SAFETY OBSERVATION CARD SAFETY OBSERVATION CARD
Decide Observe Act Report Decide Observe Act Report
CARD ANALYSIS
THIS SECTION IS FOR OFFICIAL USE ONLY
Significant Aspects of Observation &
RISK LEVEL: High Medium Low
Discussion
Location: Workshop
Observer Name: Kelompok 3
1. Was sufficient follow-up action taken? Yes No
Date: 10 November 2023
2. If NO for No. 1, state further action required:
Initials:
Include what task was observed, Ideas for improving task and
follow-up items, etc. Please ensure that this card is immediately
handed to your direct Supervisor for follow-up action.
Unsafe Acts / Conditions observed (Include location):
Tidak menggunakan Alat yang sesuai
Tidak ada Barricade untuk lantai yang berlubang
Enviroment dan Housekeeping yang buruk
Ergonomi pekerjaan tidak diterapkan
Supervisor to complete the following section:
TREND ANALYSIS DATA
ISSUE TYPE State follow-up action taken:
PPE NON-CONFORMANCE Did the situation require the job to be STOPPED? Yes No
Fall Protection Eye Protection Head Protection Immediate Corrective Action taken:
Foot Protection Hi-visibility Hand Protection 1. Menggunakan Alat yang sesuai seperti Tangga
Other (Please specify): 2. Memberikan Barricade untuk lantai yang rusak
REACTIONS OF PEOPLE 3. Menerapkan Housekeeping untuk lebih kondusif dengan
merapihkan segala sesuatu dengan tepat
Stopped Work Adjusted PPE Re-arranged Work 4. Memberikan ruang untuk jalur khusus Emergency
Violent behavior Negative toward QSE 5. Memberikan training dan warning safety terhadap pekerjaan untuk
Other (Please specify): Staff Office
POSITION OF PEOPLE Issue Status Open / Closed:
Hit Against Caught Between Slip/Trip/Fall SUPERVISOR SIGNATURE:
Electric Shock Over-Reaching Poor Position Upon completion by Supervisor, this card MUST be immediately
handed to the QSE Officer.
Breathing Hazardous Substance Touching Hazardous Substance
Other (Please Specify):
TOOLS AND EQUIPMENT
Wrong for job Improperly Used In Unsafe Condition
Other (Please Specify):
PROCEDURES AND HOUSEKEEPING
Procedures Inadequate Procedures Unknown
Procedures Not Followed Poor Housekeeping
Other (Please Specify):
QSE OFFICER SIGNATURE:
Kelompok 3:
1. Sindy Diah Puspita Sari 21020085
2. Made Yogi Narayana 21020046
3. Pere Martias 21020066
4. Rayhandra Zaula 21020076
5. Dodi Hermawan 21020078
SAFETY OBSERVATION CARD SAFETY OBSERVATION CARD
Decide Observe Act Report Decide Observe Act Report
CARD ANALYSIS
THIS SECTION IS FOR OFFICIAL USE ONLY
Significant Aspects of Observation &
RISK LEVEL: High Medium Low
Discussion
Location: Workshop
Observer Name: Kelompok 3
1. Was sufficient follow-up action taken? Yes No
Date: 10 November 2023
2. If NO for No. 1, state further action required:
Initials:
Include what task was observed, Ideas for improving task and
follow-up items, etc. Please ensure that this card is immediately
handed to your direct Supervisor for follow-up action.
Unsafe Acts / Conditions observed (Include location):
Tidak menggunakan APD/PPE yang lengkap
Tidak ada Barricade untuk lantai yang berlubang dan area kerja
yang tidak aman
Enviroment yang tidak aman
Tempat kerja yang berantakan dan tidak sesuai tempatnya
TREND ANALYSIS DATA Tidak ada jalur khusus untuk forklift dan pembawa barang
ISSUE TYPE
Ergonomi pekerjaan tidak diterapkan
PPE NON-CONFORMANCE
Supervisor to complete the following section:
Fall Protection Eye Protection Head Protection
State follow-up action taken:
Foot Protection Hi-visibility Hand Protection
Did the situation require the job to be STOPPED? Yes No
Other (Please specify):
Immediate Corrective Action taken:
REACTIONS OF PEOPLE
1. Memberikan APD yang lengkap seperti Helm, Safety Shoes, Full
Stopped Work Adjusted PPE Re-arranged Work Body Harness
Violent behavior Negative toward QSE 2. Memberikan Barricade untuk lokasi dan pekerjaan yang tidak
Other (Please specify): aman
3. Menerapkan Housekeeping Workshop untuk lebih kondusif
POSITION OF PEOPLE dengan merapihkan segala sesuatu dengan tepat
Hit Against Caught Between Slip/Trip/Fall 4. Memberikan jalur khusus untuk forklift dan pekerjaan
Electric Shock Over-Reaching Poor Position pengangkatan lainnya
5. Memberikan training dan warning safety terhadap pekerjaan
Breathing Hazardous Substance Touching Hazardous Substance
unntuk workshop
Other (Please Specify): Issue Status Open / Closed:
TOOLS AND EQUIPMENT SUPERVISOR SIGNATURE:
Wrong for job Improperly Used In Unsafe Condition Upon completion by Supervisor, this card MUST be immediately
Other (Please Specify): handed to the QSE Officer.
PROCEDURES AND HOUSEKEEPING
Procedures Inadequate Procedures Unknown
Procedures Not Followed Poor Housekeeping
Other (Please Specify):
QSE OFFICER SIGNATURE:
Kelompok 3:
1. Sindy Diah Puspita Sari 21020085
2. Made Yogi Narayana 21020046
3. Pere Martias 21020066
4. Rayhandra Zaula 21020076
5. Dodi Hermawan 21020078
