HAZARD REPORT FORM FRM-BSI-SHE-006 –

Formulir Pelaporan Bahaya Hazard report

Bagian 1 Laporan Bahaya – Temuan Bahaya

(Part 1 Hazard Report – Hazard Finding)
Nama (Name)
Departemen (Department)
Tanggal (Date)
Jam (time)
Lokasi Bahaya (Hazard Location)
Rincian identifikasi bahaya
(Details of identified hazard)
Kresna Yasha
OPP/Maintenance
22 Nov 2017
14:00
OPP W/Shop
 Substandard Three Phase portable power board ex JPC
for hot splicing, found the Panel not equipped with
grounding and used cable grounding (yellow green for
Neutral – violation to regulation PUIL), cable size from
MCCB too small compare to MCCB size (violation).
 Three phase extension cord to supply power to the
portable power board, both end used male plugs and

Tindakan yang telah dilakukan oleh

Pelapor Brought the equipment to workshop and band from usage
(Action has been taken by
Observer)
Tindakan Perbaikan yang diminta Replace with standard and safe equipment as per BSI
(Action required) Standard

Dokumen Pendukung Bagian 1

(Supporting Document Part 1)

JPC’s Power Board for Hot Inside the Power Board, Single Phase output cable
Splicing Machine power MCB not fixed to the DIN not using cable gland.
rail and grounding cable
used for Neutral

# Bagian 1 dilengkapi oleh Pelapor (Part 1 completed by Observer)

# Bagian 2 dilengkapi oleh Penanggung Jawab Lokasi (Part 2 completed by Area owners) Page 1
 HAZARD REPORT FORM FRM-BSI-SHE-006 –
Formulir Pelaporan Bahaya Hazard report

Cable size from the Grounding cable MCBs not fixed to the DIN rail
MCCB too small compare (yellow green) used as
to MCCB rating neutral

No cable entry and sharp Extension Cord male to male, potential hazards of electrocution
edge could damage the when not handle properly.
cable insulation

# Bagian 1 dilengkapi oleh Pelapor (Part 1 completed by Observer)

# Bagian 2 dilengkapi oleh Penanggung Jawab Lokasi (Part 2 completed by Area owners) Page 2
 HAZARD REPORT FORM FRM-BSI-SHE-006 –
Formulir Pelaporan Bahaya Hazard report

Bagian 2 Laporan Bahaya – Perbaikan

(Part 2 Hazard Report – Corrective Action)
Penanggung Jawab Lokasi Kerja
(Area Owner)
Nama Manger/Supervisor
(Name of Manager/Supervisor)
Jenis Pengendalian
(Hazard control type)
Taggy and Asian
Jarrod Taylor
X Penghilangan sumber bahaya (Elimination)
X Penggantian (Substitusion)
Perbaikan (Repairs/Maintenance)
Pemisahan (Isolation)
Pelatihan (Training)
Pengadaan alat (Equipment Purchase)
Pembuatan prosedur kerja (Procedure Development)
Audit - Inspeksi (Audit - Inspection)
Kebersihan lingkungan kerja (Housekeeping)
Alat Pelindung Diri (APD)
Note:

Status perbaikan Belum selesai (Incomplete)

(Corrective Action Status) Sudah selesai (Complete)
Manager’s signature (tanda
tangan

Dokumen Pendukung Bagian 2

(Supporting Document Part 2)

# Bagian 1 dilengkapi oleh Pelapor (Part 1 completed by Observer)

# Bagian 2 dilengkapi oleh Penanggung Jawab Lokasi (Part 2 completed by Area owners) Page 3