Investigasi Kecelakaan Fatal Supervisor Thiess meninggal dunia ketika kendaraan TC560 yang ditumpanginya terlindas oleh dozer CAT D10R (DZ3003) di Areal Dumping Belut; 22 Juli 2010 – pukul 09.28 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 Peran
Nama
Jabatan
Ketua
Galang Jaya
Mine Inspector – Jakarta
Wakil
Markus Taruk Allo
Mine Inspector – Samarinda
Sekertaris
Erwin Hambali
Snr. Supv. Safety Monitoring & Comm.
Fasilitator
Muhammad Rudy
Acting COO/KTT
Armin Haryadi Wardono Bina Sembiring Redo Gusman Rafael M Toni Samali Dedi Mulyana Anhar Al A’la Sjamsi Josal Masykur Dafid Feri Eryanto
Mine Inspector – Kutim Manager OHS Manager Contract Mining Thiess Staf Subdit DTMB – Jakarta Staf Subdit DTMB – Jakarta Staf Distamben – Kutim Supt. Safety Safety Monitoring & Comm. Supt. HSE CMD Coord. HSE CMD Project Manager Thiess Supt. Safety Thiess – Balikpapan Act. Supt. Safety Thiess
Anggota
Kronologi Kejadian • 09.25 – Dozer DZ3003 sedang mendorong material OB ke dalam kolam ketika kendaraan ringan TC560 dikemudikan oleh Senior Supervisor / Acting Superintendent ditemani Supervisor (korban), datang dan diparkir di jalur kerja di belakang dozer tersebut. • 09.26 – Senior Supv (pengemudi TC560) turun dari kendaraan dan berjalan ke sisi sebelah kanan 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 tidak berhasil. Dozer terus mundur. • 09.28 – Track sebelah kanan dozer melindas TC560 dari bagian kiri depan hingga ke bagian kanan belakang kabin, sementara korban masih berada di dalam kabin. • 09.29 – Operator dozer melihat Senior Supv., menghentikan dozernya dan menyadari bahwa dozernya telah melindas sebuah kendaraan. Ia lalu memajukan dozernya. • 09.33 – Safety Thiess diberitahu. Safety, ambulance and paramedic Thiess menuju ke tempat 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 tulang terbuka di kaki kiri.
Foto Lokasi Kejadian DZ3003 TC560
m ,7 8 4
67,9 m
Lighting Plant & Pondok Supv
35.5 m
DZ3006 Saksi mata
1. Lokasi kejadian: Areal Dumping Belut RL-10 (setelah kejadian – 22 Juli 2010)
Foto-foto Kejadian
2. Tim Rescue KPC menyiapkan pengambilan korban
4. TC560 dilihat dari kanan depan DZ3003
3. TC560: sedang diperiksa oleh KTT setelah korban dievakuasi
5. Peragaan posisi korban oleh Personil Senior Rescue KPC
Lighting Plant Supv. Hut
,7
an
39 ,7
m
B lO ia er at
m
48
M
64,9 m
DZ3006 (saksi mata)
67,9 m
Denah Lokasi Kejadian
Jal ur do z er 35.5 m
DZ3003
Kolam
Ja l
TC560
Mat
eria l
OB
LV TC560 seharusnya diparkir dekat Lighting Plant: bukan di jalur dozer
Penyebab Kecelakaan Penyebab Langsung: • Pelanggaran prosedur dan pengambilan keputusan yang tidak tepat: – Senior Supv memasuki dan memarkir kendaraannya (TC560) pada jalur kerja dozer di belakang dozer tersebut (DZ3003). – Senior Supv tidak melakukan kontak positif dengan operator dozer dan memastikan 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 memarkir kendaraannya (TC560) pada jalur kerja dozer di belakang dozer tersebut (DZ3003) Penyebab Sistem: • Ketergesaan karyawan sendiri: – Senior supervisor (pengemudi TC560) memasuki areal kerja dozer tanpa mempertimbangkan bahaya atau risikonya karena merasa terburu-buru.
REKOMENDASI • Menginstruksikan ke semua staff PT. TCI site Sangatta untuk mematuhi peraturan dan prosedur Keselamatan Kerja yang ada serta saling mengingatkan agar tidak ada yang melanggar. • Mensosialisasikan kembali kepada semua karyawan dan 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 FATAL DI KPC & KONTRAKTOR 1990 – 2010
Jumlah Kecelakaan Fatal & LTI vs. LTIFR 1996 – YTD 25 Jul 2010
45
3.50
Prima Nirbhaya/NOSA Implementation
40
CONT.
2.86
2.43
2.00
14 15
19
13 12
25
0.93
1.11
5
18 2
1
18
0.50
11
2
1
1
10
9
8
2
6
1
0.23
5
3
1998
1999
2000
2001
2002
2003
2004
2005
Fatality
LTI
Fatality
LTI
Fatality
LTI
Fatality
LTI
Fatality
LTI
Fatality
LTI
Fatality
LTI
Fatality
LTI
Fatality
LTI
Fatality
Fatality
LTI
LTI
1997
2006
0.56
9
0.32
12
0
1996
1.00
11
1
2007
3
1
2008
9
LTI
20
0.80
0.76
9 0.33
1
2009
0.50
2
1 Fatality
1.36
15
1.50
17
9
1.51
10
23
LTI
20
Fatality
17
Fatality
17
25
FPE & New Golden Rules Implementation
LTI
30 16
2.50
2.31
Fatality
14
YTD 25 July 10
0.00
LTIFR (per 1.000.000 Manhours)
LTIFR
2.59
LTI
35
No. of LTI and Fatality
3.00
KPC
Rangkuman Kecelakaan – YTD 2010 (KPC & Kontraktor)
Lost Time Injury Division
Potential Fatality
Significant Incidents
Fatality
Number of Event
Actual
Threshold 2010
MSD
7
5
1
1
0
6
MOD
1
4
1
3
0
4
KPC
TCI
2
4
10
1
1
2
Mining
PAMA
0
4
0
3
0
3
Contract
PT.DH
0
4
1
4
0
4
PID
0
2
0
0
0
0
EPD
0
1
0
0
0
0
MDD + HR
1
1
0
1
0
1
HSE
0
1
0
0
0
0
MKT
0
1
0
0
0
0
SCD
0
1
0
0
0
0
TOTAL
11
28
13
13
1
20
Note : Based on the decision at the EXCO meeting on 21 Sept ’05: 1 Fatality equals to 10 Potential Fatality Incidents
20
0 Jan-03 Mar-03 MayJul-03 SepNovJan-04 Mar-04 MayJul-04 SepNovJan-05 Mar-05 MayJul-05 SepNovJan-06 Mar-06 MayJul-06 SepNovJan-07 Mar-07 MayJul-07 SepNovJan-08 Mar-08 MayJul-08 SepNovJan-09 Mar-09 MayJul-09 SepNovJan-10 Mar-10 MayJul-10
No of Incidents
LTI SIG
PF Rolling LTIFR
Rolling SIGFR Rolling PFFR
Rolling LTIFR = 0.52 Rolling PFFR = 0.36 Rolling SIGFR = 0.50
YTD LTIFR YTD PFFR YTD SIGFR
= 0.33
4.00
3.50
15 3.00
2.50
10 2.00
1.50
5 1.00
0.50
= 0. 38 = 0.38
-
Frequency Rate (per 1.000.000 Manhours)
Kejadian Berbahaya vs. Tingkat Kekerapan YTD 25 Jul’10 4.50
DAFTAR KECELAKAAN FATAL 1990 – YTD 26 Jul 2010
No
Date
1
20-May-90
Injured Company / Position KPC / CONT Name Dept Yohanis
CONT
Whilst 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
Truck Operator
CONT
Whilst 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
Truck Operator
CONT
Fatally 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
Thiess
Truck Operator
Thiess
2
22-Jul-90
3
27-Oct-90 Musdiyanto UT Rental
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
CONT
A 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.
CONT
Fataly 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.
KNE Fuel Truck Helper CONT
A 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.
6
7
23-May-92
10-Aug-92
Nurtan M
Remarks
Dwisiswai
Wijanto
GTS
Mechanic
FATALITY INCIDENT LIST 1990 – YTD 26 Jul 2010
No
Date
Injured Name
8
05-Apr-95
Suparlan
Company / Position Dept
Whilst 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 Whilst 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.
CONT
KPC
Fatality 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.
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.
24-Sep-95
Iwan Insani
Hana Mas
10
18-Dec-96
Yulius Sutrisno
Surya Dept
Shovel Operator
Irianzach
CONT
Truck Operator
9
16-Jun-97
Remarks
DWL
Compactor Operator
11
KPC / CONT
Bintang Dept.
Act. Supv. Civil
KPC
Whilst 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.
12
09-Aug-97
Mardjit
Hatari Dept.
Truck Operator
13
31-Jan-98
Wayan Suadnyana
Bintang 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
KPC
An 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 LIST 1990 – YTD 26 Jul 2010
No
16
17
18
19
Date
Injured Company / Position KPC / CONT Dept Name
30-May-00 Paulus Tira PT Gemini
27-Jan-02 Sion Manik
Yunus 23-May-05 Thomassaw a
09-Aug-05
Rustan
PT KPPS
Bintang Dept.
Labor
Dozer Operator
Shovel Operator
Hatari Dept. Pump Crew
Remarks
CONT
A 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.
CONT
Whilst 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.
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 victim’s 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
KPC
A 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.
FATALITY INCIDENT LIST 1990 – YTD 26 Jul 2010
No
Date
Injured Company / Position KPC / CONT Dept Name
20
Hendris PT Pama 23-Jan-07 Susilawarta Persada
Truck Operator
21
Geology Dept.
Asst. Geology
21-Mar-08
Yusran
Remarks
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.
KPC
A 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
23
22-Jul-10
ROBERTUS RIA
Z38293
Supervisor
CONT
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. 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.
Note : Total of Fatality Incidents are 23 Incidents ( KPC = 9 ; Cont = 14 )
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-orang yang dicintainya. • Ke-23 orang ini mungkin merupakan tulang punggung ekonomi bagi keluarganya. • Kita harus melakukan sesuatu untuk mencegah kisah sedih ini terjadi pada diri kita dan rekan-rekan kerja kita. • Mari kita berdoa dan berjanji pada diri sendiri bahwa kita akan melakukan yang terbaik bagi keselamatan diri kita sendiri dan orang 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 tidak aman: – Operator yang sedang membersihkan kaca kabin depan CAT785 terpeleset dan terjatuh ke tanah – Kendaraan ringan terlindas dozer D11 yang sedang mundur karena 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 terjadinya kecelakaan • 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 ini kepada Supt dan Supt. Kepada karyawan ATAU Manager/Supt. Kepada semua karyawan • Menyerahkan daftar hadirnya ke Bp. Johnry Sihombing di Dept. OHS paling lambat tanggal 30 Agustus 2010 untuk dicatat dalam Catatan Pelatihan Karyawan
