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INCIDENT INVESTIGATION REPORT

REPORT NUMBER : ACCS/HSE/INC/RPT/0044 PROJECT NAME/ NUMBER: SMELTER PROJECT

CLIENT NAME : PT AMMAN MINERAL INDUSTRI

1. GENERAL INFORMATION
TYPE OF REPORT ✘ Preliminary Final

DATE OF REPORT Thursday, 25 May 2023 ✘

YES　　　　　　　 NO
AUTHORITIES INFORMED
REPORTING ENTITY PT. Pengembangan Industri Logam If Yes, Who? AMIN

INCIDENT AT: Cathode

PERSON IN CHARGE Taufiqurrahman Nur Ashar Work Related Non-work Related
Storage ✘

INCIDENT OWNERSHIP Client Incident Contractor Incident Other:

✘

NEARMISS (potential accident)

TYPE OF
INJURY TYPE DAMAGE ENVIRONMENTAL HEALTH
INCIDENT
PHYSICAL HUMAN
Injury Fatality Equipment Fire Occupational Illness Fire fall
Damage LTI Property Landslid Congenital disease Landslid tumble
Enviromental MT Restricted Leakage/Spillage Epidemic of a disease Leakage/Spillage crash
Health MT Non Restricted Explosion/Burst Pollution pinch
✘
Nearmiss First Aid Pollution Exposure electric shock
Others Exposure Property Damage traffic accident
touch high/low temperature
Flooding Explosion/Burst
thing
Other foreign object in the eye
touch/inhalation of
poisonous thing
shortage of oxygen
Other

NAME OF INVOLVED Mr Samsul Arifin GENDER Male Female

✘

EMP. NO./ ID NO. PIL33002499 AGE/PLACE & DATE OF BIRTH 27 Y.O / 27 May 1995

DEPT./SECTION Construction POSITION/ EXPERIENCE ON POSITION Rigger YEARS : 0 MONTHS: 1

FULL TIME PART TIME COMPANY/ SUPERVISOR NAME MCC 15 CHEN JINZHAO
EMPLOYEE STATUS
✘ CONTRACT TRAINEE DATE OF HIRING/ WORK EXPERIENCE 5-Apr-23 YEARS : 0 MONTHS: 1

2. FACTS OF INCIDENT
DATE 25-May-23 TIME (HH:MM) 9:45 AM

WHEATHER FINE CLOUDY DRIZZLE RAIN OTHERS:

✘

LOCATION Cathode Storage

WITNESSES

NAME POSITION/ COMPANY ACTIVITY AT THE TIME OF THE INCIDENT

LI PENG FOREMAN MONITORING LIFTING ACTIVITY

CHEN JINZHAO SUPERVISOR MONITORING LIFTING ACTIVITY

HARTO MANOLOP TAMPO BOLON OPERATOR CRANE 90T OPERATE THE CRANE TO RESPONSIBILITY THE LIFTING
Thursday, May 25th 2023.
Samsul - Rigger (33002499)
08.00 Pak Samsul received instructions from Pak Reza (TRANSLATOR MCC15) to coordinate with the operator to move the crane position from the FSF Area to Cathode Storage.
08:15 After arriving at the Cathode Storage area, Mr. Samsul was directed by Mr. Li Peng (Foreman) to guide the crane operator in positioning the crane facing north. Then Mr. Samsul
prepared the lighting gear. Under the direction of Mr Li Peng, the Rafter H-Beam will be placed on the west side of the crane.
09:00 Perform binding using wire sling 5T (4) shackle 9T (4).
09:20 Start lifting. The lifting of the H-Beam rafter which is in the northeast direction of the crane will be moved to the west crane position, when the material is in the west crane position,
two workers pull the tagline and direct the rafter behind the crane. The operator increases the lifting height of the H-beam rafter 150 cm from the initial height of 30 cm to avoid the lifted
material hitting the container.
09:45 The rear right outrigger collapsed and Pak Samsul ran around the crane (counterclockwise) looking for a position to be seen by the crane operator, then gave the operator a code to
unload the material

Harto Manolo Tampo Bolon - Operator Crane 90T (33003553)

08:15 Pak Harto asked Mr. Li Peng for crane placement. then fill out the daily checklist form and ask Pak Samsul (rigger) regarding soil stability in the work area.
08:25 Perform crane leveling and carry out a 360° swing test without load to ensure the outrigger is stable.
08:30 Issued a 32 meter long boom crane and sling area.
08:49 Position the hook just above the material to be lifted.
09:20 Carry out the lifting in accordance with the initial agreement that the material is placed to the left / west of the crane from the initial position of the material. With a lifting height of 60
cm from the ground.
09:25 Get the code from the love worker to swing back south towards the crane. Due to obstruction of the container, the operator increases the lifting height 150cm from the initial height
09.45 The right aft outrigger collapsed, at the initiative of the Operator to maintain the stability of the crane by swinging the boom towards the west by slowly inserting the telescopic boom
crane and the sling area to lower the material.

Mr. Li Peng - Foreman (3300267)

06:50 Mr. Li Peng conducted a briefing in the MCC15 office area to discuss plans to lift the rafter beam.
08:00 Mr Li Peng left for the appointment location.
08:20 Mr Li gave directions regarding appointments to all workers.
09:45 Memerintahkan pekerja untuk mengamankan material agar tidak terjatuh
10:00 Mr Li asked the operator to position the crane safely and remove all wire slings that had been installed.

INJURED PART OF BODY

NATURE OF INJURY TREATMENT AT
(NEARMISS: POTENTIAL)

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Strain/Sprain Pain First Aid Doctor’s office

Fracture Amputation Emergency Room Hospitalization

Laceration/Cut Concussion Name and address of treating Physician or Fatality

Bruising Foreign Body

Scratch/Abrasion Burn/Scald by heat

Dislocation Burn/Scald by chemical

Detail: Others :

Remarks:

3. CLASSIFICATION
WORK ACTIVITY lifting rafter beam

ACTIVITIES DETAIL moving rafter beam using crane 90T to lifting area crane 180T for erection

CONTRACTOR / SUBCONTRACTOR INVOLVED PT PIL / MCC 15

ACTUAL LOST Harm to people (Proceed to 3.1)
Environment (Proceed to 3.2)
Fire / Explosion (Proceed to 3.3)
Occupational Illness (Proceed to 3.4)
Equipment/ Property damage (proceed 3.5) (if Due to Traffic incident proceed 3.6)
Project Schedule Impact

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3.1 HARM TO PEOPLE (IP = INJURED PERSON)
NAME OF IP GENDER Male Female

EMP. NO./ ID NO. AGE/PACE & DATE OF BIRTH

DEPT./SECTION POSITION/ EXPERIENCE ON POSITION / YEARS : 0 MONTHS:

FULL TIME PART TIME COMPANY/ SUPERVISOR NAME

EMPLOYEE STATUS
CONTRACT TRAINEE DATE OF HIRING/ WORK EXPERIENCE / YEARS : MONTHS: -

SALARY WAGES HOURLY RATE DAILY RATE MONTHLY RATE YEARLY RATE OTHERS:

WORKING TIME/ SHIFT ARR. Day shift SHIFTS DATE OF MOBILIZATION ON SITE:

NUMBER HOURS OF WORKING (IP) PROPORTION OF SHIFT ACTUAL REST TIME

BEFORE INCIDENT WORK 50% or Less 50% - 100% overtime BEFORE NEW SHIFT:

1st FULL DAY OF INCAPACITATION TO WORK: FOR LTI /RWC (Estimate days lost): Day(s)

Induction Training REMARKS:

Task Specific Training

TRAINING PROVIDED
Both above

Neither of the above

3.2 ENVIRONMENT
TYPE OF RELEASE WASTE WATER CHEMICAL HYDROCARBON OTHERS:

VOLUME (liters/ M2) DURATION (min)/ TIME: /From to SAMPLING WAS PERFORMED: YES NO

LANDSLID/FLOODING AREA (M2) LAND CONDITION AFTER INCIDENT : STABLE UNSTABLE OTHER:
DESCRIPTION:

3.3 FIRE / EXPLOSION

FIRE TYPE PRIMARY EXTINGUSHING SYSTEM

IGNITION SOURCES VOLUME USED

DESCRIPTION
3.4 OCCUPATIONAL ILLNESS
NAME GENDER Male Female

EMP. NO./ ID NO. AGE/PACE & DATE OF BIRTH

DEPT./SECTION POSITION/ EXPERIENCE ON POSITION / YEARS : MONTHS:

WORKING TIME/ SHIFT ARR. FROM TO SHIFTS DATE OF MOBILIZATION ON SITE:

DISEASES CAUSE BY PHYSICAL AGENT BIOLIGICAL AGENT CHEMICLAL AGENT MISCELLANEOUS AGENT
First Aid Clinic Emergency Room Doctor’s office Hospitalization
TREATMENT AT
Name and address :

DOCTOR/PARAMEDIC
OBSERVATION

TYPE OF ILLNESS INFECTIOUS DISEASES EPIDEMIC ENDEMIC GENETIC OTHER :

3.5 EQUIPMENT/PROPERTY DAMAGE
Kind of equipment, property, or material damage: Object or Substance Inflicting Damage : Describe Damage:

3.6 TRAFFIC INCIDENT (detail see Traffic incident investigation Appendix-3)

DRIVER NAME GENDER Male Female

EMP. NO./ ID NO. AGE/PACE & DATE OF BIRTH

DEPT./SECTION POSITION/ EXPERIENCE ON POSITION Engineer / YEARS : MONTHS:

WORKING TIME/ SHIFT ARR. FROM TO SHIFTS DATE OF MOBILIZATION ON SITE:

VEHICLE NO CRASH WITH :

DESCRIPTION

4. LOSS POTENTIAL (see matrix)

POTENTIAL RECURRENCE / SEVERITY POTENTIAL RISK

Potential recurrence/ Probability: A B C D E

✘ ✘

Severity / Consequences 1 2 3 4 ✘ 5 LOW MEDUIM HIGH

5. FOLLOWING INCIDENTS HAVE TO BE IMMEDIATELY COMMUNICATED TO HEAD OFFICE

Major Incident High Potential Incidents (10 -25) LTI

✘

6. EVENT
Struck Against ( Running or bumping into) Caught on ( Snagged, Hung)
Struck by ( Hit by moving object) Caught Between ( Crushed or Amputated)
Fall to lower level Contact with:
Fall on same level ( Slip and fall, tip over) ✘ Overstress, Overexertion, Overload
Caught in ( pinch and Nip Points) Other:

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6. IMMEDIATE CAUSES - Report immediate causes at first instance. Consult the following list and describe more as needed. Check below which causes best indicate reason for existence of acts and/or
conditions identified. Add other causes if not listed. Why it happened? - Which condition was under-standard? - Generally more than one.

Substandard Act Substandard Condition

Operating Equipment Without Authority Inadequate Guards or barriers
Failure to Warn Inadequate or Improper Protective Equipment
Failure to Secure Defective Tools / Equipment or Materials
Operating at Improper Speed Congested or restricted action
Making safety devices inoperable Inadequate warning system
Using defective equipment Fire and explosion hazards
Falling to use PPE properly Poor Housekeeping, disorder
Improper Loading Noise Exposure
Improper Placement Radiation Exposure

✘ Improper Lifting Temperature extremes

Improper Position for Task Inadequate or Excess Illumination
Servicing Equipment in operation Inadequate Ventilation
Drug or Alcohol Use Hazard Environmental
Horseplay

✘ Using Equipment improperly

IMMEDIATE CAUSES - Report the immediate causes and describe more if needed.

1 Do not install the steel plate on the outrigger

IMMEDIATE ACTIONS - Report identified immediate actions to handle with casualties and the impact of events so that the consequences of the incident are not widespread and work can be quickly
started again. Try to be S.M.A.R.T ( Specific, Measurable, Achievable, Realistic, Timed) (control action to be registered at Appendix-6)

IMMEDIATE ACTION PLAN TO BE EXECUTED BY DUE-DATE

1 Stop activity Mr. Li Peng 25-May-23

2 Conduct a briefing at the end of the incident Ari Wisnoe 25-May-23

SEE DETAIL OF ROOT CAUSE ANALYSIS (Appendix-4 )

7. UNDERLYING CAUSES - Which specific human factor or work factor have leaded to immediate causes (at least one for each immediate cause)? - Why that act or condition was present? - The root
causes shall be removed by an action plan.
Personal factor Job factor
Inadequate physical/Physiological Capability Inadequate supervision
Inadequate mental / psychological capability ✘ Inadequate Engineering
Physical or physiological stress Inadequate purchasing
Mental or psychological Stress Inadequate maintenance
Lack of Knowledge Inadequate tools and equipment
Lack of Skill ✘ Inadequate Work Standards
Improper Motivation Exercise Wear and Tear

Abuse or Misuse

UNDERLYING CAUSES - Report the Underlying causes and describe more if needed.

1 There is no procedure requiring the use of a steel plate as the base of the outrigger

2 Misunderstood regarding lifting activity

8. FAILURE TO MAINTAIN COMPLAINCE WITH ADEQUATE STANDARDS

Leadership & Administration Personal protection equipment
Management Training Health control
Planned Inspections Program Evaluation System
Task Analysis and procedures ✘ Engineering Control
Accident and incident investigation Personal Communication
Task Observation Group Meeting
Emergency preparedness General Promotion
Organization Rules Hiring and Placement
Accident/ incident analysis Purchasing Controls

Employee training Off the Job Safety

Detail Description

1 Create standard operating procedures regarding outrigger mats

5
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9. FACT FINDING

1. Using wooden blocks as outriggers

2. Changing the location of laying the material without the knowledge of the operator and when the Rafter H-Beam is still hanging

3. Not making a lifting certificate

4. There is no risk of the outrigger collapsing in the JSA, and no steps for installing the outrigger base are listed

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10. CORRECTIVE AND PREVENTIVE ACTIONS - Report identified actions to remove root causes and prevent recurrence - Use the following guidelines as needed. Report in sequence of priority.
Assign a target time and person / company responsible to complete the corrective action and give feed-back of completion. Try to be S.M.A.R.T ( Specific, Measurable, Achievable, Realistic, Timed)
(control action to be registered at Appendix-5)

CORRECTIVE ACTION PLAN TO BE EXECUTED BY DUE-DATE

1 Stop work Li Peng (foreman) 25-May-23

2 Conduct briefings Ari Wisnoe (HSE PMC) 25-May-23

3 Conduct investigation Taufiqurrahman Nur Ashar HSE MCC15) 25-May-23

4 Make SOP related to lifting activities MCC15 28-May-23

5 Replace beam with steel plate MCC15 28-May-23

6 Adding the risk of the outrigger collapsing in the JSA and socializing it to workers MCC15 28-May-23

11. LESSON LEARNT

1 Follow the SOP that applies in the work area related to the type of work being done

2 Always conduct briefings with all workers when there is a change in the work plan

3 Do not use wooden beams to make the outrigger base, and must use a steel plate

12. APPENDICES - Root Cause analysis, Photos, Witnesses statement/Interview (appendix-7), Medical report, Corrective actions sheet, Other

No TITLE DOCUMENT NAME

1 ID Badge

2 PTW, JSA

3 Crane Sany, SRC900T, 90 T

4 Outrigger

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5 Statement Letter

13. INVESTIGATION TEAM

No. NAME POSITION SIGNATURE REMARKS

1 Mr. 'He Zhengbing (33000260) PIL HSE Manager

2 Mr. Tegar (33001978) PIL HSE

3 Mr. Arie Wisnoe (33000032) PIL HSE

4 Taufiqurrahman Nur Ashar (33000473) MCC 15 HSE

5 CHEN JINZHAO (33003155) Supervisor

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