LAPORAN KECELAKAAN

INJURY REPORT
Injured employee and supervisor / medic to initiate. INJURY REPORT No. : INJ 01/SS/IX/1001C/01
1. PERSONAL DETAILS / DATA PRIBADI
First Name:/Nama Depan: Birth Date:/Tanggal lahir: Gender/Jenis kelamin:
Yohanes Bandaso (Y-0529) 09/October/1953 M / F
Injury Date:/Tanggal Kejadian: Injury time:/Waktu kejadian: Occupation:/Jabatan Country/Negara
06/September/2001 13.45 Carpenter Indonesia
Petrosea Employee?/Karyawan Petrosea? Employer's Name:/Nama Perusahaan: Project Name/Nama Proyek Project No./No Proyek:
Yes Petrosea Sanggatta 1001 C
Starting Time:/Jam Mulai Kerja: Finishing time:/Jam selesai kerja: Supervisor Name:/Nama Supervisor
7.30 16.00 ML. Tobing

Division: (" x " the Box)

Divisi: Corporate Clough WA SA & NZ Saiclo Beta Clough
Offshore NA & PHG International Petrosea

What was being done at the time?/Apa yang sedang dilakukan pada saat itu ?
Try to lift grating to making space for access on to beam cloumn bolt installation

How was the injury sustained and treated?/Bagaimana jenis luka/cidera dan perawatan?
His tip midle finger right hand side was crash by cought between grating where lifted and existing grating. The injured person was brought to
SOS field clinic and followed with medivac to Rumah Sakit Islam-Samarinda. Finally the tip finger that crash was amputated.

Date Reported:/Tanggal dilaporkan: To Whom (suprvisor)/Kepada Siapa: Time Report:/Waktu diLaporkan :

08/September/2001 ML. Tobing and John Paul Thomas 14.00 am / pm
Date Reported to First Aid / Tanggal dilaporkan pada P3K : Treating person:/Orang yang merawat: Time Report:/Waktu diLaporkan :
Immediate action AEA-SOS Clinic Immediately on Accident
Notifiable to Statutory Authorities? Yes / No To Whom:/Kepada Siapa: By Whom:/Oleh Siapa: Date:/Tanggal: Time:/Jam:
Dilaporkan kepihak berwenang? Yes / No KPC-Client JPT & Edi Oslie 06/Sept/2001 Immediately
2. INJURY DETAILS / RINCIAN CIDERA
Details of the most serious injury sustained should be recorded below. "X" one of the following boxes under each heading.

Nature of Injury/Sifat cidera Body Location/Anggota tubuh Mechanism of injury / Mekanisme cidera
Fractures/Patah tulang L R Falls form height Slide or cave-in
Fracture (vertebral column) Arms and Shoulders/Lengan dan bahu Falls on same level Meluncur atau ambruk
Dislocation/Dislokasi Ear / Telinga Hitting objects with body Vehicle accident
Sprain & strain/Keseleo & Terkilir Eye / Mata Mechanical vibration Kecelakaan kendaraan
Intracanitial injury Feet and Toes/Kaki dan jari kaki Hit by moving objects Other and multiple
Internal (trunk)/Tubuh bagian dalam Hands & Fingers/Tangan dan jari tangan Sharp, sudden sound Lain-lain dan berganda
Amputation/Amputasi Knee / Lutut Long term sound Unspecified
Open wound/Luka terbuka Legs and Hips/Paha dan betis Pressure Tidak khusus
Superficial injury/Cidera Repetitive movement
Contusion/Bingung Back/Punggung Other muscular stress Cought
Foreign body/Benda asing Face/Wajah Electricity
Burns/Terbakar General/unspecified/Umum/tak khusus Heat / Cold
Nerves and spinal cord/Gugup Head / kepala Radiation
Poisoning/Keracunan Internal Organs/Organ bagian dalam Single contact with chemical
External Multiple locations/Lokasi ganda Long term contact with chemical
Multiple injuries/Luka/cidera berganda Neck / Leher Bites / Stings
Damage to artificial aids Trunk / Tubuh Biological factors
Unspecified/Tidak khusus Mental stress

Category/Kategori : Work Related Injury/Berhubungan dengan pekerjaan Non-work Related Injury/Tidak Berhubungan dengan pekerjaan
Severity/Keparahan : Fatality/Meninggal LTI RDI MTI FAI No T/ment/Tidak Memerlukan Perawatan
Estimated Work Days Lost/Taksiran kehilangan hari kerja: Days Restricted Duties Days/Pembatasan Hari Kerja: Days Workers Compensation/Kompensasi karyawan? Y/N
3. SIGNATURES / TANDA TANGAN
INJURED PERSON/ORANG YANG CIDERA SUPERVISOR/PENGAWAS SAFETY DEPT./DEPARTEMENT KESELAMATAN KERJA

PROJECT MANAGER/PIMPINAN PROYEK

Investigation Level Category/Tingkat Penyelidikan : 1 / 2 / 3 / 4 / 5

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