OFS-HSE12-PRO-001-2021-R4 Prosedur Insiden & Investigasi

hmfLEMBAR JUDUL
PROSEDUR INSIDEN DAN INVESTIGASI

MEDCO E&P OFFSHORE
(INCIDENT AND INVESTIGATION PROCEDURE
MEDCO E&P OFFSHORE)
LEMBAR PENGESAHAN
Document No. : OFS-HSE12-PRO-001-2021-R4 Revision: 04

Document Level :2
Document Title : PROSEDUR INSIDEN AND INVESTIGASI MEDCO E&P OFFSHORE
(INCIDENT AND INVESTIGATION PROCEDURE MEDCO E&P OFFSHORE)
Name Position Date Signature
Specialist HSE Offshore

Prepared by. Ramzi Limboro 11 Oct 2021
Reporting Data
Manager HSE Offshore

Reviewed by. Teguh Yuwono Performance Assurance & 15 Oct 2021
Audit
Manager HSE Offshore

Teguh Yuwono Performance Assurance & 15 Oct 2021
Audit
Approved by.
Asep Bunawan Senior Manager HSE 18 Oct 2021

Sugiana Offshore Asset
Doc. OFS-HSE12-PRO-001-2021-R4
PROSEDUR (PROCEDURE)
Rev. 04 Page iii from vii
PROSEDUR INSIDEN DAN INVESTIGASI MEDCO
E&P OFFSHORE
Date: 24 September 2021 (INCIDENT AND INVESTIGASTION PROCEDURE
MEDCO E&P OFFSHORE)
Tidak ada bagian dari panduan ini yang boleh No part of this publication may be reproduced,
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dalam bentuk apapun atau dengan cara apapun, any means, including photo-copying, without
termasuk dengan cara memfotocopi tanpa the written consent of Medco E&P.
persetujuan tertulis dari Medco E&P.
Diterbitkan oleh Published by

Medco E&P Medco E&P
Jakarta, Indonesia Jakarta, Indonesia
Rev. 04 Page iv from vii
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LEMBAR REVISI
No. Dokumen : OFS-HSE12-PRO-001-2021-R4 Rev: 04

Tingkat Dokumen : 2
Judul Dokumen : PROSEDUR INSIDEN DAN INVESTIGASI MEDCO E&P
OFFSHORE
DI INISIASI
REV. BAGIAN CATATAN REVISI TANGGAL
OLEH
0  Dokumen ini dibuat hanya untuk tujuan sementara dan Bram Prawiro 22 May 2017
dimaksudkan sebagai pedoman selama masa transisi sebelum
mengeluarkan prosedur tetap
 Jika terdapat hal yang tidak konsisten antara dokumen ini dan
dokumen lain yang berlaku di Medco E&P Natuna Ltd.,
approver harus memiliki kebijaksanaan untuk menentukan
ketentuan yang berlaku
1  Revisi Risk Rank Matrix sesuai dengan Medco E&P risk matrix Bram Prawiro 27 May 2019
(Gambar 3 and Lampiran 5)
 Menindaklanjuti rekomendasi Safety Assessment DuPont:
 Menghapus “Significant risk” pada kategori risiko untuk
kriteria investigasi.
 Revisi beberapa definisi (yaitu: Incident Owner, Site Line Ramzi Limboro 25 May 2020
Manager), menambahkan beberapa poin (e.g. accident, HiPo),
dan mengapus “HLVE”
 Revisi bagian 4 Tugas dan Tanggung Jawab
 Revisi bagian 5 Pelaporan Insiden dan Near miss
 Revisi bagian 6 Investigasi Insiden:
 Memasukkan persyaratan training untuk ketua tim
2 investigasi
 Mengganti “RCA (Root Cause Analysis)” dengan “LCA
(Latent Cause Analysis)”
 Revisi bagian 6.2.5 durasi penyelesaian laporan
investigasi
 Revisi Lampiran 1 – Gamabr 2
 Menambahkan Lampiran 14 – Example of Incidents/ Cases to
describe application of “Incident Owner” and “Site Line
Manager”
 HSE Annual Document Review oleh HSE Performance Ramzi Limboro 15 Sept 2020
Assurance Team and HSE Offshore Operations, HSE Well
Operations Drilling, HSE Project dan Subject Matter Expert
(SME) lainnya yang terkait dengan prosedur
 Penambahan penjelasan definisi dan Sistem Tier Process
Safety Event
3  Modifikasi klasifikasi Motor Vehicle Incident / Traffic Accident
Case dari sebelumnya Major-Serious-Slight menjadi Major-
Medium-Minor dengan Major menjadi Recordable Incident
sesuai alignment dengan HSE Corporate
 Penambahan informasi waktu management review untuk
keefektifan Learning From Event / Learning From Incident
setiap 3 tahun sekali atau kapanpun diperlukan jika terjadi
perubahan yang signifikan
 Penambahan penjelasan pada bagian 6.6 Komunikasi Belajar Ramzi Limboro 28 June 2021
Dari Insiden (LFI) untuk memastikan adanya komunikasi dari (sesuai hasil SIP OE
pembelajaran tersebut dalam bentuk Lesson Learned,
Assessment 2020)
Bulletins, Alert atau komunikasi langsung (meetings) dengan
menyertakan analisa, pengukuran kecenderungan dan evaluasi
 Penambahan penjelasan pada bagian 6.8 Prosedur Corrective
4 Action Needed (CAN) butir 6.8.8. untuk inisiasi proses
pendampingan dan konsultasi untuk memastikan tindakan
korektif dari sebuah insiden atau near miss
 Pembaharuan definisi Process Safety Event dan penambahan Ramzi Limboro 24 September
definisi dari Near Miss Process Safety di butir 5.2.10 (sesuai hasil SIP OE 2021
 Perubahan nomor dokumen dari sebelumnya Assessment 2020)
MEPN/HSE/GEN/0008 menjadi OFS-HSE12-PRO-001-2021-
R4
Rev. 04 Page v from vii
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REVISION SHEET
Document Number : OFS-HSE12-PRO-001-2021-R4 Rev: 04

Document Level :2
Document Title : INCIDENT AND INVESTIGATION PROCEDURE MEDCO
E&P OFFSHORE
INITIATED
REV. PART REVISION NOTES DATE
BY.
0  This document is produced for interim purpose only and Bram Prawiro 22 May 2017
intended to serve as a guidance during the transitional term
prior to issuing the definitive procedure.
 Should there is any inconsistency between this document and
other applicable documents at Medco E&P Natuna Ltd., the
approver shall have the discretion to determine the prevailing
term.
1  Revised the Risk Rank Matrix according to Medco E&P risk Bram Prawiro 27 May 2019
matrix (Figure 3 and Appendix 5)
 Following up recommendation from DuPont safety assessment:
 Remove “Significant risk” on risk categorization for
investigation criteria.
 Revised several definition (e.g. Incident Owner, Site Line Ramzi Limboro 25 May 2020
Manager), added several items (e.g. accident, HiPo), and
removed “HLVE”
 Revised Section 4 Roles & Responsibility
 Revised Section 5 Incident & Near Miss Reporting
 Revised Section 6 Incident Investigation:
2  Included training requirement of investigation lead
 Replaced “RCA (Root Cause Analysis)” with “LCA
(Latent Cause Analysis)”
 Revised Sect 6.2.5 the duration of completion of the
investigation report
 Revised Appendix 1 – Figure 2
 Added Appendix 14 – Example of Incidents/ Cases to describe
application of “Incident Owner” and “Site Line Manager”
 HSE Annual Document Review by HSE Performance Ramzi Limboro 15 Sept 2020
Assurance Team and HSE Offshore Operations, HSE Well
Operations Drilling, HSE Project and other Subject Matter
Expert (SME) related to the procedure
 Additional description of Process Safety Event (PSE) definitions
and Tier system
3  Modification of the classification of Motor Vehicle Incident /
Traffic Accident Case from previously Major-Serious-Slight to
Major-Medium-Minor with Major classification is regarded as
Recordable Incident (based on alignment with HSE Corporate)
 Additional information of the management review information
for the effectiveness of Learning From Event / Learning From
Incident every 3 years or whenever needed if there is a
significant change
 Additional information in section 6.6 Communication Learning Ramzi Limboro 28 June 2021
From Incidents (LFI) to ensure there is communication from the (based on SIP OE
learning in the form of Lesson Learned, Bulletins, Alerts or direct
Assessment 2020)
communication (meetings) that includes analysis, trend
measurement and evaluation
 Additional information in section 6.8 Procedure for Corrective
Action Needed (CAN) point 6.8.8. to initiate the mentoring and
4 consultation process to ensure corrective action from an incident
or near miss
Ramzi Limboro 24 September
 Update definition of Process Safety Event and additional
information of definition of Near Miss Process Safety in section (based on SIP OE 2021
5.2.10 Assessment 2020)
 Change document numbering from MEPN/HSE/GEN/0008 to
OFS-HSE12-PRO-001-2021-R4
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DAFTAR ISI
1. TUJUAN ..................................................................................................................................................... 1
2. RUANG LINGKUP ..................................................................................................................................... 1
3. DEFINISI .................................................................................................................................................... 2
4. TUGAS & TANGGUNG JAWAB................................................................................................................ 9
4.1. LINE MANAGEMENT ................................................................................................................................ 9
4.2. SITE LINE MANAGER............................................................................................................................... 9
4.3. HSE PERFORMANCE ASSURANCE MANAGER ................................................................................. 10
4.4. HSE TEAM LEAD .................................................................................................................................... 10
4.5. HSE ADVISOR ........................................................................................................................................ 11
5. PELAPORAN INSIDEN ........................................................................................................................... 11
5.1. GAMBARAN UMUM PERSYARATAN PELAPORAN ............................................................................. 11
5.2. PROSEDUR (PELAPORAN INSIDEN DAN NEAR MISS)...................................................................... 13
5.3. PELAPORAN CORPORATE ................................................................................................................... 20
5.4. PELAPORAN KE LEMBAGA PEMERINTAH .......................................................................................... 20
5.5. PERSYARATAN PEMBERITAHUAN ...................................................................................................... 21
6. INVESTIGASI INSIDEN .......................................................................................................................... 21
6.1. GAMBARAN UMUM ................................................................................................................................ 21
6.2. INVESTIGASI INSIDEN – PEDOMAN UMUM ........................................................................................ 22
6.3. MENILAI TINGKAT KEPARAHAN INSIDEN ........................................................................................... 25
6.4. SUSUNAN TIM INVESTIGASI INSIDEN................................................................................................. 25
6.5. MELAKUKAN INVESTIGASI ................................................................................................................... 27
6.6. KOMUNIKASI BELAJAR DARI INSIDEN (LFI) ....................................................................................... 28
6.7. INSIDEN BERULANG ............................................................................................................................. 29
6.8. PROSEDUR CORRECTIVE ACTION NEEDED (CAN) .......................................................................... 30
7. PENINJAUAN ULANG DAN PEMBARUAN ............................................................................................ 32
8. DAFTAR BUKTI-BUKTI IMPLEMENTASI PANDUAN ............................................................................ 32
9. REFERENSI ............................................................................................................................................ 32
10. LAMPIRAN .............................................................................................................................................. 32
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TABLE OF CONTENT
1. PURPOSE ................................................................................................................................................. 1
2. SCOPE ...................................................................................................................................................... 1
3. DEFINITION .............................................................................................................................................. 2
4. ROLES & RESPONSIBILITIES ................................................................................................................. 9
4.1. LINE MANAGEMENT ................................................................................................................................ 9
4.2. SITE LINE MANAGER............................................................................................................................... 9
4.3. HSE PERFORMANCE ASSURANCE MANAGER ................................................................................. 10
4.4. HSE TEAM LEAD .................................................................................................................................... 10
4.5. HSE ADVISOR ........................................................................................................................................ 11
5. INCIDENT REPORTING ......................................................................................................................... 11
5.1. OVERVIEW OF REPORTING REQUIREMENTS ................................................................................... 11
5.2. PROCEDURE (INCIDENT AND NEAR MISS REPORTING) ................................................................. 13
5.3. CORPORATE REPORTING ................................................................................................................... 20
5.4. REPORTING TO THE REGULATORY AUTHORITIES .......................................................................... 20
5.5. NOTIFICATION REQUIREMENT ............................................................................................................ 21
6. INCIDENT INVESTIGATION ................................................................................................................... 21
6.1. OVERVIEW ............................................................................................................................................. 21
6.2. INCIDENT INVESTIGATION – GENERAL GUIDANCE ......................................................................... 22
6.3. ASSESSING INCIDENT SEVERITY ....................................................................................................... 25
6.4. INCIDENT INVESTIGATION TEAM COMPOSITION ............................................................................. 25
6.5. CONDUCTING THE INVESTIGATION ................................................................................................... 27
6.6. COMMUNICATION OF LEARNING FROM INCIDENTS (LFI) ............................................................... 28
6.7. REPEAT INCIDENTS .............................................................................................................................. 29
6.8. PROCEDURE FOR CORRECTIVE ACTION NEEDED (CAN)............................................................... 30
7. REVIEW & UPDATE................................................................................................................................ 32
8. LIST OF EVIDENCE ................................................................................................................................ 32
9. REFERENCE ........................................................................................................................................... 32
10. APPENDIX ............................................................................................................................................... 32
No. Dok: OFS-HSE12-PRO-001-2021-R4
Rev. 04 Hlm 1 dari 75
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Tanggal: 24 September 2021 (INCIDENT AND INVESTIGASTION PROCEDURE
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1. TUJUAN 1. PURPOSE
 Untuk memastikan bahwa semua  To ensure that all incidents and near
insiden dan near miss di seluruh misses throughout Medco E&P
Medco E&P (Offshore) dilaporkan dan (Offshore) are reported and that the
bahwa pelaporannya akurat dan sama. reporting is both accurate and uniform.
 Untuk memastikan bahwa persyaratan  To ensure that the incident and near
pelaporan insiden dan nea rmiss di miss reporting requirements of Medco
Medco E&P Corporate, Sistem E&P Corporate, Medco E&P (Offshore)
Manajemen K3 Medco E&P (Offshore) HSE Management System and
dan Peraturan Perundangan Republik Republic of Indonesia Regulations are
Indonesia telah dipatuhi. complied with.
 Untuk memastikan bahwa semua  To ensure that all incidents and near
insiden dan near miss diinvestigasi misses are investigated and that the
dan bahwa tingkat investigasi sesuai level of investigation is appropriate to
dengan tingkat keparahan insiden the incident severity.
tersebut.
 Untuk memastikan bahwa penyebab  To ensure that the latent causes of
laten dari insiden dan near miss incidents and near misses are identified
diidentifikasi dan bahwa tindakan and that the necessary corrective
perbaikan yang diperlukan dilakukan actions are taken to prevent recurrence.
untuk mencegah kejadian terulang
kembali.
 Untuk menyediakan jejak metris yang  To provide an accurate trailing metric of
akurat dari Kinerja Keselamatan dan Medco E&P (Offshore) Safety &
Lingkungan Medco E&P (Offshore). Environmental performance.
 Untuk menyediakan sistem yang dapat  To provide an auditable system for the
diaudit terkait pelaporan, investigasi reporting, investigation and prevention
dan pencegahan insiden. of incidents.
2. RUANG LINGKUP 2. SCOPE

Prosedur ini berlaku untuk semua lokasi This procedure applies to all Medco E&P
operasi Medco E&P (Offshore) dan semua (Offshore) operated sites and all Contractor
kegiatan operasi Kontraktor di mana terdapat operations where there is a contractual
persyaratan pada kontrak untuk melaporkan requirement to report incidents to Medco
insiden ke Medco E&P (Offshore) (misalnya E&P (Offshore) (e.g. Medco E&P (Offshore)
komplek perkantoran Medco E&P (Offshore), office complexes, contract drill rigs,
kontrak pengeboran rig, kapal produksi, production vessels, diving spreads, vessels
diving spreads, kapal dan lokasi konstruksi). and construction sites). If there is any doubt
Jika ada keraguan tentang penerapan as to the applicability of this procedure at a
prosedur ini di lokasi tertentu, ini harus particular location, it should be assumed to
dianggap berlaku sampai mendapatkan apply until it has been confirmed otherwise
konfirmasi sebaliknya (lihat juga Lampiran (see also Appendix 5).
5).
Cedera yang dilaporkan untuk karyawan Reportable Injuries for Medco E&P
Medco E&P (Offshore) juga termasuk lost (Offshore) employees also include “Off-The-
time injuries “di luar pekerjaan” yang diderita Job” lost-time injuries suffered while not at
saat tidak bekerja. Ini termasuk kasus di work. This will include any case in which an
mana seorang karyawan tidak dapat bekerja employee is unable to work a full shift on the
penuh pada hari setelah cedera. day following the injury.
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Insiden yang dilaporkan yang mempengaruhi Reportable incidents affecting the

lingkungan termasuk Loss of Primary environment include Loss of Primary
Containment (LOPC) dan pelanggaran atas Containment (LOPC) and breaches of
persetujuan pembuangan dan batas discharge consents and other operational
operasional lainnya yang ditetapkan untuk limits set for environmental protection.
perlindungan lingkungan.
3. DEFINISI 3. DEFINITION
Kecelakaan – peristiwa yang tidak diinginkan Accident – an unwanted event that caused
yang menyebabkan kerugian, cedera, harm, injury, illness, damage to property /
penyakit, kerusakan properti/produk, products / environmental and process losses.
kerugian lingkungan dan proses.
Tumpahan Bahan Kimia - Tumpahan bahan Chemical Spill - A chemical spill is defined as
kimia didefinisikan sebagai peristiwa an accidental uncontrolled release event
pelepasan tak terkendali yang tidak from primary containment of chemical
disengaja dari penahanan primer bahan materials other than liquid petroleum-related
kimia selain dari bahan terkait minyak bumi materials. Examples of chemical spills
cair. Contoh tumpahan bahan kimia include but are not limited to: caustic, acid,
termasuk tetapi tidak terbatas pada: caustic, glycol, catalyst, hazardous waste.
asam, glikol, katalis, limbah B3.
Kontraktor - Setiap karyawan Medco E&P Contractors - Any Medco E&P (Offshore)
(Offshore) yang melakukan pekerjaan untuk, employee performing work for, or on behalf
atau atas nama Medco E&P (Offshore) of, Medco E&P (Offshore) Exceptions are
pengecualian tercantum dalam Lampiran A listed in Appendix A of Occupational Injury
Prosedur Pelaporan dan Pencatatan Cedera and Illness Reporting and Recording
dan Penyakit Akibat Kerja. Procedure.
Penyebab yang Berkontribusi - Satu atau Contributing Causes – One or more

lebih keadaan, kondisi, atau tindakan yang circumstances, conditions, or actions which
mempengaruhi kemungkinan Insiden terjadi impacted the probability for the Incident to
atau meningkatkan keparahan Insiden atau occur or increased the severity of the Incident
konsekuensinya. or its consequences.
First Aid Case - kasus pertolongan pertama First Aid Case – a first aid case is any case
adalah setiap kasus yang melibatkan that involves the treatment listed.
perawatan yang tercantum dibawah.
First Aid Treatment - (perawatan apa pun First Aid Treatment- (any treatment NOT
yang TIDAK tercantum dianggap sebagai listed is considered Medical Treatment)
Medical Treatment)
1. Menggunakan obat non resep seuai 1. Using nonprescription medication at
dengan anjuran yang tertera nonprescription strength
2. Melakukan imunisasi (khusus) tetanus 2. Administering tetanus (only)
immunizations
3. Membersihkan, membasuh atau 3. Cleaning, flushing or soaking wounds
merendam luka di permukaan kulit on the surface of the skin
4. Menggunakan penutup luka seperti 4. Using wound coverings such as
perban, Band-Aids™, kain kasa, dll.; bandages, Band-Aids™, gauze pads,
atau menggunakan plester jenis kupu- etc.; or using butterfly bandages or
kupu atau Steri-Strips™ Steri-Strips™.
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5. Menggunakan obat-obatan untuk 5. Using hot or cold therapy

demam atau flu
6. Menggunakan sarana pembantu yang 6. Using any non-rigid means of support,
tidak kaku, seperti perban elastis, such as elastic bandages, wraps non-
wraps non-rigid back belts, dll. rigid back belts, etc.
7. Menggunakan perangkat imobilisasi 7. Using temporary immobilization devices
sementara saat mengangkut korban while transporting an accident victim
kecelakaan (misalnya bidai, slings, (e.g. splints, slings, neck collars,
neck collars, backboards, dll.) backboards, etc.).
8. Mengerik kuku jari atau kuku kaki 8. Drilling of a fingernail or toenail to
untuk mengurangi tekanan, atau relieve pressure, or draining fluid from a
mengeluarkan cairan dari lepuhan blister.
9. Menggunakan penutup mata 9. Using eye patches.
10. Mengangkat benda asing dari mata 10. Removing foreign bodies from the eye
hanya dengan irigasi atau kapas using only irrigation or a cotton swab.
11. Menghilangkan serpihan atau benda 11. Removing splinters or foreign material
asing dari area selain mata dengan from areas other than the eye by
irigasi, penjepit, kapas atau cara irrigation, tweezers, cotton swabs or
sederhana lainnya other simple means.
12. Menggunakan finger guard 12. Using finger guards.
13. Melakukan pijat selain daripada 13. Using massages other than chiropractic
perawatan chiropractic atau terapi fisik treatment or physical therapy.
14. Meminum cairan untuk menghilangkan 14. Drinking fluids for relief of heat stress
heat stress
CATATAN: Perawatan Medis TIDAK NOTE: Medical Treatment does NOT

termasuk: include:
A. Kunjungan ke dokter atau profesi A. Visits to a physician or other licensed
kesehatan tersertifikasi lainnya health care professional solely for
semata-mata untuk observasi observation or counseling
atau konseling B. The conduct of diagnostic
B. Pelaksanaan prosedur diagnosa, procedures, such as x-rays and
seperti rontgen dan tes darah, blood tests, including the
termasuk pemberian obat resep administration of prescription
yang digunakan semata-mata medications used solely for
untuk tujuan diagnosa (misalnya, diagnostic purposes (e.g., eye
tetes mata untuk melebarkan drops to dilate pupils, mantoux
pupil, tes mantoux). test ).
Bergantung pada situasinya, A & B di atas Depending on the circumstances, A & B

bahkan mungkin bukan kasus pertolongan above may not even be first aid cases. For
pertama. Untuk tujuan pencatatan cedera the purposes of recording injuries and
dan penyakit, perawatan yang tercantum di illnesses, the above listed treatments are
atas dianggap sebagai pertolongan considered first aid. All other treatments not
pertama. Semua perawatan lain yang tidak listed here are considered medical
tercantum disini dianggap perawatan treatment beyond first aid and if used results
medis di luar pertolongan pertama dan jika in a recordable case.
dilaksanakan menjadi recordable case.
Bahaya - kondisi atau praktik yang Hazard – a condition or practice that could
berpotensi menyebabkan kerugian, cedera potentially cause harm, Injury / illness,
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/ sakit, kerusakan properti / produk / damage to property / products /

kerusakan lingkungan dan proses. environmental and process losses.
Insiden HiPo (Berpotensi Tinggi) - HiPo HiPo (High Potential) Incident – HiPo are
didefinisikan sebagai bahaya atau insiden defined to be any hazard or incident that
yang, dalam keadaan lain, secara realistis could, in other circumstances, have
dapat mengakibatkan satu atau lebih realistically resulted in one or more fatalities.
korban jiwa.
Insiden- Peristiwa yang tidak direncanakan Incident – An unplanned / unwanted event

/ tidak dikehendaki yang terjadi tanpa atau that has occurred without or with
dengan konsekuensi yang tidak diinginkan, undesirable consequences, such as:
seperti:
 Kebakaran  A fire,
 Cedera atau penyakit atau pajanan  An injury or illness or industrial
higiene industri hygiene exposure,
 Kerusakan properti (termasuk  A property damage (including HSE-
vandalisme terkait K3LL related vandalism),
 Tabrakan kendaraan  A vehicle impact,
 Pelepasan ke lingkungan (tumpahan  An environment release (liquid
hidrokarbon cair/produced water, hydrocarbon/produced water spill, or
atau tumpahan bahan kimia) atau chemical spill) or gas release from
pelepasan gas dari penahanan primary containment that meets
primer yang memenuhi kategori Process Safety Event (PSE)
Process Safety Event (PSE) Threshold Release Category,
Threshold Release
 Kontak dengan masyarakat umum  A public contact,
 Tindakan penegakan hukum  An enforcement action
Insiden harus diidentifikasi, dilaporkan pada Incidents requires to be Identified, reported

waktu yang tepat, diselidiki, ditangani, dan in timely manner, Investigated, Addressed,
dilacak sampai akhir. and Tracked to closure.
Intervensi adalah terlibat dalam percakapan Intervention is engaging in a face-to-face

tatap muka dengan individu untuk conversation with the individual to discuss
membahas pengamatan tentang tindakan / the observation on the individual’s unsafe
perilaku tidak aman individu, dan acts/ behaviors, and agree on the corrective
menyetujui tindakan korektif agar tidak action(s) to avoid recurrence.
terulang kembali.
Incident Owner - Divisi atau Departemen Incident Owner – A Division or Department

yang memiliki Insiden. Didefinisikan that owns the Incident. Define as the
sebagai Divisi atau Departemen yang Division or Department that have interest,
memiliki kepentingan, pengawasan structured oversight and or direct
terstruktur dan atau pengendalian / control/supervision of particular activity and
pengawasan langsung atas aktivitas responsible for the activity. Statistic of any
tertentu dan bertanggung jawab atas incident will be under incident owner
aktivitas tersebut. Statistik insiden apa pun Division or Department. The incident owner
akan berada di bawah Divisi atau shall manage formal incident reporting and
Departemen Incident Owner. Incident investigation.
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Owner harus mengelola pelaporan formal

dan investigasi insiden.
Cedera - kondisi abnormal atau gangguan Injuries – abnormal conditions or health

kesehatan yang dialami oleh korban / IP problems experienced by victim / IP (injured
(orang yang terluka) person)
Investigasi - Metode, proses, dan prosedur Investigation – Methods, processes, and

yang digunakan oleh satu orang atau lebih procedures employed by one or more
untuk mengumpulkan fakta terkait suatu people gathering facts related to an event
peristiwa dengan tujuan untuk mengetahui with the intent of discovering WHY the event
MENGAPA peristiwa tersebut terjadi. happened.
Penyebab Laten – Komponen atau ‘sistem’ Latent Causes – The often underlying, or
penyebab yang sering mendasari terjadinya “system”, component of the causes of a
suatu kegagalan. Penyebab Laten sering failure. Latent Causes are often revealed by
kali terungkap dengan mengajukan asking the question, “What is it about the
pertanyaan, "Apa yang menyebabkan cara way we do business here that contributed to
melakukan pekerjaan disini yang this failure?”
menyebabkan kegagalan ini?"
Tumpahan Hidrokarbon Cair - Tumpahan Liquid Hydrocarbon Spills – A spill is defined

didefinisikan sebagai peristiwa pelepasan as an accidental uncontrolled release event
tak terkendali yang tidak disengaja dari from primary containment of -liquid
penahanan primer -bahan yang petroleum-related material to the
berhubungan dengan minyak bumi ke surrounding Environment (sea or land).
lingkungan sekitarnya (laut atau darat). Examples of hydrocarbon materials include:
Contoh bahan hidrokarbon antara lain: gasoline, crude oil, produced water
bensin, minyak mentah, kandungan hydrocarbon content, residuals, distillates,
hidrokarbon produced water, residu, asphalt, jet fuel, lubricants, naphtha, light
sulingan, aspal, bahan bakar jet, pelumas, ends, bilge oil, kerosene, benzene, liquefied
nafta, light end, bilge oil, minyak tanah, natural gas, waxes and LPG. If the liquid
bensin, gas alam cair, lilin dan LPG. Jika spills still contained in the secondary
tumpahan cairan masih terkandung di containment, it would be classified as
dalam penahanan sekunder, maka akan LOPC.
diklasifikasikan sebagai LOPC.
Loss of Primary Containment (LOPC) - Loss of Primary Containment (LOPC) – An

Pelepasan material yang tidak unplanned or uncontrolled release of
direncanakan atau tidak terkendali dari material from primary containment. Primary
penahanan primer. Penahanan primer containment includes a tank, vessel, pipe,
meliputi tangki, bejana, pipa, rail car, atau rail car, or equipment intended to serve as
peralatan yang dimaksudkan untuk the primary container or used for transfer of
berfungsi sebagai wadah utama atau the material.
digunakan untuk memindahkan material.
Lost Time Injury (LTI) - cedera atau Lost Time Injury (LTI) – an injury or an
penyakit, dimana karyawan tidak dapat illness, in which the employee is unable to,
bekerja pada hari berikutnya berdasarkan or prescribed, by a licensed health care
anjuran dari layanan kesehatan berlisensi, provider, not to return to work the next
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terlepas dari apakah karyawan tersebut calendar day, whether or not the employee
dijadwalkan untuk bekerja atau tidak hari is scheduled to work that day.
itu.
Medical Treatment Injury (MTI) - cedera Medical Treatment Injury (MTI) – an injury
atau penyakit yang melibatkan perawatan or illness involving any treatment other than
selain yang terdaftar sebagai perawatan what is listed as first aid treatment (see First
pertolongan pertama (lihat Kasus First Aid). Aid Case).
Near Miss - Insiden tanpa konsekuensi, Near Miss – An incident with no

tetapi dengan keadaan yang dapat consequences, but with circumstances that
mengakibatkan kebakaran, cedera, could have resulted in fire, injury, property
kerusakan properti, gangguan proses, damage, process upset, spill, release, or
tumpahan, pelepasan, atau kegagalan other failure. Near misses are required to be
lainnya. Near miss harus diidentifikasi, identified, reported in timely manner,
dilaporkan secara tepat waktu, diselidiki, investigated, addressed, and tracked to
ditangani, dan dilacak sampai selesai closure as required in the HSE Management
seperti yang dipersyaratkan dalam Sistem System.
Manajemen K3LL.
Penyakit Akibat Kerja - penyakit yang Occupational illness – an illness / disease

disebabkan oleh pekerjaan atau lingkungan caused by work or the working environment.
kerja.
Pengendalian Operasional - Medco E&P Operational Control – Medco E&P

(Offshore) dianggap memiliki pengendalian (Offshore) is considered to have operational
operasional atas aset yang dioperasikan control on Company operated assets and
Perusahaan dan aset di mana Medco E&P assets where Medco E&P (Offshore) has
(Offshore) memiliki kewenangan decision authority on HSE-related elements
pengambilan keputusan atas elemen of the operation. This includes contracted
operasi terkait HSE. Ini termasuk aktivitas activities where Medco E&P (Offshore) has
kontrak di mana Medco E&P (Offshore) the decision authority to institute the
memiliki kewenangan pengambilan Company’s HSE Management System
keputusan untuk menerapkan persyaratan requirements, or has accepted and bridged
Sistem Manajemen K3LL Perusahaan, atau to the contractor’s HSE Management
telah menerima dan menjembatani Sistem System and has structured oversight and/ or
Manajemen K3LL kontraktor dan memiliki direct supervision.
pengawasan terstruktur dan / atau
pengawasan langsung.
Process Safety Event (PSE) - LOPC yang Process Safety Event (PSE) – An
tidak direncanakan atau tidak terkontrol dari unplanned or uncontrolled LOPC of any
bahan apa pun termasuk bahan yang tidak material including non-toxic and non-
beracun dan tidak mudah terbakar flammable materials (e.g. steam, hot
(misalnya: uap, kondensat panas, nitrogen, condensate, nitrogen, compressed CO2 or
CO2 terkompresi atau udara terkompresi) compressed air) from a process, or an
dari suatu proses, atau peristiwa atau undesired event or condition that, under
kondisi yang tidak diinginkan yang , dalam slightly different circumstances, could have
keadaan yang berbeda sedikit dapat resulted in a LOPC of a material.
berakibat LOPC material.
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Cedera / Penyakit Terkait Proses - Cedera / Process Related Injury/Illness – An injury /

penyakit yang diakibatkan oleh Insiden illness that is a result of a Process Safety
Process Safety termasuk salah satu dari Incident including any of the following:
yang berikut ini:
 Kematian dan atau LTI dari seorang  A fatality and or LTI of an employee or
karyawan atau kontraktor; contractor;
 Kematian atau cedera / penyakit dari  A third-party fatality or injury/illness
pihak ketiga yang membutuhkan requiring admission to a hospital.
perawatan di rumah sakit.
Sebagaimana dibahas dalam kriteria As discussed in the reporting criteria, the

pelaporan, cedera, penyakit, atau kematian injury, illness, or fatality must be the direct
harus merupakan akibat langsung dari sifat result of the inherent properties of material
bawaan material (misalnya klorin), sifat fisik (e.g., chlorine), physical properties of the
material (mis., Energi proses - material material (e.g., process energy – hot
panas, tekanan tinggi, dll. ), atau terjadi material, high pressure, etc.), or occurs due
karena pemakaian bahan dalam proses to the application of the material within the
(misalnya, kebocoran nitrogen dalam ruang process (e.g., nitrogen leak within a
terbatas). confined space).
Properti - properti / instalasi / peralatan yang Property – property / installations /

dimiliki atau di bawah kendali perusahaan. equipment owned, or under the control of
the company.
Kerusakan Properti – Kerugian properti Property Damage – The Loss of Company’s

perusahaan atau properti di bawah property or property under Company
pengawasan Perusahaan karena process supervision due to process event or due
event atau operasi yang tidak tepat, tidak improper operation, excluding vandalism
termasuk kasus vandalisme. Kerusakan cases. Recordable property damage is
properti yang dapat dicatat (recordable) equal or more than US$ 10,000 in loss.
adalah kerugian sama dengan atau lebih
dari 10.000 dolar.
Restricted Workday Injury (RWI) - cedera Restricted Workday Injury (RWI) – an injury
atau penyakit yang menghalangi karyawan or an illness that prevents the employee
untuk melakukan satu atau lebih fungsi rutin from performing one or more of the routine
pekerjaannya, atau untuk bekerja penuh functions of his or her job, or from working
pada hari kerja yang seharusnya the full workday that he or she would
dijadwalkan untuk bekerja. otherwise have been scheduled to work.
Fungsi Rutin - untuk tujuan pencatatan, Routine Functions – for recordkeeping

fungsi rutin karyawan adalah aktivitas kerja purposes, an employee's routine functions
yang dilakukan karyawan secara teratur are those work activities the employee
setidaknya sekali seminggu. regularly performs at least once per week.
Akar Penyebab - penyebab utama Root Cause – the true ultimate causes of an
sebenarnya dari suatu Insiden. Selain Incident. In addition to the obvious physical
penyebab fisik yang jelas, Akar Penyebab causes, Root Causes include the underlying
mencakup penyebab budaya atau sistem cultural or system causes that allowed the
yang mendasari yang memungkinkan circumstances and behavior (Contributing
Causes) to exist.
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keadaan dan perilaku (Penyebab yang

Berkontribusi) terwujud.
Site - Lokasi geografis tertentu yang berisi Sites – Specific geographical locations that
fasilitas (lihat ‘fasilitas’). contain facilities (see ‘facilities’).
Site Line Manager - Pejabat atau Site Line Manager - The highest-ranking
perwakilan perusahaan tingkat tertinggi company official or representative that have
yang memiliki kendali / pengawasan direct control/ supervision and responsible
langsung dan bertanggung jawab atas for the activity.
aktivitas.
Lihat Lampiran 14 untuk contoh insiden / See Appendix 14 for examples of incidents/
kasus untuk menjelaskan penerapan cases to describe application of the above
definisi di atas. definition.
Manajemen Lini - mengacu pada Line Management - refers to the

manajemen karyawan atau kontraktor yang management of employees or contractors
terlibat langsung dalam aktivitas. Ini dimulai who are directly involved in the activities.
dari level terendah hingga level tertinggi This goes from the lowest level up to the
dalam organisasi Perusahaan. highest level in the organization of the
Company.
Pekerja Servis Terbatas atau Sementara - Temporary or Limited Service Employees –

Ini adalah orang-orang yang dipekerjakan These are people employed by the
oleh perusahaan (karyawan) untuk company (employees) to provide a service
memberikan layanan secara paruh waktu on a part-time or temporary basis. They are
atau sementara. Mereka dibayar langsung paid directly by Medco E&P (Offshore) and
oleh Medco E&P (Offshore) dan jam kerja their hours and occupational
serta cedera / penyakit akibat kerja dicatat injuries/illnesses are to be recorded by the
oleh unit tempat mereka bekerja. unit in which they are employed.
Total Recordable Injury (TRI) - Jumlah Total Recordable Injury (TRI) – The sum of
kematian Lost Time Injury (LTI), Restricted fatalities Lost Time Injury (LTI), Restricted
Workday Injury (RWI), dan Medical Workday Injury (RWI), and Medical
Treatment Injury (MTI). Treatment Injury (MTI).
Total Recordable Injury Rate (TRIR) - Total Recordable Injury Rate (TRIR) – The
Jumlah total recordable rate dihitung total recordable rate is calculated on a
berdasarkan 1.000.000 jam kerja / Man 1,000,000 -employee hour base/Man Hours
Hours (500 karyawan penuh waktu yang (500 full-time employees working 50 weeks,
bekerja 50 minggu, 40 jam per minggu) 40 hours per week) as follows:
sebagai berikut: Number of (fatalities + LTI + RWI + MTI) x
Jumlah (Kematian + LTI + RWI + MTI) x 1,000,000 / (Actual Man-hours).
1.000.000 / (Jam Kerja Aktual).
Perilaku Tidak Aman & Kondisi Tidak Aman Unsafe Act & Unsafe Condition – practices
- praktik dan kondisi yang tidak memenuhi and conditions that do not meet the set of
standar yang ditetapkan atau berpotensi standards or potentially harmful.
membahayakan.
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Lingkungan Kerja - pendirian dan lokasi lain Work Environment – the establishment and
di mana satu atau lebih karyawan bekerja other locations where one or more
atau hadir sebagai syarat kerja mereka. employees are working or are present as a
Lingkungan kerja tidak hanya mencakup condition of their employment. The work
lokasi fisik, tetapi juga peralatan atau bahan environment includes not only physical
yang digunakan oleh karyawan selama locations, but also the equipment or
pekerjaannya. materials used by the employee during the
course of his or her work.
4. TUGAS & TANGGUNG JAWAB 4. ROLES & RESPONSIBILITIES

4.1. Line Management 4.1. Line Management
 Mendukung budaya yang mendorong  Support a culture that promotes sharing
berbagi informasi insiden, near miss, HSE and asset and operating integrity
dan lainnya terkait HSE dan asset dan incidents, near misses, and other
integritas operasi melalui program HSE information through HSE programs
(Safety Card, nearmiss, pelaporan (Safety Card, near miss, incident
insiden, safety discussion, dll.) reporting, safety discussion, etc.)
 Menanggapi insiden sesuai dengan  Respond to the incident in accordance
tanggung jawabnya sesuai kerangka with his/her responsibility within the
waktu yang berlaku. applicable time frame.
 Mendukung proses investigasi dan  Support the investigation and corrective
tindakan korektif dari insiden dan action processes to identify and act on
nearmiss untuk mengidentifikasi dan root causes, contributing
menindaklanjuti akar penyebab, individual/organizational, and
kontribusi individu / organisasi, dan management system deficiencies of
kekurangan dalam sistem manajemen. incidents and near misses.
 Menunjukkan kepemimpinan melalui  Demonstrate leadership through active
keterlibatan aktif dalam meninjau involvement in incident or near miss
investigasi insiden atau near miss untuk investigation reviews for below events:
kejadian di bawah ini:
o Insiden berisiko tinggi dan near o High risk ranked incidents and
miss near misses,
o Recordable injuries/illnesses o Recordable injuries/illnesses,
o Process Safety Event, dan o Process Safety Events, and
o Insiden lain yang sesuai o Other incidents as appropriate.
4.2. Site Line Manager 4.2. Site Line Manager

 Pemilik insiden  Own the Incident.
• Menanggapi insiden dengan  Respond to the incident by coordinating
mengkoordinasikan pengamanan the securing incident site, rescue and
lokasi insiden, kegiatan penyelamatan salvage activities immediately.
dengan segera.
• Melaporkan secara lisan ke manajemen  Report verbally to the higher
yang lebih tinggi dan line management management and the line management
terkait terjadinya insiden dalam waktu of the establishment about the incident
satu jam setelah insiden. within an hour of the incident.
• Membuat laporan tertulis terkait insiden  Produce the written report of the
tersebut dalam kerangka waktu yang incident within the applicable time frame
berlaku (sesuai dengan jenis insiden). (as per the incident type).
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• Memastikan validitas laporan tertulis  Ensure validity of the written report (one
(ringkasan satu halaman) sebelum page summary) prior to submission.
diserahkan.
• Menjadi sumber informasi utama  Be the main source of information about
tentang apa yang sebenarnya terjadi what really happened in the incident.
dalam insiden tersebut.
• Menjadi bagian dari tim Investigasi  Be part of the Incident Investigation
Insiden jika diperlukan team if so required.
4.3. HSE Performance Assurance 4.3. HSE Performance Assurance

Manager Manager
 Melakukan pemeriksaan kualitas  Carry out quality checks when report is
laporan ketika dimasukkan ke Incident submitted to Incident Reporting System
Reporting System di BPM. Revisi dapat in BPM. Revision could be requested if
diajukan jika perlu. necessary.
 Memverifikasi apakah bukti yang  Verify if evidence submitted has been
diajukan telah memadai untuk menutup adequate to close the follow up action
follow-up action atau mungkin masih or may still need additional evidence.
membutuhkan bukti tambahan.
 Memberikan saran terkait klasifikasi  Provide advice on incident or near miss
insiden atau near miss dan persyaratan classification and its reporting
pelaporannya. requirement.
 Memfasilitasi proses pelaporan untuk  Facilitate the reporting process to
memastikan pelaporan dan proses ensure the incident reporting and
investigasi insiden serta pelaporannya investigation process and reporting
sesuai dengan persyaratan. align with the requirement.
4.4. HSE Team Lead 4.4. HSE Team Lead

 Menginformasikan HSE Performance  Inform HSE Performance Assurance
Assurance Manager untuk setiap Manager for any incident or near miss
insiden atau near miss dan memastikan occurrence and ensure the report goes
laporan masuk ke Incident Reporting to Incident Reporting System in BPM
System di BPM dalam jangka waktu within the applicable time frame. (in 12
yang berlaku (dalam 12 jam untuk hours for Fatality, Partial & Total
Fatality, Partial & Total Disability dan Disability and Lost Time Injury. In 24
Lost Time Injury. Dalam 24 jam untuk hours for other kind of incident).
kejadian lain).
 Meninjau insiden dan laporan  Review the incident and investigation
investigasi bersama incident owner. report with incident owner.
 Memantau pencatatan insiden dan  Monitor the incident recording and
proses investigasi dan pelaporan untuk investigation process and reporting to
memastikan kesesuaiannya dengan ensure its align with the requirement.
persyaratan.
 Melakukan pemeriksaan kualitas  Carry out quality checks before the
sebelum menyetujui laporan insiden approving incident and investigation
dan investigasi. Laporan tersebut harus report. The report should include both
mencakup kualitas dan kelengkapan the quality and comprehensiveness of
investigasi dan tindakan korektif serta the investigation and corrective actions
kelengkapan administrasi. as well as the administrative
completeness.
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4.5. HSE Advisor 4.5. HSE Advisor

 Melaksanakan pemeriksaan kualitas  Carry out quality checks before the
sebelum laporan insiden yang lengkap completed Incident Report is submitted
dimasukkan ke Incident Reporting to Incident Reporting System in BPM.
System di BPM.
 Melakukan pemeriksaan kualitas  Carry out quality checks before the
sebelum laporan investigasi insiden completed Incident Investigation Report
yang lengkap dimasukkan ke Incident is submitted to Incident Investigation
Investigation Reporting System di BPM. Reporting System in BPM. The report
Laporan tersebut harus mencakup should include both the quality and
kualitas dan kelengkapan investigasi comprehensiveness of the investigation
dan tindakan korektif serta kelengkapan and corrective actions as well as the
administrasi. administrative completeness.
5. PELAPORAN INSIDEN 5. INCIDENT REPORTING

Semua Insiden harus dilaporkan dan All Incidents shall be reported and initially
dievaluasi awal melalui Medco E&P evaluated through Medco E&P (Offshore) to
(Offshore) ke Incident Reporting System di Incident Reporting System in BPM within the
BPM dalam jangka waktu yang berlaku applicable time frame (in 12 hours for
(dalam 12 jam untuk Fatality, Partial & Total Fatality, Partial & Total Disability and Lost
Disability dan Lost Time Injury. Dan dalam 24 Time Injury. And in 24 hours for other kind of
jam untuk jenis insiden lain) dan juga incident) and also using One-Page Summary
menggunakan One-Page Summary of Brief of Brief Executive Summary Preliminary
Executive Summary Preliminary Incident Incident Report (BESPIR) (Appendix 12).
Report (BESPIR) (Lampiran 12).
Semua insiden dapat dilaporkan mengikuti All incidents are reportable under this
prosedur ini. Site Line Manager Medco E&P procedure. The Medco E&P (Offshore) Site
(Offshore) bertanggung jawab untuk Line Manager is accountable for initiating the
memulai Pelaporan Insiden. Manajer Divisi / Incident Reporting. The Manager of the
Departemen Incident Owner bertanggung Incident Owner Division / Department is
jawab untuk memulai proses Investigasi accountable to initiate the Incident
Insiden, dengan menunjuk seorang Ketua Investigation process, by appointing an
Tim Investigasi. Investigation Team Leader.
Manajer Divisi / Departemen Incident Owner The Manager of Incident Owner

memvalidasi informasi Insiden (tingkat risiko Division/Department validates the Incident
insiden dapat dikonsultasikan dengan information (the incident risk rank could be
Departemen HSE), memulai penyelidikan, consulted to the HSE Department), initiates
menugaskan pemimpin tim investigasi dan the investigation, assigns the investigation
menyetujui laporan investigasi dan item team leader and approves the investigation
tindakan. report and action items.
5.1. GAMBARAN UMUM PERSYARATAN 5.1. OVERVIEW OF REPORTING

PELAPORAN REQUIREMENTS
5.1.1. Semua insiden pekerjaan yang 5.1.1. All occupational incidents involving
melibatkan Karyawan Medco E&P a Medco E&P (Offshore) or
(Offshore) atau Kontraktor di lokasi Contractor’s Employee at Medco
kerja Medco E&P (Offshore), E&P (Offshore) work site, shall be
harus segera diberitahukan notified to the supervisor of the
kepada supervisor kegiatan di activities at the worksite (Site Line
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lokasi kerja (Site Line Manager). Manager) immediately. The

Pengawas kegiatan (Site Line supervisor of the activities (Site
Manager) harus membuat Laporan Line Manager) shall make Incident
Insiden sesuai petunjuk dalam Report as directed in Incident
Reporting Requirement Summary Reporting Requirement Summary
(Lampiran 5). (Appendix 5).
Perlu dicatat bahwa program It should be noted that the

pelaporan SAFETY CARD dan / SAFETY CARD and/or Near Miss
atau Near miss kemungkinan reporting program may uncover
mengungkap potensi insiden yang significant potential incidents, i.e.
signifikan, yaitu insiden kategori those in HIGH category, these too
TINGGI, ini juga harus dilaporkan should be reported under this
mengikuti prosedur ini. procedure.
HI Potential Near Miss harus HI Potential Near Miss shall be

dilaporkan dan dimasukkan ke reported and entered into the
dalam Incident Reporting System Incident Reporting System in BPM
di BPM untuk investigasi lebih for further investigation and
lanjut dan pelacakan hingga tracking to closure.
selesai.
Semua insiden lingkungan All environmental incidents

(tumpahan hidrokarbon dan bahan (hydrocarbon and chemical spill,
kimia, polusi udara, polusi air, air pollution, water pollution, soil
polusi tanah, kebisingan & getaran pollution, noise & vibration with
dengan dampak ke masyarakt) di public impact) at Medco E&P
tempat kerja Medco E&P (Offshore) worksite shall be
(Offshore) harus dilaporkan ke reported to HSE Department.
Departemen HSE.
Baik formulir Incident Report Both the Incident Report form and
maupun formulir Incident Incident Investigation form are web
Investigation berbasis web based, that is, they are available
tersedia di intranet (di BPM) on the Medco E&P (Offshore)
Medco E&P (Offshore). intranet (on the BPM).
5.1.2. Semua insiden pekerjaan 5.1.2. All occupational incidents are

diselidiki; tingkat investigasi harus investigated; the level of
sesuai dengan tingkat keparahan investigation shall be appropriate
Insiden seperti yang dijelaskan to severity of the Incident as
pada bagian 6.3 dan 6.4. described in section 6.3 and 6.4.
Tanggung jawab penilaian ini The responsibility for this
terletak pada Incident Owner. assessment lies with the Incident
Owner.
Petunjuk untuk menilai potensi Instructions for assessing incident

keparahan insiden dapat dilihat potential severity are to be found in
pada Lampiran 1. Appendix 1.
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5.1.3. Melaporkan insiden yang tidak 5.1.3. Reporting a non-work related

terkait dengan pekerjaan yang incidents involving personal injury
melibatkan cedera pribadi bersifat is optional depending on the
opsional, bergantung pada Incident Owner or Site Line
kebijaksanaan Incident Owner Manager’s discretion in
atau Site Line Manager dalam recognizing the potential of
mengenali potensi kejadian di occurrence in work environment.
lingkungan kerja.
5.1.4. Semua Motor Vehicle Incident 5.1.4. All Motor Vehicle Incidents (MVI)
(MVI) yang melibatkan kendaraan involving Medco E&P (Offshore)
perusahaan Medco E&P company vehicles or Medco E&P
(Offshore) atau kendaraan sewa (Offshore) rent vehicle regardless
Medco E&P (Offshore) terlepas of whether the vehicle are being
dari apakah kendaraan tersebut used for company or personal
digunakan untuk perusahaan atau business, shall be reported. MVI
bisnis pribadi, harus dilaporkan. classified as minor, medium, and
MVI diklasifikasikan menjadi major depends on its damage
minor, medium dan major criteria.
bergantung pada kriteria
kerusakannya.
5.2. PROSEDUR (PELAPORAN INSIDEN 5.2. PROCEDURE (INCIDENT AND NEAR

DAN NEAR MISS) MISS REPORTING)
5.2.1. Segera setelah Insiden terjadi, 5.2.1. As soon as Incident occurs, but no
tetapi tidak lebih dari 12 jam, later than 12 hours, verbal
pemberitahuan lisan harus dibuat notification shall be made by Site
oleh Site Line Manager kepada Line Manager to the Manager of
Manajer Divisi / Departemen Incident Owner
Incident Owner, yang kemudian Division/Department, who will then
akan meneruskan informasi forward the information to the
tersebut ke Line Manager yang applicable higher Line
lebih tinggi dan Sr. Manager HSE. Management and Sr. HSE
Laporan Insiden Resmi harus Manager. Formal Incident report
dimasukkan ke Incident Reporting should be posted in Incident
System di BPM dalam kerangka Reporting System in BPM within
waktu yang berlaku (dalam 12 jam the applicable time frame. (in 12
untuk Fatality, Partial & Total hours for Fatality, Partial & Total
Disability dan Lost Time Injury. Disability and Lost Time Injury. In
Dalam 24 jam untuk insiden lain). 24 hours for other kind of incident).
Silakan merujuk ke HSE Incident Please refer to HSE Incident
Notification Guideline di Lampiran notification guideline in Appendix
12. 12.
Catatan: Note:
Proses untuk mengumpulkan dan The process for capturing and
menyimpan bukti segera setelah preserving evidence immediately
Insiden harus dilakukan dan after an Incident must be
didokumentasikan dengan baik conducted and properly
dalam laporan (lihat Referensi documented in the report (see
Gambar 1). Reference Figure 1).
MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
5.2.2. Manajer Divisi / Departemen 5.2.2. Manager of Incident Owner

Incident Owner harus menunjuk Division / Department shall appoint
Ketua Tim Investigasi untuk Investigation Team Leader to
memulai investigasi dan initiate investigation and its
pelaporannya. reporting.
5.2.3. Incident Owner atau Site Line 5.2.3. Incident Owner or Site Line
Manager bertanggung jawab Manager is accountable to
untuk mengisi Formulir Incident complete Incident Report Form
Report dalam jangka waktu pada within timeframe of Incident
Incident Reporting Requirement Reporting Requirement Summary
Summary (Lampiran 5) - dan (Appendix 5) – and using the
menggunakan formulir elektronik electronic form on the Intranet, or
di Intranet, atau jika tidak tersedia, when not available, the manual
gunakan versi manual (Lampiran version (Appendix 12).
12).
5.2.4. Site Medical Doctor harus 5.2.4. Site Medical Doctor shall report all
melaporkan semua insiden, incidents, including First Aid Cases
termasuk First Aid Cases kepada to the Site Line Manager, using the
Site Line Mangaer, menggunakan ‘Doctor Certificate’ (Appendix 4).
'Sertifikat Dokter' (Lampiran 4).
5.2.5. Ketika melibatkan insiden fatality, 5.2.5. When involving fatality incident,
laporan harus diserahkan oleh Site report shall be submitted by the
Line Manager kepada polisi Site Line Manager to local police
setempat dan dokter pemerintah and government doctor to obtain
untuk mendapatkan sertifikat death certificate. The report shall
kematian. Laporan tersebut harus be copied to Sr. HSE Manager.
dibuatkan salinan untuk Sr. HSE
Manager.
5.2.6. Ketika melibatkan cedera, Site 5.2.6. When involving injury, Site Line
Line Manager dan Site Medical Manager and Site Medical Doctor
Doctor harus menyiapkan Surat should prepare a Recordable
Pernyataan Recordable Injury Injury Statement Letter using
menggunakan Recordable Injury Recordable Injury Statement Form
Statement Form sesuai contoh as per Template at Appendix 6
pada Lampiran 6 “Recordable “Recordable Injury Statement
Injury Statement Form” once the IP Form” once the IP can go back to
can go back to normal duty”. normal duty”.
5.2.7. Perhitungan dan Pelaporan untuk 5.2.7. Calculation and Reporting for
Lost/Restricted Workdays Lost/Restricted Workdays
Jumlah LTI atau Restricted The number of LTI or Restricted
Workdays (berturut-turut atau workdays (consecutive or not)
tidak) harus dihitung di luar hari shall be measure beyond the day
cedera atau timbulnya penyakit, of injury or onset of illness, the
karyawan tidak bekerja atau employee was away from work or
terbatas sampai dibatasi aktivitas limited to restricted work activity
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kerja dikarenakan cedera atau because of an occupational injury

penyakit akibat kerja. LTI / RWI or illness. LTI / RWI begin the next
mulai pada kalender hari calendar day following the
berikutnya setelah batasan yang prescribed restriction and are
ditentukan dan merupakan actual calendar days, and NOT
kalender hari sebenarnya, dan just workdays the employee
BUKAN hanya hari kerja yang actually missed. For extended
benar-benar terlewat oleh cases, the days are capped at 180
karyawan. Untuk kasus yang days. LTI that accumulate in the
diperpanjang, hari dibatasi year after the case actually occurs
menjadi 180 hari. LTI yang are recorded in the year the case
terakumulasi pada tahun setelah actually recorded.
kasus benar-benar terjadi dicatat
pada tahun dimana kasus
sebenarnya dicatat.
5.2.8. Insiden Lingkungan: 5.2.8. Environmental incidents:

Semua insiden lingkungan harus All environmental incidents shall
dilaporkan ke Departemen HSE; be reported to HSE Department;
namun, terdapat batasan waktu however, the following volume of
untuk melaporkan kejadian spill have time limit to report:
tumpahan:
 Tumpahan Minyak (>15 bbls)  Oil Spill (>15 bbls) shall be
harus dilaporkan ke reported to HSE Department,
Departemen HSE, dan and will further report it to
selanjutnya akan dilaporkan MIGAS within 24 hours.
ke MIGAS dalam waktu 24
jam.
 Tumpahan bahan kimia  Toxic chemical spills shall be
beracun harus dilaporkan ke reported to HSE Department
Departemen HSE dalam within 24 hours.
waktu 24 jam.
Berikut ini adalah persyaratan The following are the

pelaporan tumpahan hidrokarbon requirements for Medco E&P
cair dan bahan kimia di Medco (Offshore) liquid hydrocarbon and
E&P (Offshore): chemical spill reporting:
A. Tumpahan Hidrokarbon: A. Hydrocarbon Spill:
Setiap tumpahan Any hydrocarbon Spill shall
hidrokarbon harus dilaporkan be reported into Medco E&P
ke Online Incident Reporting (Offshore) Online Incident
System Medco E&P Reporting System in BPM,
(Offshore) di BPM, dan and to Corporate using LAK
kepada Corporate dengan format and one-page
menggunakan format LAK summary within 1 x 24 hours.
dan ringkasan satu halaman
dalam waktu 1 x 24 jam.
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B. Tumpahan Produced Water: B. Produced Water Spill:

Setiap tumpahan produced Any produced water spill shall
water harus dilaporkan ke be reported into Medco E&P
Online Incident Reporting (Offshore) Online Incident
(Offshore) di BPM, dan and to Corporate using LAK
kepada Corporate dengan format and one-page
format LAK dan ringkasan summary within 1 x 24 hours.
satu halaman dalam waktu 1
x 24 jam.
C. Tumpahan Bahan Kimia: C. Chemical Spill:
Setiap tumpahan bahan Any chemical spill shall be
kimia harus dilaporkan ke reported into Medco E&P
Online Incident Reporting (Offshore) Online Incident
(Offshore) di BPM, dan and to Corporate using one-
kepada Corporate page summary within 1 x 24
menggunakan ringkasan hours.
satu halaman dalam waktu 1
x 24 jam.
D. Pelepasan Gas: D. Gas Release:
Setiap pelepasan gas harus Any gas release shall be
dilaporkan ke Online Incident reported into Medco E&P
Reporting System Medco (Offshore) Online Incident
E&P (Offshore) di BPM, dan Reporting System in BPM,
kepada Corporate and to Corporate using one-
menggunakan ringkasan page summary within 1 x 24
satu halaman dalam waktu 1 hours.
x 24 jam.
Catatan: Note:
Tumpahan termasuk Spills include any accidental
pelepasan yang tidak or unplanned release from:
disengaja atau tidak
direncanakan dari:  Primary containment
 Penahanan primer  Sabotage, earthquakes
 Sabotase, gempa bumi or other accidental
atau pelepasan tidak release due to events
disengaja lainnya outside operational
karena kejadian di luar control
kendali operasional
 Transportasi yang  Company-owned and
dimiliki dan operated transport
dioperasikan oleh
perusahaan
 Kandungan hidrokarbon  The hydrocarbon
dalam campuran content of oil/water
minyak / air (mis. Emulsi mixtures (e.g. oil-water
minyak-air, dasar emulsions, tank
tangki) bottoms)
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 Kebocoran di atas atau  On-going aboveground

bawah tanah yang terus or underground leakage
terjadi sepanjang waktu, over time, counted once
dihitung sekali dalam in the month it is
sebulan saat identified.
teridentifikasi.
Tumpahan tidak termasuk: Spills do not include:

 Riwayat atau bekas  Historical or past
Kebocoran dari tanki leakage that reaches
yang mencapai the natural environment
lingkungan alam, pipa from tanks, pipes or
atau kapal lain, tidak other vessels, not
terkait dengan associated with a
pelepasan saat ini. current release.
5.2.9. Perhitungan tumpahan/pelepasan 5.2.9. Calculation of spill/release

Perkiraan volume tumpahan Best estimate of volume of
hidrokarbon terbaik harus hydrocarbon spilled should be
diperoleh dengan menggunakan obtained using the most
metode yang paling tepat. Dalam appropriate methods. In most
kebanyakan kasus, ini akan cases it will be derived from
diperoleh dari pengetahuan knowledge of original volume and
tentang volume awal dan isi wadah contents of the container involved
yang terlibat dalam tumpahan. in the spill.
Volume yang tumpah harus The volume spilled should be
didasarkan pada jumlah perkiraan based on the amount of the total
total kehilangan dari penampung estimated lost from primary
primer, dan tidak boleh dikurangi containment, and should not be
dengan jumlah recovered reduced by the amount of
hydrocarbon. hydrocarbon recovered.
5.2.10. Process Safety Events 5.2.10. Process Safety Events

Loss of Primary Containment Unintentional and/or
(LOPC) yang tidak disengaja uncontrolled loss of primary
dan/atau tidak terkendali dari containment (LOPC) of
fluida proses hidrokarbon
hydrocarbon process fluid (oil,
(minyak, kondensat, gas) dan air
terproduksi atau material condensate, gas) and produced
terkait/pendukung dengan water or associated/supporting
konsekuensi mengacu pada API material with consequence refer
RP 754 di fasilitas produksi hulu to API RP 754 in upstream
yang berada di bawah kendali production facility under
operasional perusahaan. company operational control.
PSE Tier 1 dan Tier 2 PSE Tier 1 and Tier 2

Cedera karyawan atau kontraktor Employee or contractors injury
 Tier 1: menyebabkan LTI dan  Tier 1 : causing lost time injury
atau kematian, atau and or fatality, or hospital
menyebabkan harus di-rumah
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sakit-kan dari pihak ketiga (non- admission of external party

karyawan / kontraktor). (non-employee/contractors).
 Tier 2: menyebabkan recordable  Tier 2 : causing recordable
injury
injury
Dampak terhadap evakuasi /
tempat penampungan masyarakat Impact upon community
 Tier 1: menyebabkan evakuasi evacuation/ shelter
komunitas atau tempat  Tier 1: causing officially
penampungan komunitas yang declared community evacuation
diumumkan secara resmi. or community shelter in place.
 Tier 2: tidak diaplikasikan
 Tier 2 : n/a
Kebakaran atau Ledakan
 Tier 1: menyebabkan biaya Fire or Explosion
langsung ke perusahaan lebih  Tier 1: causing direct cost to
besar atau sama dengan USD company greater or equal to
100.000, - USD 100.000,-
 Tier 2: menyebabkan biaya  Tier 2: causing direct cost to
langsung ke perusahaan lebih
company greater or equal to
besar atau sama dengan USD
2.500, - USD 2.500,-
Di atas ambang batas Over threshold

Setiap pelepasan dari primary Any release from primary
containment yang lebih besar dari containment greater than stated
yang terdapat di Lampiran 15,
on Appendix 15, including
termasuk pelepasan dari Pressure
Relief Device baik secara release from Pressure Relief
langsung atau melalui Device whether directly or via
downstream destructive device downstream destructive device
yang mengakibatkan cairan that result on liquid carryover,
terbawa, dibuang ke lokasi yang discharge to unsafe location, on
tidak aman, di tempat site shelter or public area.
penampungan atau area publik.
 Tier 1, greater than table 1 on
 Tier 1, lebih besar dari tabel 1
(Lampiran 15) Appendix 15
 Tier 2, lebih besar dari tabel 2  Tier 2, greater than table 2 but
tetapi tidak melebihi tabel 1 not exceed table 1 on Appendix
(Lampiran 15) 15
PSE Tier 3 – Challenge to

PSE Tier 3 - Tantangan untuk
Safety Systems
Sistem Keamanan
Tujuan - Biasanya mewakili • Purpose − Typically represent
tantangan terhadap sistem challenges to the barrier system
penghalang yang berkembang di that progressed along the path to
sepanjang jalur menuju bahaya, harm, but were stopped short of
tetapi dihentikan sebelum a Tier 1 or Tier 2 PSE
konsekuensi PSE Tier 1 atau Tier
consequence
2
Contoh: Ekskursi Batas Operasi Examples − Safe Operating

yang Aman - Inspeksi Penahanan Limit Excursions − Primary
Utama atau Hasil Pengujian Di Containment Inspection or
Luar Batas yang Dapat Diterima - Testing Results Outside
Tuntutan pada Sistem Acceptable Limits − Demands on
Keselamatan - LOPC Lainnya.
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Safety Systems − Other LOPC

Events
Process Safety Near Miss Process Safety Near Miss

Suatu kejadian yang tidak An undesired event that under
diinginkan yang dalam keadaan slightly different circumstances
yang sedikit berbeda dapat could have resulted in PSE that
mengakibatkan PSE yang potentially harm to people,
berpotensi membahayakan orang, damage to asset, equipment or
kerusakan aset, peralatan atau environment or loss of process.
lingkungan atau hilangnya proses.
Examples of Process Safety
Contoh dari Process Safety Near Miss:
Near Miss: • External cause under company
• Penyebab dari eksternal yang operational control, e.g.
berada dibawah kendali dropped object, vehicle impact,
operasional perusahaan, anchor dragging, vessel
misalnya: benda jatuh, benturan impact, that potentially could
kendaraan, tarikan jangkar, resulted LOPC
benturan kapal, yang berpotensi • Free span exceeding
mengakibatkan LOPC acceptance criteria
• Free span melebihi kriteria yang • Vibration exceeding
diterima acceptance criteria
• Getaran melebihi kriteria • Exceeding SOL for pressure
diterima protection system
• Melebihi SOL untuk sistem • Activation of trip system that
perlindungan tekanan directly leading to LOPC, i.e.
• Aktivasi sistem trip yang level trip on Flare KO Drum
langsung menuju ke LOPC, • Activation of system used for
yaitu level trip pada Flare KO maintain SOL, i.e. under
Drum condition based on design act
• Aktivasi sistem yang digunakan as last layer protection, e.g.
untuk memelihara SOL, yaitu PCV used as relief system
dalam kondisi berdasarkan • Activation of last well barrier
desain bertindak sebagai system, e.g. BOP, SCSSV,
perlindungan lapisan terakhir, Master Valve (if the well have
mis. PCV digunakan sebagai no SCSSV), etc.
sistem bantuan • Exceeding mechanical
• Aktivasi sistem well barrier temperature design limit of the
terakhir, misalnya BOP, SCSSV, well, piping, equipment, tank or
Master Valve (jika well tidak vessel
memiliki SCSSV), dll. • A plugged process line that
• Melebihi batas desain suhu could have realistically led to
mekanis dari sumur, perpipaan, loss of primary containment
peralatan, tangki atau vessel • Identification of valve
• Process line terpasang yang misalignment prior to
secara realistis dapat performing work that could
menyebabkan loss of primary have realistically led to loss of
containment primary containment
• Identifikasi ketidaksejajaran • Release of acid gas, steam,
valve sebelum melakukan sulphur, H2S, hot oil, nitrogen
pekerjaan yang secara realistis that potential could harm
dapat menyebabkan loss of personnel in the release area
primary containment under different circumstances
• Pelepasan gas asam, uap,
belerang, H2S, hot oil, nitrogen
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yang berpotensi
membahayakan personel di
area pelepasan dalam keadaan
berbeda
5.2.11. Departemen HSE akan meringkas 5.2.11. HSE Department shall summarize
semua laporan, menyiapkan all reports, prepare company and
statistik perusahaan dan corporate statistic, and share the
corporate, dan membagikan report to all operating
laporan tersebut ke semua departments.
departemen yang beroperasi.
5.3. PELAPORAN CORPORATE 5.3. CORPORATE REPORTING

Semua insiden dan near miss All incidents and near miss are
dilaporkan ke Medco E&P Corporate, reportable to Medco E&P Corporate, as
begitu pula statistik insiden keseluruhan are overall incident statistics and
dan data jam pajanan. Persyaratan ini exposure hour data. These
ditentukan dalam Lampiran 5. requirements are specified in Appendix
Pertanggungjawaban pelaporan ke 5. The accountability for corporate
corporate berada di Medco E&P reporting lies with the Medco E&P
Corporate Senior VP Offshore Asset, Corporate Senior VP Offshore Asset,
dan dapat didelegasikan kepada VP and could be delegated to VP Operation
Operation untuk Operation dan kepada for Operation and to Sr. Mgr. Well
Sr. Mgr. Well Operations for Drilling. Operations for Drilling.
Semua insiden Kontraktor harus All Contractors incidents must be

dilaporkan ke Divisi HSE Offshore reported to Offshore Asset HSE
Asset; pertanggungjawaban untuk ini Division; the accountability for this lies
berada di Incident Owner / Site Line with the Incident Owner / Site Line
Management. Management.
Departemen Legal dan HR Medco E&P Medco E&P (Offshore) Legal and HR
(Offshore) juga harus disarankan Departments must also be advised of
mengenai setiap cedera yang diderita any injuries suffered by anyone working
oleh siapa pun yang bekerja atas nama on behalf of Medco E&P (Offshore).
Medco E&P (Offshore). Ini dicapai This is achieved by copy of the full form
dengan salinan formulir lengkap ke to the Legal Department, Jakarta by
Departemen Legal Jakarta oleh Divisi Offshore Asset HSE Division.
HSE Offshore Asset.
5.4. PELAPORAN KE LEMBAGA 5.4. REPORTING TO THE REGULATORY

PEMERINTAH AUTHORITIES
Insiden tertentu dapat dilaporkan Certain incidents are reportable to the
kepada Lembaga Pemerintah, biasanya Regulatory Authorities, normally by Sr.
oleh Sr. HSE Manager dan Technical HSE Manager and assigned Technical
Head/Prospector/Deputies yang Head/Prospector/Deputies. These
ditunjuk. Lembaga ini termasuk MIGAS Authorities include MIGAS and various
dan lembaga lainnya yang berkaitan others relating to environmental
dengan insiden lingkungan. Jika incidents. If there is any doubt
terdapat keraguan mengenai regarding the requirement to report to
persyaratan pelaporan ke Lembaga the Regulatory Authorities, Offshore
MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
Pemerintah, harus segera berkonsultasi Asset HSE Division should be consulted

dengan Divisi HSE Offshore Asset. without delay.
5.4.1. Insiden yang Dilaporkan ke 5.4.1. MIGAS Reportable Incidents

MIGAS
Insiden yang harus dilaporkan ke The incidents that are reportable to
MIGAS terdapat pada Lampiran 5. MIGAS are contained in Appendix
Formulir yang akan dilaporkan 5. The forms to be reported are
terdapat pada Lampiran 4. contained in Appendix 4.
Untuk suatu insiden, laporan For an incident, the completed

lengkap yang ditandatangani oleh report, signed by the registered
"Kepala Teknis" yang terdaftar, “Technical Head”, should be sent
harus dikirim ke Divisi HSE to Offshore Asset HSE Division for
Offshore Asset untuk diteruskan on-passing and not directly to
dan tidak langsung ke MIGAS. Sr. MIGAS. The Sr. HSE Manager
HSE Manager yang ditunjuk designated as the focal point for
sebagai titik fokus kontak dengan contact with MIGAS will formally
MIGAS akan secara resmi transmit all HSE reports to MIGAS.
mengirimkan semua laporan HSE
ke MIGAS.
Setiap tumpahan hidrokarbon Any spill of hydrocarbons over 15

lebih dari 15 bbls (misalnya bbls (e.g. oil, diesel, condensate
minyak, solar, kondensat dan and spills of oil-based mud (unless
tumpahan lumpur berbasis minyak it has been proved to be non-
(kecuali telah terbukti non-TOXIC TOXIC after toxicity tests)) shall be
setelah uji toksisitas)) harus reported to MIGAS by Sr. HSE
dilaporkan ke MIGAS oleh Sr. Manager and assigned Technical
Manager HSE dan Technical Head/Prospector/Deputies.
Head/Prospector/Deputies yang Guidance on spill response,
ditugaskan. Panduan penanganan including the reporting
tumpahan, termasuk persyaratan requirements, is given in the
pelaporan, diberikan di lokasi Oil location Oil Spill Contingency Plan
Spill Contingency Plan (OSCP). (OSCP).
5.5. PERSYARATAN PEMBERITAHUAN 5.5. NOTIFICATION REQUIREMENT

Peristiwa harus dilaporkan sesuai Events must be reported per Appendix
dengan Lampiran 12 Persyaratan 12 Medco E&P (Offshore) Incident
Pemberitahuan Insiden Medco E&P Notification Requirements.
(Offshore).
6. INVESTIGASI INSIDEN 6. INCIDENT INVESTIGATION

6.1. GAMBARAN UMUM 6.1. OVERVIEW
Semua insiden yang dilaporkan dalam All reported incidents in the Incident
formulir Incident Report harus Report form shall be investigated. The
diinvestigasi. Hasil dari semua outcome of all investigations will result
investigasi yaitu: in:
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• Identifikasi penyebab dasar  Identification of the basic causes

sesuai dengan versi terbaru dari as per the latest version of the
Systematic Causes Analysis Systematic Causes Analysis
Technique (SCAT), Technique (SCAT),
• Belajar dari mana organisasi  Learning from which the
dapat memperoleh manfaat, organisation can benefit,
• Tindakan untuk mencegah  Actions to prevent recurrence
terulang kembali (diperlukan (corrective action needed –
tindakan korektif - CAN), CAN),
• Kepatuhan terhadap peraturan  Regulatory and Corporate
dan persyaratan pelaporan reporting requirements
Corporate. compliance.
Investigasi Insiden dan near miss risiko Investigations High Risk incidents and
tinggi harus didokumentasikan dan item near misses are to be documented and
tindakan harus dilacak hingga selesai action items shall be tracked to closure
menggunakan database lokal. Semua using the local database. All ‘High’ risk
insiden dan near miss risiko ‘Tinggi’ incidents and near misses must be
harus diinvestigasi menggunakan investigated using any investigation
metode investigasi apa pun yang method that allow the investigation
memungkinkan tim investigasi mencari team to seek root/basic causes and
akar / dasar penyebab dan penyebab latent causes (e.g. Failsafe - Latent
laten (misalnya, Failsafe – Latent Cause Analysis).
Cause Analysis).
Insiden Rendah dan Menengah Low and Medium (Risk Category I and
(Kategori Risiko I dan II) dapat II) incidents can utilize intranet SCAT-
menggunakan metode Intranet SCAT- based method or Failsafe Training:
based atau Failsafe Training: Latent Latent Cause Analysis methodology,
Cause Analysis methodology, depending on the discretion of the
tergantung pada kebijaksanaan line respective line management.
management terkait.
Dalam proses pemilihan anggota tim In the selection process of LCA

investigasi LCA, Investigator Utama investigation team members, the Lead
harus menghadiri Pelatihan LCA Investigator shall have attended LCA
(Failsafe Training: Latent Cause Training (Failsafe Training: Latent
Analysis) atau pelatihan investigasi Cause Analysis) or any similar
serupa seperti TapRoot®. Untuk investigation training such as
investigasi SCAT, Investigator Utama TapRoot®. For SCAT investigations,
harus menghadiri Pelatihan Medco E&P the Lead Investigator shall have
(Offshore) tentang Investigasi Insiden attended Medco E&P (Offshore)
dan Sistem Pelaporan. Training of Incident Investigation and
Reporting System.
Panduan Lengkap tentang investigasi Complete Guidance on incident

insiden menggunakan SCAT dapat investigation using SCAT is presented
dilihat pada Lampiran 2. in Appendix 2.
6.2. INVESTIGASI INSIDEN – PEDOMAN 6.2. INCIDENT INVESTIGATION –

UMUM GENERAL GUIDANCE
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6.2.1. Ketua Tim Investigasi akan 6.2.1. The Investigation Team Leader
membentuk tim investigasi dengan shall form the investigation team in
berkonsultasi dengan Manajer consultation with Manager of the
Divisi / Departemen Incident Incident Owner Division/
Owner. Department.
6.2.2. Semua insiden dan near miss 6.2.2. All incidents and near misses must
harus diidentifikasi, dilaporkan, be identified, reported, recorded,
dicatat, diinvestigasi, ditangani, investigated, addressed, and
dan dilacak sampai selesai. tracked for closure.
6.2.3. Investigasi insiden dan near miss 6.2.3. Investigations of ‘High Potential’
risiko ‘High Potential’ dan nyaris risk incidents and near misses must
celaka harus diselesaikan dan be completed and documented
didokumentasikan dalam waktu 30 within 30 (thirty) days of the incident
(tiga puluh) hari sejak insiden atau or near miss. In term of the
near miss. Dalam hal proses investigation process requires
investigasi yang memerlukan extension due to waiting for other
perpanjangan karena menunggu action completion, such as
penyelesaian action lain, seperti uji laboratory test, or waiting key
laboratorium, atau menunggu personnel return from CTO for
personel utama kembali dari CTO interview purpose, etc, the incident
untuk keperluan wawancara, dll, owner shall inform the Vice
incident owner harus President and HSE Division if an
menginformasikan kepada Vice investigation cannot be closed
President dan Divisi HSE jika within 30 (thirty) days and provide
investigasi tidak dapat ditutup justification an extension is
dalam waktu 30 (tiga puluh) hari warranted. Format of request
dan memberikan justifikasi incident investigation deferral is
menjamin perpanjangan. Format presented in Appendix 10.
permintaan penangguhan
investigasi insiden dapat dilihat di
Lampiran 10.
6.2.4. Kekurangan sistem manajemen 6.2.4. Management system deficiencies

yang teridentifikasi dalam identified in investigations of ‘High’
investigasi insiden dan near miss risk incidents and near misses must
risiko 'Tinggi' harus diidentifikasi be identified and recorded. Actions
dan dicatat. Tindakan yang proposed to address the root
diusulkan untuk mengatasi akar cause(s) identified during the
masalah yang telah diidentifikasi incident or near miss investigation
selama investigasi insiden atau must also address the HSEMS
nearmiss juga harus membahas element(s) that need to be
elemen HSEMS yang perlu strengthened.
diperkuat.
6.2.5. Investigasi insiden harus 6.2.5. The investigation incidents shall be

diselesaikan dalam waktu 30 (tiga completed within 30 (thirty) days for
puluh) hari untuk investigasi SCAT or Latent Cause Analysis
dengan SCAT atau Latent Cause (Failsafe® or TapRoot®)
investigation.
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Analysis (Failsafe® atau

TapRoot®).
6.2.6. Duration of investigation could be
6.2.6. Durasi investigasi dapat prolonged if further analysis is
diperpanjang jika analisis lebih required utilizing the external
lanjut diperlukan dengan parties (i.e. laboratory analysis).
memanfaatkan pihak eksternal
(misalnya analisis laboratorium).
6.2.7. Consultation with a Company Legal
6.2.7. Konsultasi dengan Penasihat Counsel is required prior to the
Hukum Perusahaan diperlukan initiation of an investigation of the
sebelum memulai penyelidikan following events:
untuk peristiwa berikut:  A fatality
• Kematian  An injury requiring overnight
• Cedera yang membutuhkan hospitalization in which
rawat inap semalaman yang treatment is required
memerlukan perawatan  A potential significant
• Potensi dampak lingkungan environmental impact
yang signifikan  An evacuation of workers
• Evakuasi pekerja dari fasilitas from Company facilities
Perusahaan  An evacuation or shelter-in-
• Evakuasi atau tempat place of members of the
berlindung dari masyarakat surrounding community
sekitar  Irrespective of the level of the
• Terlepas dari tingkat investigation, the process
investigasi, proses harus shall have initial response,
memiliki respons awal, information collection, causal
pengumpulan informasi, analysis, develop and take
analisis sebab akibat, action.
membuat dan mengambil
tindakan.
6.2.8. In the event of multiple casualties,
6.2.8. Dalam hal terjadi banyak korban, serious injury, or a fatality, the
cedera serius, atau kematian, scene of the incident shall be
tempat kejadian harus diamankan secured for preserving evidence.
untuk menjaga bukti. Terdapat There are exceptions, such as
pengecualian, seperti mematikan shutting down power, bleeding off
daya listrik, membuang tekanan, pressure, providing medical
penanganan medis, dll., sesuai attention, etc., as necessary. The
kebutuhan. Lokasi insiden tidak incident scene is not to be disturbed
boleh diganggu sampai until approval is obtained from the
persetujuan diperoleh dari Department Manager.
Manajer Departemen.
6.2.9. An investigation of High Potential

6.2.9. Investigasi insiden dan near miss risk incidents and near misses shall
risiko High Potential harus identify type of incident, immediate
menentukan jenis insiden, causes, basic causes, Control
penyebab langsung, penyebab Areas for Improvement Actions and
dasar, control area untuk Tindakan Corrective Action Need (CAN) as
Perbaikan dan Corrective Action per the latest version of the
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Need (CAN) sesuai dengan versi Systematic Causes Analysis

terbaru dari Sytematic Causes Technique (SCAT)
Analysis Technique (SCAT)
6.2.10. Aircraft/boat incidents shall be
6.2.10. Insiden pesawat / kapal harus investigated immediately, led by the
segera diselidiki, dipimpin oleh Manager of Incident Owner
Manajer Divisi / Departemen Division/Department. The
Incident Owner. Pesawat / kapal aircraft/boat is to be shut down until
akan dimatikan sampai the preliminary investigation is
penyelidikan awal selesai. Manajer completed. The Manager of the
perusahaan kontraktor pesawat / aircraft/boat contractor company,
kapal, Manajer Logistik & MM, dan Logistics & MM Manager, and HSE
Manajer HSE harus segera Manager shall be informed as soon
diberitahu setelah kejadian after the incident as is practicable.
tersebut jika memungkinkan. Incidents of this nature may require
Insiden semacam ini mungkin specialist investigators.
memerlukan penyelidik ahli.
6.3. ASSESSING INCIDENT SEVERITY
6.3. MENILAI TINGKAT KEPARAHAN
INSIDEN The first stage in the investigation and
Tahap pertama dalam proses reporting process is to assess the
investigasi dan pelaporan adalah severity / consequence of the Incident.
menilai tingkat keparahan / Once an Incident has occurred and has
konsekuensi insiden. Setelah Insiden been reported, the Incident Owner will
terjadi dan telah dilaporkan, incident assess the severity of the Incident using
owner akan menilai tingkat keparahan the approved Risk Matrix. Incident
insiden menggunakan Matriks Risiko Owner may involve consultations with
yang disetujui. Incident Owner HSE as appropriate. Instructions for
sewajarnya mungkin berkonsultasi assessing incident severity based on
dengan HSE. Petunjuk untuk menilai Risk Matrix are contained in Appendix 1.
tingkat keparahan insiden berdasarkan
Matriks Risiko terdapat di Lampiran 1.
The Incident Owner must use the Risk
Incident Owner harus menggunakan Matrix to risk rank the event and assess
Matriks Risiko untuk memeringkat risiko the damage or injury that could have
kejadian dan menilai kerusakan atau occurred. The most realistic potential
cedera yang mungkin terjadi. consequence is used, assessing the
Digunakan potensi konsekuensi yang damage or injury that could have
paling realistis dalam menilai kerusakan occurred.
atau cedera yang mungkin terjadi.
Incidents may be wholly safety related,
Insiden dapat sepenuhnya terkait property related, wholly environmental,
keselamatan, properti, lingkungan, atau or combinations of safety, property and
kombinasi konsekuensi keselamatan, environmental consequences. Incident
properti, dan lingkungan. Tingkat severity is assessed differently for the
keparahan insiden dinilai secara safety, property, environmental or other
berbeda untuk keselamatan, properti, consequences.
lingkungan atau konsekuensi lainnya.
6.4. INCIDENT INVESTIGATION TEAM
6.4. SUSUNAN TIM INVESTIGASI COMPOSITION
INSIDEN
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Setelah indeks / kategori keparahan Once the severity index/category has

ditentukan, Ketua Tim Investigasi harus been determined, the Investigation
menunjuk tim investigasi yang sesuai Team Leader should appoint an
dengan berkonsultasi pada Manajer appropriate investigation team in
Divisi / Departemen Incident Owner. consultation with Manager of Incident
Owner Division/Department.
Prinsip panduannya adalah bahwa The guiding principle is that team

kemandirian tim harus meningkat independence should increase with
sesuai tingkat keparahan insiden. incident severity. The following
Bagian berikut menunjukkan tingkat sections indicate the required degree of
kemandirian yang diperlukan untuk independence for the Team Leader and
Ketua Tim dan Anggota Tim. Bahkan Team Members. Even for
untuk insiden dengan peringkat risiko LOW/MEDIUM risk ranked incidents,
RENDAH / SEDANG, Pimpinan dan the Leader and Team Members must
Anggota Tim tidak boleh terlibat not have been directly involved in the
langsung dalam insiden tersebut. incident.
I/RENDAH: baik Ketua maupun Tim I/LOW: both Leader and Team can be
bisa dari Bagian atau Departemen yang from the Section or Department
terlibat dalam insiden tersebut. involved in the incident.
II/SEDANG: seperti I/RENDAH. II/MEDIUM: as for I/LOW, however, it is

Namun, lebih disukai jika Ketua berasal preferable for the Leader to be from a
dari Bagian atau Departemen yang different Section or Department (e.g.
berbeda (misalnya, Operations Operations Supervisors for a
Supervisor untuk insiden di bagian Maintenance incident).
Maintenance).
III/TINGGI: Ketua dan sebagian besar III/HIGH: the Leader and the majority of
Tim harus dari Bagian atau Departemen the Team must be from a different
yang berbeda. Namun, beberapa Section or Department. However, some
anggota Bagian atau Departemen yang members of the Section or Department
terlibat dalam insiden tersebut dapat involved in the incident can be included
dimasukkan untuk pengetahuan lokal, for local knowledge, with consultation to
dengan konsultasi ke Departemen HSE Department.
HSE.
For High Risk incidents and near misses
Untuk insiden dan near miss risiko that are evaluated as Risk Category III,
Tinggi yang dievaluasi sebagai Risiko the investigation shall be led by an
Kategori III, investigasi harus dipimpin appropriately trained investigator
oleh penyelidik terlatih yang didukung supported by a manager or supervisor.
oleh manajer atau supervisor. Ketua Team Leaders should be Supervisors,
Tim haruslah Supervisor, Manajer, Managers, Section Leaders or other
Section Leader atau personel lain personnel with sufficient experience,
dengan pengalaman, kredibilitas, dan credibility and authority. All Leaders
otoritas yang memadai. Semua Ketua must have been trained in this
harus dilatih berdasarkan prosedur ini; procedure; it is preferable that Team
sebaiknya Anggota Tim juga dilatih. Members are also trained.
HSE Advisor dapat memberikan The HSE Advisor can provide advice
masukan, namun, jika memungkinkan but wherever practicable, should remain
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harus tetap objektif dalam investigasi sufficiently detached from the

agar laporan investigasi dapat dibuat investigation to be able to carry out a
dengan kualitas yang berarti. meaningful quality check on the
investigation report.
6.5. MELAKUKAN INVESTIGASI 6.5. CONDUCTING THE INVESTIGATION

Tujuan dari investigasi adalah untuk The objective of an investigation is to
menetapkan penyebab dasar, Area establish the basic cause(s), Control
Kontrol untuk Tindakan Perbaikan Areas for Improvement Actions (as per
(sesuai dengan versi terbaru dari the latest version of the SCAT) and to
SCAT) dan untuk meningkatkan dan raise and close-out corrective actions to
menutup tindakan korektif untuk prevent recurrence. The investigation
mencegah terulang kembali. Proses process, from initiation to action close-
investigasi dari inisiasi hingga out, is the responsibility of the Team
penutupan tindakan menjadi tanggung Leader.
jawab Ketua Tim.
Terlepas dari tingkat investigasi, Irrespective of the level of the

prosesnya harus mengikuti tahapan investigation, the process should follow
dasar berikut: the following basic stages:
 Mendapatkan dan menyimpan  Capture and preserve evidence
bukti segera setelah insiden immediately after an incident
 Mengumpulkan bukti  Collection of evidence
 Menyusun dan memeriksa  Collation and cross checking of
kembali bukti evidence
 Menganalisis akar penyebab dan  Root cause analysis and basic
mengidentifikasi dasar penyebab cause identification
 Meningkatkan tindakan korektif  Raise corrective actions to
untuk mengatasi dasar penyebab; address basic cause(s); assign
menetapkan tanggung jawab dan responsibilities and deadlines for
tenggat waktu penyelesaian; completion; ensure all actions are
memastikan semua tindakan closed-out
ditutup
Peringkat risiko akan menentukan The risk rank will determine the extent
cakupan dan kedalaman investigasi. and depth of the investigation. The
Upaya terbesar harus dipusatkan pada greatest effort should be concentrated
insiden di mana dampak sebenarnya on incidents where the actual outcome
telah mengakibatkan cedera serius, has resulted in serious injury, ill health,
kesakitan, kehilangan atau kerusakan loss or damage and those that are in the
dan yang berada di zona TINGGI dalam HIGH zones in the risk ranking.
peringkat risiko.
Sesuai Kebijakan Penyalahgunaan Zat As stated by Medco E&P (Offshore)

Medco E&P (Offshore), orang-orang Substance Abuse Policy, the person(s)
yang terlibat dalam recordable incident who are involved in recordable incident
dan insiden High Potential perlu diuji and high potential incident need to be
untuk penyalahgunaan zat (obat-obatan tested for substance abuse (drug and
dan alkohol) dalam waktu 2 hari setelah alcohol) within 2 days after event of
kejadian dan kecelakaan apabila perlu. incident and accident, if necessary.
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Formulir Laporan Investigasi harus diisi An Investigation Report Form shall be

oleh Ketua Tim Investigasi dengan completed by the Investigation Team
menggunakan formulir elektronik di Leader using the electronic form on the
Intranet, atau jika tidak tersedia, Intranet, or when not available, using
menggunakan versi manual. the manual version.
Laporan investigasi insiden dan near Investigation reports of High Risk

miss Risiko Tinggi harus menggunakan incidents and near misses shall use the
format standar Medco E&P (Offshore). Medco E&P (Offshore) standard format.
Penyimpangan persyaratan ini harus Deviation of this requirement shall
dilanjutkan dengan persetujuan Line proceed with Line Management and
Manager dan HSE. HSE approvals.
6.6. KOMUNIKASI BELAJAR DARI 6.6. COMMUNICATION OF LEARNING

INSIDEN (LFI) FROM INCIDENTS (LFI)
Komunikasi belajar dari insiden (LFI) The communication of the learning from
merupakan bagian penting untuk incidents (LFI) is a vital part of
mencegah insiden terulang kembali. Ini preventing recurrence. This must be
harus dikenali oleh tim investigasi dan recognized by investigation teams and
tindakan rekomendasi dimunculkan recommendation actions are raised to
untuk memastikan bahwa komunikasi ensure that communication of learning
pembelajaran sesuai, cukup dan tepat is suitable, sufficient and timely. This is
waktu. Ini adalah tanggung jawab Ketua the responsibility of the Investigation
Tim Investigasi. Team Leader.
Komunikasi bisa di lokasi (melalui crew Communication can be on-location (by

briefing) atau antar lokasi (dengan crew briefing) or between locations (by
petunjuk tertulis). Bergantung pada written advice). Depending on the
pentingnya pembelajaran dan keluasan significance of the learning and the
relevansinya, formal Lessons Learned, breadth of its relevance, formal Lessons
Bulletins atau Alerts dapat dimunculkan Learned, Bulletins or Alerts may be
oleh Divisi HSE Offshore Asset atau raised by Offshore Asset HSE Division,
lintas industry oleh Divisi HSE Offshore or cross-industry, by Offshore Asset
Asset. Insiden atau near miss dengan HSE Division. Incident or near miss with
High Potential (HIPO) harus dibagikan High Potential (HIPO) shall be shared to
ke Corporate HSE. Corporate HSE.
Site Line Manager atau Supervisor Site Line Manager or the next direct
langsung berikutnya (jika mereka supervisor (if they are not available:
tidak ada: Field Manager atau Project Field Manager or Project Manager) is
Manager) diharuskan untuk required to present the High Potential
mempresentasikan Risiko High Risk and near misses and Recordable
Potential dan near miss dan Recordable Injury incidents to HSE Action
injury incident kepada HSE Action Committee.
Committee.
Kepala Divisi HSE / HSE Corporate Head of HSE Division/Corporate shall

wajib mengkaji efektifitas Learned From review the effectiveness of Learned
Incident (LFI) dengan membuat analisa, From Incident (LFI) by making analysis,
pengukuran kecenderungan (trending) trending and evaluation at least in every
dan evaluasi menyeluruh minimal
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setiap 3 (tiga) tahun sekali atau 3 (three) years or whanever a significant

bilamana terjadi perubahan yang change occurs.
signifikan.
Sesi Lesson Learned paling efektif bisa

dilakukan dengan proses yang Lessons learned sessions are most
terdefinisi dengan baik dibawah ini: effective with below well-defined
• Identifikasi dan mengumpulkan process:
semua rekomendasi • Identify and collect all
• Dokumentasikan semua temuan dan recommendations
di bagikan dengan pemangku • Document all findings and share
kepentingan them with key stakeholders
• Menganalisis, mengevaluasi dan • Analyze, evaluate and organize all
mengatur semua dokumentasi untuk documentation for future application
penerapan di masa depan • Store documentation in a repository
• Menyimpan dokumentasi dalam that can be accessed by all key
repositori yang dapat diakses oleh stakeholder
semua pemangku kepentingan • Retrieve documentation for use on
• Ambil dokumentasi untuk digunakan current or future incidents
pada insiden saat ini atau masa
depan
6.7. INSIDEN BERULANG

6.7. REPEAT INCIDENTS
Insiden berulang menjadi penting
Repeat incidents are significant as they
karena menunjukkan bahwa tindakan
indicate that previous corrective
korektif sebelumnya dan lesson learned
actions and lessons learned were
tidak efektif dalam mencegah insiden
ineffective in preventing recurrence.
terulang kembali. Pengulangan insiden
The repeat of Serious incidents (High
Serius (Risiko Tinggi) merupakan
Risk) is a particularly important issue to
masalah yang sangat penting untuk
be addressed during an investigation.
ditangani selama investigasi.
Tidak ada definisi sederhana terkait apa

There is no simple definition of what
yang membuat insiden berulang. Kunci
makes a repeat incident. The key to
untuk mengidentifikasi pengulangan
identifying a repeat is recognizing that
adalah mengenali adanya kecocokan
there is a significant match between
Dasar Penyebab yang signifikan antara
the Basic Causes of the two incidents,
kedua insiden tersebut sehingga
so that the corrective actions from the
tindakan korektif dari insiden yang
first should have prevented recurrence.
pertama seharusnya dapat mencegah
insiden terulang kembali.
Tidak ada jangka waktu di mana suatu

There is no time period beyond which
insiden dapat dianggap berulang; hal ini
an incident can be considered a
terbatas hanya dari rekaman corporate.
repeat; it is limited only by corporate
memory.
Karena identifikasi insiden berulang
Since identification of repeat incidents
bergantung pada pengetahuan sejarah
relies on historical knowledge of
insiden sebelumnya, semua personel
previous incidents, all personnel
yang terlibat dalam pelaporan insiden
involved in incident reporting are
bertanggung jawab untuk
responsible for identifying if a repeat
mengidentifikasi jika insiden berulang
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telah terjadi. Ini termasuk personel has occurred. This includes site
lapangan serta Divisi HSE. personnel as well as HSE Division.
Siapa pun yang mencatat insiden

berulang harus memberi tahu Ketua Whoever notes a repeat incident
Tim Investigasi. Tim investigasi should advise the Investigation Team
kemudian harus mempertimbangkan Leader. The investigation team should
mengapa tindakan sebelumnya tidak then consider why the previous actions
efektif dan hal berbeda apa yang were ineffective and what should now
sekarang harus dilakukan untuk be done differently to avoid further
menghindari insiden terulang kembali. recurrence.
6.8. PROSEDUR CORRECTIVE ACTION

NEEDED (CAN) 6.8. PROCEDURE FOR CORRECTIVE
6.8.1. Tindakan Korektif harus ACTION NEEDED (CAN)
dimunculkan untuk menangani 6.8.1. Corrective Action must be raised to
semua Area Kontrol untuk address all of the Control Areas for
Tindakan Perbaikan sesuai Improvement Actions as per the
dengan versi terbaru dari SCAT. latest version of SCAT.
6.8.2. Tindakan harus ditulis agar

terpisah dan dapat dimengerti oleh 6.8.2. Action must be written to be stand-
siapa pun di luar tim investigasi. alone and to be understandable to
anyone outside the investigation
team.
6.8.3. Pernyataan tindakan harus
menyertakan tindakan yang jelas 6.8.3. Action statement must include a
di dalamnya; pernyataan tanpa clear action in them; statements
tindakan dinilai tidak berharga. with no actions are worthless.
6.8.4. Setiap tindakan harus menyatakan

siapa yang bertanggung jawab 6.8.4. Each action must state who is
dan tanggal penutupan yang responsible and a realistic close-out
realistis. date.
6.8.5. Setiap kali tindakan dimunculkan,

pihak yang terlibat harus diberi 6.8.5. Whenever actions are raised, action
tahu tentang tanggung jawab parties must be advised of their
mereka dan harus menyetujui responsibilities and should agree to
tindakan tersebut dan target waktu the action and the target date for
tanggapan; Hal ini terutama response; this is particularly so for
berlaku untuk tindakan yang action assigned to off - location
ditugaskan kepada personel di luar personnel.
lokasi.
6.8.6. Line Management bertanggung

jawab untuk memastikan pihak- 6.8.6. The Line Management is
pihak terkait dan menentukan responsible for ensuring action
target waktu untuk penutupan. parties and securing close out by
Tanggal penutupan harus realistis. the target date. Close out dates
Hanya untuk kondisi pengecualian should be realistic. Only under
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batas waktu ini dapat diperpanjang exception circumstances can this

dan hanya dengan persetujuan deadline is extended and only with
Senior Line Manager. Persetujuan the approval of Senior Line
tertulis resmi harus diperoleh oleh Management. A formal written
Ketua Tim Investigasi dengan approval shall be obtained by
menggunakan Corrective Action Investigation Team Leader using
Revision Form (lihat Lampiran 7). Corrective Action Revision Form
Corrective Action Revision Form (see Appendix 7). The Corrective
dan proses persetujuannya harus Action Revision Form and its
diselesaikan setidaknya 2 minggu approval process shall be
sebelum tanggal awal jatuh tempo. completed at least 2 weeks before
Untuk merevisi tindakan korektif the original due date.
dari setiap insiden (termasuk atau To revise a corrective action
tidak termasuk orang yang (including or not including its
bertanggung jawab atau tanggal responsible person or due date) of
jatuh tempo) diperlukan any incident, respective Vice
persetujuan Vice Precident atau President or Senior Manager’s
Senior Manager. approval is required.
6.8.7. Incident Owner / Site Line

Manager harus memantau setiap 6.8.7. Incident Owner / Site Line Manager
penutupan tindakan. shall monitor the close out of any
action.
6.8.8. Line Management dari Incident
Owner harus menginisiasi proses 6.8.8. Line Management of the Incident
pendampingan dan konsultasi Owner shall initiate mentoring and
untuk memastikan tindakan consultation processes to ensure
korektif dari sebuah insiden atau that the corrective actions of the
near miss dapat dilakukan dengan incident and nearmiss is carried out
memadai dan sesuai rencana. properly and according to the plan.
Tidak ada ketentuan untuk periode There is no provision of mentoring
pendampingan dan konsultasi, and consultation periods, yet these
namun hal ini perlu disesuaikan should be adjusted in accordance
dengan insiden atau near miss with the incidents or near misses.
yang terjadi. Selama proses During the mentoring and
pendampingan dan konsultasi consultation periods, all the
berlangsung, semua dokumen necessary documents shall be
yang diperlukan terdokumentasi. documented. Line Management
Line Management harus shall manage the corrective actions
mengelola bukti kelengkapan proof of completeness for future
tindakan korektif untuk keperluan verification purpose.
verifikasi di masa mendatang.
6.8.9. CAN harus mencakup:

• Tindakan korektif segera 6.8.9. CAN shall include:
untuk insiden dan near miss.  Immediate corrective action
• Eliminasi sistematis akar for incident and near miss.
penyebab atau penyebab  Systemic elimination of root
laten untuk mencegah atau or latent causes to prevent or
memitigasi kejadian di masa mitigate future occurrence.
depan.
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• Kekurangan sistem  Management system

manajemen jika sesuai. deficiencies where
• Identifikasi potensi bahaya appropriate.
baru yang tercipta dari  Identification of potential new
tindakan ini. hazards created from these
• Tanggung jawab atas actions.
implementasi dan waktu  Responsibility for
penutupan tindakan. implementation and timing for
• Langkah-langkah mitigasi the closure of action.
sementara untuk item  Interim mitigating measures
dengan peringkat risiko for High risk ranked items.
tinggi.
6.8.10. Waktu untuk penutupan CAN

harus sesuai dengan waktu yang
diidentifikasi dalam dokumen 6.8.10. Timing for the closure of CAN must
manajemen risiko BU (jika align with timing identified in the BU
tersedia). risk management document (if
available).
7. PENINJAUAN ULANG DAN PEMBARUAN
Prosedur ini harus ditinjau ulang setiap tiga
(3) tahun sekali dan setiap ada perubahan 7. REVIEW & UPDATE
sistem atau organisasi untuk This procedure shall be reviewed every three
mengidentifikasi perubahan yang diperlukan (3) years and whenever changes occur in the
agar implementasi panduan ini system or organization, to identify any
mencerminkan praktek terbaik bagi sistem changes needed so that the implementation
manajemen K3LL perusahaan. of this manual reflects the best practices for
HSE management system.
8. DAFTAR BUKTI-BUKTI
N/A
8. LIST OF EVIDENCE
9. REFERENSI N/A
 UU No.1/1970 tentang Keselamatan
Kerja 9. REFERENCE
 UU No.32/2009 tentang Perlindungan  Act No.1/1970 for S&OH
dan Pengelolaan Lingkungan Hidup
 Peraturan Pemetintah No.27/2012:  Act No.32/2009 for Environmental
Izin Lingkungan Management and Protection
 Peraturan Tambang MIGAS tentang  Government Regulation No. 27/2012:
Pelaporan Keselamatan Kerja Environment Permit
(Oktober 1996)  MIGAS Mining Regulation for
Occupational Safety Reporting
(October 1996)
10. LAMPIRAN
 Lampiran 1 – Pedoman Investigasi
Insiden 10. APPENDIX
 Lampiran 2 – SCAT (Systematic  Appendix 1 – Guidance on Incident
Causal Analysis Technique) Investigation
 Lampiran 3 – Tabel SCAT (Contoh)  Appendix 2 – SCAT (Systematic
 Lampiran 4 – Laporan dari/ke MIGAS Causal Analysis Technique)
 Appendix 3 – SCAT Table (Example)
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 Lampiran 5 – Ringkasan Persyaratan  Appendix 4 – Report from/to MIGAS

Pelaporan Insiden  Appendix 5 – Incident Reporting
 Lampiran 6 – Formulir Pernyataan Requirement Summary
Recordable Injury  Appendix 6 – Recordable Injury
 Lampiran 7 – Formulir Revisi Statement Form
Corrective Action  Appendix 7 – Corrective Action
 Lampiran 8 – Pedoman Revision Form
Pemberitahuan Insiden HSE  Appendix 8 – HSE Incident Notification
 Lampiran 9 – BPM Incident and Guideline
Investigation Report Approval Process  Appendix 9 – BPM Incident and
 Lampiran 10 – Request for Incident Investigation Report Approval Process
Investigation Defferal  Appendix 10 – Request for Incident
 Lampiran 11 – Communication Investigation Defferal
Incident to Leadership Team  Appendix 11 – Communication
 Lampiran 12 – Incident Notification Incident to Leadership Team
Requirement  Appendix 12 – Incident Notification
 Lampiran 13 – Operational Control, Requirement
Work Function and Contractor Safety  Appendix 13 – Operational Control,
Statistics Work Function and Contractor Safety
 Lampiran 14 – Example of Statistics
Incidents/Cases Describe Application  Appendix 14 – Example of
of Incident Owner and Site Line Incidents/Cases Describe Application
Manager of Incident Owner and Site Line
 Lampiran 15 – Tabel Batasan Manager
Pelaporan Process Safety Event  Appendix 15 – Process Safety Event
(PSE) (PSE) Tables Reporting Threshold
APPENDIX 1 – Guidance on Incident Investigation
Figure 1:
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Medco E&P (Offshore) LCA Technical Authority for Investigating HSE-Related Event
Mini
Event / Incident Investigation
Low
HSE SEOFF Risk Midi

related? No Technical Rank Investigation
Authority (TA)
Medium /
Significant
Yes High
HSE
Technical
Maxi
Authority
Investigation
(HSE-TA)
No
High Risk? Low & Medium Risk:
SCAT Investigation
Method facilitated
by HSE
Yes
Yes
High Risk &
Medium Risk (discretion):
RCA Investigation (LCA
Failsafe or TapRoot)
Method facilitated by HSE
Note:
HSE Offshore Asset team will assists the Mandate Form, team selection and member composition, and facilitates
investigation process and schedule/timeline
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Figure 2: Medco E&P (Offshore) Investigation Work Process

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FIGURE 3: Risk and Investigation Method Determination
Incident Risk Ranking
To improve safety and health performance by ensuring that the potential of all incidents is understood and
subsequently abated through incident investigation, sharing lessons learned, and taking appropriate action to prevent
future or similar incidents from recurring.
Select the most realistic potential case scenario of the incident occurred (e.i. number of people that could have been
hurt, severity of the injury, property damage or environmental damage) and utilizes Risk Matrix Standard. Below is
the Risk Rank’s matrix used to determine the incident risk category (5x 4).
Click this pdf file version of Medco E&P Risk Matrix
Adobe Acrobat
Document
No. Dok: OFS-HSE12-PRO-001-2021-
R4 PROSEDUR (PROCEDURE)

MEDCO E&P OFFSHORE
Tanggal: 24 September 2021 (INCIDENT AND INVESTIGASTION
PROCEDURE MEDCO E&P OFFSHORE)

MEDCO E&P OFFSHORE
Tanggal: 24 September 2021 (INCIDENT AND INVESTIGASTION
PROCEDURE MEDCO E&P OFFSHORE)
FIGURE 3 (Continued): Risk and Investigation Method Determination
NM / Incident / Investigation Investigation

Risk Investigation Lead Team
5 Investigation Owner Methodology Timelines
Category
Supervisor or Both Leader and Team can be from the Section or Department
I 1
Trained Investigator SCAT 30 working days involved in the incident, the complete team including the Leader
(Low)
Line Manager does not need to be more than two.
Line Manager 1
II Trained Investigator SCAT 30 working days
4
(Medium) Preferable for the Leader to be from a different Section or
OIM for SCAT
2a
Department
Trained Investigator LCA 60 days
FM for LCA
2b 6 Shall be led by an appropriately trained investigator supported by a

Sr. Manager Trained Investigator LCA 60 days
manager or supervisor
Investigation supervisor ideally will be an individual who has formal

training and field experience in the method used. He must be
III
3 6 someone who is not directly involved in the day-to-day operation of
VP Asset Trained Investigator LCA 60 days
5 the facility or organization experiencing the event. The investigation
(High)
supervisor will obtain the services of a trained and competent
Principle Investigator who will lead the investigation process.
Note 1: Lead Investigator shall have attended Medco E&P (Offshore) Training of Incident Investigation and Reporting System
Note 2a: Lead Investigator shall have attended Medco E&P (Offshore) Training of LCA investigation method and experience as LCA team lead or member
Note 2b: Lead Investigator shall have attended Medco E&P (Offshore) Training of LCA investigation method and experience as LCA team lead
Note 3: Lead Investigator shall have attended Medco E&P (Offshore) Training of LCA investigation method and experience as LCA team lead for high risk events
Note 4: Risk Category II incidents will be assessed and assigned as a SCAT or LCA at the discretion of Line Management.
Note 5: Medco E&P (Offshore) Sr. Manager HSE should be consulted on investigation team lead and make-up of the team for the incident and NM
Note 6: The Accountable person must inform the Sr. Manager HSE if an investigation cannot be closed within 60 days and why an extension is warranted

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FIGURE 4: RACI Chart for Classification of Injuries

ConocoPhillips Indonesia
RACI Chart
Injury Classification RACI Chart
Rev. No. 2 / Date: October 2014
Primary Tasks and Activities Line Management Jakarta Medical

Doctor on Duty/Paramedics HSE Performance Assurance
& HSE Team Lead (Chief Medical Officer)
Injury occured Start
Form III.i issued
Form III.i reviewed Beyond 14 First 14 First Aid

(treatment given and HSE Aid Treatment Treatment
Treatment given?
classification status)
FAC
Recordable*
Medical referral or evacuation to

hospital/Licensed Health Provider
(if needed)
Form III.i updated
Form III.i updated

(treatment given and HSE
Beyond 14 First Treatment given? 14 First Aid
classification status)
Aid Treatment Treatment
FAC
MTC
If possibility of
RWC/LWC
occurs
Discussion among LM, Medical

Team, and HSE PA on any RWC/
IP back to work
LWC cases IP cannot with restriction
back to work (light duty)
RWC
LWC
Prepare draft reporting to

IMPACT
IP status monitored 7 days
End
*Treatment provided beyond first aid is considered medical treatment even when provided by someone other than a physician or other licensed health care professional. If conflicting medical opinion
related with LWC and RWC occurs, employer must decide which opinion is the most authoritative (best documented or better medical reasoning).
** For incident related to contractor, any Health Care Provider/Hospital Arrangement shall be arranged by Contractor Company and IP status shall be informed to Company Doctor everyday until 7 days.
Process Owner Coordinator HSE Performance Assurance
Process Team Lead HSE Performance Assurance Specialist
Purpose
To define the process to clarify injuries based on OSHA 1904
Scope
Occupational injury and illness
Definitions
None
Legend
Start/End Decision Output
Process Document

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APPENDIX 2 – SCAT (SYSTEMATIC CAUSAL ANALYSIS SYTEM)
Type of Incident :
What caused the incident.
Penyebab Insiden.
Possible immediate Cause :

Possible un-safe act and/or un-safe condition, which can be seen or sense, that caused the incident to occur.
Kemungkinan tindakan dan/atau kondisi kerja tidak aman, yang terlihat atau terasa, sehingga menyebabkan insiden
terjadi.
Un-safe Act:
Behavior that could permit the occurrence of the incident.
Tindakan atau perilaku kerja yang mungkin menyebabkan insiden terjadi.
Un-safe Condition:
Working condition that could permit the occurrence of an accident.
Keadaan atau kondisi kerja yang mungkin menyebabkan insiden terjadi.
Contributory Cause:
The reason why the substandard act and condition occurred. Often, these consist of two categories : Personal Factor
and Job Factor.
Alasan mengapa perilaku dan kondisi dibawah standar terjadi. Biasanya terdiri dari dua kategori : faktor manusia
dan faktor pekerjaan.
Personal Factor :
Factor contributed by the personal condition (such as lack of knowledge, lack of skills, stress, improper motivation).
Faktor yang ada pada kondisi seseorang (seperti kurangnya pengetahuan, kurangnya keahlian, stress, kurangnya
motivasi kerja).
Job Factor:
Factor contributed by the work system (such as inadequate leadership or supervision, inadequate tools and
equipment, inadequate work standard)
Faktor yang berasal dari sistem kerja (seperti kurangnya pengawasan, kurangnya peralatan dan perlengkapan,
kurangnya standar kerja)
Type of Incident (Cause/Agency)

Select the type of energy transfer, substance contact, and/or agent causing the incident.
1. Struck Against : running or bumping into
Tabrakan : menabrak atau membentur sesuatu
2. Struck By : hit by moving object
Ditabrak : ditabrak oleh atau terbentur obyek bergerak
3. Falling Object : the object falls and hit the IP
Benda jatuh : benda jatuh dan mengenai IP
4. Fall on Same Level : the body falls on the same level, such as slip and trip
Jatuh di lantai/tingkat yang sama : seseorang jatuh di lantai seperti terpleset atau tersandung
5. Fall to Lower Level : the body falls to a lower level
Jatuh ke lantai/tingkat yang lebih rendah : orang jatuh ke tingkat yang lebih rendah
6. Caught In or On : snagged, hung, pinched, and nip points
Tersangkut di atau pada : tersangkut, menggantung, dan terjepit

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7. Crane Operations : incidents related to crane operations

Pengoperasian Derek angkut : insiden yang berhubungan dengan pengoperasian Derek angkut
8. Electric Shock : contact with electric current.
Tersengat listrik : berhubungan langsung dengan arus listrik
9. Fire/Explosion : any incident involving uncontrolled open fire/explosion.
Kebakaran/ledakan : kecelakaan yang meliputi api.ledakan yang tidak terkontrol
10. Hand Tool : any incident involving hand tools (improper tool or use)
Peralatan tangan : kecelakaan yang meliputi peralatan tangan (alat yang tidak sesuai atau salah
penggunaan)
11. Caught Between, Crushed or Amputated : incidents resulted as part of body caught/crushed between objects
whether it is ampulated or not.
Terjepit di antara, patah atau amputasi : incident yang mengakibatkan bagian tubuh terjepit/patah karena
suatu benda, baik diamputasi maupun tidak.
12. Contact With (heat, cold, radiation, toxic, etc): the body contacts with any harmful energy or substance ;
includes ignition, explosions, emissions, heat, cold, radiation, toxics, etc.
Kontak dengan (panas, dingin, radiasi, racun, dan lain-lain) : tubuh terkena energy atau substansi yang
menyakitkan; termasuk kebakaran, ledakan, emisi, panas, dingin, radiasi, racun, dan lain-lain.
13. Transport : involving all kind of transportation (vehicle, boat, aircraft)
Transportasi : meliputi berbagai macam alat tranportasi (kendaraan bermotor, kapal, pesawat)
14. Equipment Failure : involving the failure to meet standard from any part of the equipment.
Kegagalan peralatan : kegagalan bagian-bagian perlatan untuk memenuhi standar
15. Pollution/Environmental : involving the uncontrolled release of material (liquid,solid,gas)
Polusi lingkungan : limbah yang terbuang dengan tidak terkontrol (cair, padat, gas)
16. Handling/Lifting : improper process in handling/lifting materials that causes property damage or
environmental damage.
Pengangkutan : meliputi proses pengangkutan barang yang tidak sesuai sehingga menyebabkan kerusakan
perlatan dan lingkungan
17. Overstress, Overexertion, Overload, Overexposure, Ergonomics : improper position to conduct task that
exceed human ability, including repetitive motions, awkward position, and static posture.
Stres, Tekanan, Beban, dan Pemaparan yang berlebihan, Ergonomi : sikap yang salah dalam melakukan
tugas yang melebihi kemampuan seseorang, meliputi gerkan berulang, posisi yang tidak ergonomis, postur
yang statis.
18. Use of Machinery : involving the use of an equipment or machinery that causes property damage or
environmental damage.
Penggunaan mesin : meliputi penggunaan peralatan atau mesin yang menyebabkan kerusakan perlatan atau
lingkungan
19. Cut by
Teriris/Terpotong

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Possible Immediate Causes

Unsafe Act :
1. Operating Equipment without Authority : non authority/certified person operate the equipment.
Mengoperasikan peralatan tanpa ijin : bukan orang yang berhak/mempunyai ijin untuk mengoperasikan
perlatan.
2. Failure to Warn : warning instructions are not properly communicated and understood.
Kegagalan peringatan : instruksi peringatan tidak dikomunikasikan dan dimengerti dengan baik
3. Failure to Secure : failure to put adequate safety device on equipments/tools.
Kegagalan untuk mengamankan : kegagalan penyediaan ala pengaman pada perlatan/perlengkapan.
4. Operating at Improper Speed : failure to operate in safe speed
Mengoperasikan alat dengan kecepatan yang tidak sesuai : gagal dalam megoperasikan pada kecepatan
yang aman
5. Making Safety Devices Inoperative : Safety Devices is de-activated or by passed
Tidak dapat dioperasikannya alat keselamatan : alat pengaman tidak diaktifkan atau tidak dipakai
6. Using Defective Equipment : operate out of service equipment.
Penggunaan alat rusak : menggunakan peralatan yang sedang rusak
7. Failure ti use PPE Properly : failure to use PPE required by standard/procedure.
Kegagalan menggunakan PPE dengan benar : gagal menggunakan PPE sesuai dengan standar prosedur.
8. Horseplay : physically make fun or play around each other with coworker
Permainan : bermain atau bercanda secara fisik antara sesame teman kerja
9. Under Influence of Alcohol and/or other Drugs : uncontrolled behavior under effect of alcohol/drugs.
Dibawah pengaruh alcohol dan/atau obat-obatan : sikap yang tidak terkendali karena pengaruh alcohol dan
obat-obatan.
10. Using Equipment Improperly/Unsafely : the way to use the equipment is improper and in unsafe act.
Menggunakan peralatan dengan tidak sesuai/tidak aman : cara penggunaan perlatan tidak sesuai dan/atau
tidak aman.
11. Failure to Follow Procedure : Procedure is available, adequate but is not followed.
Kegagalan mengikuti prosedur : prosedur ada dan tersedia tapi tidak diikuti.
12. Improper Physical Effort/Act : Position of posture is not properly/awkward position.
Tindakan/Upaya fisik yang tidak sesuai : posisi postur tubuh tidak ergonomis.
13. Operating Without Adequate Training : person who operate tools/equipment without certificate/license or
sufficient training.
Mengoperasikan alat tanpa pelatihan cukup : orang yang mengoperasikan perlatan/alat tanpa ijin atau tanpa
training yang cukup.
14. Riding Hazardous Equipment : Equipment is unsafe condition during operate.
Menjalankan perlatan yang tidak aman : alat pada kondisi tidak aman pada saat dioperasikan
15. Using Hand tools Unsafety : Hand tools are used incorrectly as standard and procedure.
Menggunakan perkakas tangan dengan tidak aman : perkakas tangan tidak digunakan secara benar sesuai
standard an prosedur
Unsafe Condition :
16. Inadequate Guards/Barriers : the guards / barrier use to protect human being, machine/equipment is in
adequate.
Pengamanan tidak memadai : pengamanan yang digunakan untuk melindungi seseorang atau pada
mesin/peralatan tidak memadai
17. Inadequate/Improper Protective Equipment : PPE use is not right for the job.
Alat Pelindung Diri tidak memadai/sesuai : penggunaan APD tidak sesuai dalam melakukan pekerjaan.
18. Defective Tools, Equipment or Materials : Tools, Equipment or Materials use during incident is damage,
broken, imperfect, out-of-order, flawed.
Perkakas, peralatan, atau bahan rusak : Perkakas, perlatan atau bahan yang digunakan pada saat insiden
pada kondisi rusak, pecah, tidak sempurna, tidak dapat dipakai, cacat.

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19. Congestion or Restricted Action : a limited action as result of restricted or confined space.
Terbatasnya ruang gerak : gerakan yang terbatas dikarenakan ruang gerak yang sempit.
20. Inadequate Warning Syste, : Poor warning and safety devices (such as defective warning system, inadequate
safety devices, sign is not clear, blur, invisible).
Sistem peringatan yang tidak memadai : alat pengaman dan peringatan yang kurang baik (seperti system
peringatan yang rusak, alat pengaman tidak memadai, tanda yang kurang jelas, kabur, tidak terlihat)
21. Fire and Explosion Hazards : Potential condition for fire or explosion to occur.
Bahaya kebakaran dan ledakan : kondisi yang berpotensi terjadinya kebakaran/ledakan
22. Poor Housekeeping.Disorder : Inadequate orderliness
Pengaturan yang kurang baik/ketidakaturan : pengaturan yang tidak memadai
23. Noise Exposure : Expose to noise more than allowable rate (Threshold Limit Value)
Kebisingan : tingkat kebisingan nilai ambang batas (NAB).
24. Radiation Exposure : Expose to radiation from radioactive material and non-ionization (sunrays, electric
voltage) more than allowable rate (Threshold Limit Value)
Paparan radiasi : paparan radiasi dari bahan radioaktif dan tidak terionisasi (sinar matahari, voltase listrik)
melebihi nilai ambang batas (NAB)
25. Temperature Extreme : Expose to heat or cold temperature more than allowable rate (Threshold Limit Value)
Temperatur yang berlebihan : temperatur panas atau dingin melebihi nilai ambang batas (NAB).
26. Inadequate or Excessive Illumination : too much or too low light for working conditions.
Penerangan yang kurang memadai atau berlebihan : cahaya yang terlalu terang atau terlalu redup untuk
kondisi kerja
27. Inadequate Ventilation : too low fresh airflow for working conditions.
Ventilasi yang kurang memadai : kurangnya aliran udara bersih untuk kondisi kerja
28. Hazardous Environmental Conditions : working condition that contains hazardous material (H2S, toxic gas)
Kondisi lingkungan yang berbahya : kondisi kerja yang mengandung bahan-bahan berbahaya (H2S, gas
beracun).
29. Inadequate Visual Contact : due to visibility and barrier/obstacles that limit the visual
Jarak pandang tidak memadai : berdasarkan jarak penglihatan dan penghalang yang membatasi pandangan
30. Projection Hazard : incident occurred as the result of projectile substance (i.e.: blasting operations)
Bahaya proyeksi : insiden terjadi karena substansi proyeksi (operasi ledakan)
31. Unexpected Movement Hazard : uncontrolled movement of material
Bahaya Gerakan tidak terduga : pergerakan yang tidak terkontrol
Contributing Causes
Personal Factors :
1. Physical Capability : (i.e. in-appropriate eye vision, hearing loss, limited physical strength)
Kemampuan fisik : (contoh: penglihatan tidak jelas, kehilangan pendengaran, terbatasnya kemampuan fisik)
2. Physical Condition : i.e. fatique, over-exertion, health barrie
Kondisi fisik : contoh : kelelahan, stress, keterbatasan kesehatan
3. Mental State : internal emotional (personal condition) disturbance (i.e.: fears, phobia)
Kondisi mental : gangguan emosi jiwa (kondisi seseorang), (contoh : ketakutan, fobia)
4. Mental Stress : external factor (work atmosphere condition) that creates mental disturbance (dead line, target
achievement)
Stres mental : factor diluar diri manusia (kondisi lingkungan kerja) yang menyebabkan gangguan mental
(deadline, pencapaian target)
5. Lack of knowledge : self-explanatory
Kurangnya pengetahuan
6. Skill level : self-explanatory
Tingkat keahlian
7. Undue Haste : in-adequate identification of critical safe behavior (i.e. improper performance reward)

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Ketergesa-gesaan: ketidakmampuan identifikasi tindakan aman yang penting (contoh : penghargaan atas
kemampuan yang tidak sesuai)
8. In-attention : lack of attention resulted frm mental illness, pre-occupation with problem, lack of incentive
Tidak perhatian : kurangnya perhatian ditimbulkan dari sakit mental, suasana kerja yang bermasalah,
kurangnya motivasi
9. Training and Knowledge Transfer : Inadequate training or knowledge transfer
Pemberian pengetahuan dan pelatihan : pemberian pengetahuan dan pelatihan yang tidak memadai
Job Factors :
10. Management/Supervision/Employee Leadership : lack of management/supervision/employee as a result of
conflicting roles and responsibilities. Inadequate correction of prior hazard, lack of safety meeting,
audit/inspection.
Manajemen/supervise/pimpinan karyawan : kurangnya manajemen/supervise terhadap pekerja karena konflik
antara peran dan tanggung jawab ketidakmampuan mengoreksi pekerja karena konflik antara peran dan
tanggung jawab ketidakmampuan mengoreksi bahaya sebelumnya kurangnya pengetahuan tentang
keselamatan, audit/inspeksi
11. Inadequate Engineering/Design : self-explanatory
Desain atau tehnik yang tidak memadai
12. Inadequate Supply : i.e.: in-adequate speisification, inventory, minimum stock
Kurangnya persediaan : contoh : spesifikasi tidak memadai, inventaris, persediaan minimum
13. Inadequate Maintenance : self-explanatory
Kurangnya pemeliharaan/perawatan
14. Inadequate Tools and Equipment : self-explanatory
Kurangnya alat dan perlengkapan
15. Inadequate Work Procedures: procedures are not available or updated or ot sufficient for the job or lack of
detail
Prosedur kerja yang tidak memadai : tidak ada prosedur atau tidak diperbaharui atau tidak mencukupi untuk
pekerjaan atau kurangnya penjelasan
16. Excessive Wear abd Tear : improper extension of service life
Penggunaan alat yang berlebihan : pemakaian yang melewati masa pakai
17. Abuse or Misuse : use of equipment which is over/under specification
Penyalahgunaan : penggunaan alat yang tidak sesuai spesifikasi
18. Communication : i.e.: improper radio communication because of distortion, language barrier,
Komunikasi : contoh: komunikasi radio yang tidak memadai karena distorsi, keterbatasan bahasa.
19. Weather Conditions : self-explanatory
Kondisi cuaca.
20. Poor warning/Safety Device : lack/in-adequate of warning/safety devices
Kurangnya peringatan/alat pengaman : tidak adanya peringatan/alat pengaman
21. In-adequate PPE : in-adequate/defective PPE for potential hazard
Alat pelindung diri tidak memadai : kurangnya APD utnuk bahaya potensial
22. Hazardous Environment : working condition that contains hazardous material (H2S, toxicgas, oxygen
deficiency)
Lingkungan berbahaya : kondisi kerja yang mengadnung bahan berbahaya (H2S, gas beracun, kurang
oksigen)
23. Inadequate Job Description : Job description is not available or not adequate
Deskripsi kerja tidak memadai : deskripsi kerja tidak ada atau tidak memadai
24. Inadequate Isolation : in-adequate identification of work site job hazard, no proper isolation (welding operation,
electrical work, process-pressure/temperature related)
Isolasi tidak memadai : kurangnya identifikasi terhadap bahaya tempat kerja, isolasi tidak memadai
(pengelasan, pekerjaan yang berhubungan dengan listrik, proses yang berhubungan dengan
tekanan/temperatur)

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25. Poor Access : in-adequate human factor consideration, work planning, and communication
Akses yang kurang baik : pertimbangan factor manusia yang kurang baik, perencanaan kerja, komunikasi.
Control Action Need

A. Lack of Commitment, Leadership and Staffing Levels :
Relates pre-dominantly to higher level (organizational), commitment and provision of resources, as well as
leadership issues at all levels where leadership is expected. (Compare with B)
Kurangnya Komitmen, Kepemimpinan dan Penempatan Karyawan
Berhubungan erat dengan tingkat yang lebih tinggi (organisasi), komitmen dan sumber daya, seperti halnya
kepemimpinan di semua tingkat dimana kepemimpinan diharapkan, (Bandingkan dengan B)
B. Inadequate Management/Supervision :
Relates pre-dominantly to location specific management and supervision and aspects, which would be expected to
be covered by the job description of management and supervisory position (excluding leadership issues:compare
with A)
Kurangnya Manajemen/Supervisi\
Berhubungan erat dengan manajemen dan supervisi dan aspek khusus di tiap lokasi, yang diharapkan teLCAkup
dalam deskripsi pekerjaan di posisi manajemen dan supervise (tidak termasuk kepemimpinan : bandingkan dengan
A)
C. Inadequate Written Procedure :

Relates to any type of written description of control document that specifies the way work is carried out, Including
policies, standards, procedures, written instructions, job step plans, maintenance construction, work packs, etc.
(compare with K)
Kurangnya Prosedur Tertulis
Berhubungan dengan setiap tipe penjelasan tertulis tentang pengawasan dokumen yang menjelaskan bagaimana
pekerjaan dilakukan, termasuk kebijakan, standar, prosedur, instruksi tertulis, rencana kerja, pemeliharaan,
kumpulan pekerjaan dan lain-lain (Bandingkan dengan K)
D. Inadequate Physical/Mental Capacity :

Relates to the physical and/or mental capacity of anyone contributed to the incident.
Kurangnya Kapasitas Fisik/Mental
Berhubungan dengan kapasitas fisik/mental orang yang berkaitan dengan insiden
E. Inadequate Training and Competence :

Relates to provisions of training (in-Sufficient) as well as quality of training (in-appropriate) and similarly with
competence : is it sufficient and is it appropriate.
Kurangnya Kompetensi dan Pelatihan
Berhubungan dengan penyediaan pelatihan (tidak cukup) seperti halnya kualitas training (tidak sesuai), juga dengan
kompentensi : apakah cukup dan tepat.
F. Poor Communications :
Relates to any form of communication, excluding that involved in training.
Kurangnya Komunikasi
Berhubungan dengan bentuk komunikasi apapun, tidak termasuk dalam pelatihan
G. Poor on the Job Risk Management and Evaluation :

Relates to the local planning, risk evaluation and risk management carried out just prior to and during an activity,
i.e.: on the job (compare with H)
Kurangnya pengetahuan tentang Manajemen Resiko dan Analisa

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Berhubungan dengan rencana, evaluasi risiko dan manajemen risiko yang dilaksanakan sebelum dan pada saat
beraktivitas, contoh : pada saat bekerja (Bandingkan dengan H)
H. Inadequate Planning/Organization :
Relates to higher level and/or larger scale planning activity carried out in advance of an activity, (compare with G)
and includes organization issues.
Kurangnya Perencanaan dan Pengorganisasian
Berhubungan dengan level yang lebih tinggi dan/atau skala rencana aktivitas yang lebih luas yang dilakukan
sebelum beraktivitas, (Bandingkan dengan G) dan termasuk hal mengenai pengorganisasian.
I. Inadequate Design Standards :

Relates not only to design standards, but also to the processes that control design and construction.
Kurangnya Standar Desain
Tidak hanya berhubungan dengan standar desain, tetapi juga proses yang mengontrol desain dan konstruksi.
J. Inadequate Inspection and Audits :

As it suggests.
Kurangnya Audit dan Inspeksi:
Sebagaimana disarankan.
K. Inadequate Work Processes/Activity :

Relates to work processes or activity of which there is no written description or control document, i.e.: part of normal
routine activity (compare with C)
Kurangnya Aktivitas Kerja/Proses
Berhubungan dengan proses/aktivitas kerja yang tidak mempunyai deskripsi secara tertulis atau control dokumen,
contoh : bagian dari aktivitas rutin sehari-hari (bandingkan dengan C)
J. Inadequate Maintenance System :

As it suggests.
Sistem Pemeliharaan/Perawatan yang kurang baik:
Sebagaimana disarankan.

MEDCO E&P OFFSHORE
Tanggal: 28 June 2021 (INCIDENT AND INVESTIGASTION PROCEDURE
MEDCO E&P OFFSHORE)
APPENDIX 3 – SCAT TABLE


MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 4 – REPORT FROM / TO MIGAS
FAX
Kepada Yth:
Direktorat Jenderal MIGAS
U.P./Attn: Direktur Teknik dan Lingkungan MIGAS
Fax Number: (021) 5269037
Copies:
Divisi Penunjang Operasi/Dinas FKKLL SKK Migas
U.P./Attn : Kepala Divisi
Fax Number: (021) 29249999
From: Date:
Total Pages:
Dengan hormat,
Berikut laporan pemberitahuan kecelakaan kerja

Hari, Tanggal/waktu :
Tempat kejadian :
Nama :
Jenis kelamin/umur :
Perusahaan :
Pekerjaan :
Uraian singkat terjadinya kecelakaan kerja:
Demikian laporan pemberitahuan kecelakaan kerja ini untuk dapat diketahui.
Hormat kami,
Kepala Teknik Tambang/Penyelidik

Technical Head/Prospector

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
FAX
Kepada Yth:
Fax Number: (021) 5269037
Copies:
Fax Number: (021) 29249999
From: Date:
Total Pages:
Dengan hormat,
Berikut laporan pemberitahuan kecelakaan kerja

Hari, Tanggal/waktu :
Tempat kejadian :
Kerusakan yang dialami :
Uraian singkat terjadinya kecelakaan instansi:
Demikian laporan pemberitahuan kecelakaan kerja ini untuk dapat diketahui.
Hormat kami,


MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
FAX
Kepada Yth:
Fax Number: (021) 5269037
Copies:
Fax Number: (021) 29249999
From: Date:
Total Pages:
Dengan hormat,
Berikut laporan pemberitahuan kecelakaan lingkungan:


MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
LAPORAN TERJADINYA PENCEMARAN
1. Nama Perusahaan :
2. Lokasi :
3. Tanggal dan waktu terjadinya pencemaran:
4. Sebab pencemaran :
5. Jumlah pencemar (dalam barrel):

6. Jenis dan spesifikasi dari pencemar:
7. Keadaan perairan dan daratan pada saat pencemaran:

a. Kecepatan dan arah arus:
b. Kecepatan dan arah angin:
c. Tinggi gelombang:
d. Luas daerah yang tercemar:
8. Cara penanggulangannya:
a. Mekanis:
b. Bahan Kimia: i) Merk:

ii) Jumlah:
9. Keterangan mengenai tingkat kebersihannya setelah penanggulangan:
10. Keterangan lain-lain:
Date:


MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
PEMBERITAHUAN TENTANG KECELAKAAN TAMBANG KEPADA KEPALA INSPEKSI DI JAKARTA

REPORT ABOUT MINING ACCIDENT TO CHIEF PROSPECTOR OF MINES, JAKARTA
Duplikat pemberitahuan kepada Pamong Praja setempat di :

....................................................................…………………………………………..
Copy of this report sent to Civil Administrator at
Nomor urut tentang kecelakaan dari daftar kecelakaan tambang No. :

............................................................................................….
Serial number of accident in Register for mining Accident No.
Mengenai Pekerjaan Penambangan/Pekerjaan Penyelidik :

.....................................................................................................……….
Concerning Production/Exploration
Terletak di : ..................................................................................................................................…………………..
Located
1. Titik waktu, hari, jam kecelakaan :

................................................................………………………………………………………
Day, date and hour of the accident
2. Tempat kecelakaan :
................................................................................……………………………………
Place of accident
3. Nama, jenis kelamin, umur, nomor buku, asal-usul, dan/atau no. daftar dari :
......................................................................................…………………………….
Name, sex, age, serial number register origin and/or registration number of
4. Jabatan apakah dan berapa lama dipegang oleh orang yang mendapat celaka :
......................................................................................…………………………….
What kind of job and how long is he performing the job before the accident
5. Sifat kecelakaan :
....................................................................................……………………………….
Type of accident
6. Tatkala pekerjaan apa kecelakaan terjadi :

..............................................................................................……………………
During performing of what kind of job when the accident occurred
7. Semua saksi dalam kecelakaan itu :

........................................................................................…………………………..
Witness of the accident
8. Uraian tentang kecelakaan itu & sebab-sebab :

..............................................................................................…………………….
Summary of the accident and cause

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
Kecelakaan tersebut telah didaftarkan pada tanggal .....................20.........dalam daftar kecelakaan tambang yang
disediakan untuk itu & surat pemberitahuan ini dibuat pada tanggal ................................20........... dan dikirim
kepada Inspeksi Tambang Jakarta.
Above mentioned accident recorded on ................................20.…….. in the accident register and this report
made up on .......................... 20........ and forwarded to the Chief Inspector for Mining in Jakarta.
Kepala Teknik/Penyelidik
Diterima oleh Pamong Praja setempat di ..................................... tanggal......................20..............

Received by the local Civil Administrator at ............................. on ..................................20.............
1. Luka enteng, berat (oleh sebab itu mungkin lebih dari tiga minggu tidak sanggup bekerja) atau mati (terjadi
dalam sehari setelah kecelakaan selanjutnya sifat luka-luka.
Not serious, serious (possibility incapable for work more than 3 week) or dead (happening within 24 hours after
the accident): furthermore kind of wounds.
2. Semua orang disebabkan tidak memandang bangsa
Same all witnesses, perspective nationality
3. Segala keterangan dapat dipergunakan untuk menimbang kecelakaan dari sudut teknik berhubung dengan
reglement Polisi Pertambangan (Staatblad 1930No.341) harus disebut
All particular to be mentioned which can be evaluate for technical point of view possible illustrated a sketch
and (or) design on scale.

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
SURAT KETERANGAN DOKTER

( Lampiran Bentuk III i )
DOCTOR’S CERTIFICATE
( Attachment form III i )
TENAGA YANG MENDAPAT KECELAKAAN TAMBANG KARENA HUBUNGAN KERJA

EMPLOYEE EXPERIENCING A WORK RELATED INJURY
Instalasi / Installation: ...........
Dokter yang merawat harus melaporkan keadaan korban dalam 2 ( dua ) hari sesudah diperiksa
Doctor who taken cares have to report during two (days ) after examination
Nama Korban / Injured Person: Umur / Age:

Jabatan / Position: Tgl & waktu / Date & time:
Alamat / Address: Tempat / Location:
Keterangan tentang luka-lukanya.

Sebutkan bagian badan yang cidera dengan R L
R L
sifat lukanya( tunjukkan juga pada gambar ) :
Mention the part of the body that injured and
wound location (show at picture also) :
…………………………………………………..
Perawatan dan pengobatan.

Cara Perawatan dan pengobatan yang diberikan:
Nursing and Treatment
The way of nursing and treatment:
…………………………………………………..
Kehilangan hari kerja.

Akibat lukanya apakah yang bersangkutan
diperlukan istirahat untuk dapat melaksanakan
kembali pekerjaannya. (Sebutkan kira-kira berapa
hari) :
Workday Lost R L
Due to the injury, should the victim take a rest then
get back to work (Mention the estimated days):
………………………………………………….
Uraian singkat terjadinya kecelakaan dengan R L R L R L

sebab-sebabnya:
Short summary of accident and the root causes:
………………………………………………….
Keterangan lain-lain:
Other :
………………………………………………….
Tanggal pemeriksaan/Date of examination: …… ……………….. 20……
Site Line Management Signature Diperiksa oleh Dokter / Examined by : ……………………………………

………………………………….
Tanda tangan/Signature : …………………………………………………
Alamat/Address : …………………………………………………………

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 5 – INCIDENT REPORTING REQUIREMENT SUMMARY
CORPORATE & MEDCO E&P OFFSHORE INCIDENT REPORTING REQUIREMENT SUMMARY
INTERNAL NOTIFICATION CORPORATE (MEPI) NOTIFICATION OTHER REQUIRE REPORT

CATEGORY OF INCIDENT
WHO PREPARE WHO SENT TO WHOM TIME LINE WHO PREPARE WHO SENT TO WHOM TIME LINE WHO PREPARE WHO SENT TO WHOM TIME LINE
OCCUPATIONAL INJURY
Fatality - Incident resulting in an Site Line Department Respective LT Members Site Line LT Members: BOD : Department Manager Sign by Technical Ditjen MIGAS with cc 1 x 24 hrs
on-the-job employee or Management or Manager (1) VP Operation for Management or (1) VP Operation for Production (1) Ronald Gunawan Head/Prospector to SKK MIGAS
contractor fatality, or public incident owner Production Operation, incident owner Operation, (2) Amri Siahaan
fatality (2) Sr. Manager Well (2) Sr. Manager Well Operations for Reviewed by Legal &
Operations for Drilling/ Well Drilling/ Well Intervention AND cc. to Relation
Intervention Operations Operations (3) Sr. Mgr HSE - MEPI
(3) VP POEE for project and (3) VP POEE for project (4) GM - MEPN Send by HSE
OEE (4) Sr. Manager HR and GS for Jakarta Department
(4) Sr. Manager HR and GS for incident Site Line Management Site Line Management Local Police Immediate (within 12
Jakarta incident hours)
Immediate
AND cc. to 1X12hrs
(within 12 hours)
(5) Senior Manager HSE
(6) General Manager (GM)
Same as above Same as above Same as above Same as above Same as above Same as above Department Manager Sign by Technical Ditjen MIGAS with cc 1 x 24 hrs
Permanent Total Disability
Head/Prospector to SKK MIGAS Reported in monthly
report
Permanent Partial Disability
Reviewed by Legal &
Relation
Lost Time Injury
Send by HSE
Department
Restricted Work Injury (RWI) and Same as above Same as above Same as above Same as above Same as above Same as above 1 x 24 hrs Same as above Same as above Same as above Reported in monthly
Medical Treatment Injury (MTI) report
Same as above Same as above Same as above 1 x 24 hrs Same as above Same as above Same as above 2 x 24 hrs Same as above Same as above Same as above Reported in monthly
First Aid
report
Serious Nearmiss (HiPO) Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs Not required to be reported
SPILL AND RELEASE
Oil or HC Spill (non PSE) > 15 bbls Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs Department Manager Sign by Technical Ditjen MIGAS with cc 1 x 24 hrs
and Hazardous Chemical Spills Head/Prospector to SKK MIGAS and
greater than 5,000 lbs 1x24 hrs related partners
Send by HSE
Oil or HC Spill (non PSE) < 15 bbls Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs HSE Department HSE Department MIGAS Monthly Report
WELL CONTROL INCIDENTS
Well Control Incident - Loss of Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs The reporting would be based on the consequences (e.g. environment spill, personnel injury,
well control that endangers the etc)
1 x 24 hrs
rig, onsite personnel, or the
environment.
PROCESS SAFETY
TIER 1 Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs N/A except of the TIER 1 N/A except of the TIER N/A except of the N/A except of the TIER
incident cause spill > 15 1 incident cause spill > TIER 1 incident cause 1 incident cause spill >
TIER 2 bbls (then see point 15 bbls (then see point spill > 15 bbls (then 15 bbls (then see point
1 x 24 hrs spill/ release) spill/ release) see point spill/ spill/ release)
release)
TIER 3 Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs N/A N/A N/A N/A
PROPERTY DAMAGE
PROPERTY DAMAGE > 10000 USD Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs Department Manager Sign by Technical Ditjen MIGAS with cc 1 x 24 hrs
Head/Prospector to SKK MIGAS
1 x 24 hrs
Send by HSE
PROPERTY DAMAGE < 10000 USD Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs N/A N/A N/A N/A
TRAFFIC ACCIDENT
Traffic Accident (Medium and Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs N/A N/A N/A N/A
1x24 hrs
Major) Accident (Minor)
Traffic 2 x 24 hours
NON RELATED WORK INCIDENT
Non Accidental Death (Non Work Same as above Same as above Same as above Same as above Same as above Same as above 1X24 hrs Department Manager Sign by Technical Ditjen MIGAS with cc 1 x 24 hrs
Related) Head/Prospector to SKK MIGAS
Reviewed by Legal &

Relation
1x24 hrs
Send by HSE
Department
Site Line Management Site Line Management Local Police Immediate (within 12
hours)
Away from Work (Non Work Same as above Same as above Same as above HSE Department HSE Department Same as above Reported on N/A N/A N/A N/A
Related) weekly statistic

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 6 – RECORDABLE INJURY STATEMENT FORM
Recordable Injury Statement Form
This letter is to state that after an injury that happened on (mm/dd/yr) ____________
to personnel named below :
Name : ___________________
Position : ___________________
Company : ___________________
The above Person can go back to normal duty on (mm/dd/yr) : ____________
(Acknowledged by Company Doctor : ________________________________)
Final classification : MTI/RWI/LTI
With counted days (if any)
For Job Transfer/Restricted Work: _____days from _______to _______
For Lost Workdays: ________________ days from _______to _______
Line Management
________________

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 7 – CORRECTIVE ACTION REVISION FORM
Corrective Action Revision Form
Responsible Dept.: CAP/Doc. No.: Event/Due Date:
Type of Event:
Incident Investigation Internal Audit
External Audit Others: …………………………………….
Brief Description:
Corrective Action Plan (CAP):
Responsible Personnel: Target Date:
Progress Status and Justifications:
Proposed Amendment:
Revised Responsible Party: Revised Target Date:
Respective Manager Approval VP Operations Approval


MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 8 – HSE INCIDENT NOTIFICATION GUIDELINE


MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 9 – BPM INCIDENT AND INVESTIGATION REPORT APPROVAL PROCESS


MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 10 – REQUEST FOR INCIDENT INVESTIGATION DEFERRAL
Responsible Unit: Incident No. Incident Date:
Incident Type:
Incident Brief Description:
Progress Status and Justifications:
Proposed Amendment:
Target Date for Investigation: Revised Target Date for Investigation:
Approval Sr. Manager Operations Approval VP Operations


MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 11 – COMMUNICATION INCIDENT TO LEADERSHIP TEAM
Below is the guidance to communicate incidents to Leadership Team (reported through presentation in
Leadership Team Meeting):
 All incidents and near misses.

 HSE Statistic.
 Summary of week activities and next week expectations.
 Significant activities
 Other issues/concerns (CAN, CAP, etc)

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 12 – INCIDENT NOTIFICATION REQUIREMENT
HSE Notification Requirements Medco E&P Notification

(Offshore) to Corporate
notification via IIR
INJURY
Fatality - Incident resulting in an on-the-job and off-the job employee 1x12 Hrs 1 x 12 hrs
or contractor fatality, or public fatality
Lost Time Incident - Lost workday on-the-job injury to an employee 1x24 Hrs 1 x 24 hrs
or contractor
Injury(ies) - Incident resulting in a one or more injury(ies) requiring 1x24 Hrs 1 x 24 hrs
immediate overnight hospitalization and treatment of employee,
contractor or the public
Injury - Incident resulting in multiple injuries /illnesses to employees, 1x24 Hrs 1 x 24 hrs
contractors or the public
Injury – Recordable Incident (LTI, RWI, MTI) 1x24 Hrs 1 x 24 hrs
Injury – All First Aid Case 1x24 Hrs 1 x 24 hrs
Spill & Release

Liquid hydrocarbon spills or gas releases (any volume) to 1x24 Hrs 1 x 24 hrs
environmentally sensitive areas, recreational areas or wildlife
habitats/refuges which are likely to attract media attention or cause
closure, stoppage or re-routing of traffic on public road or waterway.
Liquid hydrocarbon spills or releases from primary containment 1x24 Hrs 1 x 24 hrs
greater than 100 barrels (15.9 cubic meters).
Hazardous chemical spills or releases from primary containment 1x24 Hrs 1 x 24 hrs
greater than 5,000 pounds (2.27 metric tons).
Liquid hydrocarbon spills or releases from primary containment 1x24 Hrs 1 x 24 hrs
greater than 1 barrels (1.59 cubic meters).
LOPC - PSE TIER – 1 and 2 1x24 Hrs 1 x 24 hrs
LOPC - PSE TIER – 3 1x24 Hrs 1 x 24 hrs
PROPERTY DAMAGE/BUSINESS INTERRUPTION/OTHER

Property damage events likely to exceed USD 10,000 net in 1x24 Hrs 1 x 24 hrs
estimated damages (example fires, explosions, collisions, acts of
nature, vandalism, theft, etc.)
Unscheduled HSE related business interruption that will likely 1x24 Hrs 1 x 24 hrs
result in USD 100,000 or more net in estimated losses
Any situation that should be brought to the attention of corporate 1x24 Hrs 1 x 24 hrs
management due to actual, or potential, impact on the company.
EVACUATION/SHELTER IN PLACE
Evacuation beyond facilities of company employees and 1x24 Hrs 1 x 24 hrs
contractor personnel.
Sheltering-in-place of the public. 1x24 Hrs 1 x 24 hrs
Mandatory evacuation of the public 1x24 Hrs 1 x 24 hrs
WELL CONTROL INCIDENTS

Loss of well control that endangers the rig, onsite personnel, or the 1x24 Hrs 1 x 24 hrs
environment.

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
PUBLIC RELATIONS/ACTUAL OR POTENTIAL CO. IMPACT

Serious ranked marine, truck, aviation, rail, pipeline or other 1x24 Hrs 1 x 24 hrs
transportation incident involving personnel, our products, property
damage, spills or releases, traffic stoppages, evacuations, etc.
Acts of terrorism (e.g., bomb threats, sabotage, kidnapping, 1x24 Hrs 1 x 24 hrs
employee violence, etc.)
Any incident that attracts or could attract media attention 1x24 Hrs 1 x 24 hrs
including but not limited to confrontations with anti-industry groups.
Multiple complaints of acute illness by third parties allegedly 1x24 Hrs 1 x 24 hrs
caused by our operations or products. (ie. Calls by more than one
individual).
Nearmiss
Nearmiss incident with risk rank significant and above (HIPO) 1x24 Hrs 1 x 24 hrs
MVI (Traffic Accident)

Accident involving company’s motor vehicle with risk rank medium 1x24 Hrs 1 x 24 hrs
and above
Note:
1. Expected time of Preliminary Incident Report (1 page & LAK), for incident case:
a) >LTI (Fatality, Permanent Total Disability, Permanent Partial Disability, LTI, any extreme incident) ---
define max 1 x 12 hrs & on the same day of the accident. (1 page Powerpoint Template & preliminary
report/ LAK refer to OS/ Operating System)
b) < LTI (RWI; MTI; FA; Traffic/ Slight - Major; Property Damage /Slight - Major; Serious Near Miss/ HIPO;
LOPC Tier-1,2,3; Oil Spill) ----Max 1 x 24 hrs
c) Non Accidental Death & Away From Work (Non Work Related Work) & Security/ Vandalism cases ----
Max 1x 24 Hrs
2. Report Hierarchy
a) Operations/ Construction or Project/ Drilling Company/ Field Managers (supported by HSE onsite
Coordinator/ Lead and/ or HSE Manager) – report to (GM/ Deputy/ Kepala Teknik)
i. cc to HSE Corporate (HSE Sr. Manager & Safety Manager)
b) GM/ Deputy (Kepala Teknik) -- report to BOD Medco E&P Corporate
i. Senior VP Offshore Asset Medco E&P (Offshore) could delegate to Medco E&P (Offshore) Katek/
VP Operations for Operation and to Sr. Mgr. Well Operations for Drilling
ii. cc Operations/ Production Sr. VP/ Development Sr. VP/ (Related Directors/ VPs)
iii. cc to HSE Corporate (Sr. HSE Manager & Safety Manager)
One-Page Summary Brief Executive Summary Preliminary Incident Report (BESPIR) Template:
Template One Page

Summary BESPIR 2020 Rev 01.PPTX

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 13 – OPERATIONAL CONTROL, WORK FUNCTION AND CONTRACTOR SAFETY STATISTICS
Operational Control must be decided early in the procurement phase to ensure the proper duty and
care of our Contractors and to accurately capture Contractor hours. If Medco E&P (Offshore) exerts
Operational Control, the business must ensure that they have decision authority, structured
oversight and/or direct supervision of the activity. This appendix describes
An asset for which Medco E&P (Offshore) has Operational Control is defined to include:
 Medco E&P (Offshore) operated assets; or
 Assets/projects where Medco E&P (Offshore) has decision authority over the operation.
Within assets for which Medco E&P (Offshore) has Operational Control, there may be activities
where the Medco E&P (Offshore) may not have Operational Control per the definition below.
Medco E&P (Offshore) has Operational Control of contracted activities when:
 Medco E&P (Offshore) has the decision authority to institute the MEPN’s HSE Management
System requirements, or has accepted and bridged to the Contractor’s HSE Management
System; and
 Medco E&P (Offshore) has structured oversight and/or direct supervision.
Examples of when Medco E&P (Offshore) does and does not have Operational Control of
contracted activities can be found in Table 1 of this appendix.
For traceability, all decisions shall be documented as part of the Contractor management process.
Work Functions
The following Work Functions are regularly undertaken by the Medco E&P (Offshore) and shall be
included in Medco E&P (Offshore) and Contractor statistics in situations where the Medco E&P
(Offshore) has determined Operational Control. The italicized Work Function definitions have been
established by the International Association of Oil & Gas Producers (IOGP) for consistency in
benchmarking performance across the industry, and have been adopted by Medco E&P (Offshore)
as work functions where the Medco E&P (Offshore) will strive to exert Operational Control. Some
definitions have been further elaborated upon to establish expectations for where Medco E&P
(Offshore) will exert Operational Control to assure worker protection, protect company reputation
and provide consistency across Medco E&P (Offshore). This list is not all-inclusive.
Operational Control should be carefully considered using the guidance above and definitions related
to Decision Authority, Direct Supervision, Influence, and Structured Oversight.
Exploration: Include, but not limited to, geophysical, seismographic and geological activities,
inclusive of administrative and engineering aspects, maintenance, materials supply and
transportation of personnel and equipment.
Common activities which are typically included are: Studies conducted prior to commencing an
exploration project such as GeoChem, Autonomous Underwater Vehicle surveys, Shallow Hazard
Surveys; Underwritten seismic activities conducted solely for Medco E&P (Offshore); Proprietary
Seismic activities (marine and land); Exploration Drilling.

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
Activities typically excluded are: Seismic data purchase; Underwritten seismic activities conducted
for multiple clients; Spec Shoots conducted for multiple clients.
Well Operations: Includes all exploration, appraisal and production drilling, wireline, completion
and workover as well as their administrative, engineering, construction, materials supply, and
transportation aspects. It includes site preparation, rigging up and down and restoration of the
drilling site upon work completion.
Construction: Includes all construction, fabrication activities and also disassembly, removal and
disposal (decommissioning) at the end of the facility life. It includes construction of process plant,
fabrication yard construction of structures (owned by Medco E&P (Offshore)) where Medco E&P
(Offshore) has operational control or accountability of the project deliverables with a workforce
assigned and dedicated to direct the construction, offshore installation, hook-up and
commissioning, and removal of redundant process facilities are all examples to be included.
Production: Covers petroleum and natural gas production operations, including administrative and
engineering aspects, repairs, maintenance and servicing, materials supply and transportation of
personnel and equipment. It covers all mainstream production operations including:
 Work on production wells under pressure;
 Oil (including condensates) and gas extraction and separation (primary production);
 Heavy oil production (i.e., steam assisted gravity drainage) production;
 Primary oil processing (water separation, stabilization);
 Primary gas processing (dehydration, liquids separation, sweetening, CO2 removal);
 Floating Storage Units (FSUs) and sub-sea storage units;
 Gas processing activities with the primary intent of producing gas liquids for sale;
 Secondary liquid separation (i.e., Natural Gas Liquids (NGL) extraction using refrigeration
processing);
 Liquefied Natural Gas (LNG) and Gas to Liquids (GTL) operations;
 Flow-lines between wells and pipelines between facilities associated with field production
operations;
 Oil and Gas loading facilities, including land or marine vessels (trucks and ships) when
connected to an oil or gas production process;
 Pipeline operations (including booster stations) operated by Medco E&P (Offshore)
business.
Contractor Safety Statistics
Medco E&P (Offshore) uses a variety of Contractors, Sub-Contractors and suppliers to support our
operations and business activity. The degree of influence and oversight of the Contractors vary
within the Company and Business Units.
The purpose of this section is to clarify reporting responsibility by ensuring that Contractor hours
and incidents are captured for those that are under Medco E&P (Offshore) operational control and
to establish expectations for where Medco E&P (Offshore) will exert Operational Control to assure
worker protection and consistency across Medco E&P (Offshore).
Medco E&P (Offshore) will continue to have the same expectations for incident reporting, incident
management, risk ranking, investigation, and corrective actions for any Contractor injury that occurs
on our locations - regardless of whether the injury is included in our injury rate calculation.

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
The philosophy behind the exclusions is to eliminate from our statistics, those Contractors whose
safety performance is not, or cannot be strongly influenced or managed by Medco E&P (Offshore),
even when they are on our locations.
Hours from excluded Contractors must not be used for purposes of calculating Contractor injury
rates. Close review of Contractors and Contractor activities vs. the exclusions in this procedure will
be required for anyone reporting Contractor hours for injury rate calculation purposes.
A Contractor is any non- Medco E&P (Offshore) employee, within operational control, performing
work for, or on behalf of, Medco E&P (Offshore) except:
 Off-site construction sites, fab shops, design and engineering firms unless Medco E&P
(Offshore) has operational control of the project with a workforce assigned and dedicated to
the project
 Contracted marine crude and product transport, work boats and supply vessels (including
product/cargo/tank contract inspectors/surveyors)
 Contracted aviation services, including helicopters and fixed wing transport, when not fully
dedicated to Medco E&P (Offshore).
 Contracted public road transportation, buses, vans, automobiles and trucks
 Third party truck deliveries and shipments (crude, product and other) when not fully dedicated
to Medco E&P (Offshore). If the injury or illness occurs in our work environment/ Company
property where we have control of the work environment, under Medco E&P (Offshore)
supervision, the injury or illness is considered recordable
 Service vendors for such things as, vending machines, floor mats, laundry/uniform service,
automobile service, Medco E&P (Offshore) copier repair, compressed gas deliveries and
other similar incidental service vendors. This exception would generally not apply to service
vendors who work on company owned fixed assets in the operational environment and are
under the control of Medco E&P (Offshore) (leak repair, HVAC repair, specialized electrical
and instrumentation service, etc.)
 Visitors, tour groups, public officials and regulators
TABLE 1 Examples of when Medco E&P (Offshore) does and does not have Operational Control
of contracted activities
Examples where Medco E&P (Offshore) Examples where Medco E&P (Offshore)
has Operational Control include but are does not have Operational Control include
not limited to: but are not limited to:
 Parties who provide services on our  Consulting engineers working off site or in
location which are under contract, their own offices unless they are fully
subcontract, or purchase order to Medco dedicated to Medco E&P (Offshore) and
E&P (Offshore) who work within the facility meet other requirements of Operational
under the Medco E&P (Offshore) HSE Control.
Management System.  Governmental/agency personnel, partners
 Contracts where Medco E&P (Offshore) etc.
has decision authority over the work  Parties that are off Medco E&P (Offshore)
performed on behalf of the company (e.g.: clock but are still on our location,

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
drilling site, contracted offshore drilling conducting work on their own behalf which
platform, major construction site dedicated Medco E&P (Offshore) has not have
to Medco E&P (Offshore)) and Medco E&P structured oversight and/or direct
(Offshore) has structured oversight and/or supervision of HSE related aspects.
direct supervision of HSE related aspects.  Parties who provide services on our
 Crew member on supply vessel when location which are not under contract,
involved in platform operations within 500m subcontract, or purchase order to Medco
zone (e.g., pumping mud to platform, lifting E&P (Offshore).
containers from vessel to platform) and  Parties contracted to do work on our
Medco E&P (Offshore) has structured locations, but not yet arrived at our location
oversight and/or direct supervision of HSE or in transit between our locations. This
related aspects. includes third party truck deliveries and
 Major construction site operating under shipments and those transporting product
Medco E&P (Offshore) HSE Management for which ownership of the product has
System requirements or under the transferred to a customer or transporter or
Contractor’s HSE Management System purchased product for which ownership has
which has been bridged to Medco E&P not yet transferred to Medco E&P
(Offshore) and Medco E&P (Offshore) has (Offshore) even if the shipment is
structured oversight and/or direct dedicated to Medco E&P (Offshore). This
supervision. excludes those Contractors that are being
transported by Medco E&P (Offshore)
provided transportation.
 Major construction site operating under the
Contractor’s HSE Management System
which has been bridged to Medco E&P
(Offshore) HSE Management System, and
for which Medco E&P (Offshore) works to
influence HSE performance but for which
Medco E&P (Offshore) does not have
structured oversight and/or direct
supervision.
 Crew members or Contractors/Sub-
Contractors on supply vessel working in
galley, machine room etc. even when
vessel and other crew members are
involved in platform operations (e.g.,
pumping mud to platform, lifting containers,
etc.)

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 14 – EXAMPLE OF INCIDENT / CASES DESCRIBE APPLICATION OF INCIDENT OWNER AND

SITE LINE MANAGER
 Maintenance and Operation activities on platform, the Site Line Manager shall be the Offshore Installation
Manager (OIM), and Operation Department is the Incident Owner.
 Well Intervention activities on platform, the Site Line Manager shall be the Well Intervention Supervisor
(WISU), and the Incident Owner is Well Operation Division.
 Project Division’s activities on platform, the Site Line Manager shall be the Construction Superintendent
on site, and the Incident Owner is Project Division.
 Well Intervention activities that borrows the crane or any other equipment or personnel from Operation to
help Well Intervention Group with their activities: the Site Line Manager shall be the Well Intervention
Supervisor (WISU), and the Incident Owner is Well Operation Division.
 Project Division’s activities that borrows the crane or any other equipment or personnel from Operation
to help Project Division with their activities: the Site Line Manager shall be the Construction
Superintendent on site, and the Incident Owner is Project Division.
 All Marine related incident happened on the Marine Vessels: the Site Line Manager shall be the Vessel’s
Captain and Logistic (Marine) Department is the Incident Owner.
 Lifting of load from marine vessel to drilling rig using the crane from drilling rig: the Site Line Manager
shall be the Drilling Supervisor, and the Incident Owner is Well Operation Division.
 All Aviation related incident happened on the Aviation Aircraft (Rotary Wing and Fixed Wing): the Site
Line Manager shall be the Aircraft’s Captain and Logistic (Aviation) Department is the Incident Owner.
 For Non Work Related incident on facility/platform: the Site Line Manager shall be the Offshore Installation
Manager (OIM) / Base Superintendent, and Operation Department is the Incident Owner.
 For Non Work Related incident on marine / aviation: the Site Line Manager shall be the Vessel’s Captain
(Marine) or Aircraft’s Captain (Aviation) and Logistics Operation Department is the Incident Owner.
 For Non Work Related office incident: the Site Line Manager shall be the General Service Manager, and
Human Resources Department is the Incident Owner.

MEDCO E&P OFFSHORE
MEDCO E&P OFFSHORE)
APPENDIX 15 – PROCESS SAFETY EVENT (PSE) TABLES of REPORTING THRESHOLD

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hmfLEMBAR JUDUL

PROSEDUR INSIDEN DAN INVESTIGASI

Document No. : OFS-HSE12-PRO-001-2021-R4 Revision: 04

Name Position Date Signature

Specialist HSE Offshore

Manager HSE Offshore

Manager HSE Offshore

Asep Bunawan Senior Manager HSE 18 Oct 2021

Diterbitkan oleh Published by

No. Dokumen : OFS-HSE12-PRO-001-2021-R4 Rev: 04

Document Number : OFS-HSE12-PRO-001-2021-R4 Rev: 04

2. RUANG LINGKUP 2. SCOPE

Insiden yang dilaporkan yang mempengaruhi Reportable incidents affecting the

Penyebab yang Berkontribusi - Satu atau Contributing Causes – One or more

5. Menggunakan obat-obatan untuk 5. Using hot or cold therapy

CATATAN: Perawatan Medis TIDAK NOTE: Medical Treatment does NOT

Bergantung pada situasinya, A & B di atas Depending on the circumstances, A & B

/ sakit, kerusakan properti / produk / damage to property / products /

Insiden- Peristiwa yang tidak direncanakan Incident – An unplanned / unwanted event

Insiden harus diidentifikasi, dilaporkan pada Incidents requires to be Identified, reported

Intervensi adalah terlibat dalam percakapan Intervention is engaging in a face-to-face

Incident Owner - Divisi atau Departemen Incident Owner – A Division or Department

Owner harus mengelola pelaporan formal

Cedera - kondisi abnormal atau gangguan Injuries – abnormal conditions or health

Investigasi - Metode, proses, dan prosedur Investigation – Methods, processes, and

Tumpahan Hidrokarbon Cair - Tumpahan Liquid Hydrocarbon Spills – A spill is defined

Loss of Primary Containment (LOPC) - Loss of Primary Containment (LOPC) – An

Near Miss - Insiden tanpa konsekuensi, Near Miss – An incident with no

Penyakit Akibat Kerja - penyakit yang Occupational illness – an illness / disease

Pengendalian Operasional - Medco E&P Operational Control – Medco E&P

Cedera / Penyakit Terkait Proses - Cedera / Process Related Injury/Illness – An injury /

Sebagaimana dibahas dalam kriteria As discussed in the reporting criteria, the

Properti - properti / instalasi / peralatan yang Property – property / installations /

Kerusakan Properti – Kerugian properti Property Damage – The Loss of Company’s

Fungsi Rutin - untuk tujuan pencatatan, Routine Functions – for recordkeeping

keadaan dan perilaku (Penyebab yang

Manajemen Lini - mengacu pada Line Management - refers to the

Pekerja Servis Terbatas atau Sementara - Temporary or Limited Service Employees –

4. TUGAS & TANGGUNG JAWAB 4. ROLES & RESPONSIBILITIES

4.2. Site Line Manager 4.2. Site Line Manager

4.3. HSE Performance Assurance 4.3. HSE Performance Assurance

4.4. HSE Team Lead 4.4. HSE Team Lead

4.5. HSE Advisor 4.5. HSE Advisor

5. PELAPORAN INSIDEN 5. INCIDENT REPORTING

Manajer Divisi / Departemen Incident Owner The Manager of Incident Owner

5.1. GAMBARAN UMUM PERSYARATAN 5.1. OVERVIEW OF REPORTING

lokasi kerja (Site Line Manager). Manager) immediately. The

Perlu dicatat bahwa program It should be noted that the

HI Potential Near Miss harus HI Potential Near Miss shall be

Semua insiden lingkungan All environmental incidents

5.1.2. Semua insiden pekerjaan 5.1.2. All occupational incidents are

Petunjuk untuk menilai potensi Instructions for assessing incident

5.1.3. Melaporkan insiden yang tidak 5.1.3. Reporting a non-work related

5.2. PROSEDUR (PELAPORAN INSIDEN 5.2. PROCEDURE (INCIDENT AND NEAR

5.2.2. Manajer Divisi / Departemen 5.2.2. Manager of Incident Owner

kerja dikarenakan cedera atau because of an occupational injury

5.2.8. Insiden Lingkungan: 5.2.8. Environmental incidents:

Berikut ini adalah persyaratan The following are the

B. Tumpahan Produced Water: B. Produced Water Spill:

 Kebocoran di atas atau  On-going aboveground

Tumpahan tidak termasuk: Spills do not include:

5.2.9. Perhitungan tumpahan/pelepasan 5.2.9. Calculation of spill/release

5.2.10. Process Safety Events 5.2.10. Process Safety Events

PSE Tier 1 dan Tier 2 PSE Tier 1 and Tier 2

OFS-HSE12-PRO-001-2021-R4 Prosedur Insiden & Investigasi

OFS-HSE12-PRO-001-2021-R4 Prosedur Insiden & Investigasi