FLEET DIVISION

FORM
LAPORAN KERUSAKAN/ KETIDAKSESUAIAN
Damage/ Non-conformance Report
Instruksi / Instruction :
1. Diisi oleh personel yang bertanggung jaab !an !i"iri# "epa!a D$%& 'MR !an %rsip yang bersang"utan.
To be filled by the responsible personnel and send to DPA, QMR and file.
2. (eri"an tan!a )he)" *+ untu" "olo# *apabila a!a+ ji"a ite# tersebut !ila"sana"an& !an "osong"an untu" yang ti!a" !i"erja"an.
Give the check sign ( for col!"n (if any if ite"s have been done, and leave it e"pty #hich has not been done.
No. Laporan
Report $o.
, -1
.asil %u!it Internal
Res!lt of %nternal A!dit
$erihal
&!b'ect
, $ER(%I/%N R%D%R D%N INM%RS%T 0
.asil %u!it E"sternal
Res!lt of ()ternal A!dit
/apal 1 /antor
*essel + ,ffice
, MER%T2S MED%N 3 0usto#er 0o#plaint
Lo"asi /eja!ian
-ocation
, L%2T 4%5%
Lainnya ,
,thers
RINCIAN KETIDAKSESUAIAN
Detail of Non-conformance

1. Ra!ar "anan *1+ , Tuningnya le#ah
3. Ra!ar "iri *3+ , Sering #ati sen!iri
6. In#arsat 0 , %!!res "iri#& ti!a" se#uanya ter"iri#
Tanggal ,
Date
4a# ,
Ti"e
Na#a 7 4abatan ,
$a"e . Position
Tan!a Tangan
&ignat!re
ANALISA / INVESTIGASI
Analyze/ Investigation

Tanggal ,
Date
4a# ,
Ti"e
Na#a 7 4abatan ,
$a"e . Position
Tan!a Tangan
&ignat!re
TINDAKAN PERBAIKAN DAN PENCEGAHAN
Corrective and Preventive Action
No.
Tin!a"an
Action
$enanggung
4aab
Responsible Person
Target
$enyelesaian
Target of
/o"pletion
Tanggal
Realisasi
Real of
/o"pletion
Repair :

Preenti!n :


TINDAK LAN"UT DAN VERI#IKASI
Follow p and !erification
DA#TAR DISTRIBUSI
Distri"ution #ist

Fleet Dire)tor
Ship Manager
Superinten!ent
'MR 7 D$%
Others
Tanggal ,
Date
4a# ,
Ti"e
Na#a 7 4abatan ,
$a"e . Position
Tan!a Tangan
&ignat!re
Re8ision 1 File 1 Fre9 , R: 1 OV 1 SET Do). No. , FR%RM;D$%-1<
Re8ision Date , 331-313-1- $age , $ !% $
For#at No& MRT;FR;STD.=.3;-1.-1
Re8ision 3