Incident Report Form

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Lokasi Kejadian : Perumahan Gunung Gembira Baru Ilir Departemen : D4K3 Universitas Balikpapan Tanggal Kejadian : 16 Maret 2014 Waktu : Pukul 03.15 WITA Tanggal Pelaporan :17 Maret 2014 Pekerja Yang Bersangkutan : Reza Hermawan SS# : Tidak Ada ID : 0885 Jabatan : Tidak Ada Tanggal Diterima : Tidak Ada Waktu Bekerja : 16 Maret 2014 Kerusakan Alat / Properti : Tidak Ada Biaya : Tidak Ada Lamanya Kerusakan : Tidak Ada 2 Kondisi Tak Aman Saat Kecelakaan : 3 Prilaku Tak Aman Saat Kecelakaan : 4 Saksi Kecelakaan : 5 Kronologi Kecelakaan : 1 Nugraha Dwi Prasetyo Pada saat kebakaran diperumahaan tersebut, banyak orang yang berlari untuk menyelamatkan harta benda mereka, sehingga memaksa untuk ikut berlari, kondisi di perumahan tersebut sangat gelap karena listrik padam, karena terburu-buru, dan tidak hati-hati lalu ditambah saya tidak menggunakan senter ( flashlight ) dan sepatu safety. Sehingga saya tak melihat ada sebuah kayu balok sepanjang 3 meter yang melintang tepat di bawah saya. Karena kondisi gelap saya tabrak balok tersebut dan hasilnya ibu jari kaki kanan saya memar karena menabrak balok tersebut. Data Umum Kebakaran di Perumahan Baru Ilir, gang sempit, kondisi pada saat itu gelap karena listrik padam, banyak benda tumpul berserakan dijalanan seperti kayu balok, dll Tidak menggunakan Senter ( Flashlight ), menggunakan sendal, tidak memperhatikan sesuatu yang ada di sekitar tempat itu Laporan Utamakan Kesehatan dan Keselamatan Kerja Formulir Laporan Kecelakaan ( Tanpa Cedera )

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Incident Report untuk Mata Kuliah Investigasi Insiden Jurusan K3

Transcript of Incident Report Form

Page 1: Incident Report Form

Lokasi Kejadian : Perumahan Gunung Gembira Baru Ilir

Departemen : D4K3 Universitas Balikpapan

Tanggal Kejadian : 16 Maret 2014 Waktu : Pukul 03.15 WITA

Tanggal Pelaporan :17 Maret 2014

Pekerja Yang Bersangkutan : Reza Hermawan SS# : Tidak Ada ID : 0885Jabatan : Tidak Ada Tanggal Diterima : Tidak Ada Waktu Bekerja : 16 Maret 2014

Kerusakan Alat / Properti : Tidak Ada

Biaya : Tidak Ada

Lamanya Kerusakan : Tidak Ada

2Kondisi Tak Aman Saat

Kecelakaan:

3Prilaku Tak Aman Saat

Kecelakaan:

4 Saksi Kecelakaan :

5 Kronologi Kecelakaan :

1

Nugraha Dwi Prasetyo

Pada saat kebakaran diperumahaan tersebut, banyak orang yang berlari untuk menyelamatkan harta

benda mereka, sehingga memaksa untuk ikut berlari, kondisi di perumahan tersebut sangat gelap

karena listrik padam, karena terburu-buru, dan tidak hati-hati lalu ditambah saya tidak menggunakan

senter ( flashlight ) dan sepatu safety. Sehingga saya tak melihat ada sebuah kayu balok sepanjang 3

meter yang melintang tepat di bawah saya. Karena kondisi gelap saya tabrak balok tersebut dan

hasilnya ibu jari kaki kanan saya memar karena menabrak balok tersebut.

Data Umum

Kebakaran di Perumahan Baru Ilir, gang sempit, kondisi pada saat itu gelap karena listrik padam,

banyak benda tumpul berserakan dijalanan seperti kayu balok, dll

Tidak menggunakan Senter ( Flashlight ), menggunakan sendal, tidak memperhatikan sesuatu yang

ada di sekitar tempat itu

Laporan

Utamakan Kesehatan dan Keselamatan Kerja Formulir Laporan Kecelakaan

( Tanpa Cedera )

Page 2: Incident Report Form

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Apa yang seharusnya

dilakukan agar kecelakaan

ini tidak terjadi ?

:

Supervisor

: D4K3 Universitas Balikpapan

: Ir. Maslina

: 29 April 2014Tanggal

Departemen

Seharusnya sebelum membantu memadamkan kebakaran saya harus menggunakan sepatu safety

dan juga menggunakan senter untuk penerangan. Kemudian dalam keadaan gelap saya harusnya

lebih berhati-hati dan memperhatikan keadaan disekitar saya.


bloximages.newyork1.vip.townnews.com...INCIDENT REPORT FORM INCIDENT IR 14-45869 14112 DATE OF INCIDENT: 10/28/2014 TIME OF INCIDENT: 2100 ... to spot my unit so we can go. Ofc Salamoni

bloximages.newyork1.vip.townnews.com...INCIDENT REPORT FORM INCIDENT IR 14-45869 14112 DATE OF INCIDENT: 10/28/2014 TIME OF INCIDENT: 2100 ... to spot my unit so we can go. Ofc Salamoni

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