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 Mine Inspector Kutim
Anggota
Haryadi Wardono Manager OHS
Bina Sembiring Manager Contract Mining Thiess
Redo Gusman Staf Subdit DTMB Jakarta
Rafael M Staf Subdit DTMB Jakarta
Toni Staf Distamben Kutim
Samali Supt. Safety Safety Monitoring & Comm.
Dedi Mulyana Supt. HSE CMD
Anhar Al Ala Coord. HSE CMD
Sjamsi Josal Project Manager Thiess
Masykur Supt. Safety Thiess Balikpapan
Dafid Feri Eryanto Act. Supt. Safety Thiess
 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

35.5 m
m
67,9 m 8,7
4
Lighting DZ3006
Plant & Saksi mata
Pondok
Supv

1. Lokasi kejadian: Areal Dumping Belut RL-10 (setelah kejadian 22 Juli 2010)
 Foto-foto Kejadian

2. Tim Rescue KPC menyiapkan 3. TC560: sedang diperiksa oleh KTT

pengambilan korban setelah korban dievakuasi

5. Peragaan posisi korban oleh

4. TC560 dilihat dari kanan depan DZ3003 Personil Senior Rescue KPC
 Lighting Plant
Supv. Hut
Denah Lokasi Kejadian

67,9 m
DZ3006 (saksi mata)

48

m
M

,7
at

64,9
m
er
ia

m
lO

,7
B

39
an
TC560

l
Ja
Mat
eria
DZ3003 l OB
z er
do

LV TC560 seharusnya
m
ur

diparkir dekat Lighting

35.5
Jal

Plant: bukan di jalur

Kolam 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
40 Implementation CONT.
2.86 3.00
KPC
35 2.59 LTIFR
2.43

LTIFR (per 1.000.000 Manhours)

14 2.50
2.31
30
FPE & New Golden
No. of LTI and Fatality

16
17 17 Rules Implementation
2.00
25
14
15 19
20 13 23
1.50
1.51 9 17

15 1.36 12
0.93 0.80
25 1.11 1.00
0.76 11
10 20
18 18 0.50
0.56
12 0.32 9 9 0.50
5 11 10
9 0.23 9 0.33
2 2 8 2
1 1 1 1 6 5 1 1 1
3 3 2
0 1 0.00
LTI

LTI

LTI

LTI

LTI

LTI

LTI

LTI

LTI

LTI

LTI

LTI

LTI

LTI

LTI
Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality

Fatality
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 YTD 25
July 10
 Rangkuman Kecelakaan YTD 2010
(KPC & Kontraktor)
Lost Time Injury
Potential Significant Number of
Division Threshold Fatality
Actual Fatality Incidents Event
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
 No of Incidents

0
5
10
15
20
Jan-03
Mar-03
May-
Jul-03
Sep-
Nov-
Jan-04 PF
LTI

Mar-04
May-
Jul-04
Rolling SIGFR

Sep-

YTD LTIFR
Nov-
Jan-05
Mar-05
May-

Rolling LTIFR = 0.52

= 0.33
Jul-05
SIG

Sep-
Nov-
Jan-06
Rolling PFFR
Rolling LTIFR

Mar-06

YTD PFFR
May-
Jul-06
Sep-
Nov-
Jan-07

Rolling PFFR = 0.36

= 0. 38
Mar-07
May-
Jul-07
Sep-
YTD 25 Jul10

Nov-
Jan-08

YTD SIGFR
Mar-08
May-
Jul-08
Sep-
= 0.38
Rolling SIGFR = 0.50
Nov-
Jan-09
Mar-09
May-
Jul-09
Sep-
Nov-
Jan-10
Mar-10
May-
Jul-10
Kejadian Berbahaya vs. Tingkat Kekerapan

-
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50

Frequency Rate (per 1.000.000 Manhours)

 DAFTAR KECELAKAAN FATAL
1990 YTD 26 Jul 2010

Injured Company /
No Date Position KPC / CONT Remarks
Name Dept

Truck Whilst travelling from loading point to dumping area, a haul truck uncontrolled and hit
1 20-May-90 Yohanis Thiess CONT
Operator safety berm. Operator thrown out of the truck because he wasn't wearing seatbelt

Whilst travelling to PBI Construction area, a dump truck uncontrolled due to improper
Truck
2 22-Jul-90 Nurtan M Thiess CONT speed and rolled over along 9 meters. This incident resulted in death (serious leg
Operator
injuries to the operator). He wasn't wearing seatbelt

Truck Fatally injured after loosing control of a truck due to improper speed and rolled
3 27-Oct-90 Musdiyanto UT Rental CONT
Operator over a bank enroute to Pit K, the cabin striking a tree

A contractor employee was using portable hand drill during contruction activities when
4 21-Mar-91 Sudarno Gemini Labor CONT
he got electric shock. This incident resulted in death

Aswin A light vehicle (Toyota Hardtop) was run over by haul truck (Cat785) at 4F intersection.
5 10-May-91 Petrosea Electrician CONT
Kasiran This incident resulted in fatality to the L/V driver. Critical factor was driver fatigue.

Fataly injured when the Dynapac vibrating roller over turned after control was lost
6 23-May-92 Dwisiswai GTS Mechanic CONT due to improper speed on a steep road. The equipment was not fitted with a
R.O.P.S.
A spotter was directing to reposition the truck during refuelling activity. In the process
7 10-Aug-92 Wijanto KNE Fuel Truck Helper CONT directing of truck, he caught between fuel truck dan dozer. This incident resulted in
fatal injury.
 FATALITY INCIDENT LIST
1990 YTD 26 Jul 2010

Injured Company /
No Date Position KPC / CONT Remarks
Name Dept

Whilst travelling to Panel 4, a explosive truck uncontrolled and hit safety berm. Use of
Truck
8 05-Apr-95 Suparlan DWL CONT defective equipment was the causes of the incident. This incident resulted the death to
Operator
the explosive truck driver

Whilst travelling to Flamboyan road, a compactor uncontrolled and tipped over. The
Compactor
9 24-Sep-95 Iwan Insani Hana Mas CONT operator caught between compactor and ground. He wasn't wearing a seatbelt.
Operator
This Incident resulted in the death.
Fatality injured and was found buried by the collapsed damp soil inside the shovel
Yulius Shovel
10 18-Dec-96 Surya Dept KPC bucket soon after he put himself between the bench face and shovel bucket for
Sutrisno Operator
some reason.
Whilst travelling from loading to dumping area, a GINAF truck T-803 hit a L/V.
Bintang Act. Supv. Combination excessive speed of L/V and incorrect truck position (in the middle of
11 16-Jun-97 Irianzach KPC
Dept. Civil the road) were the causes of the incident. This incident resulted in death to the L/V
driver.

Whilst spraying roads around Rozano road and Hatari Pit office, a water truck (DJB 300)
Truck accidentally the engine shut down by it self. It made truck reversed, hit safety berm
12 09-Aug-97 Mardjit Hatari Dept. KPC
Operator and tipped over. The operator caught between truck cabin and ground. This incident
resulted in the death.

Whilst travelling from dumping area to Panel 5, a haul truck T-525 (Cat785) run over
Wayan Bintang Truck
13 31-Jan-98 KPC safety berm and fell down from high around 34 metre. Fatigue was the cause of the
Suadnyana Dept. Operator
incident. This incident resulted in the death.

Bintang HE Operator An operator was cleaning font mirror of the haul truck (Cat 785) when he slipped and
14 11-Aug-98 Arifin Bono KPC
Dept. Trainee fell down to the ground. This incident resulted the death.

Hexindo vehicle was hit and ran over by the reversing D11 N CAT B.dozer, caused
15 09-Jul-99 Jumarsono PT Hexindo Welder CONT
fatality
 FATALITY INCIDENT LIST
1990 YTD 26 Jul 2010

Injured Company /
No Date Position KPC / CONT Remarks
Name Dept

A subcontractor employee under PT.TU (PT. Gemini) was stopping a wheelbarrow by

16 30-May-00 Paulus Tira PT Gemini Labor CONT placing the steel leg on the portable light electrical cable when he got electrical
shock. This incident resulted in the death.
Whilst clearing the area of the loading point, a dozer (Cat D11) rolled over along 20
Dozer
17 27-Jan-02 Sion Manik PT KPPS CONT metres. The operator caught between dozer and ground. He wasn't wearing a
Operator
seatbelt. This Incident resulted in the death.
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
Yunus
Bintang Shovel two mechanics heard a thundering noise and felt the shovel shaking due to ground
18 23-May-05 Thomassaw KPC
Dept. Operator movement. One of the mechanics observed the shovel operator attempting to get out
a
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 victims 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
A pump operator for Hatari Pit had attempted to swim out to recover a small rowing boat
19 09-Aug-05 Rustan Hatari Dept. Pump Crew KPC 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

Injured Company /
No Date Position KPC / CONT Remarks
Name Dept

A Pamapersada Nusantara (PAMA) HD785 Dump Truck (DT785), collided into the back
Hendris PT Pama Truck
20 23-Jan-07 CONT of another HD785 Dump Truck (DT3008) which had broken down on OB Haul Road at
Susilawarta Persada Operator
KPC Bendili Pit, due to fatigue of the DT785 operator.

A Geology Assistant in the Geology Department parked his vehicle (LS490) and went
Geology Asst.
21 21-Mar-08 Yusran KPC out of the vehicle to direct a farm tractor. The vehicle (LS490) then moved and he tried
Dept. Geology
to stop it. Unfortunately, he failed and was struck by the vehicle.
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
22 22-Oct-09 Junaedi HT Operator KPC
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)
ROBERTUS
23 22-Jul-10 Z38293 Supervisor CONT who was sitting on the front left passenger seat could not escape and fatally injured
RIA
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