Event Record and Simple Investigation Form

1. EVENT DETAILS
Event ID 515021.W1.PP.220324.00358066
Event Title LHs counterweight of Liebherr Excavator R9350 EX9014 was scratched found by night shift operator when prestart
check
Entity
☐ Administration ☒ Mining ☐ Workshop
Event Date
Occurred 22 March 2024 Reported 22 March 2024
Event Time
Occurred 07:00 ☐ AM ☒ PM Reported 07:05 ☐ AM ☒ PM
Specific Area Benggeris Pit
Work Crew Crew B
Person Involved - Not required to be completed for Hazards and Report Only events
First Name Sigit Last Name Sudarsono
Supervisor Name Andi Bau Onggong Shift ☐ Day ☒ Night
Hours Worked 5 Days Since Last Day Off
Experience in Role/Equipment
Other Involved
Event Description - A detailed description of what happened
» On 21 March 2024 at the beginning of the night shift, The operator (Sigit Sudarsono) assigned to operated EX9014 at block 75 Seam C
by top loading method accommodated by 10 dump trucks and dumping to Kinong Dumping point.
» At 02.30 am, the operator stopped the activity for a toilet. While embarking on the cabin, the operator noticed a scratch on LHs
counterweight, then the excavator operator confirmed the depth of the scratch by using grease waste gloves found in the machine
/engine room.
» The operator not report the event to supervisor
» The operator claimed that there was no contact with the dump truck during the loading process.
» The operator was working near the wall on LHs of the excavator. While operation, the operator did not estimate the distance between
unit swing area and the wall.
» Scratch on the counterweight occurred due to touch with the wall in the loading point while the excavator swung for loading.
Additional Info:
» Mining supervisor conducted loading point inspection and no finding was noted on the inspection form.
» Lighting tower was available for the activity 70 meters from the location.

Title: Event Record Form and Simple Investigation Form

ID: MSID-4-743 Version: 6.0 Date Published: 06/05/2020
Thiess Governance System - Uncontrolled Document when Printed 1 of 6
 Attachment

Working location of EX9014

Immediate Actions - The actions taken immediately following the event

Report the event to Supervisor and Safety
Event Owner
☒ Thiess/Joint Venture ☐ Contractor ☐ Public/Visitor
Reported By Marthen Karurung
Reported To Andi Bau Onggong

2. EVENT CLASSIFICATION
Event and Event Type - Select one Event and one Event Type
☒ Incident ☐ Near Hit (no actual ☐ Hazard ☐ Report Only ☐ Stakeholder Contact
outcome)

Title: Event Record Form and Simple Investigation Form

ID: MSID-4-743 Version: 6.0 Date Published: 06/05/2020
Thiess Governance System - Uncontrolled Document when Printed 2 of 6
 ☐ Business ☐ Business Interruption ☐ Environment ☐ Business Interruption ☐ Complaint
Interruption
☐ Equipment/Property ☐ Equipment/Property ☐ Client Incident ☐ Enquiry
☒ Damage Damage
☐ Damage not caused by ☐ Feedback
Equipment/Property
☐ Environment ☐ Safety work
Damage ☐ Proactive
☐ Safety (Injury) ☐ Environment
☐ Environment
☐ Journey
☐ Safety (Injury)
☐ Injury at social activity
☐ Medical incident not
caused by work
☐ Notice of exceedance
☐ Public theft/damage

Event Mechanism

☐ Contact UG/OH services
☐ Fall from height
☐ Falling/flying objects
☐ Fitness for work
☐ Fixed equipment
☐ Ground Disturbance
☐ Hand tools
☐ HV/HV interaction
☐ HV/LV interaction
☐ Lifting Ops-crane/device failure
☐ Lifting Ops-rigging failure
☐ Manual handling
☐ Mechanical failure
☒ Mobile plant
☐ Motor vehicle accident
☐ People/equipment interaction
☐ Physical work environment
☐ Physical Assault
☐ Slip/trip hazards
☐ Slips of ground/cave in
☐ Structural failure
☐ Terrorism/sabotage
☐ Trespass/vandalism
☐ Uncontrolled explosion
☐ Uncontrolled fire
☐ Uncontrolled movement
☐ Uncontrolled release-comp air
☐ Uncontrolled release-electrical energy
☐ Uncontrolled release-hydraulics
☐ Uncontrolled release-mech. Energy
☐ Uncontrolled. release-chemicals/gas
☐ Uncontrolled release - contam water
☐ Uncontrolled release - solids (dust)
☐ Vibration

Actual Consequence - More detail required in section 3. Impact Details

☐ Injury/Illness ☐ Environment ☒ Equipment/Property Damage ☐ Business Interruption

☐ No Treatment ☐ Low Severity Impacts ☒ Damage < $50,000 ☐ Affects single areas, <10%
(Class 3) (Class 3)
effect on profit
☐ First Aid Injury (Class 3)
(Class 3)
☐ Moderate Severity Impacts ☐ Damage > $50,000 but <
(Class 2)
$1,000,000 ☐ Affects multiple areas, >10%
☐ Medical Treatment Injury (Class 2)
but <20% effect on profit
(Class 2)
☐ High Severity Impacts (Class 2)
(Class 1)
☐ Damage > $1,000,000
☐ Restricted Work Injury
(Class 2)
(Class 1)
☐ Affects whole site, >20% effect
on profit
☐ Lost Time Injury (Class 1)
(Class 2)

☐ Permanent Disability
(Class 1)

☐ Fatality
(Class 1)

☐ Occupational Illness

Potential Consequence - Most probable outcome for each Actual Consequence

☐ Injury/Illness ☐ Environment ☒ Equipment/Property Damage ☐ Business Interruption

Title: Event Record Form and Simple Investigation Form

ID: MSID-4-743 Version: 6.0 Date Published: 06/05/2020
Thiess Governance System - Uncontrolled Document when Printed 3 of 6
 ☐ No Injury or Minor Injury ☐ Low Severity Impacts ☐ Superficial Damage ☐ Negligible impact, little effect on
(Class 5) (Class 5)
(Class 5 profit
(Class 5)

☐ Occupational Illness or ☐ Moderate Severity Impacts ☒ Damage < $50,000

First Aid Injury
(Class3)
(Class 4) ☐ Limited impact, <5% effect on
(Class 4) profit
☐ High Severity Impacts ☐ Damage > $50,000 but < (Class 4)
(Class 1)
☐ Medical Treatment Injury $250,000
(Class 3) (Class 3) ☐ Affects single areas, <10%
effect on profit
☐ Restricted Work Injury ☐ Damage > $250,000 but < (Class 3)
(Class 2)
$1,000,000
(Class 2)
☐ Affects multiple areas, >10%
☐ Lost Time Injury
but <20% effect on profit
(Class 2)
☐ Damage > $1,000,000
(Class 1) (Class 2)
☐ Permanent Disability
(Class 1) ☐ Affects whole site, >20% effect
on profit
☐ Fatality (Class 1)
(Class 1)

Likelihood - of actual event happening again

☐ Almost Certain ☐ Likely ☐ Moderate ☐ Unlikely ☒ Rare

Likely to occur again A similar incident A similar incident A similar incident could Similar incident is unlikely to
during the next month. could be expected to could be expected to be expected to occur in occur again.
occur in the next six occur in the next 1 the next 5 years.
months. year.

3. IMPACT DETAILS - Details of Actual Consequences selected in section 2. Event Classification

INJURY/ILLNESS DETAILS
Human Impact Type
☐ Illness ☐ Injury
Injury Mechanism

☐ Awkward Posture ☐ Exposure Non-Ionising Radiation ☐ Long Term Exposure to Sound

☐ Body Jolt / Jar ☐ Exposure Pressure Variation ☐ Muscular Stress
☐ Contact / Exposure Biological ☐ Exposure Sharp Sound ☐ Psychological
☐ Contact Electricity ☐ Exposure to Mechanical Vibration ☐ Respective Movement
☐ Crush / Caught Between ☐ Fall From Height ☐ Single Contact Hazardous Chemical
☐ Drown / Asphyxiation ☐ Fall on Same Level ☐ Strike Object
☐ Exposure Heat / Cold ☐ Insect / Animal Bite / Sting ☐ Struck by Object
☐ Exposure Ionising Radiation ☐ Long Term Exposure to Chemicals
Injury Location Treatment Details

☐ Left ☐ Right
☐ Front ☐ Back

Title: Event Record Form and Simple Investigation Form

ID: MSID-4-743 Version: 6.0 Date Published: 06/05/2020
Thiess Governance System - Uncontrolled Document when Printed 4 of 6
 ENVIRONMENT DETAILS
Primary Classification Driver
☐ Environmental Harm ☐ Legal ☐ Community/Media ☐ Cost
Environment Category
☐ Acid Sulphate Soil ☐ Discharge Surface Water ☐ Noise/Vibration/Light
☐ Archaeological Heritage/Cultural ☐ Dust/Odour/Emissions ☐ Solid/Other Wastes
☐Contaminate Land/Groundwater ☐ Erosion/Sediment Controls ☐ Use of Land/Water/Fuel/Energy
☐ Dirt/Mud on Public Roads ☐ Flora/Fauna ☐ No Direct Impact
Offsite Impact
☐ Day ☐ Night
Product Name Released Quantity
Currency Cost

EQUIPMENT/PROTPERTY DAMAGE DETAILS

Type of Equipment/Property
☐ Fixed Equipment ☒ Mobile Equipment ☐ Infrastructure
Detailed Equipment/Property Type Excavator Liebherr 9350
Damage Details LH counterweight scratched.
Currency USD Cost 266.47
Ownership
☒ Thiess/Joint Venture ☐ Contractor ☐ Client ☐ Public/Visitor
Asset Number
EX9014

BUSINESS INTERRUPTION DETAILS

Source
☐ Industrial ☐ Maintenance ☐ Natural Disasters ☐ External Service Interruption ☐ Preserve Scene
Currency Cost

4. NOTIFICATIONS
Type
☐ Client ☐ Regulator
Date Time ☐ AM ☐ PM
Notified By
Organisation Details

5. CAUSES/ INVESTIGATION (To be used for Severity 4 and 5 events)

Causal Factors: Scratch on the counterweight occurred due to touch with the overburden hard material (stone) on the wall in the
loading point while the excavator swung for loading.
Operator failed to immediately the scratch on counterweight to supervisor during the shift triggered by human
error.

6. ACTIONS
Action Description Emphasize to all excavator operators the importance of carrying out safe loading methods when operating near
a wall, ensuring no damage is caused to the counterweight of the excavator.
Due Date 24 April 2024 Assigned To Oscar Pardede
Assigned By H. Anaruddin

Title: Event Record Form and Simple Investigation Form

ID: MSID-4-743 Version: 6.0 Date Published: 06/05/2020
Thiess Governance System - Uncontrolled Document when Printed 5 of 6
 Action Description Discipline to be applied to the excavator Operator in accordance with Thiess disciplinary action guideline for
failure to adhere to excavator safety operational procedure
Due Date 24 April 2024 Assigned To Oscar Pardede
Assigned By H. Anaruddin

7. COMPLETED BY:
Name: H. Anaruddin
Signature: Date 25 March 2024
Forward completed Event Record Form to site Health & Safety Department by end of shift

Title: Event Record Form and Simple Investigation Form

ID: MSID-4-743 Version: 6.0 Date Published: 06/05/2020
Thiess Governance System - Uncontrolled Document when Printed 6 of 6