Fatality Investigation Report

InvestigasiInvestigasi KecelakaanKecelakaan FatalFatal

Supervisor Thiessmeninggal dunia ketikakendaraan TC560 yang ditumpanginya terlindasoleh dozer CAT D10R (DZ3003) di Areal Dumping Belut; 22 Juli 2010 pukul09.28 WITA.

Apa yang terjadi?Mengapa bisa terjadi?Bagaimana mencegahnya?

DATA KORBAN

Korban: Nama: Robertus Ria Umur: 38 tahun Jabatan: Supervisor Jenis kelamin: Laki-laki DOH: 21 April 2004

Tanggungan: Robertus meninggalkan seorang istri

dan 3 orang anak yang masih kecil.

TIM INVESTIGASI

Mine Inspector KutimManager OHSManager Contract Mining ThiessStaf Subdit DTMB Jakarta Staf Subdit DTMB Jakarta Staf Distamben KutimSupt. Safety Safety Monitoring & Comm.Supt. HSE CMDCoord. HSE CMDProject Manager ThiessSupt. Safety Thiess Balikpapan Act. Supt. Safety Thiess

ArminHaryadi WardonoBina SembiringRedo GusmanRafael MToniSamaliDedi MulyanaAnhar Al AlaSjamsi JosalMasykurDafid Feri Eryanto

Anggota

Acting COO/KTTMuhammad RudyFasilitatorSnr. Supv. Safety Monitoring & Comm.Erwin HambaliSekertarisMine Inspector SamarindaMarkus Taruk AlloWakilMine Inspector JakartaGalang JayaKetuaJabatanNama Peran

Kronologi Kejadian 09.25 Dozer DZ3003 sedang mendorong material OB ke dalam kolam ketika kendaraan

ringan TC560 dikemudikan oleh Senior Supervisor / Acting Superintendent ditemaniSupervisor (korban), datang dan diparkir di jalur kerja di belakang dozer tersebut.

09.26 Senior Supv (pengemudi TC560) turun dari kendaraan dan berjalan ke sisi sebelahkanan jalur dozer (+ 5,8 m) untuk mengontak operator, sedangkan Supervisor (korban) tetap berada di dalam kabin di kursi penumpang kiri depan.

09.27 Dozer DZ3003 mundur untuk siap mendorong material berikutnya di sisi kiri. Senior Supv. Berupaya mengontak operator dozer untuk menghentikan dozer tersebut tetapi tidakberhasil. Dozer terus mundur.

09.28 Track sebelah kanan dozer melindas TC560 dari bagian kiri depan hingga kebagian kanan belakang kabin, sementara korban masih berada di dalam kabin.

09.29 Operator dozer melihat Senior Supv., menghentikan dozernya dan menyadaribahwa dozernya telah melindas sebuah kendaraan. Ia lalu memajukan dozernya.

09.33 Safety Thiess diberitahu. Safety, ambulance and paramedic Thiess menuju ketempat kejadian.

09.35 Tim Rescue KPC dipanggil dan segera menuju tempat kejadian. 10.04 Tim Rescue KPC tiba dan segera mengevakuasi korban yang terjepit. 10.45 Korban tiba di Klinik ISOS Swarga Bara dan dinyatakan telah meninggal dunia

seketika di tempat kejadian akibat cedera sangat serius di kepalanya dan patah tulangterbuka di kaki kiri.

Foto Lokasi Kejadian

1. Lokasi kejadian: Areal Dumping Belut RL-10 (setelah kejadian 22 Juli 2010)

TC560DZ3003

Lighting Plant & PondokSupv

67,9 m35.5 m

DZ3006Saksi mata

48,7 m

2. Tim Rescue KPC menyiapkanpengambilan korban

3. TC560: sedang diperiksa oleh KTT setelah korban dievakuasi

4. TC560 dilihat dari kanan depan DZ3003

FotoFoto--fotofoto KejadianKejadian

5. Peragaan posisi korban olehPersonil Senior Rescue KPC

Kolam

Material

OB

Material OB

Lighting PlantSupv. Hut

64,9

m

67,9

m

48,7

m

Jalan

39,7

m

35.5

m

Denah Lokasi Kejadian

LV TC560 seharusnyadiparkir dekat Lighting Plant: bukan di jalurdozer

DZ3006 (saksi mata)

Jalu

rdo

zer

TC560

DZ3003

Penyebab KecelakaanPenyebab Langsung: Pelanggaran prosedur dan pengambilan keputusan yang tidak tepat:

Senior Supv memasuki dan memarkir kendaraannya (TC560) pada jalurkerja dozer di belakang dozer tersebut (DZ3003).

Senior Supv tidak melakukan kontak positif dengan operator dozer danmemastikan dozer tersebut sudah diparkir, mesin dimatikan dan operator turun dari kabin sebelum memasuki areal kerja dozer.

Tidak memperingatkan: Supervisor (korban) yang duduk di samping pengemudi tidak

memperingatkan si pengemudi ketika akan memasuki dan memarkirkendaraannya (TC560) pada jalur kerja dozer di belakang dozer tersebut(DZ3003)

Penyebab Sistem: Ketergesaan karyawan sendiri:

Senior supervisor (pengemudi TC560) memasuki areal kerja dozer tanpamempertimbangkan bahaya atau risikonya karena merasa terburu-buru.

REKOMENDASI

Menginstruksikan ke semua staff PT. TCI site Sangatta untuk mematuhi peraturan dan prosedurKeselamatan Kerja yang ada serta salingmengingatkan agar tidak ada yang melanggar.

Mensosialisasikan kembali kepada semua karyawandan staff TCI pemegang Pit Access Kimper (L/V) : Radius blind spot Dozer CAT D10R. SOP mendekati alat berat bergerak. Prosedur parkir di dalam Pit.

TINJAUAN KECELAKAAN FATALDI KPC & KONTRAKTOR

1990 2010

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2.59

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1.511.36

1.110.93

0.760.80

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CONT.

KPC

LTIFR

Prima Nirbhaya/NOSAImplementation

FPE & New GoldenRules Implementation

JumlahJumlah KecelakaanKecelakaan Fatal & LTI vs. LTIFRFatal & LTI vs. LTIFR1996 1996 YTD 25 Jul 2010YTD 25 Jul 2010

RangkumanRangkuman KecelakaanKecelakaan YTD 2010YTD 2010(KPC & (KPC & KontraktorKontraktor))

Note : Based on the decision at the EXCO meeting on 21 Sept 05: 1 Fatality equals to 10 Potential Fatality Incidents

Number of EventFatality

Significant Incidents

Potential Fatality

Lost Time InjuryDivision

28

1

1

1

1

1

2

4

4

4

4

5

Threshold 2010

201131311TOTAL

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30300PAMAMining

211102TCIKPC 40311MOD60117MSD

Actual

05

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LTI SIG

PF Rolling LTIFR

Rolling SIGFR Rolling PFFR

Rolling LTIFR = 0.52 Rolling PFFR = 0.36 Rolling SIGFR = 0.50

YTD LTIFR = 0.33 YTD PFFR = 0. 38 YTD SIGFR = 0.38

KejadianKejadian BerbahayaBerbahaya vs. vs. TingkatTingkat KekerapanKekerapanYTD 25 Jul10YTD 25 Jul10

No Date Injured NameCompany /

Dept Position KPC / CONT Remarks

1 20-May-90 Yohanis Thiess Truck Operator CONTWhilst travelling from loading point to dumping area, a haul truck uncontrolled and hit safety berm. Operator thrown out of the truck because he wasn't wearing seatbelt

2 22-Jul-90 Nurtan M Thiess Truck Operator CONTWhilst travelling to PBI Construction area, a dump truck uncontrolled due to improper speed and rolled over along 9 meters. This incident resulted in death (serious leg injuries to the operator). He wasn't wearing seatbelt

3 27-Oct-90 Musdiyanto UT Rental Truck Operator CONTFatally injured after loosing control of a truck due to improper speed and rolled over a bank enroute to Pit K, the cabin striking a tree

4 21-Mar-91 Sudarno Gemini Labor CONT A contractor employee was using portable hand drill during contruction activities when he got electric shock. This incident resulted in death

5 10-May-91 Aswin Kasiran Petrosea Electrician CONTA light vehicle (Toyota Hardtop) was run over by haul truck (Cat785) at 4F intersection. This incident resulted in fatality to the L/V driver. Critical factor was driver fatigue.

6 23-May-92 Dwisiswai GTS Mechanic CONTFataly injured when the Dynapac vibrating roller over turned after control was lost due to improper speed on a steep road. The equipment was not fitted with a R.O.P.S.

7 10-Aug-92 Wijanto KNE Fuel Truck Helper CONTA spotter was directing to reposition the truck during refuelling activity. In the process directing of truck, he caught between fuel truck dan dozer. This incident resulted in fatal injury.

DAFTAR KECELAKAAN FATALDAFTAR KECELAKAAN FATAL1990 1990 YTD 26 Jul 2010YTD 26 Jul 2010



8 05-Apr-95 Suparlan DWL Truck Operator CONTWhilst travelling to Panel 4, a explosive truck uncontrolled and hit safety berm. Use of defective equipment was the causes of the incident. This incident resulted the death to the explosive truck driver

9 24-Sep-95 Iwan Insani Hana Mas Compactor Operator CONTWhilst travelling to Flamboyan road, a compactor uncontrolled and tipped over. The operator caught between compactor and ground. He wasn't wearing a seatbelt. This Incident resulted in the death.

10 18-Dec-96 Yulius Sutrisno Surya DeptShovel

Operator KPCFatality injured and was found buried by the collapsed damp soil inside the shovel bucket soon after he put himself between the bench face and shovel bucket for some reason.

11 16-Jun-97 Irianzach Bintang Dept.Act. Supv.

Civil KPC

Whilst travelling from loading to dumping area, a GINAF truck T-803 hit a L/V. Combination excessive speed of L/V and incorrect truck position (in the middle of the road) were the causes of the incident. This incident resulted in death to the L/V driver.

12 09-Aug-97 Mardjit Hatari Dept. Truck Operator KPCWhilst spraying roads around Rozano road and Hatari Pit office, a water truck (DJB 300) accidentally the engine shut down by it self. It made truck reversed, hit safety berm and tipped over. The operator caught between truck cabin and ground. This incident resulted in the death.

13 31-Jan-98 Wayan SuadnyanaBintang Dept.

Truck Operator KPC

Whilst travelling from dumping area to Panel 5, a haul truck T-525 (Cat785) run over safety berm and fell down from high around 34 metre. Fatigue was the cause of the incident. This incident resulted in the death.

14 11-Aug-98 Arifin Bono Bintang Dept.HE Operator

Trainee KPCAn operator was cleaning font mirror of the haul truck (Cat 785) when he slipped and fell down to the ground. This incident resulted the death.

15 09-Jul-99 Jumarsono PT Hexindo Welder CONT Hexindo vehicle was hit and ran over by the reversing D11 N CAT B.dozer, caused fatality

FATALITY INCIDENT LISTFATALITY INCIDENT LIST1990 1990 YTD 26 Jul 2010YTD 26 Jul 2010



16 30-May-00 Paulus Tira PT Gemini Labor CONTA subcontractor employee under PT.TU (PT. Gemini) was stopping a wheelbarrow by placing the steel leg on the portable light electrical cable when he got electrical shock. This incident resulted in the death.

17 27-Jan-02 Sion Manik PT KPPS Dozer Operator CONTWhilst clearing the area of the loading point, a dozer (Cat D11) rolled over along 20 metres. The operator caught between dozer and ground. He wasn't wearing a seatbelt. This Incident resulted in the death.

18 23-May-05Yunus

Thomassawa

Bintang Dept.

Shovel Operator KPC

Early into the night shift, the Shift Supervisor received a report from the previous Shift Supervisor that Shovel S-311 had a hydraulic hose leak. The Shift Supervisor then took the operators of the shovel and dozer, as well as, two Hexindo mechanics to the location of the shovel. Whilst in the process of repairing the shovel one of them saw the shovel operator get into their light vehicle (Hex-60) to take a rest. At about 00.10 AM the two mechanics heard a thundering noise and felt the shovel shaking due to ground movement. One of the mechanics observed the shovel operator attempting to get out of the light vehicle (Hex-60), however he was too late and was trapped in the vehicle as it was tumbled in the sliding slope material. As a result of this accident, the victims left leg was badly fractured causing him to loose a significant amount of blood. The victim was then evacuated to the SOS clinic for medical treatment, but unfortunately the SOS doctor announced his death by 04.00 AM

19 09-Aug-05 Rustan Hatari Dept. Pump Crew KPCA pump operator for Hatari Pit had attempted to swim out to recover a small rowing boat that had drifted to the other side of the pond. He was not wearing life jacket and drown in the water.


Note : Total of Fatality Incidents are 23 Incidents ( KPC = 9 ; Cont = 14 )




20 23-Jan-07 Hendris SusilawartaPT Pama Persada

Truck Operator CONT

A Pamapersada Nusantara (PAMA) HD785 Dump Truck (DT785), collided into the back of another HD785 Dump Truck (DT3008) which had broken down on OB Haul Road at KPC Bendili Pit, due to fatigue of the DT785 operator.

21 21-Mar-08 Yusran Geology Dept.Asst.

Geology KPCA Geology Assistant in the Geology Department parked his vehicle (LS490) and went out of the vehicle to direct a farm tractor. The vehicle (LS490) then moved and he tried to stop it. Unfortunately, he failed and was struck by the vehicle.

22 22-Oct-09 Junaedi HT Operator KPC

Whilst dumping an overburden at box cut RL 160 area, a dump truck T-731 (Cat789) caught fire.The operator was panicked and got out from cabin without following emergency procedure so that he got burn injury and fell from step #4 from the top (2.5 m) when climbing down the ladder in front of cabin. This is categorized as fatal injury resulted in death. The critical factor cuasing the fire incident was steering hose burst, spraying oil mist that was exposed to heat source from turbo or exhaust and air blown from radiator fan so that fire spread qiuckly.

23 22-Jul-10 ROBERTUS RIA Z38293 Supervisor CONT

While reversing to prepare pushing next material, dozer DZ3003 run over LV TC560 which was parked on the dozer working path behind the dozer. The victim (supervisor) who was sitting on the front left passenger seat could not escape and fatally injured inside the cabin. The critical factor was breach of in pit parking and approaching heavy equipment procedures.

RENUNGAN Sudah 23 kecelakaan fatal terjadi sejak 1990 hingga July 2010. Ini berarti 23 rekan kerja kita telah kehilangan nyawanya dan 23

keluarga (anak/istri/orang tua) telah kehilangan orang-orangyang dicintainya.

Ke-23 orang ini mungkin merupakan tulang punggung ekonomibagi keluarganya.

Kita harus melakukan sesuatu untuk mencegah kisah sedih initerjadi pada diri kita dan rekan-rekan kerja kita.

Mari kita berdoa dan berjanji pada diri sendiri bahwa kita akanmelakukan yang terbaik bagi keselamatan diri kita sendiri danorang lain.

Kecelakaan Fatal vs FPE

Dari total 23 Kecelakaan Fatal: 14 FPE 2.18 Pengoperasian Kendaraan / Alat Bergerak

3 FPE 2.19 Kondisi Kendaraan / Alat Bergerak

2 FPE 2.21 Keselamatan Listrik

2 FPE 1.10 Keselamatan Lereng Tambang

1 FPE 2.14 Bekerja di Ketinggian 1 FPE 2.24 Bekerja di Dekat Air

Kecelakaan Fatal vs Penyebabnya 6 kasus: Pelanggaran Aturan / Prosedur K3:

Keluar dari kabin di dalam radius 1.5x tinggi lereng Under cutting slope slope failure Bekerja di air tanpa pelampung Meninggalkan kendaraan dalan kondisi mesin hidup Panik dan tidak mengikuti prosedur darurat saat trucknya terbakar Memasuki dan memarkir kendaraan di jalur kerja dozer di belakang dozernya

4 kasus: Mengoperasikan dengan kecepatan tidak sesuai: Truk tidak terkendali, terbalik dan kabinnya membentur pohon Dynapack vibrating roller tak terkendali, terbalik, tidak dilengkapi ROPS LV kecepatan terlalu tinggi bertabrakan dengan Ginaf coal truck Truk tidak terkendali, terbalik dan operator tidak memakai seatbelt

4 kasus: Tidak memakai sabuk pengaman (seatbelt): Truk tidak terkendali, menabrak safety berm dan operator terlempar keluar Compactor tidak terkendali, terbalik dan operator tertimpa unitnya Dozer terguling 20 m ke jurang, operator tertimpa unitnya Lihat kasus kecepatan tidak sesuai di atas

Kecelakaan Fatal vs Penyebabnya 3 kasus: Mengalami keletihan (fatigue) saat mengoperasikan alat:

LV terlindas dump truck CAT785 akibat pengemudi mengalami keletihan (fatigue) Dump truck CAT785 melewati safety berm dan masuk jurang 34 m akibat operator

mengalami keletihan (fatigue) Dump truck Komatsu HD785-5 menabrak HD785 lain yang sedang rusak di jalan

akibat operator mengalami keletihan (fatigue) 2 kasus: Tersengat listrik akibat Sistem / Alat Plindung tidak memadai:

Pekerja bangunan tersengat listrik saat menggunakan bor tangan Pekerja tersengat listrik saat kereta besi yang didorongnya menggilas kabel listrik

aktif di lantai semen

2 kasus: Mengoperasikan peralatan yang rusak / sub-standard: Explosive truck yang sistem remnya rusak tidak bisa dikendalikan, menabrak safety

berm Water truck DJB300 yang sedang menyiram jalan di tanjakan tiba-tiba mati mesin,

termundur, menarbak safety berm dan terguling

Kecelakaan Fatal vs Penyebabnya

2 kasus: Terkait kondisi (di tempat kerja) yang tidakaman:

Operator yang sedang membersihkan kaca kabin depanCAT785 terpeleset dan terjatuh ke tanah

Kendaraan ringan terlindas dozer D11 yang sedang mundurkarena tidak bisa keluar dari lokasi

1 kasus: Mengambil posisi tidak aman: Seorang spotter terjepit di antara fuel truck dan dozer saat

memberi aba-aba

APA YANG HARUS SEGERA DILAKUKAN?

SETIAP ORANG HARUS MEMATUHI ATURAN BAKU/GOLDEN RULES dan Aturan serta Prosedur K3 lainnya SETIAP SAAT

SALING MENGINGATKAN untuk MENCEGAH PELANGGARAN yang dapat mengakibatkan terjadinyakecelakaan

Selalu menjaga kebugaran; BERHENTI JIKA MERASA NGANTUK, Lakukan Peregangan dan lapor ke pengawas

HINDARI JALAN PINTAS: INGAT TIDAK ADA JALAN PINTAS UNTUK SELAMAT!!!

TUGAS UNTUK PIMPINAN DEPARTMENT/KONTRAKTOR

Manager harus mempresentasikan materi inikepada Supt dan Supt. Kepada karyawanATAU Manager/Supt. Kepada semuakaryawan

Menyerahkan daftar hadirnya ke Bp. Johnry Sihombing di Dept. OHS paling lambattanggal 30 Agustus 2010 untuk dicatat dalamCatatan Pelatihan Karyawan

Fatality Investigation Report

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