LAPORAN KETIDAK-SESUAIAN
NON CONFORMITY REPORT
Unit Kerja / Nama Kapal:
Hari/Day
Ship Name
Tanggal/Date
Lokasi Kejadian:
Waktu/Time
Location of Non Conformity
Uraian kejadian/Description:
Detail of incident
Gunakan kertas tambahan bila diperlukan/use blank copy if necessary
Tingkat Potensi Keparahan: (Potential Severity Level)
‫ ٱ‬Minor
‫ ٱ‬Moderate
‫ ٱ‬Serious
‫ ٱ‬Major
‫ ٱ‬Catastrophic
Lihat tabel potensi keparahan
(see potential severity level table)
Penyebab Langsung
Komentar (jika ada) Comment (if any)
Immediate Cause
Tindakan pencegahan dan perbaikan:
Preventive and Corrective Action
Dilaporkan oleh/Reported by
Jabatan/Occupation
Tindakan perbaikan telah selesai dilaksanakan pada:
Corrective action completely satisfactory on
Diketahui oleh/Aknowledged by
Nama/Name
Jabatan/Occupation
Disampaikan kepada Departemen HSE pada
Tanda tangan/Sign
Tanggal/Date
Jam/Time
Tanda tangan/Sign
Tanggal
Jam
Date
Time