DRAFT

NIGHT LIFTING EXCEED PREDETERMINED WORKING HOURS

MARCH 10,2021 @09.26 PM
 INVESTIGATION TEAM

Investigation Team:
1. ..
2. …

Person Involved :
3. Agus Marpaung (JGC Area Supervisor)
4. Gardani (SK Site Manager)
5. Darmanto (SK Lifting Supervisor)
6. Yamin (SK HSSE Lead)
7. Putri (SK HSSE Officer)
8. Cendana (SK Permit Holder)
9. Agus Santoso (JGC Lifting SPV)
10. Syahroni (JGC Safety SPV)
11. Abdul Majid (JGC HSE Deputy Manager)
 BRIEF DESCRIPTION

On March 10, 2021 at 09.26 PM, Shell HSSE Supervisor and Instrument engineer found lifting activity performed
by PT SK at laydown area, to make sure the activity running accordance to guidelines Shell HSSE Supervisor and
Instrument engineer checking work location and found Permit was not communicate and approved by Shell
Representative for extended working time.
Permit Holder also found not in place for standby and supervision, Shell HSSE Supervisor and Instrument
engineer immediately Stop the job and standdown meeting conducted.

CONSEQUENCE

Consequences Real Potential Severity

Human None ??
Material/production None ?
Environment None ?
CHRONOLOGY (1/3)
Time Description
March 10, 2021
JGC Team
01.00 PM • Incoming material to be unload at PT SK laydown area
• PTW Ready
04.00 PM • Area Supervisor asking to ensure when the materials can be unload
04.30 PM • PT SK found technical problem on crane that need to be solve by technician.
07.00 PM • Area Supervisor communicate again with PT SK regarding crane availability
• Permit Holder get information at 07.00 PM there will be unloading activity
08.00 PM • Crane and crew start to unload materials
• Unloading activity attended by :
1. Agus Marpaung (JGC Area Supervisor)
2. Gardani (SK Site Manager)
3. Darmanto (SK Lifting Supervisor)
4. Yamin (SK HSSE Lead)
5. Putri (SK HSSE Officer)
6. Cendana (SK Permit Holder)
• Permit available in place, working time is not mentioned in PTW General, working time
mentioned in daily clearance certificate. It stated until 21.00 PM.
CHRONOLOGY (2/3)

Time Description
March 10, 2021
JGC Team
08.00 PM • Permit available in place, working time is not mentioned in PTW General, working time
mentioned in daily clearance certificate. It stated until 21.00 PM.

08.30 PM • Agus Santoso (JGC Lifting SPV) was informed there is lifting activity at laydown area and
with Syahroni Ismail (JGC Safety SPV) went to laydown area, and just found out if there
is unloading activity there.
• 2 of 10 (total load) unloading activity was performed
08.40 PM • Remaining 3 unloading activity to be done
• Syahroni (JGC Safety SPV) inform to Abdul Majid (JGC HSE Deputy Manager) there is
unloading activity at laydown area will exceed PTW working hours
• Abdul Majid (JGC HSE Deputy Manager) ask medic and ambulance remain stay on-site
08.45 PM • Safety PT SK remind parties regarding limit working time
08.46 PM • Safety PT SK Forget to communicate to SHELL to get permission to extend the overtime
CHRONOLOGY (2/2)

Time Description
March 10, 2021
JGC Team
08.52 PM • Permit Holder permission to leave the laydown area to public toilet due to stomach
ache
• Permit holder leave the construction site without inform all involved parties
09.00 – 09.10 PM • Last unloading activity performed (all parties are aware and violate the working hour
limit)
09.26 PM • Unloading activity known by Shell HSSE Supervisor
09.40 • Stand down meeting conducted
PICTURE
PICTURE
PICTURE (PH Attendance Record)
FACT FINDING

1. From the morning Agus (JGC Area Supervisor) get information that there will be material entering the location
by email at 09.00 PM
2. The material came to the site at 01.00 PM and waited to be unload
3. Agus (JGC Area Supervisor) info to PT SK 02.00 PM to unload
4. 04.30 PM Area Supervisor gets info that crane has technical problems
5. 04.31 PM crane still used for unloading urgent structure
6. Area Supervisor at 17.00 PM tried communication again for cranes availability
7. Permit Holder knows unloading plan at 07.00 PM
8. At 08.00 SKcrew started unloading (total 10 cargo to be unloaded)
9. Area Supervisor liaise with PH supervising unloading of material
10. At 08.30 Agus (JGC Lifting Supervisor) got the info that there was an unloading activityt at PT SK, but at that
time it had been done 2 lifting
11. Agus (JGC Lifting Supervisor) asked PTW to agus (JGC Area Supervisor) about PTW validity, and answered its
all OK, he did not know / not familiar with the time restrictions that apply.
12. At 08.40 Syahroni (JGC Safety SPV) informed Abdul Majid (HSE Deputy Manager) that the activity would
exceed the time specified in the permit
13. Abdul Majid (HSE Deputy Manager) told medics and ambulances to stay on site as there were still people
working.
FACT FINDING

14. No one informed shell.

15. Yamin (SK Safety SPV) informs that the time is already at 08.45 PM to the person involved, but no one stop
the activity including him self
16. At 08.58 PM Cendana (Permit Holder) left marunda 2.0 after previously feeling stomachache and went to the
public toilet. People at the location site knew the PH went to the toilet, but did not know the PH left the
Marunda 2.0 project site.
17. Agus (JGC Area Supervisor) just before 09.00 PM and 3 more unload to be done, felt need to finish the job.
18. Yamin (SK HSE Lead) aware the clock already 09:10 PM, but the team on site felt they had to finish the job,
and no one has informed Shell
 CTA
Need to
Job Preparation / All Crane unload
coordination busy Normal material for
constructions
Lack of Communication

Maintenance The Crane has a

program technical problem
Lack of Maintenance Pending job
from 01.00
PM
Night Lifting
Exceed
Truck has to
Predetermine
get back to
d Working
garage
Hours
Normal
Rushed job
need to finish
Lack of Dicipline

Save effort

Stop Work
Authority
Failed
Lack of Knowledge /Awareness
ANALISYS
1. Immediate Causes
 Unsafe Acts
 All person involved unloading activity are failed to apply Stop Work Authority
 Unsafe Situation
 Night Lifting
2. Root Causes
 Human factor, bad behaviour
 Lack of discipline
All supervisor fail to comply with the work limit procedures written in PTW
 Lack of Knowledge and awareness
PH does not clearly know his duties and responsibilities
 Job Factor
 Lack of Communication
JGC constructions team not prepare well related to crane usage
RECOMMENDATION

1. To give refreshing training to PH and AS relating to task and responsibility of PTW.

2. Stop Authorization must be socialized to all workers.
3. JGC management shall review Supply Chain Management that related to usage of crane