ROOT CAUSE ANALYSIS TECHNIQUE

Worksheet
(Lembar Kerja RCat)
LAPORAN INSIDEN / INCIDENT REPORT
AA No. : ____________________
Perusahaan / Company GG
Unit Usaha / Business unit GG
Bagian / Section GG
Tanggal insiden / Date of incident GG
Waktu insiden / Time of incident GG
Waktu pelaporan / Time reported GG
Lokasi insiden / Location of the incident GG
Saksi insiden / Witness to the incident GG
Jenis insiden / Type of incident GG
Deskripsi terjadinya insiden (termasuk tempat, pekerjaan yang sedang dilakukan, keadaan fisik area sekitar, APD, proses)
Description of how the incident occurred (include place, work being performed, physical surroundings, PPE, procees)
GG
GG
GG
GG
GG
GG
GG
Deskripsi kerugian / Description of the loss
GG
GG
GG
GG
GG
GG
GG
Rincian orang-orang yang terlibat / mengalami cedera / Details of person/s involved / injured
Nama lengkap / Initials and surname GG
No. Karyawan / Employee No. or ID No. GG
Jenis Kelamin / Sex of person GG
Usia / Age GG
Pengalaman kerja pada jabatan terakhir GG
Experience in current position
Golongan / Grade GG
Sifat cedera / Nature of injury (if any) GG
Bagian tubuh cedera / Part of body affected GG
Nama pengawas / Name of supervisor GG

© Copyright 2002 - IRCA

 ROOT CAUSE ANALYSIS TECHNIQUE
Teknik Analisis Akar Masalah

© Copyright 2002 - IRCA

AGEN / AGENCY: cc

JENIS KONTAK / TYPE OF CONTACT: AA

SEBAB
LANG-
SUNG TINDAKAN-TINDAKAN / KONDISI-KONDISI DI BAWAH STANDAR
IMME- SUB STANDARD ACTS / CONDITIONS
DATE
CAUSE
NAMA PENYEBAB LANGSUNG ALASAN / PENJELASAN
No. IMMEDIATE CAUSE NAME REASON / EXPLANATION

INVESTIGATOR: SUPERVISOR:

_________________________________ _______________________________
TTD / SIGNATURE TANGGAL / DATE TTD / SIGNATURE TANGGAL / DATE

TEAMs
TIM PENYELIDIK / INVESTIGATIONROOT CAUSE ANALYSIS TECHNIQUE
Teknik Analisis Akar Masalah
© Copyright 2002 - IRCA
SEBAB SEBAB
LANG- DASAR
SUNG TINDAKAN-TINDAKAN / KONDISI-KONDISI DI BAWAH STANDAR
IMME- BASIC SUB STANDARD ACTS / CONDITIONS
DATE CAUSE
CAUSE
SEBAB DASAR UTAMA SUB-SUB SEBAB DASAR ALASAN / PENJELASAN
No’s No’s BASIC CAUSE HEADING BASIC CAUSE SUB-ITEM REASON / EXPLANATION

MANAGER: HEALTH & SAFETY REP:

_________________________________ _________________________________
TTD / SIGNATURE TANGGAL / DATE TTD / SIGNATURE TANGGAL / DATE

ENGINEER: R/C OFFICER:

_________________________________ _________________________________
TTD / SIGNATURE TANGGAL / DATE TTD / SIGNATURE TANGGAL / DATE
Ketidakcukupan Tindakan yang akan Dilakukan / Action To Be Taken
pengendalian
ROOT CAUSE ANALYSIS TECHNIQUE
Teknik Analisis Akar Masalah
© Copyright 2002 - IRCA
 Sebab-sebab akibat
ketidakcukupan

Penanggungjawa

Tindakan Selesai
TINDAKAN YANG DISARANKAN

Tgl Perkiraan
No Element system

memperbaiki
BASIC CAUSE No

Mengurangi
No Sebab Dasar

Mencegah

Mentolerir
Pemenuhan
PROPOSED ACTION
Standar
Sistem

KETUA KOMITE K3 / CHAIRMAN OF HEALTH & SAFETY COMMITTEE: ____________________________

TTD / SIGNATURE TANGGAL / DATE

PENYELIDIKAN DIVERIFIKASI OLEH / INVESTIGATION VERIFIED BY : _____________________________

TTD / SIGNATURE TANGGAL / DATE

© Copyright 2002 - IRCA