Form Laporan Kejadian Nyaris Celaka (Nearmiss Incident) [PDF]

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PT. GATOTKACA TRANS SYSTEMINDO Jl. Enggano No. 40-C Tanjung Priok Jakarta Utara - Tel : 021-43933201



LAPORAN KEJADIAN NYARIS CELAKA (NEARMISS INCIDENT REPORT)



1. SAKSI YANG MELIHAT KEJADIAN (PELAPOR) Nama



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NIK



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Dept



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2. DATA KEJADIAN Tanggal :_____________________________________________________________________________ Jam



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Lokasi



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3. Kronologis Kejadian Nyaris Celaka _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 4. Kemungkinan Cedera / Kerusakan _____________________________________________________________________________________ _____________________________________________________________________________________ 5. Fakta Kejadian Unsafe Action / Tindakan Tidak Aman _____________________________________________________________________________________ _____________________________________________________________________________________ Unsafe Condition / Kondisi Tidak Aman _____________________________________________________________________________________ _____________________________________________________________________________________ 6. Saran / Tindakan Perbaikan _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________



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