date of brith Date 14 Month April Year 1974 Age 32 Years HUMAN FACTORS EQUIPMENT FACTORS MANAGEMENT FACTORS
Joint Date Date 21 Month Jan Year 1998 Exp. Y8 M5. 1. The machine itself is the main cause ? 1. Is there any mismanagement that cause this
1. What action which has taken that cause the accident ?
Position Operator Other : ~ accident ?

Yes, there is No, there is not

Used improper (pipe diameter
Normal shift 3 shifts 2 shifts
tool's to big)
Type of work Others : ~ No, is not Tools
Acc. Record 1st Date of last accident ~
Date and time Date : 03. Month : June. Year : 2006. Time : .14.30 Hours .14 Minutes 30
2. Why he/she took those unsafe action ? 2. Why such unsafe condition remain stay in 2. If it is yes, what was that ?
Shift & Work type Normal Morning Afternoon Night Regular Overtime that position for long time ?
To shorten downtime without consider about working safely
Where J11 - INS-Line #1 No.2 Robot Machine ~ ~
What Injured Ring Finger (Right Hand)
Type of Injured Nail Brush 3. Others 3. Others 3. Others
Degree of Injured Yes 3.1 Less Experience 3.1 Safety devices 3.1 Unclear order or procedure
Very Serious Serious Fair Light Minor Recovering days Hospitalized
No 3.2 Operation Method 3.2 Operation environment 3.2 SOP ; anyone are informed
1. What was he/she is doing when accident happened ? (Illustration) 3.3 Health Condition 3.3 Maintenance & Inspection 3.3 Training
Replacement Robot M/C due to trouble happen Pipe not 3.4 Advance Age 3.4 Tools 3.4 Man Power placement
suitable 3.5 Body position of work 3.5 Lack or/and no signboard 3.5 Operation organization
3.6 No authority to do this job 3.6 Lay-Out 3.6 Operation scheduling
2. Under what situation did it happen ? 3.7 Work beyond the limit 3.7 Breaking the safety regulation
Pushing extension pipe for hexagonal L key-wrench 3.8 Looks no good condition (since he/she start working) 3.8 Unsafe workpiece material
3.9 Other 3.9 Other
3. What action did he / she do ? COUNTER MEASURE Scheduled In Charge
Retighten bolt of base Robot M/C
Right hand crash to HUMAN FACTOR
S

bracket - Dont' working in hurry, please Safety First 05-June-06 Hadi S

T
C
A

4. What did it happen next ?

F

Extension pipe suddendly loosen out & his hand crash to bracket machine surround working area

Standing position
when tighten bolt
5. What does injured ?
Ring Finger & nail brush of Right hand

EQUIPMENT Budget Scheduled In Charge

FACTOR - Prepare specials tools extension bar join to Hexagonal Key wrench Y/N 06-June-06 Hadi/Supriyo
The Manager suggestion To avoid this ame accident may happen again, every one in this Department have to pay attention to : Y/N
Y/N
Y/N
Y/N
Y/N
The suggestion of each Manager To avoid any equal potential accident occur in other department, every one in related Department have to pay more attention to : Y/N

MANAGEMENT Scheduled In Charge

FACTOR - Remind All Mechanical Member regarding working with safety conditions 05 June 2006 Gatot Maladi

Doc.No :IR-SEC-002 /Rev.02

PT.Video Display Glass Indonesia
Safety Environment Control Center

Doc.No :IR-SEC-002 /Rev.02