Investigasi

Investigasi
Kecelakaan
Kecelakaan
Fatal
Fatal
Supervisor Thiess
meninggal dunia ketika
kendaraan TC560 yang
ditumpanginya terlindas
oleh dozer CAT D10R
(DZ3003) di Areal Dumping
Belut; 22 Juli 2010 pukul
09.28 WITA.
Apa yang terjadi?
Mengapa bisa terjadi?
Bagaimana mencegahnya?
DATA KORBAN
Korban:
Nama: Robertus Ria
Umur: 38 tahun
Jabatan: Supervisor
Jenis kelamin: Laki-laki
DOH: 21 April 2004
Tanggungan:
Robertus meninggalkan seorang istri
dan 3 orang anak yang masih kecil.
TIM INVESTIGASI
Mine Inspector Kutim
Manager OHS
Manager Contract Mining Thiess
Staf Subdit DTMB Jakarta
Staf Subdit DTMB Jakarta
Staf Distamben Kutim
Supt. Safety Safety Monitoring & Comm.
Supt. HSE CMD
Coord. HSE CMD
Project Manager Thiess
Supt. Safety Thiess Balikpapan
Act. Supt. Safety Thiess
Armin
Haryadi Wardono
Bina Sembiring
Redo Gusman
Rafael M
Toni
Samali
Dedi Mulyana
Anhar Al Ala
Sjamsi Josal
Masykur
Dafid Feri Eryanto
Anggota
Acting COO/KTT Muhammad Rudy
Fasilitator
Snr. Supv. Safety Monitoring & Comm. Erwin Hambali Sekertaris
Mine Inspector Samarinda Markus Taruk Allo Wakil
Mine Inspector Jakarta Galang Jaya Ketua
Jabatan Nama Peran
Kronologi Kejadian
09.25 Dozer DZ3003 sedang mendorong material OB ke dalam kolam ketika kendaraan
ringan TC560 dikemudikan oleh Senior Supervisor / Acting Superintendent ditemani
Supervisor (korban), datang dan diparkir di jalur kerja di belakang dozer tersebut.
09.26 Senior Supv (pengemudi TC560) turun dari kendaraan dan berjalan ke sisi sebelah
kanan jalur dozer (+ 5,8 m) untuk mengontak operator, sedangkan Supervisor (korban)
tetap berada di dalam kabin di kursi penumpang kiri depan.
09.27 Dozer DZ3003 mundur untuk siap mendorong material berikutnya di sisi kiri. Senior
Supv. Berupaya mengontak operator dozer untuk menghentikan dozer tersebut tetapi tidak
berhasil. Dozer terus mundur.
09.28 Track sebelah kanan dozer melindas TC560 dari bagian kiri depan hingga ke
bagian kanan belakang kabin, sementara korban masih berada di dalam kabin.
09.29 Operator dozer melihat Senior Supv., menghentikan dozernya dan menyadari
bahwa dozernya telah melindas sebuah kendaraan. Ia lalu memajukan dozernya.
09.33 Safety Thiess diberitahu. Safety, ambulance and paramedic Thiess menuju ke
tempat kejadian.
09.35 Tim Rescue KPC dipanggil dan segera menuju tempat kejadian.
10.04 Tim Rescue KPC tiba dan segera mengevakuasi korban yang terjepit.
10.45 Korban tiba di Klinik ISOS Swarga Bara dan dinyatakan telah meninggal dunia
seketika di tempat kejadian akibat cedera sangat serius di kepalanya dan patah tulang
terbuka di kaki kiri.
Foto Lokasi Kejadian
1. Lokasi kejadian: Areal Dumping Belut RL-10 (setelah kejadian 22 Juli 2010)
TC560
DZ3003
Lighting
Plant &
Pondok
Supv
67,9 m
35.5 m
DZ3006
Saksi mata
4
8
,
7

m
2. Tim Rescue KPC menyiapkan
pengambilan korban
3. TC560: sedang diperiksa oleh KTT
setelah korban dievakuasi
4. TC560 dilihat dari kanan depan DZ3003
Foto
Foto
-
-
foto
foto
Kejadian
Kejadian
5. Peragaan posisi korban oleh
Personil Senior Rescue KPC
Kolam
M
a
t
e
r
i
a
l

O
B
M
a
t
e
r
i
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O
B
Lighting Plant
Supv. Hut
6
4
,
9

m
6
7
,
9

m
4
8
,
7

m
J
a
l
a
n
3
9
,
7

m
3
5
.
5

m
Denah Lokasi Kejadian
LV TC560 seharusnya
diparkir dekat Lighting
Plant: bukan di jalur
dozer
DZ3006 (saksi mata)
J
a
l
u
r
d
o
z
e
r
TC560
DZ3003
Penyebab Kecelakaan
Penyebab Langsung:
Pelanggaran prosedur dan pengambilan keputusan yang tidak tepat:
Senior Supv memasuki dan memarkir kendaraannya (TC560) pada jalur
kerja dozer di belakang dozer tersebut (DZ3003).
Senior Supv tidak melakukan kontak positif dengan operator dozer dan
memastikan dozer tersebut sudah diparkir, mesin dimatikan dan operator
turun dari kabin sebelum memasuki areal kerja dozer.
Tidak memperingatkan:
Supervisor (korban) yang duduk di samping pengemudi tidak
memperingatkan si pengemudi ketika akan memasuki dan memarkir
kendaraannya (TC560) pada jalur kerja dozer di belakang dozer tersebut
(DZ3003)
Penyebab Sistem:
Ketergesaan karyawan sendiri:
Senior supervisor (pengemudi TC560) memasuki areal kerja dozer tanpa
mempertimbangkan bahaya atau risikonya karena merasa terburu-buru.
REKOMENDASI
Menginstruksikan ke semua staff PT. TCI site
Sangatta untuk mematuhi peraturan dan prosedur
Keselamatan Kerja yang ada serta saling
mengingatkan agar tidak ada yang melanggar.
Mensosialisasikan kembali kepada semua karyawan
dan staff TCI pemegang Pit Access Kimper (L/V) :
Radius blind spot Dozer CAT D10R.
SOP mendekati alat berat bergerak.
Prosedur parkir di dalam Pit.
TINJAUAN KECELAKAAN FATAL
DI KPC & KONTRAKTOR
1990 2010
9
2
14
16
17 17
19
23
9
1
3 3
5
12
6
10
9
8
11
18 18
20
25
1
2 2 2
1
1
9
11
12
9
13
15
14
1 1
1
1
17
0.56
0.33
2.31
2.43
2.59
2.86
1.51
1.36
1.11
0.93
0.76
0.80
0.50
0.32
0.23
0
5
10
15
20
25
30
35
40
45
L
T
I
F
a
t
a
l
i
t
y
L
T
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F
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1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 YTD 25
July 10
N
o
.

o
f

L
T
I

a
n
d

F
a
t
a
l
i
t
y
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
L
T
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F
R

(
p
e
r

1
.
0
0
0
.
0
0
0

M
a
n
h
o
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r
s
)
CONT.
KPC
LTIFR
Prima Nirbhaya/NOSA
Implementation
FPE & New Golden
Rules Implementation
Jumlah
Jumlah
Kecelakaan
Kecelakaan
Fatal & LTI vs. LTIFR
Fatal & LTI vs. LTIFR
1996 1996 YTD 25 Jul 2010 YTD 25 Jul 2010
Rangkuman
Rangkuman
Kecelakaan
Kecelakaan

YTD 2010
YTD 2010
(KPC & (KPC & Kontraktor Kontraktor) )
Note : Based on the decision at the EXCO meeting on 21 Sept 05: 1 Fatality equals to 10 Potential Fatality Incidents
Number of
Event
Fatality
Significant
Incidents
Potential
Fatality
Lost Time Injury
Division
28
1
1
1
1
1
2
4
4
4
4
5
Threshold
2010
20 1 13 13 11 TOTAL
0 0 0 0 0 SCD
0 0 0 0 0 MKT
0 0 0 0 0 HSE
1 0 1 0 1 MDD + HR
0 0 0 0 0 EPD
0 0 0 0 0
PID
4 0 4 1 0 PT.DH Contract
3 0 3 0 0 PAMA Mining
2 1 1 10 2 TCI KPC
4 0 3 1 1 MOD
6 0 1 1 7 MSD
Actual
0
5
10
15
20
J
a
n
-
0
3
M
a
r
-
0
3
M
a
y
-
J
u
l
-
0
3
S
e
p
-
N
o
v
-
J
a
n
-
0
4
M
a
r
-
0
4
M
a
y
-
J
u
l
-
0
4
S
e
p
-
N
o
v
-
J
a
n
-
0
5
M
a
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-
0
5
M
a
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-
J
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l
-
0
5
S
e
p
-
N
o
v
-
J
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-
0
6
M
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0
6
M
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J
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-
0
6
S
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p
-
N
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0
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M
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7
M
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8
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N
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9
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9
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-
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-
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
F
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R
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1
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)
LTI SIG
PF Rolling LTIFR
Rolling SIGFR Rolling PFFR
Rolling LTIFR = 0.52 Rolling PFFR = 0.36 Rolling SIGFR = 0.50
YTD LTIFR = 0.33 YTD PFFR = 0. 38 YTD SIGFR = 0.38
Kejadian
Kejadian
Berbahaya
Berbahaya
vs.
vs.
Tingkat
Tingkat
Kekerapan
Kekerapan
YTD 25 Jul10 YTD 25 Jul10
No Date
Injured
Name
Company /
Dept
Position KPC / CONT Remarks
1 20-May-90 Yohanis Thiess
Truck
Operator
CONT
Whilst travelling from loading point to dumping area, a haul truck uncontrolled and hit
safety berm. Operator thrown out of the truck because he wasn't wearing seatbelt
2 22-Jul-90 Nurtan M Thiess
Truck
Operator
CONT
Whilst travelling to PBI Construction area, a dump truck uncontrolled due to improper
speed and rolled over along 9 meters. This incident resulted in death (serious leg
injuries to the operator). He wasn't wearing seatbelt
3 27-Oct-90 Musdiyanto UT Rental
Truck
Operator
CONT
Fatally injured after loosing control of a truck due to improper speed and rolled
over a bank enroute to Pit K, the cabin striking a tree
4 21-Mar-91 Sudarno Gemini Labor CONT
A contractor employee was using portable hand drill during contruction activities when
he got electric shock. This incident resulted in death
5 10-May-91
Aswin
Kasiran
Petrosea Electrician CONT
A light vehicle (Toyota Hardtop) was run over by haul truck (Cat785) at 4F intersection.
This incident resulted in fatality to the L/V driver. Critical factor was driver fatigue.
6 23-May-92 Dwisiswai GTS Mechanic CONT
Fataly injured when the Dynapac vibrating roller over turned after control was lost
due to improper speed on a steep road. The equipment was not fitted with a
R.O.P.S.
7 10-Aug-92 Wijanto KNE Fuel Truck Helper CONT
A spotter was directing to reposition the truck during refuelling activity. In the process
directing of truck, he caught between fuel truck dan dozer. This incident resulted in
fatal injury.
DAFTAR KECELAKAAN FATAL DAFTAR KECELAKAAN FATAL
1990 1990 YTD 26 Jul 2010 YTD 26 Jul 2010
No Date
Injured
Name
Company /
Dept
Position KPC / CONT Remarks
8 05-Apr-95 Suparlan DWL
Truck
Operator
CONT
Whilst travelling to Panel 4, a explosive truck uncontrolled and hit safety berm. Use of
defective equipment was the causes of the incident. This incident resulted the death to
the explosive truck driver
9 24-Sep-95 Iwan Insani Hana Mas
Compactor
Operator
CONT
Whilst travelling to Flamboyan road, a compactor uncontrolled and tipped over. The
operator caught between compactor and ground. He wasn't wearing a seatbelt.
This Incident resulted in the death.
10 18-Dec-96
Yulius
Sutrisno
Surya Dept
Shovel
Operator
KPC
Fatality injured and was found buried by the collapsed damp soil inside the shovel
bucket soon after he put himself between the bench face and shovel bucket for
some reason.
11 16-Jun-97 Irianzach
Bintang
Dept.
Act. Supv.
Civil
KPC
Whilst travelling from loading to dumping area, a GINAF truck T-803 hit a L/V.
Combination excessive speed of L/V and incorrect truck position (in the middle of
the road) were the causes of the incident. This incident resulted in death to the L/V
driver.
12 09-Aug-97 Mardjit Hatari Dept.
Truck
Operator
KPC
Whilst spraying roads around Rozano road and Hatari Pit office, a water truck (DJB 300)
accidentally the engine shut down by it self. It made truck reversed, hit safety berm
and tipped over. The operator caught between truck cabin and ground. This incident
resulted in the death.
13 31-Jan-98
Wayan
Suadnyana
Bintang
Dept.
Truck
Operator
KPC
Whilst travelling from dumping area to Panel 5, a haul truck T-525 (Cat785) run over
safety berm and fell down from high around 34 metre. Fatigue was the cause of the
incident. This incident resulted in the death.
14 11-Aug-98 Arifin Bono
Bintang
Dept.
HE Operator
Trainee
KPC
An operator was cleaning font mirror of the haul truck (Cat 785) when he slipped and
fell down to the ground. This incident resulted the death.
15 09-Jul-99 Jumarsono PT Hexindo Welder CONT
Hexindo vehicle was hit and ran over by the reversing D11 N CAT B.dozer, caused
fatality
FATALITY INCIDENT LIST FATALITY INCIDENT LIST
1990 1990 YTD 26 Jul 2010 YTD 26 Jul 2010
No Date
Injured
Name
Company /
Dept
Position KPC / CONT Remarks
16 30-May-00 Paulus Tira PT Gemini Labor CONT
A subcontractor employee under PT.TU (PT. Gemini) was stopping a wheelbarrow by
placing the steel leg on the portable light electrical cable when he got electrical
shock. This incident resulted in the death.
17 27-Jan-02 Sion Manik PT KPPS
Dozer
Operator
CONT
Whilst clearing the area of the loading point, a dozer (Cat D11) rolled over along 20
metres. The operator caught between dozer and ground. He wasn't wearing a
seatbelt. This Incident resulted in the death.
18 23-May-05
Yunus
Thomassaw
a
Bintang
Dept.
Shovel
Operator
KPC
Early into the night shift, the Shift Supervisor received a report from the previous Shift
Supervisor that Shovel S-311 had a hydraulic hose leak. The Shift Supervisor then
took the operators of the shovel and dozer, as well as, two Hexindo mechanics to the
location of the shovel. Whilst in the process of repairing the shovel one of them saw the
shovel operator get into their light vehicle (Hex-60) to take a rest. At about 00.10 AM the
two mechanics heard a thundering noise and felt the shovel shaking due to ground
movement. One of the mechanics observed the shovel operator attempting to get out
of the light vehicle (Hex-60), however he was too late and was trapped in the vehicle
as it was tumbled in the sliding slope material.
As a result of this accident, the victims left leg was badly fractured causing him to loose
a significant amount of blood. The victim was then evacuated to the SOS clinic for
medical treatment, but unfortunately the SOS doctor announced his death by 04.00 AM
19 09-Aug-05 Rustan Hatari Dept. Pump Crew KPC
A pump operator for Hatari Pit had attempted to swim out to recover a small rowing boat
that had drifted to the other side of the pond. He was not wearing life jacket and drown in
the water.
FATALITY INCIDENT LIST FATALITY INCIDENT LIST
1990 1990 YTD 26 Jul 2010 YTD 26 Jul 2010
Note : Total of Fatality Incidents are 23 Incidents ( KPC = 9 ; Cont = 14 )
FATALITY INCIDENT LIST FATALITY INCIDENT LIST
1990 1990 YTD 26 Jul 2010 YTD 26 Jul 2010
No Date
Injured
Name
Company /
Dept
Position KPC / CONT Remarks
20 23-Jan-07
Hendris
Susilawarta
PT Pama
Persada
Truck
Operator
CONT
A Pamapersada Nusantara (PAMA) HD785 Dump Truck (DT785), collided into the back
of another HD785 Dump Truck (DT3008) which had broken down on OB Haul Road at
KPC Bendili Pit, due to fatigue of the DT785 operator.
21 21-Mar-08 Yusran
Geology
Dept.
Asst.
Geology
KPC
A Geology Assistant in the Geology Department parked his vehicle (LS490) and went
out of the vehicle to direct a farm tractor. The vehicle (LS490) then moved and he tried
to stop it. Unfortunately, he failed and was struck by the vehicle.
22 22-Oct-09 Junaedi HT Operator KPC
Whilst dumping an overburden at box cut RL 160 area, a dump truck T-731 (Cat789)
caught fire.
The operator was panicked and got out from cabin without following emergency
procedure so that he got burn injury and fell from step #4 from the top (2.5 m) when
climbing down the ladder in front of cabin. This is categorized as fatal injury resulted in
death. The critical factor cuasing the fire incident was steering hose burst, spraying oil
mist that was exposed to heat source from turbo or exhaust and air blown from radiator
fan so that fire spread qiuckly.
23 22-Jul-10
ROBERTUS
RIA
Z38293 Supervisor CONT
While reversing to prepare pushing next material, dozer DZ3003 run over LV TC560
which was parked on the dozer working path behind the dozer. The victim (supervisor)
who was sitting on the front left passenger seat could not escape and fatally injured
inside the cabin. The critical factor was breach of in pit parking and approaching heavy
equipment procedures.
RENUNGAN
Sudah 23 kecelakaan fatal terjadi sejak 1990 hingga July 2010.
Ini berarti 23 rekan kerja kita telah kehilangan nyawanya dan 23
keluarga (anak/istri/orang tua) telah kehilangan orang-orang
yang dicintainya.
Ke-23 orang ini mungkin merupakan tulang punggung ekonomi
bagi keluarganya.
Kita harus melakukan sesuatu untuk mencegah kisah sedih ini
terjadi pada diri kita dan rekan-rekan kerja kita.
Mari kita berdoa dan berjanji pada diri sendiri bahwa kita akan
melakukan yang terbaik bagi keselamatan diri kita sendiri dan
orang lain.
Kecelakaan Fatal vs FPE
Dari total 23 Kecelakaan Fatal:
14 FPE 2.18 Pengoperasian Kendaraan / Alat Bergerak
3 FPE 2.19 Kondisi Kendaraan / Alat Bergerak
2 FPE 2.21 Keselamatan Listrik
2 FPE 1.10 Keselamatan Lereng Tambang
1 FPE 2.14 Bekerja di Ketinggian
1 FPE 2.24 Bekerja di Dekat Air
Kecelakaan Fatal vs Penyebabnya
6 kasus: Pelanggaran Aturan / Prosedur K3:
Keluar dari kabin di dalam radius 1.5x tinggi lereng
Under cutting slope slope failure
Bekerja di air tanpa pelampung
Meninggalkan kendaraan dalan kondisi mesin hidup
Panik dan tidak mengikuti prosedur darurat saat trucknya terbakar
Memasuki dan memarkir kendaraan di jalur kerja dozer di belakang dozernya
4 kasus: Mengoperasikan dengan kecepatan tidak sesuai:
Truk tidak terkendali, terbalik dan kabinnya membentur pohon
Dynapack vibrating roller tak terkendali, terbalik, tidak dilengkapi ROPS
LV kecepatan terlalu tinggi bertabrakan dengan Ginaf coal truck
Truk tidak terkendali, terbalik dan operator tidak memakai seatbelt
4 kasus: Tidak memakai sabuk pengaman (seatbelt):
Truk tidak terkendali, menabrak safety berm dan operator terlempar keluar
Compactor tidak terkendali, terbalik dan operator tertimpa unitnya
Dozer terguling 20 m ke jurang, operator tertimpa unitnya
Lihat kasus kecepatan tidak sesuai di atas
Kecelakaan Fatal vs Penyebabnya
3 kasus: Mengalami keletihan (fatigue) saat mengoperasikan alat:
LV terlindas dump truck CAT785 akibat pengemudi mengalami keletihan (fatigue)
Dump truck CAT785 melewati safety berm dan masuk jurang 34 m akibat operator
mengalami keletihan (fatigue)
Dump truck Komatsu HD785-5 menabrak HD785 lain yang sedang rusak di jalan
akibat operator mengalami keletihan (fatigue)
2 kasus: Tersengat listrik akibat Sistem / Alat Plindung tidak memadai:
Pekerja bangunan tersengat listrik saat menggunakan bor tangan
Pekerja tersengat listrik saat kereta besi yang didorongnya menggilas kabel listrik
aktif di lantai semen
2 kasus: Mengoperasikan peralatan yang rusak / sub-standard:
Explosive truck yang sistem remnya rusak tidak bisa dikendalikan, menabrak safety
berm
Water truck DJB300 yang sedang menyiram jalan di tanjakan tiba-tiba mati mesin,
termundur, menarbak safety berm dan terguling
Kecelakaan Fatal vs Penyebabnya
2 kasus: Terkait kondisi (di tempat kerja) yang tidak
aman:
Operator yang sedang membersihkan kaca kabin depan
CAT785 terpeleset dan terjatuh ke tanah
Kendaraan ringan terlindas dozer D11 yang sedang mundur
karena tidak bisa keluar dari lokasi
1 kasus: Mengambil posisi tidak aman:
Seorang spotter terjepit di antara fuel truck dan dozer saat
memberi aba-aba
APA YANG HARUS SEGERA DILAKUKAN?
SETIAP ORANG HARUS MEMATUHI ATURAN
BAKU/GOLDEN RULES dan Aturan serta Prosedur K3
lainnya SETIAP SAAT
SALING MENGINGATKAN untuk MENCEGAH
PELANGGARAN yang dapat mengakibatkan terjadinya
kecelakaan
Selalu menjaga kebugaran; BERHENTI JIKA MERASA
NGANTUK, Lakukan Peregangan dan lapor ke pengawas
HINDARI JALAN PINTAS: INGAT TIDAK ADA JALAN
PINTAS UNTUK SELAMAT!!!
TUGAS UNTUK PIMPINAN
DEPARTMENT/KONTRAKTOR
Manager harus mempresentasikan materi ini
kepada Supt dan Supt. Kepada karyawan
ATAU Manager/Supt. Kepada semua
karyawan
Menyerahkan daftar hadirnya ke Bp. Johnry
Sihombing di Dept. OHS paling lambat
tanggal 30 Agustus 2010 untuk dicatat dalam
Catatan Pelatihan Karyawan