Form CPI

F.056-Rev 10/01

NEAR MISS REPORT

Report No:

GENERAL INFORMATION 1. Company:

2. Organization:

3. Team/!per"i#ory Team:

CPI Business Partner

$. In%i&ent Type:

'. (ate o) In%i&ent:

-

Near Miss Signifcant Near Miss

-

*. Time o) In%i&ent:

-

[dd-mm-yyyy]

[hh-mm]

+. In%i&ent Lo%ation or Area:

,. In%i&ent I&enti)ie& -y: Name of Identifier:

Badge No.:

Team of Identifier (or name of Company):

INCI(ENT (ETAIL INFORMATION . o- 0!rpo#e:

1. E!ipment #e&:

Specific Tas:

Specific !"#ipment:

11. In%i&ent 4ort (e#%ription: (e#%ription:

INCI(ENT ANAL5I 12. In"e#tigation an& Root Ca!#e Ana9y#i# Re#!9t < for Significant Near Miss=: Miss =:

RECOMMEN(ATION 13. In or&er to pre"ent re%!rren%e:

a.

f.

b.

g.

c.

h.

d.

i.

e.

j.

1$. I&enti)ier6# ignat!re

1*. E Committee C4airman

1'. Lea&er A%7no89e&ge date

1+. E Team A%7no89e&ge

dat e

1,. Manager A%7no89e&ge

date

1. ;0/GM A%7no89e&ge

[for Significant Near $iss] date

[for Significant Near $iss] dat e

date

THIS REPORT TO BE USED O!" FOR PT #a$%e& Pacific I'd('e)ia ITER*! BUSIESS PURPOSE. PT #a$%e& Pacific I'd('e)ia +I!! DIS#!*I, *" !I*BI!IT" *RISI FRO, *" IFOR,*TIO O THE REPORT TH*T USED TO **IST PT #a$%e& Pacific I'd('e)ia OR PT #a$%e& Pacific I'd('e)ia E,P!O"EE.

%ist %istri ri&# &#ti tion on :

Team eam Conc Concer ern n Corporate '!S

F.05-Rev 10/01

page  of 

FIRE REPORT

Report No:


2. Organization:



$. (ate o) In%i&ent:

-

*. In%i&ent Genera9 Lo%ation:

-

'. Time o) In%i&ent:

-

Oce/Building

[dd-mm-yyyy]

Field Area

Facility Area

+. In%i&ent pe%i)i% Lo%ation or Area: [hh-mm]

INCI(ENT (ETAIL INFORMATION ,. Fa%i9ity In"o9"e&: *aci+ity Type:

$ateria+ In,o+,ed*+ash oint:

Str#ct#re!"#ipment Type:

Str#ct#re!"#ipment In,o+,ed:

/hat Str#ct#re!"#ipment is damaged0

a.

c.

b.

d.

. o8 &i& t4e Fire 4appen> (%escri&e 1hat happened2 inc+#ding a time+ine. 3se additiona+ paper if necessary.)

!,ents 4eading 3p to *ire

Time 4ine

!,ent

%isco,ery of *ire and Response

Contro+ and !5ting#ishment of *ire

1. Lo##
Str#ct#res!"#ipment:

%amage C+aim aid:

B#siness Inter#ption:

Repair Cost of !"#ipment:

6ther 4osses:

B#siness artner !mp+oyee:

#&+ic:

In7#red erson: CI !mp+oyee:

6cc#pationa+ In7#ry and I++ness Report Reference No.:

Other

8ot $edia 9ttention 0

Yes

No

(9ttach detai+s and pro,ide copies of re+ated information)

F.05-Rev 10/01

page  of 

FIRE REPORT

Report No:

INCI(ENT (ETAIL INFORMATION
-

*irst Time 3sed: SI;!

[hh-mm]

!**!CTR!S34T

orta&+e *ire !5ting#isher /ater 'ose *oam $a7or e"#ipment #sed (+arge p#mping engines): Time 9rri,es:

-

[hh-mm]

Type of 9pparat#s:

Si=e and
So#rce of /ater: 6ther !"#ipment 3sed:

ANAL5I OF FIRE 12. o!r%e# o) Fire: *#e+ So#rce(s):

65ygen So#rce(s): Air

Other

/hat made the f#e+ mi5ed 1ith o5ygen and form a f+amma&+e mi5t#re0

Ignition So#rce(s): Electrical

Fired E#ui"$ent

Static Electricity

O"en Fire

ightning

%ot Sur&aces

Phyro"oric Material

'n(no)n

Cutting/!elding

Friction

Auto Ignition

Other

/hy did the fire start0

13. ?4at Fa%i9ity/y#tem %ontri-!te& to t4e Fire> Alar$ Syste$s

-rainage/I$"ounding

S"acing *uidelines

Isolation al0es

Fire !ater Syste$

Fire"roofng

PPE

Other

Fire Fighting E#ui"$ent

Pre.fre Planning

Mo+ile Fire Fighting E#",

E$ergency 1es"onse 2ea$

Shutdo)n Syste$

Outside Assistant

'o1 it affected the *ire0

RECOMMEN(ATION 1$. In or&er to pre"ent re%!rren%e:

1'. Team Lea&er ignat!re

1+. Team Manager A%7no89e&ge

1*. E Committee C4airman date

1,. E Team A%7no89e&ge

date

1. Manager A%7no89e&ge

2. ;0/GM A%7no89e&ge

[for Critica+ Incident] date

date


date

THIS REPORT TO BE USED O!" FOR PT #a$%e& Pacific I'd('e)ia ITER*! BUSIESS PURPOSE. PT #a$%e& Pacific I'd('e)ia + I!! DIS#!*I, *" !I*BI!IT" *RISI FRO, *" IFOR,*TIO O THE REPORT TH*T USED TO **IST PT #a$%e& Pacific I'd('e)ia OR PT #a$%e& Pacific I'd('e)ia E,P!O"EE.

%istri&#tion :

Team Concern Corporate '!S2 c". Team $anager Safety and *ire re,ention 4ega+ 9ffairs and Corporate *inance (if there is potentia+ c+aim)

F.05-Rev 10/01

page  of 

OCCUPATIONAL INJURY AND ILLNESS REPORT

Report No:


2. Organization:


CPI Business Partner $. (ate o) In%i&ent:

-


-

[dd-mm-yyyy]

Oce/Building


-

Field Area

Facility Area

Other


INCI(ENT (ETAIL INFORMATION ,. Type o) In%i&ent: Fatality

-ays A)ay Fro$ !or(

1estricted !or( Acti0ity

da)

!stimated:

!stimated:

Medical 2reat$ent

da)

. In@!re& 0er#onne9: Name of !mp+oyee:

Badge No.:

9ge:

6cc#pationTit+e:

). Ser,ice year:

)

Ser,ice on this 7o&:

2('%h)

'o#rs 1ored &efore Incident:

)

2('%h)

/here taen afer incident0

Type of In7#ry:

h(3) Name of hysician:

Body art 9ffected:

Type of Contact:

Contact 1ith:

A+rasion/Cuts/Scra"es

Ar$s

Caught +et)een

Caustic

A$"utation

-igesti0e 2ract

Caught in

Cold

Bruises 3 Contusions

Eyes

Caught on

Electricity

Burn

Feet/2oes

Fall &ro$ ele0ation

%eat

-islocation

%ead/Nec(

Fall on sa$e le0el

Noise

Fracture

%earing

O0ere4ertion

1adiation

Multi"le

egs

Sli"

Poisoning

1es"iratory 2ract

Struc( against

Puncture !ound

S(in

Struc( +y

Strain/S"rain Others

2run(

2o4ic/no4ious su+stances Others

Others

Others

1. In%i&ent 4ort (e#%ription:

11. 0er#on<#= In"o9"e&: /itness(es)2 if any: Name:

9ddress:

hone:

6ther emp+oyee in7#redmade i++ in this incident0 Name of !mp+oyee:

Badge No.:

9ge:

6cc#pationTit+e:

). F.05-Rev 10/01

page  of 

OCCUPATIONAL INJURY AND ILLNESS REPORT

Report No:

INCI(ENT ANAL5I 12. Li#t t4e #e!en%e o) e"ent# 84i%4 9e& !p to t4e in%i&ent:

a. b. c. d. e. f. g. 13. In"e#tigation an& Root Ca!#e Ana9y#i# Re#!9t: Ca#se or Ca#ses of the incident:

a. b.

e. f.

c.

g.

d.

h.

Root Ca#se 9na+ysis:

RECOMMEN(ATION 1$. In or&er to pre"ent re%!rren%e:

a. b. c. d. e. f. h. i. j. 1'. Team Lea&er ignat!re

1+. Team Manager A%7no89e&ge

1*. E Committee C4airman date

1,. E Team A%7no89e&ge

date

1. Manager A%7no89e&ge

date

2. ;0/GM A%7no89e&ge



date


%istri&#tion :

Team Concern Corporate '!S

F.054-Rev 10/01

page  of 

ENVIRONMENTAL SPILL REPORT

Report No:


2. Organization:



-

*. Contra%t 9o%7 o) In%i&ent:

-

[dd-mm-yyyy]


-

[hh-mm]

CPI . 1o(an Bloc(

C32 . MF5 Bloc(

C32 . Sia( Bloc(

C32 . Nias Bloc(

C32 . CPP Bloc(

Other

+. In%i&ent pe%i)i% Lo%ation or Area:

,. Lea&er in C4arge o) t4e In%i&ent Lo%ation: Name of !mp+oyee:

Badge No.:

hone No.:

!mai+ 9ddress:

INCI(ENT (ETAIL INFORMATION . Type an& B!antity o) En"ironmenta9 pi99:

1. Ca!#e o) En"ironmenta9 pi99:

-uri Crude Oil

bb$)

E4ternal Corrosion

E#ui"$ent Failure

Su$atra ight Crude Oil

bb$)

Internal Corrosion

O0er Pressured E#ui"$ent

1efned Products

bb$)

Sand Corrosion

Inade#uate Procedure

Produced !ater

bb$)

2an(/essel/Pit O0er6o)

Che$ical

bb$) bb$)

ea(ing al0es/Fittings

%it +y E4ternal O+7ect

!ell %ead ea(s

Other

Other

Blo) Out/!ell 5ic(

11. (!ration o) En"ironmenta9 pi99:

-

-

[days-ho#rs-min#tes]

12. In%i&ent 4ort (e#%ription:

13. o!r%e<#= o) pi99: Stac( / Flare 2an( A+o0e *round 2an( 'nder *round

Shi""ing ine 2an(/2ruc(/ehicle Pit

Process/Pu$"ing E#ui"$ent

-ru$/Container

Production ine

Produced !ater ine/Canal

essel

Other

[Setch of Incident sho#+d &e attached 1ith this report]

1$. En"ironmenta9 Con&ition: Spi++ Recei,ing $edi#m: and

1i0er

Sea

a(e / Pond

Other

Building Floor

Other

/ater condition (if the medi#m is Ri,er or Sea): C#rrent Speed:

2/)

C#rrent %irection:

/ind Speed:

2/)

/ind %irection:

Tide:

2

4and condition (if the medi#m is 4and): Soil / -irt

Concrete

As"halt

F.054-Rev 10/01

page  of 

ENVIRONMENTAL SPILL REPORT

Report No:

Chemica++y:

1*. Type an& B!antity o) pi99 Re%o"ere&:

1

bb$)



bb$)

9ction taen for #n-reco,ered spi++ : 1+. Lo##
Incident Response Cost:

rod#ct >a+#e:

%amage C+aim aid:

rod#ction 4oss:

Repair Cost of !"#ipment:

6ther 4osses:

INCI(ENT ANAL5I 1,. In"e#tigation an& Root Ca!#e Ana9y#i# Re#!9t:

RECOMMEN(ATION 1. In or&er to pre"ent re%!rren%e:

a. b. c. d. e. 2. Team Lea&er ignat!re

22. Team Manager A%7no89e&ge

21. E Committee C4airman date

23. E Team A%7no89e&ge

date

2$. Manager A%7no89e&ge

date

2'. ;0/GM A%7no89e&ge



date


%istri&#tion :

Team Concern orpora e 2 c". eam

anager n, ronmen a

ro ec on

F.060-Rev 10/01

INCIDENT REVIEW TEAM MEETING MINUTES

Report No:

MEETING INFORMATION 1. Company:

2. Organization:


CPI Business Partner $. (ate o) Meeting: [dd-mm-yyyy]

-

'. Time o) Meeting: [hh-mm]

-

*. 09a%e o) Meeting:

-

INCI(ENT RE;IE? TEAM CARTER +. C4airman:

,. e%retary:

. Mem-er#:

1. Team Lea&er:

11. Ot4er Eperti#e<#=:

INCI(ENT INFORMATION 12. In%i&ent Report Re)eren%e No.: 13. In"o9"e& 0er#onne9: Name of !mp+oyee:

Badge No.:

Team of !mp+oyee (or name of Company):

re,io#s Safety Record:

%ays 4ost of In7#red:

da)7 1$. In%i&ent Type:

1'. (ate o) In%i&ent:

-

Motor ehicle Accident 1ecorda+le In7ury

-

1*. Time o) In%i&ent: [dd-mm-yyyy]

-

[hh-mm]

1+. In%i&ent Lo%ation or Area:

Fire Case En0iron$ental S"ill E#ui"$ent/2ools Acc,

1,. Ot4er Lo##e#: (Repair Cost or %o1ntime of !"#ipment or >o+#me of Spi++ed or rod#ction 4oss)

Other

INCI(ENT ANAL5I 1. Team Fin&ing an& Root Ca!#e Ana9y#i#:

RECOMMEN(ATION 2. In or&er to pre"ent re%!rren%e:

a.

g.

b.

h.

c. d.

21. C4airman

e.

date

f. THIS REPORT TO BE USED O!" FOR PT #a$%e& Pacific I'd('e)ia ITER*! BUSIESS PURPOSE. PT #a$%e& Pacific I'd('e)ia + I!! DIS#!*I, *" !I*BI!IT" *RISI FRO, *" IFOR,*TIO O THE REPORT TH*T USED TO **IST PT #a$%e& Pacific I'd('e)ia OR PT #a$%e& Pacific I'd('e)ia E,P!O"EE.

%istri&#tion :

Team Concern

orpora e

F.11-e8 10/01

FIRST AID REPORT

Report No:


2. Organization:



$. (ate o) In%i&ent:

-


-

[dd-mm-yyyy]


-

Field Area

Oce/Building

Facility Area

Other


INCI(ENT (ETAIL INFORMATION ,. In@!re& 0er#onne9: Name of !mp+oyee:

Badge No.:

Team of !mp+oyee (or name of Company):

. o- 0!rpo#e:


Specific Tas:

Specific !"#ipment:


INCI(ENT ANAL5I 12. In"e#tigation an& Root Ca!#e Ana9y#i# Re#!9t:


a.

f.

b.

g.

c.

h.

d.

i.

e.

j.

1$. (ire%t Lea&er ignat!re


1'. !per"i#ory Team Lea&er or B#ss ness artner on y date

date

date


%istri&#tion :

Team Concern '!S 6rgani=ation

Corporate '!S

F.11-e8 10/01

EQUIPMENT/TOOLS ACCIDENT REPORT

Report No:


2. Organization:



-


-

[dd-mm-yyyy]


-

Field Area

Oce/Building

Facility Area

Other


INCI(ENT (ETAIL INFORMATION ,. o- 0!rpo#e:

. E!ipment #e&:

Specific Tas:

Specific !"#ipment:

1. Lo##
%o1n Time of !"#ipment:

6ther 4osses:


INCI(ENT ANAL5I 12. In"e#tigation an& Root Ca!#e Ana9y#i# Re#!9t:


a.

f.

b.

g.

c.

h.

d.

i.

e.

j.





date


date

1. ;0/GM A%7no89e&ge



date


%istri&#tion :

Team Concern orpora e

F.114-e8 10/01

page  of 

MOTOR VEHICLE ACCIDENT REPORT

Report No:


2. Organization:



-


-

-

[dd-mm-yyyy]

*. Category: Pre0enta+le MA

[hh-mm]

Non."re0enta+le MA +. In%i&ent Lo%ation:

,. Type o) A%%i&ent:

8enera+ 4ocation:

!5act 4ocation:

S(idding

Main 1oad

Straight 1oad

Field 1oad

Intersection

In Ca$" 1oad

-ri0e)ay/ Alley

Industrial Yard

!or( or O"erating Area

Field Area

-eli0ery/oading S"ace

Bac(ing/1oll.+ac( 2urning Sides)i"ing Stri(ing 1ear o& O0erturning %ead.on Collision

Inside Sho"/Plants

1unning A)ay

Par(ing ots

1unning into Fi4ed O+7ect

Others

1unning o8 the road

INCI(ENT (ETAIL INFORMATION . (ri"er I&entity Name of !mp+oyee:

Badge No.:

9ge:

6cc#pationTit+e:

). 8o,ernment %ri,ing 4icense:

4icense Type:

Ser,ice year:

CI %ri,ing ermit:

Ser,ice on this 7o&:

)

2('%h)

/as dri,er on Company B#siness0

) Yes

'o#rs 1ored &efore Incident:

2('%h)

h(3)

No

Ot4er 0er#on<#= In"o9"e&: st erson Name:

9ddress:

8o,ernment %ri,ing 4icense:

nd erson Name:

9ddress:

8o,ernment %ri,ing 4icense:

In7#red erson:

CI !mp+oyee:

B#siness artner !mp+oyee:

#&+ic:

6cc#pationa+ In7#ry and I++ness Report Reference No.: 1. ;e4i%9e In"o9"e&: %escription of >ehic+e: ear>ehic+e 4icense No. N#m&er of assenger 9ny ,io+ation of Traffic 4a1 !stimated Repair Cost 'o1 far from ha=ard 1hen first noticed0 /hat 1as done to pre,ent the incident0 9ny signa+ gi,en0 11. In%i&ent 4ort (e#%ription:

Company >ehic+e:

/

6ther2 if any:

6ther2 if any:

/

/

F.114-e8 10/01

page  of 

MOTOR VEHICLE ACCIDENT REPORT

Report No:

#(29a' ?ehic$e

ROAD DATA

1. S%agh% *head

vehic$e)

. Oi$ed

. #ha'gi'g Taffic !i'e)

Thi) %9e (f vehic$e

:. *)9ha

%$:. ,a;i'g Righ% T3'

<. *)9ha$%ic #('ce%e

<. ,a;i'g !ef% T3'

5. #e2e'% #('ce%e

5. Ove%a;i'g a'd Pa))i'g

Ha) dive' %hi) vehic$e #(29a' ?ehic$e

1. !e)) %ha' ('e 2('%h

Gra!

. !e)) %ha' ('e ea

1. U9hi$$

:. 1 ". -  ").

. D(8'hi$$

<.  "). - 5 ").

:. !eve$

5. 5 " - 10 "). 6. 10 "). - 15 ").

C"#!$%$"# 1. D

. 15 "). - 0 ").

. +e%

. Ove 0 ea)

:. ,3dd

O%he ?ehic$e

A. For8ar&

Surfac 1. Di%

Ha) dive' 2(%(

MOVEMENT OF VEHICLES

6. D(ve Off R(ad

O%he ?ehic$e

. S%a'di'g i' Taffic - dive a% 8hee$ . I'%(/O3% (f Pa;i'g ( !(adi'g S9ace

. a%78ar& 1. I'%(/O3% (f Pa;i'g ( !(adi'g S9ace . O%he Bac;i'g

C. 0ar7e& 1. P(9e$ . I29(9e$ +('g 9$ace= d(3b$e 9a;i'g= e%c7

VISI&ILITY  W(a%(r

1. #$ea

:. Rai'i'g

. Di>>$i'g

<. F(ggi'g

:. I29(9e$ O9e' d(()= ba;e) '(% )e%= e%c7

INCI(ENT ANAL5I 13. Li#t t4e #e!en%e o) e"ent# 84i%4 9e& !p to t4e in%i&ent:

a.

d.

b.

e.

c.

f.

1$. In"e#tigation an& Root Ca!#e Ana9y#i# Re#!9t:

RECOMMEN(ATION 1'. In or&er to pre"ent re%!rren%e:

a. b. c. d. e. 1*. Team Lea&er ignat!re

1,. Team Manager A%7no89e&ge

1+. E Committee C4airman date

1. E Team A%7no89e&ge

date

2. Manager A%7no89e&ge

date

21. ;0/GM A%7no89e&ge



date


%istri&#tion :


F.10-e8 10/01

HA)ARD O&SERVATION REPORT

Report No:


2. Organization:


CPI Business Partner $. O-#er"ation Type:

'. (ate o) O-#er"ation:

-

'nsa&e Acts At 1is( Beha0ior

-

*. Time o) O-#er"ation:

-

[dd-mm-yyyy]

[hh-mm]

+. O-#er"ation Lo%ation or Area:

%a9ard Identifcation ,. O-#er"ation I&enti)ie& -y: Name of Identifier:

Badge No.:

Team of Identifier (or name of Company):

OER;ATION (ETAIL INFORMATION . o- 0!rpo#e:


Specific Tas:

Specific !"#ipment:

11. O-#er"ation 4ort (e#%ription:

OER;ATION ANAL5I 12. In"e#tigation an& Root Ca!#e Ana9y#i# Re#!9t

a.

f.

b.

g.

c.

h.

d.

i.

e.

j.





date


date

1. ;0/GM A%7no89e&ge

[for Significant 'a=ard 6&ser,ation] date

[for Significant 'a=ard 6&ser,ation] date

date


%istri&#tion :


Form CPI

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