Project No.

IK2M
INDAH KIAT (IKK) Document No. IK2M-100-15-FRM-0007
Revision No. 00

INCIDENT INVESTIGATION Page 1 of 5

REPORT FORM Issue Date November 7, 2022

A. IDENTIFICATION OF INFORMATION
1. Company Name : 2. Date / Time of Incident : 3. Location :
IKK January 14. 2024 jam 07.10 wib
Akses sementara dibawah jembatan.
January 14, 2024 at 07.10 am.
Temporary access under the bridge

4. Incident tittles :
Bus Karyawan IKK terperosok di tanjakan temporary akses dekat site office PT.WITON
The IKK employee bus got stuck on the temporary access ramp near the PT WITON site office

5. Incident Severity :
 Fatality  Property / Equipment  Hazardous Chemical Spill
 Serious Injury Damage  Environmental Damage
Medical Treatment
 Fire Incident 
 First Aid Near Miss
 Traffic Incident  HIPO (High Potential)

Injury / Illness Property / Equip. Damage Near Miss / High Potential Loss
6. Injurer Name : 13. Property / Equip name : 17. Type :
none Bus -
7. Injury to : 14. Nature property damage : 18. Cost :
none none -
8. Type of Injury : 15. Lost cost caused damage : 19. Nature of loss :
none To be confrimed -
9. Lost days during the Incident : 16. Object causing the damage : 20. Object related :
none Jalan licin dan curam -
- Slippery and steep road
10. Object causing the Injury :
none
11. Job position of Injured :
12. Experience in current jobs :
21. Person in charge when Incident happened :
Manager Konstruksi
Construction Manager
BoP/Common area
Area BoP/Common
 Project No. IK2M
INDAH KIAT (IKK) Document No. IK2M-100-15-FRM-0007
Revision No. 00

INCIDENT INVESTIGATION Page 2 of 5

REPORT FORM Issue Date November 7, 2022

B. SEQUENCES OF INCIDENT HAPPENED

22. Description how the event happened & Sketch :

Pada hari Minggu tanggal 14 Januari 2024 sekitar pukul 06.50 wib bus (No Pol B 7251 FAA) karyawan proyek IKK yang di
kendarai oleh diver atas nama Didi Risdiana tiba di Pos 1, kondisi jalan pada saat itu terdapat tanah basah dan lumpur, saat
melewati tanjakan di bawah jembatan PT.Witon pukul 07.10 am ban bagian kiri bus mengalami terperosok dikarenakan jalan
licin. Pada pukul 08.30 wib bus berhasil di evakuasi dengan bantuan excavator tidak ada korban jiwa dalam kejadian ini.

On Sunday, January 14 2024, at around 06.50 am, the bus (No. Pol B 7251 FAA) for IKK project employees driven by the driver on
behalf of Didi Risdiana arrived at Post 1, the road conditions at that time were wet and muddy, when crossing the incline under the PT.
Witon bridge at 07.10 am, the left tire of the bus fell because the road was slippery. At 08.30 am the bus was successfully evacuated with
the help of an excavator, there were no casualties in this incident.

Sketch / Pictures :

1 2 3 4 5

Keterangan foto / Photo caption :

1. Lay out akses jalan yang dilalui bus pada pukul 06.50 wib.
Lay out the access road that the bus passed at 06.50 am
2. Akses jalan yang dilalui bus menuju power plant pada pukul 07.10 wib.
The bus took the access road to the power plant at 07.10 am
3. Lokasi kejadian bus saat mengalami tergelincir.
Location of the incident where the bus slippery.
4. Kondisi jalan pada saat mengalami kecelakaan, terdapat tanah basah dan mengakibatkan jalan
menjadi licin
Road conditions when the accident occurred were wet and slippery
5. Proses Evakuasi bus menggunakan excavator
Bus evacuation process using an excavator
 Project No. IK2M
INDAH KIAT (IKK) Document No. IK2M-100-15-FRM-0007
Revision No. 00

INCIDENT INVESTIGATION Page 3 of 5

REPORT FORM Issue Date November 7, 2022

23. Flows, time sequence of incident & also determining of Cause factors :
Minggu 14 Januari 2024:
Sunday 14 January 2024 :
Pukul 06.50 wib : Bus Karwan Proyek IKK tiba di pos 1
Pukul 07.05 wib ; Bus Karwan Proyek IKK memasuki proyek IKK
Pukul 07.10wib : Saat melewati jalan menanjak ban kiri bus tergelencir yang mengakibatkan bus tidak dapat bergerak
Pukul 08.30 : Bus berhasil dievakuasi dengan bantuan excavator dengan cara di dorong.
Sunday 14 January 2024 :
At 06.50 am: The Karwan Project IKK bus arrived at post 1
At 07.05 am; IKK Project Karwan Bus entered the IKK project
At 07.10 am: While passing through an uphill road the left tire of the bus slipped which resulted in the bus not being able to
move
08.30 am : The bus was successfully evacuated with the help of an excavator by pushing it.

C. CAUSE ANALYSIS

23. Causal factor & Fishbone diagram :

People Material Method

Tidak terdapat akses alternatif yang

aman pada saat kondisi abnormal
There is no safe alternative access during
abnormal conditions (rain)

Incident
Terdapat tanah basah dijala
Jalan licin
n Slippery road
There is wet ground on the

Jalan Curam
Steep road

Environment Machine

24. Direct / Immediate Causes (please refer to Direct & Basic Causes Tables ) :

a) Unsafe Action : b) Unsafe Condition :

Jalan Curam
Steep road
Terdapat tanah basah dijalan
There is wet ground on the road
Jalan licin
Slippery road
Tidak terdapat akses alternatif yang aman pada saat
kondisi abnormal
There is no safe alternative access during
abnormal conditions (rain)
 Project No. IK2M
INDAH KIAT (IKK) Document No. IK2M-100-15-FRM-0007
Revision No. 00

INCIDENT INVESTIGATION Page 4 of 5

REPORT FORM Issue Date November 7, 2022

25. Indirectly / Basic Causes (please refer to Direct & Basic Causes Tables) :

a) Personal Factor : b) System Factor :

- Kondisi jalan curam dan licin
Road conditions are steep and slippery
Tidak terdapat akses alternatif yang aman pada saat
kondisi abnormal
There is no safe alternative access during
abnormal conditions (rain)

26. Corrective & Preventive action taken based on the indirectly / basic causes :

No Items PIC Target

1 Rekayasa desain kemiringan jalan agar tidak curam Engineer & Construction
Manager
Engineering the design of the road slope so that it is not
steep

2 Membuat jalur alternatif yang dapat digunakan Engineer & Construction

kendaraan pada saat kondisi tidak normal (hujan). Manager
create alternative routes that vehicles can use during
abnormal conditions (rain).

3 Merekayasa desain permukaan jalan agar lebih kasar Engineer & Construction
Manager
Engineering the road surface design to make it rougher

Reported by Site HSE Engineer / specialist : Approved by Construction Manager :

Yosep M
 Project No. IK2M
INDAH KIAT (IKK) Document No. IK2M-100-15-FRM-0007
Revision No. 00

INCIDENT INVESTIGATION Page 5 of 5

REPORT FORM Issue Date November 7, 2022

D. EVALUATION RECOMMENDATION BY PROJECT MANAGER

27. By Project Manager : Sign : Date / Time :

Recommendation :

E. EVALUATION HQ SERPONG ( NOT REQUIRED FOR INCIDENT LEVEL-3 )

28. By HSE HQ Serpong

Recommendation : Sign : Date / Time :

29. By Top Management / GPG Director

Recommendation : Sign : Date / Time :

E. RISK EVALUATION

Evaluation of loss potential, if 29. Loss severity potential : 30. Probability potential :
corrective & preventive action
have not been followed  Major  Frequently
 Serious  Occasional
 Minor  Seldom