Accident Investigation Report

Basic Information
An accident had occurred at Proeight Teluk Kalong QRC involving GPPA project. The accident
occurred on 14th July 2010 at 1650. The type of the accident is medical treatment case. The
work environment where the accident occurred is in non-office which is factory.
Incident Description
The phase of workday at time of incident is ending shift. The task being performed at time of
incident is cutting carbon material. This task is a routine task for the worker. The machine that
was involved in the incident is carbon grinding machine. During machining, the worker wants to
cut the material into 2 pieces and in the ending process, he wants to take the carbon to prevent
it from falling. The incident occurred and his thumb comes into contact with sharp edges of the
machine jaw. His thumb finger was cut due to the contact.

Medical Treatment Information

The care given by first responder was cleaning the cuts or injured location with Dettol cleaner
and wipes it with a clean cotton cloth. The blood did not stop and they immediately brought him
to clinic nearby, Ibnu Sina Clinic and had a treatment and dressing. He was given medicament
and medical leave for 2 days. The finger was bandage by the doctor.

Incident Analysis
The injury resulted from this accident is people where the thumb of the worker suffered a cut.
Blood flowed out from the thumb and it becomes swollen. The event that leads to this injury is
the workers thumb struck by machine jaw. The incident is analyzed in 2 stages to establish its
immediate causes and basic causes. Immediate causes are circumstances that precede the
event and usually are unsafe acts or conditions.

Immediate causes
Actions
1. Possible error in decision
making or possible lack of
judgment
2. Use of defective tools

The worker probably think that his action will not resulted in
injury
The short rod used by worker to collect the carbon put his
hand near to the machine jaw

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Absent or Failed Defenses
3. Inadequate tools
4. PPE not available
5. Inadequate guards or
protective devices
6. Inadequate Standard
Operating Procedures
(SOP)
7. Inadequate hazard
management

The machine did not provide tools with rod to prevent the
carbon from falling after being cut
Gloves for works involving carbon machine is not available
for workers usage
The machine did not have guards that protect finger from
the machine jaw
Inadequate SOP for the carbon grinding operation as only
work guide is present.
No hazards assessment, risk assessment and risk control
(HIRARC) has been done for the activity

Root causes are the underlying causes that allow for the immediate cause to happen and
eventually lead to the accident.
Immediate causes

Root causes

Description

1. Possible error in decision

making or possible lack of
judgment

Skill hazard failure

to recognize hazard
Training No training
provided
Management
Inadequate identification
of job hazard by
leadership
Tools/machine
Inadequate adjustment

The worker lack of judgment due

to the absence of training

2. PPE not available

3. Inadequate tools

4. Inadequate guards or
protective devices

5. Inadequate Standard
Operating Procedures
(SOP)
6. Inadequate hazard
management

Management
Inadequate identification
of job hazard by
leadership
Procedures Lack of
SOP for the task
Tools & Equipment
Inadequate assessment
of needs and risks

Gloves for works involving

carbon machine is not available
for workers usage
The machine did not come
complete with rod to prevent cut
carbon from falling
The worker is exposed to the
mechanical hazard of machine
jaw while collecting carbon
material
The work guide did not covers all
aspect pertaining to the
machinery safety
Risk assessment have not been
done for the activity

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Corrective action
Root cause
1. Skill level Failure
to recognize hazard
2. Training No
training provided
3. Tools/machine
Inadequate
adjustment

4. Management
Inadequate
identification of job
hazard by
leadership
5. Procedures Lack
of SOP for the task
6. Tools & Equipment
Inadequate
assessment of
needs and risks

Corrective action

Person-in-charge
HSSE

All machinist to be trained with

machinery safety and basic hazard
identification course
To blur down the sharp edges of
the machine jaw
To install rod permanently to the
machine if feasible to prevent cut
carbon from falling

HSSE & Manufacturing

PPE assessment to be done to

evaluate the needs for Safety
Gloves (Steel Mesh)

HSSE

Review the current work guide to

ensure that all aspects pertaining to
safe operation is include in it
HIRARC will be developed for all the
high risk work activities in the factory

HSSE & Manufacturing

HSSE & Manufacturing

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Pictures of the accident

Location of accident

Injury happened

Worker operating the machine

Insert rod into carbon

Using rod to take carbon