Health, Safety and Environment Management System

Form 1A-HSE
Incident Investigation Report
###
Record No.
INCIDENT INVESTIGATION REPORT/ LAPORAN INVESTIGASI KEJADIAN

1 General Information / Informasi Umum Business Unit (Unit Bisnis) : ###

Incident Type (Jenis Kejadian) ###
Injury / Illness (Cedera / Property Damage Near Hit / Miss (Hampir ###
Sakit) (Kerusakan Alat) Celaka)
Fatality (Mati) Violation (Pelanggaran) Pot. Class I ###
LTI (Lost Time Injury) (Kehilangan Pot. Class
jam
RWI kerja)
(Restrict Working Injury)(Kerja Environmental Risk (Dampak ###
II
Terbatas)
MTI (Medical Treatment Injury) Lingkungan) ###
✘ Fire (Kebakaran)
(Perawatan
FAI (First AidMedis)
Injury) Hazardous Spill ###
✘
(Pertolongan P3K) (Tumpahan B3)
###
Class II (Kelas Class III (Kelas
Incident Class (Tingkat Kejadian) ✘ Class I (Kelas I) ###
II) III)
2 Incident Details (Rincian Kejadian) ###
Department Involved (Departemen Terlibat) Incident happen (Kejadian terjadi) Time (Waktu) ###
✘ Production ###
Date (Tanggal) Month (Bulan) Year (Tahun) Time
Exploration ###
Hauling / Incident Reported (Kejadian Dilaporkan)
Transportation Date (Tanggal) Month (Bulan) Year (Tahun) Time ###
HRGA
Incident Location (Lokasi Kejadian) ###
Finance
Port Marine ###
Operations Shift Schedule (Jadwal Kerja) % Shift Worked (% Waktu Kerja) ###
✘ HSE
25 50 75 100
Workshop ✘ ✘ Day Shift / Siang ###
✘
Site %
Journey% % %
Over Time (Jam Night Shift / Malam ###
Operation : (Perjalanan) Lembur)
3 Personal Involved (Orang Yang Terlibat) Direct Supervisor (Pengawas) ###
Subject 1 (Pelaku 1) ###
Name (Nama) : Aldi Prayoga Pangestu Department Experience(s) Year(s) ###

ID No. (NIK) : 2204081 Occupation Sex Age ###

Employment (Pegawai) : Outsider / Contract ###

BIB ✘
Public or ###
Personal Involved (Orang Yang Terlibat) Direct Supervisor (Pengawas) ###
Subject 2 (Pelaku 2) ###
Name (Nama) : Kelompok 1 Department Experience(s) Year(s) ###

ID No. (NIK) : Occupation Sex Age ###

Employment (Pegawai) : Outsider / Contract ###

BIB ✘
Public or ###
Injured Person (Korban Cidera) ###
Action Be Taken
Sex Age Involvement Consequences Employment
Name (Nama)
Jenis Kelamin Umur Keterlibatan Akibat Tindakan yang diambil Karyawan

###
Incident Short Description (Penjelasan Ringkas Kejadian) ###
Kejadian tersebut disebabkan oleh kurangnya pengalaman bekerja di area pertambangan batubara ###
Kondisi area pada lokasi bkerja saat itu sangat berbahaya atau tidak aman ###
###
###
###
###
###
###
4 Injury Details (Rincian Cidera) ###
###
Agency of Injury Location Injured ###

Mechanism Cause ###

Injury Impact ###

###
5 Analysis of Fire (Analisa Kebakaran) ###
Ignation Sources Electrical ✘ Hot Surfaces Static Electricity Open Fire ###
(Sumber Pemicu) Lightning Cutting/Welding Phyroporic Material Unknown ###
Other ###
Fired Equipment Friction Auto Ignition
: ###

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 Health, Safety and Environment Management System
Form 1A-HSE
Incident Investigation Report
###
6 Analysis of Environment Impact (Analisa Pengaruh Lingkungan) ###
Source(s) of Pollution: Process/Pumping ###
Stack / Flare Shipping Line Drum/Container
(Sumber Polusi) Tank Above Equipment Produced Water ###
✘ Tank/Truck/Vehicle Production Line
Tank Under
Ground Line/Canal ###
Pit Vessel Other :
Ground ###
7 Plant/Property Damage (Kerusakan Peralatan/Properti Perusahaan) ###
Unit No. 1 Description/ bahan bakar sering mengalami penyusutan Expected Cost
Penjelasan (Perkiraan Biaya) $182.000.000,00
(No Unit)
Unit No.
Description/ Expected Cost
Penjelasan (Perkiraan Biaya) $262.000.000,00
(No Unit) 2 getaran mesin terlalu berlebihan
Description
Expected Cost (Perkiraan
Environmental Damage #### ###
8 (Gambaran) menekan polusi udara Biaya)
Statutory Notification (Perlu pemberitahuan ke pemerintah/ yang berwajib?) Yes / Ya No / Tidak Other : ###
Police / Polisi Government Body ###
###
9 Causal Factors (After Investigated) / Faktor Penyebab (Setelah Di Investigasi) ###
###
Basic Cause - Work System ###
Inadequate environmental control
Failure to secure Inadequate training Inadequate job planning ###
program
Improper engineering Working on moving equipment Improper layout or design of work ###
Improper position / methods
worn-out and
Inadequate threadbare
hiring / placement
✘
area ###
posture Inadequate supervision
✘ Improper tools / equipment ✘
Inadequate preventive
practices
✘
###
Improper or inadequate ✘ ✘ Inadequate medical monitoring
✘
procedure Inadequate
maintenancesafety management Unsafe design or construction of ###
Inadequate maintenance activities Inadequate hazard analysis or
tools/equipment ###
Inadequate Inadequate job instruction
Inadequate purchase
✘ ✘
or lack Inadequate enforcement of prevention act ###
Other :
supervision work rules and procedures ###
Unsafe Condition(s) ###
Inadequate guards or barriers ✘ Noise exposure Congested work
Unsafe floors, area/roadways
ramps, stairways, ###
Improper safety
✘
Defective equipment & Radiation exposure ✘
###
protection platforms
Hazardous chemicals/substances
High or low or
Inadequate temperature
excess
✘
###
tools Limited visibility
Inadequate working space ✘ ✘
###
illumination Adverse weather
✘ Inadequate warning system Inadequate Ventilation ###
Explosive and fire hazard Lack of supervision Poor road conditions
Defective tools, equipment, machine or
Improper material
Environment hazardstorage
condition; gas, smog, dust,
✘ Poor housekeeping ✘
vehicle
✘ Inadequate guards or protection Other :
fume, vapor
Unsafe Practice(s)
✘ Failure to use PPE properly ✘ Removing safety devices ✘ Operating without authority
✘ Failure to follow procedure Using
Under defective
influence equipment
of alcohol and / Unsafe lifting,
Improper loading
lifting, or placing
lowering, or carrying
Failure to obey safety rules
✘ Failure to secure ✘ or drugs
Improper words ✘ technique
Taking unsafe position
✘ Failure to warn Inattention Influence of alcohol or drugs
Horseplay Lack of skill or knowledge ✘ Physical or mental limitation
Improper loading / unloading Operating at improper speed Unaware of hazard
Failure to use proper tools or Servicing equipment in
Improper lifting
equipment operation
Improper placement ✘ Failure to use guards provided Using known defective equipment
Failure to use personal protective Operating equipment without authority /
Improper position for task
Making safety device equipment training
Making safety devices inoperable Other :
inoperable
Failure to follow procedures or Operating mobile equipment in unsafe manner
methods or speed
10 Corrective Action Taken & to prevent recurrence/ Tindakan perbaikan yang diambil untuk mencegah terulangnya kejadian By Whom (Oleh By When (Kapan) Sign & Date on Completion
Siapa) (Tandatangan dan Tanggal Saat
serupa Penyelesaian)

Basic Cause - Work System

1 lakukan pembersihan rutin operator 18-Nov-23
2

Unsafe Condition
1 lindungi elektronik dan lain lain
2 operator 18-Nov-23
3

Unsafe Act
1 melakukan pelunasan secara rutin
operator ###
2

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 Health, Safety and Environment Management System
Form 1A-HSE
Incident Investigation Report
###
11 Action and Effectivess of Corrective Actions (Tindakan dan Keefektifan Tindakan Perbaikan)
Direct Supervisor Action & Comment (Tindakan dan Komentar Pengawas Langsung) Sign (TTD) Date/ Tgl
jangan abaikan bahayanya

Departmental Manager / Head Action & Comment (Tindakan dan Komentar Manager / Pimpinan Departemen) Sign (TTD) Date/ Tgl
selalu pakai perlengkapan keselamatan

Workplace HSE Department Action & Comment (Tindakan & Komentar Departemen K3L di Tempat Kerja) Sign (TTD) Date/ Tgl
ikuti standar keselamatan kerja terbaru

Actual Days Lost Actual Cost (Biaya yang dikeluarkan) Is Attachment Other Investigation Report Available? (Adakah Laporan Investigasi Lain Tersedia?)
(Hari Kerja yang Hilang) Rp. 362,000,000.00 Yes / Ya ✘ No / Tidak
No /
Has short-term corrective action been implemented?(Sudahkah tindakan perbaikan jangka pendek dilakukan?) ✘ Yes / Ya
Tidak
No /
Has report been discussed with General Manager?(Sudahkah laporan ini didiskusikan dengan General Manager?) ✘ Yes / Ya
Has long-term corrective action been planned? (Apakah tindakan perbaikan jangka panjang sudah direncanakan?) Tidak
No /
✘ Yes / Ya
Tidak
12 Close Out (Penutupan Laporan Kejadian)
General Manager-KTT / Representative Comments of The Follow Up Action(s) If Required / (Komentar GM-KTT / Perwakilannya Tentang Langkah Tindak Lanjut Jika Dibutuhkan)
Sign (TTD) Date/ Tgl
jika diperintahkan evaluasi, segeralah menuju tempat berkumpul keadaan darurat

Head Office HSE Manager / Representative Comments of The Follow Up Action(s) (Komentar Manajer K3L Pusat / Perwakilannya Tentang Langkah Tindak Lanjut)
Sign (TTD) Date/ Tgl
selalu pakai perlengkapan pertambangan

Documents attached to this report (interviews, monitoring results, photographs, competency assessments etc):
Lampiran Untuk Laporan ini (Hasil Wawancara, hasil monitor, photo, penilaian kemampuan, dll)
✘ Incident Interview Form Incident Sketch
✘ Photograph Attachment Loss Insurance Form
Cause Analysis
✘ Assessment Result
Others Form
:

Close out of Incident report ( Penutupan laporan insiden )

(To be completed once all relevant sections have been completed). This incident report, including investigation and corrective actions, has been adequately closed out. The effectiveness of the corrective actions has been evaluated.

(Kolom ini hanya diisi bila semua tindakan yang terkait sudah dilakukan. Laporan insiden ini, termasuk penyelidikan dan tindakan perbaikan telah sepenuhnya dilaksanakan. Keefektifan dari tindakan perbaikan telah dievaluasi.)

Incident Report Status : ✘ Completed / Telah Diselesaikan Not Yet Completed/ Belum Diselesaikan

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rity /

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