Formulir A3 Full Reloaded

A3 Reloaded - Work Process Failure - Quadrant A

Check base conditions vs. current standards & understand the problem

1. What is the problem: Incident type/loss/cost of problem:

- Loss Time Injury
- Injured person got 6 stiches
On 02.39 PM, 13th March 2022, Gardener left foot (palm) was cut by Chainsaw during tree
trimming activities in Site Garden area Notifying Person: Template number (1-…):
HSE Manager
GA Manager

2. 5W-1H: Focus on the problem: Go to the equipment/process and observe the problem.
Describe the event in as much detail as possible, based on what you actually saw, not what you think might
have happened! Facts only!
WHAT? What not? WHERE? Where not? WHICH? Which not?
What do you see? Does the loss occur and where not or at Brands, SKUs*, formats or materials are effected &
which charges? which are not?
- The Gardener team receive order from GA Which process? Which step/activity of the process is affected & which
officer to do tree trimming in Site Garden area is not?
- They use Chainsaw to cut the big parts of tree
- Site Garden area near GA locker room - Trimming tree activities
and slices them out to become small cuts
- The Chainsaw accidentally swung to the left
foot part of the Gardener when he was just
Check base conditions vs. current standards & understand the problem

finished trimming out into small cuts on the - Trimming tree into small cuts - Not on trimming grass or other trimming activities
ground and caused the lower part of his left foot
(palm part) cut and bleeded
- His colleagues immediately provided first aid
support and took him to the nearest Hospital for
further medical treatment

WHEN? When not? TO WHOM? HOW MUCH?

Did the problem occur? When did it start? Are there variations between the teams or perAre there any characteristic trends?
What changed at that time? involved in the company? Frequencies? Growth, reduction?
- On Sunday, March 13th 2022, 02.39 PM - Non Supervised Contractor (Gardener) - This incident is the first time happened

- Trimming tree activities usually done by request

3.1 Check base condition:

Comment in case of "NO"
Were the work steps followed in the defined sequence? YES ✔ NO
The sequence was correct and easy to understand? No written trimming tree procedure available
(Including timing & duration)
Is each person involved qualified? (The person has been The Gardener has an experienced person with 11 years as
YES ✔ NO
trained? Gardener and able to operate chainsaw, however there is no
Has practical experience? Is able to perform the task on its qualification training provided to him
own?)
Supporting tools / Materials are available for the process There was found tools (Chainsaw) and PPE (Personnel
YES ✔ NO
step are according to standard? Protective Equipment) are not standard
(including utilities)
Work environment is the same as usual? (e.g. temperature,
✔ YES NO NA
light, noise, people..)
3.2 Missing base condition:
Observed
Standard Immediate measures Probable cause of the defect
condition
Standard type (SOP, Training, etc.) Defect is a deviation from the
What is good/ not good? What did you see?
standard
Procedure how to operate
Tools operating procedures for
the tools included safety
Gardening activities are not available
aspects must be in place No Gardening activities
No SOP available
Gardener must be trained procedure in place
Gardener is not qualified in how to operate Stop all gardening tools
gardening tools properly operational
Regular maintenance for
No Maintenance & No Maintenance & Inspection
gardening tools & pre-
Tools & Equipment are not standard Inspection activities activities for Gardening tools in
operational inspection
available place
(Tools & PPE)
3.3 Specify the problem:
On 02.39 PM, 13th March 2022, Gardener left foot (palm) was cut by Chainsaw during tree trimming activities in Site Garden area because there are
no written procedure available, personnel was not qualified and tools & equipment are not standard.
4. Results 5W-1H & ROS: If solved, go to D. If not, proceed with section B for deepen understanding to determine the causal factors.
In this section, the solution was not clearly defined, proceed section B.
*SKU = Stock Keeping Unit, CL = Centerlines, CIL = Cleaning Inspection Lubrication, ROS = Run-On-Standard, MTM = Machine Transformation Matrix

CR No.CR-060/11/2021
DOC Label: TMP-HSE-2-3.7-04-1
Proprietary Bayer
3.0
1 of 4
Formulir A3 Full Reloaded

A3 Reloaded - Work Process Failure - Quadrant B

Check base conditions vs. current standards & understand the problem
Collect additional facts about the work process: Draw the full, normal sequence of process steps. Focus on the
5.1
time-point and related activities that required deeper analysis.
Pre-Operational
- There is no Gardening tools operational procedure in place
- There is no Personnel training & qualification
- There is no Preventive Maintenance
- There is no Pre Operational inspection (check the chain tension and adjust as necessary)
- Safety gears / PPEs were not standard
- No detail safety measure assessed / defined in HIRA
- Person has been work for 7 days continuously
- No adequate supervision

Operational
- There is no Jig
- Stand behind the Chainsaw
- Gardener used Chainsaw with wrong hand position

Deepen understanding & establish confirm deeper base condition

Deep-dive fact collection: Collect facts & observations "on-the-floor". If this insufficient to find true root-cause,
5.2
continue to a Causal Tree Analysis
Remember key coaching: Solid facts only, One fact at a time, No value judgements.

What was different, special, odd, or unique about the work conditions at the time of execution?
There is no different special odd and unique about this process

Were there any distractions that influenced sequence of the work (Including timing & duration)? What where they?
There is no distraction

What did the individual(s) involved in the loss observe about situation?

No special observation

Who else was in the area at the time of execution, and what did they observe?
Other gardener focus on their own task

5.3 What are your conclusions from the analysis so far?

The gardener working based on practical experience (no written procedure, person training & qualification) and it was
observe that no maintenance & pre-operational inspection for Chainsaw, gardener did not use standard PPEs / safety
gears.

CR No. CR-060/11/2021
DOC Label: TMP-HSE-2-3.7-04-1
Proprietary Bayer
3.0
2 of 4
Formulir A3 Full Reloaded

A3 Reloaded - Work Process Failure - Quadrant C

Check base conditions vs. current standards & understand the problem
Deep-dive analysis/Identify potential causes: Draw the Causal Tree Diagram. Identify potential causal factors and
6
finally root causes. Confirm elimination of root causes cuts the Causal Tree
Key coaching: The event is on the right, and reverse time-line to the left. Directly responsible, Necessary & (taken
together) Sufficient

Identify & confirm specific root cause

CR No. CR-060/11/2021
DOC Label: TMP-HSE-2-3.7-04-1
Proprietary Bayer
3.0
3 of 4
Formulir A3 Full Reloaded

A3 Reloaded - Work Process Failure - Quadrant D

Understand system root cause, simplify standard & confirm solution

8. Why did it happen? Why did it happen?

WHAT are the WHY (1) it WHY (2) it showed up? WHY (3) it showed up? Countermeasure Transfer to tracking system or use this sheet
causal factors? showed up? System root cause
Step Name Date System

Create procedure for all Gardening activities

No writen procedure of No writen procedure of
(covering operationals, maintenance & Christina Widya 30-Apr-22
Gardener used gandening activities gandening activities
Gardener doesn’t know inspection)
Chainsaw with
how to use Chainsaw
Gardener left foot wrong
properly
(palm) was cut by position No Gardener training & Develop training & qualification program for
Gardener was not qualified Christina Widya 30-May-22
Chainsaw during qualification system Gardeners
tree trimming
Gardener did not Improve PPEs management of Gardening
Christina Widya 30-Apr-22
use PPEs Not adequate standard Not adequate standard activities
standard & PPEs / Safety gears PPEs / Safety gears
proper Provide standard PPEs / Safety gears Christina Widya 30-May-22
Definition of status: started in progress largly completed completed

9. Standard optimization Shows the combination of settings and tasks that eliminate the problem from reoccurance. Optimize the standard with the concept:
No tools, no time, no talents! Address the systemic fix and eliminate/minimize error traps.
No tool, no time, no talent Eliminate error traps Countermeasures
difficult to detect (1), can find deviations from standards (2), continuously monitored (3)
Understand system root cause, simplify standard & confirm solution

multitasking is required (1), task sometimes interrupted (2), focus on single task (3)
Highly qualification (1), qualified in minutes (2), self-explanatory (Poka Yoke) (3)

Data interpretation required (1), data distributed (2), data follows task flow (3)
difficult/ not standard (1), easy if qualified (2), setting is fixed (3)

high error rate (1), often sufficiently executed (2), fail-safe (3)

Completely new (1), partly known (2), similar to existing (3)

unrealistic to complete (1), challenging (2), no issue (3)

Task focus (ability to focus on task, lack of distraction)

What skill level is needed to meet the standard?

stressful (1), distracting (2), normal/no issue (3)

Ease of detection of deviations from standard?

Environment (Noise, Humidity, Temperature)

Task familiarity for the person doing the task

Try to improve the total if sum is less than 9

Try to improve the total if sum is less than 9

Task can be assessed as passed or failed?
frequent (1), rare (2), eliminated (3)

Confusing information or displays

Simplicity of the task execution?

High workload/hurrying/rushing

Total for Environmental

Total for Task Difficulty
Frequency of the task?

Transfer to tracking system or use this sheet

Step Name Date Track
Create procedure for all 1 2 3 2 1 9 3 1 3 3 3 13
Gardening activities
(covering operationals,
maintenance & inspection)
Improve PPEs 2 3 2 3 3 13 3 1 2 3 2 11
management of Gardening
activities

Definition of status: started in progress largly completed completed

10. Showing the results and/or Effectiveness Check: (eliminate to zero philosophy!) 11. Transfer the results / lessons learned:
Compare the losses caused by the problem before and after the improvement Where does the problem also occur?
(e.g. which technologies, material numbers, formats or processes)
Engineering workshop related with rotating part (grinding, cutting etc)
TBD
Operational procedure covering maintenance & inspection
12. Success control: Qualitify the reduction in loss:in safety, quality, time or money vs. the investment required
Costs around the new work to manage (€/ month)
Loss avoided (S, Q, €/ month)

Solution
YES NO If NO, continue to understand the root-cause (section C) or escalate
confirmed?

CR No. CR-060/11/2021
DOC Label: TMP-HSE-2-3.7-04-1
Proprietary Bayer