1. Observer Name *

2. Staff identification number *

Unilever Employee Contractor

Without 000

Enter Company Name if you are a contractor

3. Date and Time

4. Area *

Ageing 1 Ageing 2 Ageing 3 Ageing 4 Ageing 5 Air Compressor Ammonia BIGDRUM1 BIGDRUM2 BIGDRUM3 BULK Ceiling Mixing Ceilling-RMS Ceilling-Utility Cleaning Room Cold Storage CORN Eng & PE Room-PH General Produksi GILF GRAMBT1 GRAMBT2 GRAMRIA10 GRAMRIA14 GRAMRIA5 GRAMRIA6 GRAMRIA7 GRAMRIA8 GRAMRIA9 HWG 1 ( Mixing ) HWG 2 & 3 ( Utility ) Kantin Leader Room-PH LVMDB 1 & 2 MCC 1 MCC 2 MCC 3 MCC 4 Mixing Mixing MOCHI MOCHI MV 1 & 2 Office 1st Floor Office 2nd Floor Office 3rd Floor Office Block Office Cold Storage Office Project Palletizing Perimeter ( Luar Pagar ) Puyuan Quality Rework Room RMS / SS ROTARY Ruang Disposal Security Snowball TPS B3 TPS Sludge Cake & Produksi Utility CS Utility-PH VENTURA VERSALINE Workshop Kontraktor Workshop ULI WTP WWTP Yard Service ( Dalam Pagar ) Zudek Mixing
Ammonia
Non-ammonia

5. Type of work being observed

Type:

Lain-lain Hot Work Working at Height Lifting Low Voltage Medium Voltage Confined Space Excavation Demolition Radiography

Description:

6. Object/Name of person being observed *

7. Number of personnel

8. Response [RP]

Wearing personal protection
Change position of existing installation, workplace, or work behavior
Creating new work plan
Stopping the work
De-energizing power sources
Installing safety equipment

9. Personal Protective Equipment [PPE]

Head protection
Breathing
Face protection
Safety belt
Safety shoes
Eye protection
Hand protection
Ear/hearing protection
Body protection

10. Tools and Equipment [TE]

Damaged tools
Improper tools

11. Work Procedure and 5S [PO]

Not following the correct procedure
Lack of knowledge in correct procedure
Inadequate 5S standard
Unavailable procedure

12. Person's Position [PP]

Falling
Electric shock
Contacting extreme temperature
Contacting dangerous chemical materials
Lifting object beyond capability
Forcing beyond one's capabilities
Unproper work position
Crash by object
Trapped inside of, on top of, or between the object
Fall / impact from fall
Crushed
Impact
Slipped

13. Safe action/condition being observed

         Safe ACT Safe CONDITION

14. Unsafe action/condition being observed

         Unsafe ACT Unsafe CONDITION

15. Reason for unsafe action

Selection, RJA, be paralyzed Alertness Illusion Forgetfulness Short cut/omit Physical condition Visual direction

16. Have you done a follow-up action when reporting this SBO?

Done Not Done

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