INCIDENT INVESTIGATION REPORT

For Personal Damage, Environmental Harm & Near Misses

SECTION 1: PROJECT & INCIDENT DETAILS

1.1 PROJECT DETAILS:

Business Unit: PT.MCC EXTRACTION SOLUTIONS Report No: 010-INC-HSE-PD-06-17
Project Name &
PT.BOSS - COAL PROJECT Project No: TBA
Site/Office Location:
Project Manager Name: Muksin
Dept Mgr/Supt/Supv
Lukas DR
Responsible:
Building Civil Mining
Project Type:
COAL MINING

1.2 FINAL INCIDENT CLASSIFICATION:

Personal Injury Fatality LTI AWI MTI FAI
Classification Level 1 Pot 1 Level 2 Pot 2 Level 3
Property Damage Level 1 Level 1 Level 2 Pot 2 Level 3
Level 1 Level 2 Level 3
Nearmiss Personal Injury Property Damage
Pot 1 Pot 2
Environmental: Level 1 Pot 1 Level 2 Level 3
Was there the potential for the incident classification to be greater? Yes No
If Yes, indicate potential classification

1.3 INCIDENT DETAILS& SUMMARY:

Time of Date Time 08:35

Date of Incident: June 20th 2017 incident:
07.30 am reported:
June 20th 2017 reported: a.m.
Shift: Day Night % Shift worked 0-25% 25-50% 50-75% 75-100%

Weather Conditions: Weather in good condition.

Location of Incident:
Process or task at time of
incident:
Investigation Summary:
(Briefly summarize the
facts & highlight the
causation factors- attach
additional pages, sketches
or photographs if required)
Injured / Involved
Person Details:
Type of injury:
External Medical Treatment
Sump Area
Reposition pump from middle of eastern sump to near ramp / bench.
Immediate Causes:
1. Incorrect placement of rope to pulling direction ( penempatan tali yang tidak benar
terhadap arah penarikan).
2. Failure to warn about rope position before proceed pulling the pump (tidak
memberikan peringatan bahaya ketika tentang posisi tali sebelum melakukan
penarikan pompa ) .
Basic Causes:
1. Misunderstood/directions between supervisor dan pump crew. (kurang koordinasi
dan komunikasi antara pengawas dan kru pompa)
2. Inadequate practice of pump crew (kurangnya pengalaman lapangan dari kru
pompa ).
3. Poor JSA other procedure about pulling pump barge above water (kurangnya
prosedur atau JSA tentang penarikan ponton pompa di air).
Name & ID No: Occupation & Dept: Employee Type:
Direct Employee
Indirect Employee
Insert Company name below:
N/A Body Part N/A
injured:
No Details of medical facility injured person treated at:

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 Provided:
Yes N/A

SECTION 2. INVESTIGATION DETAILS & IDENTIFIED FACTS

2.1 INVESTIGATION TEAM:
Name & ID No: Occupation/Position:

Lead Investigator: 1. Lukas DR Mining Supt.

Facilitator: 2. Yohanes Lawing SHEQ Manager

Other Team Members: 3. Supiansyah Plant Manager

4.
5.
6.

2.2 WITNESSES TO THE INCIDENT:

Witness Name & ID No: Occupation/Position: Employer:
1. Kadang Pongpare # 1056 Mining Supervisor PT. MCC
2. Emilius Kusri # 2097 Pump Crew PT. MCC
3. Netra Wijaya # 2068 Pump Crew PT. MCC
4.
5.
6.
Attach witness statement, sketches, comments, photographs and other details where appropriate in appendix
Tick box next to name if the statement is included in report.

2.3 DESCRIPTION OF THE INCIDENT

Prompts Details

What actually happened &
describe what was being
done when the incident
occurred?
(Describe the basic sequence
of events immediately before
the occurrence of the incident).
On Tuesday June 20th 2017 approx. 7.30 am, The Supervisor and two pump
crews have task to moving pump position from middle of eastern sump to the
ramp around 50m distance, before pulling make preparation down to water
release HPDE pipe and after both pump crew finish unconnected the HDPE pipe
from pump connector the supervisor asking to tied up the rope on front left side
the pump and after that both of pump man went back to land to hook up the rope
onto the bucket tip of excavator then pulling the pump from middle to near ramp
and suddenly bogged but excavator keep pulling to move out pump position
from bogged point to several meters to the east because rope being more
tension and the handrail structures being loose and damages.
-----------------------------------------------------------------------------------------------------------
Pada hari selasa tanggal 20 Juni 2017 pukul 7.30 wita, Supervisor dan dua
orang pompa bertugas untuk memindahkan posisi pompa dari posisi tengah
sump timur ke tepi berjarak sekitar 50m, sebelum menarik kedua crew pompa
turun untuk melepas pipa HDPE dan setelah keduanya selesai melepas pipa
HDPE dari konektor pompa lalu supervisor meminta kru untuk mengikat tali
pada posisi kiri depan dan kemudian kedua nya naik ke darat untuk mengikat
ujung tali yang lain pada kuku bucket excavator kemudian pompa ditarik dari
tengah sump hingga ke tepi dan tiba tiba kandas lalu excavator terus tarik untuk
menggeser beberapa meter ke arah timur karena tali menjadi sangat kencang
hingga pagar (handrail) menjadi terlepas dan rusak.

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 What was the task being
undertaken at the time of the
incident? Moving pump from middle sump area to near the ramp
(E.g. Erecting formwork, operating
70t crawler crane, loading,
dumping, hauling). (Memindahkan pompa dari tengah sump ke dekat tepi tebing).

What equipment, tools &

1 x Excavator Cat 330 (CE077)
materials were being
used?(Describe equipment
1 x Water Pump, Coates (P40673)
model, type, unit number,
material weights, sizes etc.). 1 x Nilon Rope, + 50 meter

Sump area Pit D East.

Describe incident location &
environmental conditions Pump position about 50 meters from middle of sump pit D to ramp/bench.
(E.g. Location, distances, Morning with clear weather after rain at night. (pagi hari cerah setelah hujan malam)
ground/ slope condition,
weather, visibility, weights, etc. Excavator position on narrow and muddy road condition (jalan sempit dan becek).
Attach sketch/map, photos in
appendices)

Incorrect position of rope line when tied on, rope position thru entry access so
when pulling the rope push handrail structure.
(posisi jalur tali yang tidak tepat saat melakukan pengikatan, posisi tali melalui
What were the immediate
causal factors? akses masuk sehingga saat ditarik menekan tiang handrail).
(Specificcomments on what
happened to cause the Inadequate hazard identification of pump crew before commenced the job.
incident)
(kurangnya identifikasi bahaya oleh crew pompa sebelum melakukan tugas)
Supervisor failures to check and warn to make sure all process are safe.
(supervisor gagal memperhatikan dan memberikan peringatan jika tidak aman)

Provide comprehensive
Details of injury or damage: Direct & associated costs:
details of injuries/ damage&
record associated costs
(Describe all injuries incurred,
treatment provided, damage
LH front handrail (guard) damages Plant Estimation
incurred to equipment/plant
etc..).

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SECTION 3: RESULTS OF ICAM ANALYSIS
(To be completed for actual and potential Class1, LTI, AWI, MTI and Environment Level 1& 2 incidents)

3.1 ICAM CHART:Review the lists below and tick those that are thought to have contributed to the incident.
Organisational Task/Environment Task/Environment Individual/ Absent or
Factors Conditions (Human) Conditions (Workplace) Team Action Failed Defences

Complacency / Task Planning / Supervisory Error or

Hardware Detection Systems
Motivation/ Attitude Preparation/Manning Violation

Hazard Analysis / Operating Authority

Training Drugs / Alcohol Protection Systems
JSEA / Prestart Card Error or Violation

Familiarity with the Procedures /

Organisation Operating Speed Warning Systems
Task Availability/ Suitability

Abnormal Operating PPE use Error or

Communication Fatigue Guards / Barriers
Situation or Condition Violation
Tools / Equipment /
Situational Procedural
Incompatible Goals Materials Condition Control Systems
Awareness Compliance
and Availability
Time / Production Change Management Recovery / Backup
Procedures Housekeeping
Pressures Error System
Equip / Materials
Maintenance Peer Pressure /
Equipment Integrity Handling Error or Escape
Management Supervisory Example
Violation
Horseplay / Thrill
Design Confidence Level Weather Conditions Rescue
Seeking Violation

Physical / Mental Congestion / Hazard Recognition / Safety Device

Risk Management
Capabilities Restriction / Access Perception Operation

Management of Physical / Mental Routine / Non Hazard Management

PPE
Change Stress Routine Task Error or Violation

Contractor Fire and/or Explosion Work Method Error or Safe Work

Secondary Goals
Management Hazard Violation Instructions

Organisational Managers Tolerance Occupation Hygiene

Lighting Hazard Awareness
Culture of Violations Practices
Reliance on
Regulatory Influence Undocumented Temperature Other (Specify) Hazard Identification
Knowledge
Organisation
Personal Issues Noise Risk Controls
Learning

Organisation Tolerance Distraction /

Ventilation Supervision
of Violations Pre-occupation

Competency /
Other (Specify) Pressure Other (Specify)
Experience / Skill

Behavioural Beliefs
Gas / Dust or Fumes
(gain > risk)

Passive Tolerance of
Radiation
Violations

Poor / Inadequate
Chemical
Communication

Poor Shift Patterns /

Wild Life
Overtime

Surface Gradient /
Change of Routine
Conditions

Other (Specify) Other (Specify)

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 3.2. DESCRIPTION OF FACTORS IDENTIFIED IN THE ICAM ANALYSIS
Provide a description of each of the previously identified factors.

ABSENT OR FAILED DEFENCES:

N/A

INDIVIDUAL / TEAM ACTIONS:

N/A

TASK / ENVIRONMENTAL CONDITIONS (WORKPLACE):

N/A

TASK / ENVIRONMENTAL CONDITIONS (HUMAN):

N/A

ORGANISATIONAL FACTORS:

N/A

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SECTION 4. REMEDIAL ACTION PLAN
State the actions to be taken to prevent it happening again.
(Each identified factor for Absent/Failed defenses&Organizational factors requires an action)
Hard Soft By Whom
Short Term Action Control Control Insert name of By When
() () responsible person

1. Stop operating and report to safety (take evident foto) Kadang P. 20.06.17
2. Prestart briefing bahaya penarikan pompa Kadang P. 23.06.17
3.
The above short term actions have been verified as complete by the Project HSE Mgr/Supt Yes No

Hard Soft By Whom

Long Term Action Control Control Insert name of By When
() () responsible person

1. JSA/Prosedur Penarikan pompa di atas air. Kadang P. 24.06.17

2.
3.

The above long term actions have been verified as adequate by the Department Manager/Supt Yes No

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SECTION 5. INCIDENT INVESTIGATION REVIEW AND CLOSE OUT

5.1 INCIDENT INVESTIGATION REPORT REVIEW & APPROVAL

NOTE: The following levels of sign off are required to verify that the report has been reviewed, approved & the proposed remedial actions are deemed adequate. All levels
of sign off must be complete before the report is forwarded to Jkt HSE Dept.

Responsible Department Manager/Superintendent review comment & approval:

Department Manager/Supt Name (Print) Signed Date

Project HSE Manager/Superintendent review comment & approval:

HSE Manager/Supt Name (Print) Signed Date

Project Manager/Director review comment & approval:

Project Manager/Director Name (Print) Signed Date

5.2 INCIDENT INVESTIGATION CLOSE OUT:

NOTE: The Project Manager/Project Director must not sign off close out until all actions are verified & signed off as having been closed out in Section 4 of this report.

Project Manager/Directors Close Out Statement:

All corrective actions identified in Section 4 of this report have been closed out? Yes No

An Incident Alert has been produced & communicated to the workforce & Corporate HSE Manager Yes No

The controls are being monitored and are considered to be effective? Yes No

Final comments

Project Manager/Director Name (Print) Signed Date

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APPENDIX 1: DETAILS OF INJURED/ILL PERSON

PERSONAL DETAILS:

Full Name: Date of Birth:

ID Number: Gender: Female Male

Occupation/ Job
Date of Hire:
Title:
MCC Dept/
MCC Direct Employee Subcontractor Company Name:
Company:
No of Days Last field break
Shift: Day Night -
into Shift taken
Experience in
Current <2 Weeks <1 month 2-6 Months <12 Months 1-2 Years 2-5 Years > 5 Years
Occupation:

Injured Body Part/Location: Description of First Aid/Medical Treatment Provided:

Nature/Type of Injury/Illness:
Fracture Amputation Foreign body/puncture Internal injury Infectious & parasitic
Dislocation Crush Burn Concussion Dermatitis/Eczema
Joint sprain/strain Deep cut/laceration Heat/Cold Stress Hernia Deafness
Muscular sprain/strain Superficial cut Poisoning Nervous disorder Mental disorder
Bruise/Contusion Abrasion/graze Sing/bite/irritation Heart /circulatory Vision disturbance
Other- specify

Mechanism of Injury/Illness:
Contact with sharp
Fall from height Struck against object Dust/fume exposure Manual handling
object
Falls at same level
Struck by moving
(including trips and Contact with (Chemical) Noise exposure Repetitive movement
object
slips)
Contact with Other muscular
Vehicle collision Struck by flying object Radiation exposure
(Temperature) stress
Vehicle tip over/roll Mechanical vibration
Struck by falling object Contact with electricity
over exposure
Ground slide or cave- Caught/Pinched Animal, insect bites &
Other- specify
in between stings)

Treatment Provided Work Consequence Final Prognosis

First Aid Return to pre-injury duties FAI

Medical Placed on alternative duties MTI AWI
Hospitalizations Booked of work (loss of 1 shift) LTI Class 1
Describe alternative duties:

Date ceased work - Resumed Work Yes No of Days Off -

Name of Treatment Facility: -

Name of First Aider/Paramedic/Doctor: Dede Suhendar & Kamsar

(To be completed for all personal damage cases. In the event of multiple injured persons from a single event a separate record must be filled in for each injured
person & recorded in the project safety statistics database)

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APPENDIX 2-PHOTOGRAPHS

ATTACHMENT 1-PHOTOGRAPHS

Please insert relevant photographs below & attach any other relevant information to the back of this incident notification.

Photo 1. Position Excavator to pulling out pump barge Photo 2. The broken guardrail

Photo 3. Bogged point

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SKETCH

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