F.

056-Rev 10/01
NEAR MISS REPORT Report No:
GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Incident Type: 5. Date of Incident: 6. Time of Incident:

Near Miss - - [dd-mm-yyyy] - [hh-mm]

Significant Near Miss 7. Incident Location or Area:

8. Incident Identified by:

Name of Identifier: Badge No.: Team of Identifier (or name of Company):

INCIDENT DETAIL INFORMATION

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

11. Incident Short Description:

INCIDENT ANALYSIS
12. Investigation and Root Cause Analysis Result (for Significant Near Miss):

RECOMMENDATIONS
13. In order to prevent recurrence:
a. f.
b. g.
c. h.
d. i.
e. j.

14. Identifier's Signature 15. Leader Acknowledge 16. HES Committee Chairman
date date date

17. HES Team Acknowledge 18. Manager Acknowledge 19. VP/GM Acknowledge
[for Significant Near Miss] [for Significant Near Miss]
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
F.057-Rev 10/01 page 1 of 2

FIRE REPORT Report No:

GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Date of Incident: 6. Incident General Location:

- - [dd-mm-yyyy] Office/Building Field Area Facility Area Other

5. Time of Incident: 7. Incident Specific Location or Area:

- [hh-mm]

INCIDENT DETAIL INFORMATION

8. Facility Involved:
Facility Type: Material Involved/Flash Point:

Structure/Equipment Type: Structure/Equipment Involved:

What Structure/Equipment is damaged?

a. c.
b. d.

9. How did the Fire happen?

(Describe what happened, including a timeline. Use additional paper if necessary.)

Events Leading Up to Fire Time Line Event

Discovery of Fire and Response

Control and Extinguishment of Fire

10. Loss(es):
Incident Response Cost: Structures/Equipment: Damage Claim Paid:

Business Interuption: Repair Cost of Equipment: Other Losses:

Injured Person:
CPI Employee: Business Partner Employee: Public:

Occupational Injury and Illness Report Reference No.:

 Got Media Attention ? Yes No (Attach details and provide copies of related information)

F.057-Rev 10/01 page 2 of 2

FIRE REPORT Report No:

INCIDENT DETAIL INFORMATION (Continued)
11. Equipment Used:
Small fire equipment used: First Time Used: - [hh-mm]

TYPE SIZE QTY EFFECT/RESULT

Portable Fire Extinguisher
Water Hose
Foam

Major equipment used (large pumping engines):

Time Arrives: - [hh-mm]
Type of Apparatus: Size and Qty. Hoses used:
Source of Water:
Other Equipment Used:

ANALYSIS OF FIRE
12. Sources of Fire:
Fuel Source(s): Oxygen Source(s):

Air Other

What made the fuel mixed with oxygen and form a flammable mixture?

Ignition Source(s):

Electrical Fired Equipment Static Electricity Open Fire

Lightning Hot Surfaces Phyroporic Material Unknown
Cutting/Welding Friction Auto Ignition Other

Why did the fire start?

13. What Facility/System contributed to the Fire?

Alarm Systems Drainage/Impounding Spacing Guidelines Isolation Valves

Fire Water System Fireproofing PPE Other
Fire Fighting Equipment Pre-fire Planning Mobile Fire Fighting Eqp.
Emergency Response Team Shutdown System Outside Assistant

How it affected the Fire?

RECOMMENDATIONS
14. In order to prevent recurrence:

15. Team Leader Signature 16. HES Committee Chairman 17. Team Manager Acknowledge
date date date

18. HES Team Acknowledge 19. Manager Acknowledge 20. VP/GM Acknowledge
[for Critical Incident] [for Critical Incident]
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, cq. Team Manager Safety and Fire Prevention
Legal Affairs and Corporate Finance (if there is potential claim)
F.058-Rev 10/01 page 1 of 2

OCCUPATIONAL INJURY AND ILLNESS REPORT Report No:

GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Date of Incident: 6. Incident General Location:
- - [dd-mm-yyyy] Office/Building Field Area Facility Area Other

5. Time of Incident: 7. Incident Specific Location or Area:

- [hh-mm]

INCIDENT DETAIL INFORMATION

8. Type of Incident:
Fatality Days Away From Work Restricted Work Activity Medical Treatment

Estimated: days Estimated: days

9. Injured Personnel:
Name of Employee: Badge No.: Age: Occupation/Title:

yrs.
Service year: Service on this job: Hours worked before Incident:

yrs months yrs months hours

Where taken afer incident? Name of Physician:

Type of Injury: Body Part Affected: Type of Contact: Contact with:

Abrasion/Cuts/Scrapes Arms Caught between Caustic

Amputation Digestive Tract Caught in Cold

Bruises & Contusions Eyes Caught on Electricity
Burn Feet/Toes Fall from elevation Heat
Dislocation Head/Neck Fall on same level Noise
Fracture Hearing Overexertion Radiation
Multiple Legs Slip Toxic/noxious substances
Poisoning Respiratory Tract Struck against Others
Puncture Wound Skin Struck by

Strain/Sprain Trunk Others

Others Others

10. Incident Short Description:

11. Person(s) Involved:

Witness(es), if any:
Name: Address: Phone:

Other employee injured/made ill in this incident?

Name of Employee: Badge No.: Age: Occupation/Title:
 yrs.

F.058-Rev 10/01 page 2 of 2

OCCUPATIONAL INJURY AND ILLNESS REPORT Report No:

INCIDENT ANALYSIS
12. List the sequence of events which led up to the incident:
a.
b.
c.
d.
e.
f.
g.

13. Investigation and Root Cause Analysis Result:

Cause or Causes of the incident:
a. e.
b. f.
c. g.
d. h.

Root Cause Analysis:

RECOMMENDATIONS
14. In order to prevent recurrence:
a.
b.
c.
d.
e.
f.
h.
i.
j.

15. Team Leader Signature 16. HES Committee Chairman 17. Team Manager Acknowledge
date date date

18. HES Team Acknowledge 19. Manager Acknowledge 20. VP/GM Acknowledge
[for Critical Incident] [for Critical Incident]
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
F.059-Rev 10/01 page 1 of 2

ENVIRONMENTAL SPILL REPORT Report No:

GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Date of Incident: 6. Contract Block of Incident:

- - [dd-mm-yyyy] CPI - Rokan Block C&T - MFK Block

5. Time of Incident: C&T - Siak Block C&T - Nias Block

- [hh-mm] C&T - CPP Block Other

7. Incident Specific Location or Area:

8. Leader in Charge of the Incident Location:

Name of Employee: Badge No.: Phone No.: Email Address:

INCIDENT DETAIL INFORMATION

9. Type and Quantity of Environmental Spill: 10. Cause of Environmental Spill:

Duri Crude Oil bbls External Corrosion Equipment Failure

Sumatra Light Crude Oil bbls Internal Corrosion Over Pressured Equipment

Refined Products bbls Sand Corrosion Inadequate Procedure

Produced Water bbls Tank/Vessel/Pit Overflow Blow Out/Well Kick
Chemical bbls Leaking Valves/Fittings Hit by External Object
Other bbls Well Head Leaks Other

11. Duration of Environmental Spill:

- - [days-hours-minutes]

12. Incident Short Description: 13. Source(s) of Spill:

Stack / Flare Shipping Line

Tank Above Ground Tank/Truck/Vehicle
Tank Under Ground Pit
Process/Pumping Equipment Drum/Container
Production Line Produced Water Line/Canal
Vessel Other

[Sketch of Incident should be attached with this report]

14. Environmental Condition:

Spill Receiving Medium:

Land River Sea Lake / Pond Other

Water condition (if the medium is River or Sea):

Current Speed: m/s Current Direction:

Wind Speed: m/s Wind Direction:
Tide: m

Land condition (if the medium is Land):

Soil / Dirt Concrete Asphalt Building Floor Other

F.059-Rev 10/01 page 2 of 2

ENVIRONMENTAL SPILL REPORT Report No:

INCIDENT DETAIL INFORMATION (Continued)
15. Actions Taken to Clean up the Environmental Spill:
Mechanically: Chemically:

16. Type and Quantity of Spill Recovered: 1 bbls

2 bbls

Action taken for un-recovered spill :

17. Loss(es):
Direct Impact (Personnel Injury/Fire/Environmental Impact)

Incident Response Cost: Product Value: Damage Claim Paid:

Production Loss: Repair Cost of Equipment: Other Losses:

INCIDENT ANALYSIS
18. Investigation and Root Cause Analysis Result:

RECOMMENDATIONS
19. In order to prevent recurrence:
a.
b.
c.
d.
e.

20. Team Leader Signature 21. HES Committee Chairman 22. Team Manager Acknowledge
date date date

23. HES Team Acknowledge 24. Manager Acknowledge 25. VP/GM Acknowledge
[for Critical Incident] [for Critical Incident]
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, cq. Team Manager Environmental Protection
F.060-Rev 10/01
INCIDENT REVIEW TEAM MEETING MINUTES Report No:
MEETING INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Date of Meeting: [dd-mm-yyyy] 5. Time of Meeting: [hh-mm] 6. Place of Meeting:
- - -

INCIDENT REVIEW TEAM CHARTER

7. Chairman: 8. Secretary: 9. Members:

10. Team Leader: 11. Other Expertise(s):

INCIDENT INFORMATION
12. Incident Report Reference No.:

13. Involved Personnel:

Name of Employee: Badge No.: Team of Employee (or name of Company):

Previous Safety Record: Days Lost of Injured:

day(s)

14. Incident Type: 15. Date of Incident: 16. Time of Incident:

Motor Vehicle Accident - - [dd-mm-yyyy] - [hh-mm]

Recordable Injury 17. Incident Location or Area:

Fire Case

Environmental Spill 18. Other Losses:

Equipment/Tools Acc. (Repair Cost or Downtime of Equipment or Volume of Spilled or Production Loss)

Other

INCIDENT ANALYSIS
19. Team Finding and Root Cause Analysis:

RECOMMENDATIONS
20. In order to prevent recurrence:
a. g.
b. h.
c.
d. 21. Chairman
e. date

f.
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
F.117-New 10/01
FIRST AID REPORT Report No:
GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Date of Incident: 6. Incident General Location:
- - [dd-mm-yyyy] Office/Building Field Area Facility Area Other

5. Time of Incident: 7. Incident Specific Location or Area:

- [hh-mm]

INCIDENT DETAIL INFORMATION

8. Injured Personnel:
Name of Employee: Badge No.: Team of Employee (or name of Company):

9. Job Purpose: 10. Equipment Used:

Specific Task: Specific Equipment:

11. Incident Short Description:

INCIDENT ANALYSIS
12. Investigation and Root Cause Analysis Result:

RECOMMENDATIONS
13. In order to prevent recurrence:
a. f.
b. g.
c. h.
d. i.
e. j.

14. Direct Leader Signature 15. Supervisory Team Leader 16. HES Committee Chairman
(for Bussiness Partner only)
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

HES Organization
Corporate HES
F.118-New 10/01
EQUIPMENT/TOOLS ACCIDENT REPORT Report No:
GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Date of Incident: 6. Incident General Location:
- - [dd-mm-yyyy] Office/Building Field Area Facility Area Other

5. Time of Incident: 7. Incident Specific Location or Area:

- [hh-mm]

INCIDENT DETAIL INFORMATION

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

10. Loss(es):
Repair Cost of Equipment: Down Time of Equipment: Other Losses:

11. Incident Short Description:

INCIDENT ANALYSIS
12. Investigation and Root Cause Analysis Result:

RECOMMENDATIONS
13. In order to prevent recurrence:
a. f.
b. g.
c. h.
d. i.
e. j.

14. Identifier's Signature 15. Leader Acknowledge 16. HES Committee Chairman
date date date

17. HES Team Acknowledge 18. Manager Acknowledge 19. VP/GM Acknowledge
[for Critical Incident] [for Critical Incident]
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
F.119-New 10/01 page 1 of 2

MOTOR VEHICLE ACCIDENT REPORT Report No:

GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Date of Incident: 5. Time of Incident: 6. Category:
- - [dd-mm-yyyy] - [hh-mm] Preventable MVA

Non-preventable MVA

7. Incident Location:
General Location: Exact Location:
Main Road Straight Road Delivery/Loading Space

Field Road Intersection Inside Shop/Plants

In Camp Road Driveway/ Alley Parking Lots

Industrial Yard Bridge Service Station Yard

Field Area Work or Operating Area Others

INCIDENT DETAIL INFORMATION

8. Driver Identity
Name of Employee: Badge No.: Age: Occupation/Title:

yrs.
Government Driving License: License Type: CPI Driving Permit:

Service year: Service on this job: Hours worked before Incident:

yrs months yrs months hours

Was driver on Company Business? Yes No

9. Other Person(s) Involved:

1st Person Name: Address: Government Driving License:

2nd Person Name: Address: Government Driving License:

Injured Person: CPI Employee: Business Partner Employee: Public:

Occupational Injury and Illness Report Reference No.:

10. Vehicle Involved:

Description of Vehicle: Company Vehicle: Other, if any: Other, if any:
Year/Vehicle License No. / / /
Number of Passenger
Any violation of Traffic Law
Estimated Repair Cost
How far from hazard when first noticed?
What was done to prevent the incident?
Any signal given?

11. Incident Short Description:

F.119-New 10/01 page 2 of 2

MOTOR VEHICLE ACCIDENT REPORT Report No:

INCIDENT DETAIL INFORMATION (Continued)
12. Place Number in Box for Item in each section which applies to the incident
Company Other
DRIVER'S EXPERIENCE ROAD DATA Vehicle MOVEMENT OF VEHICLES Vehicle

Surface A. Forward
Has driven motor 1. Dirt 1. Straght Ahead
vehicles 2. Oiled 2. Changing Traffic Lines
This type of vehicle 3. Asphalt 3. Making Right Turn
4. Asphaltic Concrete 4. Making Left Turn
Has driven this vehicle 5. Cement Concrete 5. Overtaking and Passing
Company Other 6. Drove Off Road
Vehicle Grade Vehicle
1. Less than one month 7. Standing in Traffic - driver at wheel
2. Less than one year 1. Uphill 8. Into/Out of Parking or Loading Space
3. 1 Yr. - 2 Yrs. 2. Downhill
4. 2 Yrs. - 5 Yrs. 3. Level B. Backward
5. 5 Yr - 10 Yrs. Condition 1. Into/Out of Parking or Loading Space
6. 10 Yrs. - 15 Yrs. 1. Dry 2. Other Backing
7. 15 Yrs. - 20 Yrs. 2. Wet
8. Over 20 years 3. Muddy C. Parked
1. Properly
2. Improperly (Wrong place, double parking, etc)
VISIBILITY - Wheather
3. Improperly (Open doors, brakes not set, etc)
1. Clear 3. Raining
2. Drizzling 4. Fogging

INCIDENT ANALYSIS
13. List the sequence of events which led up to the incident:
a. d.
b. e.
c. f.

14. Investigation and Root Cause Analysis Result:

RECOMMENDATIONS
15. In order to prevent recurrence:
a.
b.
c.
d.
e.

16. Team Leader Signature 17. HES Committee Chairman 18. Team Manager Acknowledge
date date date

19. HES Team Acknowledge 20. Manager Acknowledge 21. VP/GM Acknowledge
[for Critical Incident] [for Critical Incident]
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
F.120-New 10/01
HAZARD OBSERVATION REPORT Report No:
GENERAL INFORMATION
1. Company: 2. Organization: 3. Team/Supervisory Team:
CPI
Business Partner
4. Observation Type: 5. Date of Observation: 6. Time of Observation:

Unsafe Acts - - [dd-mm-yyyy] - [hh-mm]

At Risk Behavior 7. Observation Location or Area:

Hazard Identification

8. Observation Identified by:

Name of Identifier: Badge No.: Team of Identifier (or name of Company):

OBSERVATION DETAIL INFORMATION

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

11. Observation Short Description:

OBSERVATION ANALYSIS
12. Investigation and Root Cause Analysis Result (for Significant Hazard Observed):

RECOMMENDATIONS
13. In order to prevent recurrence:
a. f.
b. g.
c. h.
d. i.
e. j.

14. Identifier's Signature 15. Leader Acknowledge 16. HES Committee Chairman
date date date

17. HES Team Acknowledge 18. Manager Acknowledge 19. 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