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 BENHIL BIGDRUM1 BIGDRUM2 BIGDRUM3 BULK Ceiling Mixing Ceilling-RMS Ceilling-Utility Cleaning Room Cold Storage CORN Eng & PE Room-PH General Produksi GILF GRAMBT1 GRAMBT2 GRAMBT3 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 NEWCUP 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 TPS B3 TPS Sludge Cake & Produksi Tunnel Utility CS Utility-PH VENTURA VERSALINE Workshop Kontraktor Workshop ULI WTP WWTP Yard Service ( Dalam Pagar ) Zudek Mixing

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
Prevention for spreading of Covid-19

9. Personal Protective Equipment [PPE]

Head protection
Breathing
Face protection
Safety belt
Safety shoes
Eye protection
Hand protection
Ear/hearing protection
Body protection
Covid-19 Medical mask
Covid-19 protective eyewear / face shield

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
Inhaling extreme temperature
Contacting dangerous chemical materials
Lifting object beyond capability
Repetitive unsafe act
Unproper work position
Crash by object
Dangerous work
Trapped inside of, on top of, or between the object

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 Consciousness RJA (Recognition, Judgment, Action) Alertness Illusion Forgetfulness Be paralyzed Guess/prejudice Short cut/omit Physical condition State of mind Visual direction

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

Done Not Done

Upload image (optional)

Submit Form

Submit