MANYAR SMELTER PROJECT

SHES INCIDENT FINAL REPORT

(Email to CII SHES within 10 Days from incident date)

Date of Incident: November 21, 2023 Time: 1410H Report # : MSP-IFR-2023-0321

Use format (mmmm/dd/yyyy) in this Form 24 hour clock

SECTION 1 JENIS INSIDEN / INCIDENT TYPE Tick (√)

Near Miss Injury/Illness: FAC MTC RWC LTI FAT Occupational Illness Property Damage
Motor Vehicle Incident Fire Explosion Equipment Failure/Loss w/ SHE Impact Enviro. Spill LSR Violation
Others (Specify):
Company Involved/ Perusahaan yang terlibat: PT. Wasa Mitra Engineering Scope: Mechanical

SECTION 2 PELAPOR / REPORTER (Pengawas yang terluka/ Pemilik Aset jika aset rusak dengan atau tanpa cedera/
Pengamat) / Supervisor of the injured/ Asset Owner if asset damaged with or without injury/ Observer)
Name: Izack Desius Department: SHES Section: ERT
Designation: ERT Supervisor Badge No.: MSP-CII-00181 Contact Numbers, in case further details are required:
PTFI / ISOS CII Subcontractor: Office: Mobile: +62-811-1921-7668

SECTION 3 Tugas umum sedang dilakukan pada saat kejadian

Tick (√)
General task being carried out at time of incident
Cleaning Construction Diving Driving/Travelling Emergency Response Equipment in Operation
Inspection Maintenance Operation Material Handling Shutdown Activities Training Workshop
Other(specify):
Activity within the General Task (Specify): Equipment movement at site
Tick (√)
SECTION 4 LOKASI UMUM General Location
Area A Area B Area C Area D Area E M1 M2 Jetty/Wharf Motorcycle Parking Area CML
Batching Plant Temporary Construction Facility
Other(specify):
Specific Location within the General Location (Specify): Area D1 – Material Laydown
SECTION 5 PENJELASAN INSIDEN / DESCRIPTION OF INCIDENT (Tulis nama lengkap orang yang terluka,
departemen & Perusahaan / Write the full name of the person injured, department & Company)
Description: (Detil urutan peristiwa dalam urutan kronologis. Mengidentifikasi peralatan/aset yang rusak. Berikan detail sebanyak yang tersedia.
Detail sequence of events in chronological order. Identify equipment/assets damaged. Provide as much detail as available):

At approximately 1410H on the 21st of November 2023, the 10-ton capacity Tadano rough terrain crane was to be parked next to
a temporary laydown of various steel plates and lifting accessories.

While the crane was being maneuvered, its rear left tire came into contact with the protruding lug of a forklift attachment. The
crane's tire was punctured by the lug as a result. The flagman in attendance was positioned at the front right side of the crane
while it was maneuvered to the area.
There was no injury to personnel reported.

Incident photo:

The crane's left rear tire made contact with the forklift attachment's
protruding lug. The crane's tire was punctured by the lug as a result.
SECTION 6 Tindakan Yang Langsung Dilakukan / IMMEDIATE ACTION TAKEN
(Setelah kejadian kejadian / After incident occurrence)

 The incident was reported to CII SHES.

 Incident area was barricaded to facilitate investigation.
 Breathalyzer test was conducted to the driver. It was confirmed that the driver was negative to alcohol intoxication, the
reading was 0.000 mg/L.
 Investigation commenced.

SECTION 7 Fakta-fakta Penyelidikan Awal / PRELIMINARY INVESTIGATION FACTS

(Kirim ke CII 2 HARI setelah kejadian kejadian / Submit to CII 2 DAYS after incident date)

 The crane involved was the 10-ton capacity Tadano rough terrain crane (Serial # 1576). It was operated by Lionat Winarto
(MSP-WME-01584).
 The crane was used to offload materials at the RTH in Area A and was driven to Area D1 to park.
 The crane operator did not notice the protruding lug of the forklift attachment while maneuvering the crane beside the stacked
materials.
 The flagman in attendance at the time of incident was Ferian Irwanto (MSP-WME-01323). He was positioned at the front right
side of the crane while being maneuvered in the area.

SECTION 8 Saksi / WITNESSES (Tidak wajib melapor/Not compulsory while reporting)

No Name ID No. Company/Trade Contact Number
1 Ferian Irwanto MSP-WME-01323 WME / Rigger n/a
PROPERTY INVOLVED (Equipment, Material
SECTION 9 PROPERTY DAMAGE / MOTOR VEHICLE INCIDENT Facility etc.)
Driver/Operator Name & LIC
No Property Type / Serial No. Description of Damage Company
/ID Number
1 Tadano rough terrain crane / Crane Tire (11r22.5 omn mss Lionat Winarto (MSP-WME- WME
Serial # 1576 148/145k m+s) 01584) (Mech’l)
Direct Supervisor/s who supervise task resulting incident

No Name ID No. Company/Trade Contact Number

1 Yosef Hidayat MSP- WME -01461 WME / Material Control n/a

Tunjukkan Temuan Investigasi dan SCAT Chart – Teknik Analisis Penyebab Sistematis
SECTION 10 Penyebab / CAUSES Indicate the Investigation Findings and the SCAT Chart – Systematic Cause Analysis Techniques

While the crane was being parked, its rear left tire came into contact with the protruding lug of a
DESCRIPTION OF INCIDENT
forklift attachment. The crane's tire was punctured by the lug as a result.

TYPE OF EVENT Struck against (Running or bumping into)

IMMEDIATE / DIRECT CAUSES SUBSTANDARD ACTS:
1. Improper position for task
 The flagman was positioned at the front right side of the crane while guiding the operator.
2. Failure to identify hazard/risks
 The crane operator failed to assess the area before maneuvering the crane.
SUBSTANDARD CONDITIONS:
1. Inadequate guards or barriers
 The area where the forklift attachment was stored was not barricaded.
BASIC / UNDERLYING CAUSES PERSONAL FACTORS:
1. Inadequate knowledge
 Lack of situational awareness
JOB FACTORS:
n/a
ACTIONS / RECOMMENDATIONS TO PREVENT
SECTION 11 (Add extra sheets if required)
REOCCURRENCE
Item Oleh pelapor insiden dengan berkonsultasi dengan bagian/departemennya dan juga pihak lain yang terkena dampak. Penanggung jawab Tanggal target
Ini secara selektif ditinjau oleh SHES dan digunakan untuk berbagai tujuan. untuk melaksanakan untuk
By Incident Reporter in consultation with his section/ department and also others affected. These are selectively Person Responsible to diselesaikan
reviewed by SHES and used for various purposes. implement Target date to
complete

1 Stand down to be conducted to all heavy equipment operators, drivers, riggers, and WME SM 03 Feb 2024
flagmen to discuss incident lessons learned. Proper assessment of the area before the
equipment movement to be emphasized in the toolbox meeting.
2 Last minute risk assessment (LMRA) must be re-emphasized in workgroup pre-task WME SM / HSE 03 Feb 2024
instructions and toolbox meetings.
3 Written warning to be issued to the crane operator and flagman for failing to properly WME SM 03 Feb 2024
assess the area where the crane was to be moved/positioned.
4 Refresher course re Flagman Training to be conducted to all flagman. WME SM / HSE 03 Feb 2024

5 Safety alert regarding the incident lessons learned to be disseminated sitewide. CII SHES 24 Nov 2023
(Completed)
SECTION 12 REVIEW OF ABOVE RECOMMENDATIONS BY AREA SUPERVISOR/ SUPERINTENDENT
Rincian tindakan yang diambil/komentar. Tunjukkan potensi konsekuensi-keparahan dari nyaris celaka/kecelakaan dari Project RAM:
Details of any action taken/ comments. Indicate the potential severity-consequence of the near-miss/accident from Project RAM:

……………………………………………………………………………………………………………………………………………………
Potential severity-consequence of incident:
Actual Severity Rating Potential Risk Score (RAM) Risk Rank

Minor (1) Possible (2) Low

Subcontractor Construction Manager Contractor Construction Manager

Name: Name:
Signature: Signature:
Date: Date:

SECTION 13 COMMENTS BY AFFECTED DEPARTMENT MANAGER

Details of any action taken/ comments:

Name: ……………………………………….. Staff No.: …............ Signature: ……………………. Date: …………………

CAPITAL LETTERS

SECTION 14 SUBCONTRACTOR SHES Analysis required? Yes No

Name: ……………………………………….. Staff No.: …............ Signature: ……………………. Date: …………………

CAPITAL LETTERS

SECTION 15 CLOSE-OUT BY CONTRACTOR SHES

Analysis completed? Yes No . Effectiveness of Corrective Action verified: Yes ; Close-out comments, if any:

Name: ……………………………………….. Staff No.: …............ Signature: ……………………. Date: …………………

CAPITAL LETTERS