INCIDENTINVESTIGATIONREPORT

PROCEDURE Tanggal:8 Mei 2017

Revisi:0
PT.HOATYK No.Dok:HTX-HSE-17

INCIDENT INVESTIGATION REPORT PROCEDURE

0 8 Mei 2017 IssuedforReview

REV DATE ISSUETYPE PREP’D REV’D APP’D COMPANY
BY BY BY APP’D
.
 INCIDENTINVESTIGATIONREPORT
PROCEDURE Tanggal:8 Mei 2017
Revisi:0
PT.HOATYK No.Dok:HTX-HSE-17

1.PURPOSE
The purpose of this procedure is to describe the process for investigation and reporting accident sand
incidents

2.SCOPE
This procedure applies to the technique for identifying and documenting the “root,proximate and
secondary cause (s) ” of anyincident / accident so that they can be eliminated at the work site,and to
assembling data base of the se cause (s) to identify areas or procedures that need improvement.

3.PROCEDURE
3.1 General
1. All standard form sare attached procedure as attachments
2. Collect any and all pertinent in formation and documents related to the incident / accident
3. Use photograph with negative and sketches of the scene, surrounding areas, tools or equipment
in volved wherever possible.
4. To establish the chain of events, gather the identified participants in a group around a drawing
surface that is clearly visible to them.
a. Begin by drawing a box withi ncident / accident liste das thefirstlinkon thefarright hand
side of surface
b. Continue drawing right to left. Next draw a box to show the proximate the cause.
Continue this process,link by link,asking “ Whathappened just before or led this event
or why was this done ” until no further action can be identified.(That may terminates
as “ followed instruction on drawing ”.)
5. Working from the primary chain of events flow - charts, now identify contributing causes .Show
Their relationships by listing the se blocks with connecting lines above each link in the chain of
event stowhich they distributed
6. Then review the total system for general failure types that allowed the various causes to occuror
contributed to them.
7. Finally,use the chain of event flow chart to identify the chain breakers.List the chain breaker in a
box under the chain of event swith a connecting line to the link or contributing cause.

3.2 Reporting / Recording

1. Prepare written summary of pertinent facts accompanying the flow chart to assists management and the
Accident Review Committee in the evaluation process.
2. Assemble the documentation from the involved parties (Owner, Contractor ,and Subcontractor ) and the
forward the packa get the Accident Review Committee.
3. The Accident Review committee reviews the information resulting from the investigation and identifies
and documents all cause (s) of the incident / accident. Add interview or other devices necessary to
ensure an accurate,complete investigation.
4. Use the identified cause(s) of the incident / accident to develop a list of recommended corrective
actions (chain breakers). Recommendations areshown ontheflowcharttoindicateappropriate action.
5. The Accident Review Committee prepares the design safety observation report (DSOR) as applicable.
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PROCEDURE Tanggal:8 Mei 2017
Revisi:0
PT.HOATYK No.Dok:HTX-HSE-17

6. Forward the DSOR and there portofre commended corrective actions,with all documentation , to
management for review and corrective action.
7. Preliminary report should be done within two(2) days and incident not ofication should be done within
24 hours using mobile phone or handy talky.

HSEMANAGERH T X

ALIMULYADI
PROJECTMANAGERBBB
082139465516

INCIDENT
LOCALCLINIC/MUTIARA PALUL

SITEMANAGERBBB *DependonDoctordecision

SULAWESI TENGAHHOSPITAL*

WITNESS/ IP ERTLEADER SECURITY

LOCALPOLICE

3.3 Distribution
This report is then issued to the following:
1. Operations – Corporate
2. HSE – Corporate
3. Project Director
4. Site Manager
5. Construction Manager
6. Project HSE Manager
7. Owner

3.4 Near – Miss Investigation

3.4.1 Purpose
To describe the near – miss investigation ,interm so funsafeacts,conditions,personal factors,and their
sources, the true causes of near–miss,and to develop a means of corrective action to prevent re
occurrence.

3.4.2 Definitions
Near – Miss– An occurrence that involves a significant potential for injury / illness, equipment damage ,
property damage,loss of product,or loss of product time.
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PROCEDURE Tanggal:8 Mei 2017
Revisi:0
PT.HOATYK No.Dok:HTX-HSE-17

3.4.3 Procedure
1. In Conducting a near – miss investigation, it is necessary for the investigat or to have a clear
definition term near – miss.
2. Detailed information regarding the circum stances of the near – miss is obtained from the
Employees directly involved.
3. The near – miss investigation should be conducted as soon after the incident as possible.This allows
the investigat or toget the most clear,concise information from the employees involved .
4. In the clear concise terms,describe fully how the incident happened, what unsafeacts / conditions
contributed, and recommendation stop reventre occurrence.

3.5 Lost Time Accident / Serious Incident Investigation Process

3.5.1 Purpose
To establish a means of normally investigating lost time accidents and incidents that may results in
litigation,and other accident to Near – Misses that in the judgment of Site Manager / Construction
Manager require a more through investigation than that provided by the Accident Report or Near – Miss
Investigation.

3.5.2 InvestigationPurpose
1. The investigation so accidentsisbasedonthreefacts:
a) Accidents are caused.
b) Accidents are prevented if causes are eliminated.
c) Unless the causes are eliminated, accidents will happen again.

2. While the primary reason to investigate accident is to prevent recurrence,other purpose are also
served. Prompt and thorough investigation helps establish the true cost of accident and contro l
post accident losses. Analysis of accumulated accident data helps to identify the unacceptable risks
that were taken,and to determine and initiate the corrective action required to eliminate
deficienciesin the HSE Management System.

3. All accidents that result in injury or occupational of any type must be investigated with formal and
detailed report criteria. All property damage accidents at above an established cost base ,all fires
and all near - miss incident swith potential for serious lost must also be investigated .Many
interested parties, suc has upper management,the press, insurance and or government officials,
will seek detailed information on the causes and prevention of certain of these losses.

3.5.3 Accident Review Committee

Immediately following an accident or incident where formal investigation is indicated,the Accident
Review Committee is convened and will, ingeneral, be composed of the following members :

1. Site Manager who will be the chairman of the committee.

2. HSE Manager or designee who facilitates he gathering of all factual investigative information , data
and support materials.He /she may also act the chairman’s assistant by recording committee
findings and data.
3. Superintendent or Supervisor of the area in which accident / incident occurred.
4. Supervisor / Foreman or work leader incharge.
5. Sub contractor Manager and HSE Manager.
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PT.HOATYK No.Dok:HTX-HSE-17

6. Other personnel, asdeeme dad visable by committee chairman . In the event of fatality or multiplei
injury catastrophe ,the corporate safety assigns or more individuals to participate in the project
investigation process.

3.5.4 Time lines of Investigation

The written investigation report will be prepared within two(2) days of the accident to facilitate the rapid
procurement of critical data, factual and supplemental information, it is recommended that the actual
investigation be done the same day of the occurrence. Remedial actions should be implemented as
soon as feasibly possible to minimize potential for recurrence.

3.5.5 Investigative Procedure

1. When the committee convenes and after committee chairman has stated the purpose of the
meeting, the supervisor / foreman or works leader of the crew(s) involved will be asked to describe
in detail.
2. The nature of the work being performed prior to and atthetime of incident.
3. The exactinstructions given to crew(s), and especially the employees directly involved.
4. The supervisor over the work in volved is then asked to verify and supplement the information given
above.
5. A Through interview should be conducted with any one possessing potentially help fulknowledge
regarding the incident. This may include injured or ill employee, crew members, and machine or
equipment operators. OWNER operations personnel,rescue team and by standers who witnessed
the event. Pease remember, interviews produce most of the investigation information and are
critically important to the final outcome.
6. During the establishment of facts as outline above, bring out such factors as age of employee,
lengthof experience in the type of work he/she was doing, service time on the project, his/her injury
record, and all other pertinent information which will serve informulating plans for the prevention of
similar occurrences.
7. All statements from witness shall be written statements, and must besigned and dated by the
witness.
8. Base don’t he complete assembly of facts, step stop revent recurrence in addition to
remedial actions should be taken.
9. Supplemental information shall besecured.This could include, but not limited to, photographs,
sketches, measurements, workpermit, damage material, and in volved equipment.

3.5.6 Written Report Required

1. It will be theresponsibilityoftheHSEManagerordesignatedemployeetoprepareadetailed
summaryofthecompletedinvestigation.
2. Investigationsummaryreportmustinclude:
a. Identifyinginformation
Thisincludesessential“who,what,andwhere”kindsofdata. Whowasinjured? Who
participatedintheinvestigation?Whereandwhendidtheincidentoccur? Whatpropertywas damage?
Whatinflictedtheinjury,illnessor damage?Whatkindofinjuryorillnessoccurred? What body parts
were affected? Specific identifying data of this sort is essential to
investigationreportsandremedies.

b. Accidentdescription
Thisshouldbea clearandconciseaccountingifwhathappened.Makesurethedescription
identifiestheexactsequenceofeventsthatledtotheloss(personalinjuryand/orproperty loss)ornear–
missincident.
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c. Causeanalysis
This is the primary focus point of the report. It will provide the reader with a solid
understanding ofboththe“immediate” causes,orsymptoms, andthe“basic“causes or
originsoftheproblem.

d. Riskevaluation
A knowledgeassessmentshouldbemaderegardingtheaccidents“severitypotential“and its
“recurrenceprobability“.Thelossseveritypotential(nomatterwhattheactuallosswas)may be
firstaid,physiciancare,losttime,andequipmentlossor downtime,etc.Theprobable
recurrenceratemay befrequent,occasional,or rare.Thisevaluationhelps todeterminehow
muchtime,energy andresourcesshouldbe devotedto correctiveaction.Itwillalsoaid in
determiningthemaximumacceptablelevelofriskassociatedwithtaskperformance.

e. Abatementactionourprevention
Thishighlightsthewholepurposeoftheinvestigation,whichissototakethoseactionsthat
willcontrolorprevent recurrence ofsimilar incidents. Make surethe action plancovers
appropriateintermediateaswellaspermanentaction.

3.6 Supervisor’sAccidentReport
3.6.1 Purpose
ToassistsProjectManagementin thepropercompletionanddistributionofthe“IncidentInvestigation
Report“.Thisreportrequiredtothecompletedafteranyinjuryorillnessrequiringtreatmentother
thanclassifiedasaprojectsitefirstaid.

3.6.2 General
1. Oneofthetoolsavailabletopreventaccidentreoccurrenceisthe“IncidentInvestigationReport”.
2. Thisreportprovidesameansforcategorizingandtrackinginjuriesandillness.
3. ProjectManagementisresponsibleforthispropercompletion,distributionand legibilityandthe
reportiscompleted byasupervisor and/orProject Management. Itinvolves supervision is
determiningthecause(s),assigningcorrectiveactionandfollowinguptoassurethecorrective
actionhavebeencompleted.

3.6.3 HowtoInvestigateanAccidenttoFindtheCause
Anaccidenthasadefinitedirectcauseandusuallyanumberofindirectcauses.Thedirectcauses
areunsafeactsby personsand,unsafeenvironmental(physicalormechanical)conditions.Indirect
causesofunsafeactsareusuallycharacteristicsor“personalfactors”oftheinjuredperson.Indirect
or“sources”causesofunsafeconditionsareoftenfoundinsuchareas.
1. Stepsinmakingtheinvestigation
a) Visit the scene of the accident or injury. Look at the object, tool, machine, and the surroundings.
b) Talktotheinjuredpersontogettheirversionofwhathappened,how,andwhy.Ifthewere
witness,askthemfordetails.
c) Inperformingstepsaandb,keepinmindthatyouarelookingforthespecificconditionand/
oract,withoutwhichtheaccidentandinjurywouldnothavehappened.
d) Findthetypeofaccidentfirst,thenkeepinmindtheprobablepersonalandmechanical
causes,considereachoneinturnuntilyousingleoutthosefactorsresponsible.
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PT.HOATYK No.Dok:HTX-HSE-17

2. Ininvestigatingandinjury thatresultedfromafall,forexample,youshouldfind:
a) Wherethefalltookplace.
b) Whattheinjuredpersonfellover,on,or from:
1. Uneven,wet,oily,or slipperyconditions
2. Obstructions
3. Lighting
4. Congestionorclutter
5. openings
6. Guardrails,barricades,etc.
7. Conditionandkindoffootwear
8. Physicaldefectsorconditions
9. Distractions
10.Otherhazards

c) Whathe/shewasdoing(carrying,climbing,walking,running,etc). d)
Whatoperationhe/sheperforming.
e) Whatruleorprincipleofsafeconductorpracticewasviolated:
1. Notlookingwherehe/shewasdoing
2. Running
3. Workingoninsecureormakeshiftsupport
4. Notholdingon
5. Carryingtoolsormaterialwhenclimbing
6. Horseplayorpracticaljokes
7. Unnecessaryexposureinanunsafeplace
8. Unnecessaryclimbingorjumping
9. Ridingloads,etc.
10.Otherviolations.

f) Ifthemajorcausewasanunsafeact,trytodeterminewhyitwasdonesothataction can take

topreventsimilaroccurrencesinthefuture.
g) Ifunsafecondition isfoundtobemajorcause, seethatpromptlycorrected ifwithinthe investigator’s
arearesponsibility todo so. Ifthe condition cannot becorrected, report it
immediatelytotheresponsible individualortotheindividualdesignated asthecustomer contacton
thejob.Ifappearsthattherewilladelayin correctionofthe condition,thereport
callingattentiontotheconditionshouldbewarninginwriting.

3.6.4 ReportCompletion
1. Financialnumber:Enterthefinancialnumberoftheprojectsitethereportisbeingcompleted.
2. AccidentDate:Entertheexactdateandtimetheinjury/illnessoccurred.Theinjury/illnessdate
andtimearenotknownenter“Unknown”.
3. Injurer’sName:Entertheemployee’slastname,firstname,andmiddlenameasitappearson
his/herassignmentauthority.
4. Age:Entertheemployee’sageatthetimeofinjury/illness.
5. BadgeNo:Entertheemployee’sassignmentbadgenumberoremployee’sidentificationnumber
asitappearsonhis/herassignmentauthority.
6. IDNo:Enterandverify,fromassignmentauthority,theinjuredemployee’ssocialsecuritynumber orIDNo.
7. Home Address: Enter the employee’s home address as it appears on his/her assignment
authority.
8. Injurer’s Job Title: Enter the injured employee’s complete job title as it appears on his/her
assignmentauthority.
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9. Immediate Supervisor and Title: Enter the name (first, middle, andlast) and job title ofthe
supervisortheemployeewasworkingforthetimeoftheinjury/illness.
10.DescriptionoffAccident:Enteracompletedetaileddescriptionofhowtheemployeewasinjured.
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PROCEDURE Tanggal:8 Mei 2017
Revisi:0
PT.HOATYK No.Dok:HTX-HSE-17

IncidentReportForm

IncidentClassification* : NMI FAC MVI MTI RWI LTI FAT

1.Dateandtime:

2.Location:

3.Company/Grup:

4.Supervisor:

5. PersonInvolve :

Badge:

Permit:

6.Ageofvictim:

7.Experience:

8.Injury:

9.Physician:

10.Physicianadvise:

11.Incidentdetailed:
12.Response:
13.Incidentcauses:
14.Recomendation:

Attachment

Reportedby
HOATYK–ProjectManager

*NMI:NearMissIncident
FAC:FirstAidCase
MVI:MotorVehicleIncident
MTI:MedicalTreatmentIncident
LTI:LostTimeIncident
FAT:Fatality