Leighton Contactors Indonesia

HSE INCIDENT INVESTIGATION REPORT

For All Personal Damage, Non Injury Incidents and Environmental Harm

Purpose of the Investigation

The purpose of completing this investigation is to identify all of the essential and contributing factors so that
action can be taken to prevent the accident/incident from happening again.

PROJECT DETAILS (ATTACH PROJECT ORGANISATION CHART)

Division / Project: MGM Project Report No.:

Project Manager: COLIN McCUMSTIE Project No.: 226

Immediate Supervisor: IMAM THOHARI HSE SUPERINTENDENT

No Investigation Team Members Position

1. IMAM THOHARI HSE SUPERINTENDENT

2. CAESORIA SINAGA ENVIRONMENTAL ENGINEER
3.
4.

INCIDENT DETAILS
Date/Time Of Occurrence: 1 August 2012 Date/Time Reported: 5 August 2012

Location: Camp Biawak

Weather Conditions: CLEAR

Work related Shift worked 06.00 18.00
Day Night Shift hours Overtime
from to from to

Journey/Work Environmental
Level 1 Level 2 Level 3
travel related Harm
Injury occurred
Property damaged Near Miss
(Complete Form A-details of injured person)
NII CLASS 1 NII CLASS 2 NII CLASS 3

NOTIFICATIONS
Off Site Notifications When (Date & Time) How

LAL Managing Director

LAL HSE Manager

Business Unit Manager

Company HSE Manager

Divisional Operations Manager

Statutory Body/Government Dept.

Police

Medical Services

Fire Services

Insurance Company

Others (State)

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 Leighton Contractors Indonesia

HSE Incident Investigation Report

DESCRIPTION OF THE INCIDENT

(Include detail of injuries / damage and assessment of apparent cause):

Incident Description
* Where did the incident Camp Biawak Office
happen?
(Describe site location. Attach
a sketch, if necessary)

* What was the task? Genset for Office-Camp Biawak Activities

(Describe work task being
undertaken by the victim e.g.
erecting formwork, operating
70t crawler crane)

* What was being done when

the incident happened? On August 1st 2012 it was found that there was oil spillage from gensets secondary containment
(Describe the sequence of which overflowed with rain water. The amount of the spillage approximately 5 liters of hydrocarbon.
events immediately before the
occurrence of the incident)
* What equipment, tools and Genset
materials were being used?

* Include detail of injuries/

environmental pollution (soil)
damage.
* What was the apparent Np roof for the genset, enable rain water to enter the gensets secondary containment.
cause? (General and
specific comments as
required also what
happened to cause the
damage/injury)
(Where possible, include
Distances, weights, slopes,
speeds, etc, plus photos,
Sketches and witness Stmt)

Witness Name Occupation Employer

Attach witness statement, sketches, comments, photographs and other details where appropriate. Tick box next to name if
included

ROOT CAUSES OF INCIDENT/HAZARD/NEAR MISS

Review the lists below and tick those that are thought to have contributed to the basic cause of incident
Equipment Worker Environment Management
Poor Lighting Fatigue/ Stress Ambient conditions (wind, Hazardous work method
dust, rain etc) specified
Excessive Noise Physical/disability affecting Excessive Noise Lack of supervision
performance
Difficulty in Operating Culpable Act Terrain Provision of correct safety
(tools, equipment, etc) equipment or clothing
Manual Handling Skylarking or misconduct Temperatures Inadequate training provided

Congested work area
Hazardous machine, tool
or equipment
Malfunction or defect in
machine, equipment
Unsuitable safety clothing
or equipment
Difficult to maintain
Inadequate guarding or
protection
Possible personal problem Poor Housekeeping Poor Housekeeping
Standard
Inexperience in task being Building surface conditions Poorly maintained
performed (stairs, floors) equipment
Failure to use safety Storage/ stacking of Suitable plant/equipment
clothing material unavailable
Hazardous work method Exposure or contact Inadequate or no
used chemicals or other harmful documented
material procedures
Possible influence of Exposure to infectious Insufficient inadequate
alcohol or drugs sickness/ disease instruction or information
Act or omission of another Visibility Production pressure
person

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 Leighton Contractors Indonesia

HSE Incident Investigation Report

State the Action to be taken to prevent it happening Again.

Short term action By Whom By When
Provide secondary containment below the two gensets Caesoria 05/08/12
Build roofing temporary to prevent rain water entering the secondary containment Caesoria 06/08/12
Cleaned up the secondary containment to prevent further contamination Mujiko 02/08/12

Short-term action completed

Imam Thohari
Project HSE Representative Name (Print) Signed Date

Long term action By Whom By When

Provide permanent roofing Caesoria 05/09/12
provide concrete secondary containment and oil trap Caesoria 05/09/12

PROJECT MANAGERS COMMENTS

Colin McCumstie
Project Manager Name (Print) Signed Date

PROJECT MANAGERS CLOSE OUT COMMENTS

Note: have all actions identified above been closed out? YES NO
Comments:

Colin McCumstie
Project Manager Name (Print) Signed Date
Note: Send this form to the Divisional HSE Manager within 7 days. If the actions are not closed out within 7
days, this form shall be sent as is and re-submitted when all the actions are closed.

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 Leighton Contractors Indonesia

HSE Incident Investigation Report

DETAILS OF INJURED PERSON

(Complete a separate sheet for each person)
Note: if personal details have already been completed as required by a statutory authority or client, attach a copy of the
completed details to this investigation report.

Name: Position:
Date of Birth: Age: Female Male

Employer Name: Employed in the Project Since:

Experience In Current Occupation:

INJURY DETAILS
Body Part Injured
Head/Neck Arms Hands Back Chest
Abdomen Feet Legs Skin Eyes
Internal Organs Others

Type of Injury
Amputation Fatality Paralysis Crush Burn
Sprain/Strain Concussion Fracture Laceration Dermatitis
Exposure Bruising Abrasion Other

Mechanism of Injury
Knocked Chemicals Electricity Flying object Manual Handling
Falling Object Vehicles Hand Tools Knife
Trip/Slip/Fall Machinery Other

PROTECTIVE CLOTHING & EQUIPMENT

What Protective Clothing and Equipment was being worn at the time of incident/hazard/near miss?
Safety Glasses Safety Shoes Splash Goggles Gloves Overalls
Respirator Protection Hearing Protection Safety Helmet Fall Protection Other

DAMAGE CLASSIFICATIONS
Initial Treatment Initial Prognosis Work consequences Work consequences Work consequences
- immediate - after 24 hours - after 3 days

return to pre-injury return to pre-injury return to pre-injury

hospital Class 1
duties duties duties
medical Class 2 restricted duties restricted duties restricted duties

first aid Class 3 off work off work off work

Date Ceased Work / / Resumed Work / / No of days Absent:

Duties: Modified Normal Disease Yes No

Date symptoms were first recognised / /

This damage is considered to be:

Aggravation of previous personal damage The source of the personal damage

This Injury Classified As

Class 1 Class 2 Class 3

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 Leighton Contractors Indonesia

HSE Incident Investigation Report

PHOTOS DOCUMENTATION:

Genset with no roof

Contaminated soil

Secondary Containment
Roof Installation in progress

Aug 2009 Page 5 of 5 LCI-HSE-FM-011A(01)