STUDI KASUS GROUP H

PT. Civilindo Engineering (PT CE) mendapatkan pekerjaan Civil dan Mechanical
yaitu:
1. Civil = Pile Driving & Foundation Works for WBL Tank;
2. Civil + Mechanical = Foundation, Roof and Siding works for Converting
Plant.
Klien dari PT CE tersebut merupakan Produsen Pulp & Paper yang sudah
mengimplementasikan ISO 9001:2000, ISO14001:2004, OHSAS18001:1999 dan SMK3.
Semua kontraktor (bisnis partner) yang berada di lingkungan plant tersebut
diharuskan untuk memenuhi dan menerapkan persyaratan ketentuan dari system
tersebut.
Sebelum Proyek tersebut dimulai, maka PT. CE harus membuat dan menyerahkan ke
klien tentang HSE Plan & Program, yang tentunya memenuhi semua ketentuan
peraturan perundangan dan ketentuan yang berlaku.
Ruang lingkup pekerjaan yang akan dikerjakan oleh PT CE dan para subkontraktornya
adalah sebagai berikut:

No Lingkup Pekerjaan PT. C E Klien

1 Heavy Lifting V -
2 Steel structure fabrication
for Converting building V -
including sandblasting,
painting for roofing and
siding work and Tank.
Scope yang akan diberikan kepada Sub Contractor:
1. Pilling dan concrete work
2. Sand Blasting & Painting
Tugas Team:
1. Diskusikan dengan Team Saudara dan buatlah:
 HIRARC,
 HSE Objective, Target dan HSE Program,
 Kebutuhan-kebutuhan peralatan kerja yang berkaitan dengan Aspek HSE unutu
melaksanakan proyek ini.
2. Bagaimana saudara mengelola Sub Contraktor agar S/C tersebut juga menerapkan
HSE Management Sistem seperti yang dilakukan oleh PT. CE.
3. Gunakan Form HIRARC dan PENYIDIKAN INSIDEN yang disediakan.
4. Untuk presentasi, Laptop disediakan panitia.
5. Selamat berdiskusi dan bekerja.

608670349.doc
 ACCIDENT CASE STUDY (GROUP H)

ACCIDENT INVESTIGATION, ROOT CAUSE ANALYSIS, ACCIDENT REVIEW

AND CORRECTIVE IMPROVEMENT ACTION PLAN.

Please read thoroughly and make your accident investigation, your accident report to the
management, establish your line management root cause analysis, then perform your Project
Management review in accordance with this occurrence, and ensure that the CIAP is done as
committed.
Have a nice discussion and prepare your presentation; you are allowed to have 60
minutes time.
LOST WORKDAY CASE (LWC) ACCIDENT:
Occurrence time and place; Saturday, 25 November 2005 Steel Structure erection area
– somewhere in the world.
ACCIDENT OCCURRENCE REPORT.
1. Brief description of the accident occurrence
 According to the report submitted by the direct sub-contractor; PT XX, the
incident occurred on Saturday, 25 November 2005 at approximately 15.45 hours.
 The accident report stated that the victim was erecting a scaffold support, by
means of scaffold frame structure.
 The victim was standing on the third scaffold structure on a working platform
and fixing the third lift frame.
 Upon fixing the frames, he secured his body harness to one of the frame and
proceeded to cross-bracing to the frames.
 Upon putting the cross-bracing to one frame, victim proceeded to install cross-
bracing to the other frame.
 The report added that the victim could not secure the other side of the bracing to
the frame as it was not aligned.
 No life line was placed as reported by the investigator.
 As such, the victim needed to lift-up the one of the frame scaffold.
 While attempting to lift-out (or adjust) the frame scaffold, victim lost his balance
and fell down, together with the frame scaffold that his harness lanyard was
secured to.
 According to the report, the height that the victim fell off was about 13.5 meter.
 The victim was sent to General Hospital right after the accident.
 The victim suffered fractured left leg. He was warded for a day and discharged
on Monday, 27 November 2005.
 The victim was given a hospitalization leave from 26 Nov. 2005 to 15 December
2005.
2. Findings
Preliminary investigation revealed the following:

608670349.doc
i. Interview with site staff / management / sub contractor.
No Site staff was present during the incident.
According to the site engineer, the sub-contractor, PT XX, did not submit application
for permit to work (PTW) to site management.
There was no comprehensive contractual clausal on the Quality, Health, and Safety and
Environment aspects as per regulated regulations requirements so it was not legally
stated in the work agreement.
Thus, no record from PT XX on who was working on that day.
Site staffs and workers work 6 days a week (08:00 – 17:00 hours).
Sunday is an off day.
ii. Checks on documentation
Past PTW’s were checked during the investigation.
The forms were submitted by the Subcontractor to Site Management and approved by
site engineer and HSE engineer.
The findings of the condition that day were as follow:
 There were simultaneous work scopes done at the same time – concluded heavy
lifting, welding, and other small jobs activities.
 It was observed that 350 sub-contractor workers worked that day;
 Most of the PTW descriptions of work stated in the form were very brief with no exact
location or sketch of the area of work mentioned;
 PTW’s safety requirements were not verified in the submission of the present PTW
application e.g. erection work should come with working at height PTW
(statutory requirement).
 Competent person requirement not stated in the PTW form e.g. erection work requires a
safety supervisor to be present at site. Also, occasionally, the application did not include
safety supervisor’s name for safety supervision work.
 Other contractors and other scope of work sections were not informed.
iii. Physical inspection at site
Physical inspection at the scene area (proposed Treatment Plant Building)
conducted at site by Site Manager, HSE co-coordinator, Safety Officer and Site
Engineer, on Thursday, 23 November 2006 showed the following:
 Structure already completed;
 Scaffold still intact, with no access ladders on every lift;
 Working platform not secured on scaffold frame;
 Base plates (timber plates) where the formwork footings rested were at edge of
slope and suspected to be unstable.
 Proper erection of the base plates and footings of the scaffold cannot be verified as
the scaffold erection and design of the scaffold structure plan was not available.
 A metal working platform (next to the structure) vertically into the ground.
 This might be a sign of worker throwing material from above, which is not an
acceptable safety practices.
3. Analysis of gathered information
From the information gathered, the following can be deduced:

608670349.doc
i.) The evidence sub-contractor had disregard safety rules was eminent, e.g. no
access ladder for each lift of the scaffold, working platform not secured, evident
of throwing material from height to the ground.
ii.) The violations of safety rules was eminent, again, upon observations made
during site QOHSE audit at the site, conducted on May 2006 i.e. workers not
wearing body harness when working at edge of structural beams (> 5 mtr) and
some of them removed their harness and put it on the floor, no barricade at open
edge of structure, scaffold for work access not certified by scaffold supervisor,
under height ladder placing against the vertical wall structure.
iii.) No direct supervision work on erection work, although it is a statutory
requirement to appoint and conduct direct supervision to related to erection
activities.
iv.) The statutory requirement as stated (Safety Training Courses), where it requires
that the site management is to ensure that supervisor who must undergo the
approved course, be appointed. In this case, no evident of qualified Supervisor
supervising the work during the time of the accident.
v.) PT XX also violates in-house requirement by not submitting PTW to Company
Site Management during the time of overtime work when accident occurred.
vi.) From documentation assessment, the application form for sub-contractor to Site
management was not comprehensive and approving of the PTW application
requested by sub-contractor not verified properly, e.g. relevant PTW not
included a specific competent person requirement such as Lifting Supervisor,
Safety Supervisor, etc.
vii.) Company Site Management did not set criteria as to when to assign a
supervisory and/or safety staff(s) to be around and monitors sub-contractor’s
work during overtime work.
4. Cause(s) of accident
i.) From the accident notification report and interview/discussion with Company
Site staffs, the main cause of the accident was that the victim was not careful, i.e.
by securing his harness to the frame scaffold that he was adjusting. He should
secure his harness lanyard to another rigid structure (although the victim is
trained in rigging handling – he was a certified rigger).
ii.) The supervision of the erection work was not present at site.

End results required:

You must perform a complete Accident Investigation, Root Cause Analysis and
develop your Accident Review to make the Corrective Improvement Action Plan and
recommends your penalties.

608670349.doc
 STUDI KASUS GROUP S

PT. Citraindo Engineering (PT CE) mendapatkan pekerjaan Mechanical dan Electrical
yaitu:
1. Steel Structure Erection untuk Power Plant 2x300mw
2. Electrical and Instrumentation Instalation and Calibration.
Klien dari PT CE tersebut merupakan Perusahaan Pembangkit Tenaga Listrik Swasta
yang sudah mengimplementasikan ISO 9001:2000, ISO14001:2004, OHSAS18001:1999
dan SMK3. Semua kontraktor/bisnis partner yang berada di lingkungan plant tersebut
diharuskan untuk memenuhi dan menerapkan persyaratan ketentuan dari system
tersebut. Sebelum Proyek tersebut dimulai, maka PT. CE harus membuat dan
menyerahkan ke klien tentang HSE Plan & Program, yang tentunya memenuhi semua
ketentuan peraturan perundangan dan ketentuan yang berlaku.
Ruang lingkup pekerjaan yang akan dikerjakan oleh PT CE dan para subkontraktornya adalah
sebagai berikut:
No Lingkup Pekerjaan PT. C E Klien
1 Erection Steel Structure, Boiler -
Pressure and Non Pressure Part, V
including Insulation Work.
2 Sand Blasting and painting V
works
3 Hydro Test, Oil Flushing and V -
Chemical Cleaning (this scopes
includes material procuring,
handling, storaging, and waste
handlings.
Scope yang akan diberikan kepada Sub Contractor:
1. Roofing & Siding – sandblasting & painting works.
2. Insulation.
3. NDT and PWHT.
4. Chemical Cleaning including handling of chemical material procuring and
waste management (ISO 14001).
Tugas Team:
1. Diskusikan dengan Team Saudara dan buatlah:
 HIRARC, HSE Objective, Target dan HSE Program,
 Kebutuhan-kebutuhan peralatan kerja yang berkaitan dengan Aspek HSE unutu
melaksanakan proyek ini.
2. Bagaimana saudara mengelola Sub Contraktor agar S/C tersebut juga menerapkan
HSE Management Sistem seperti yang dilakukan oleh PT. CE.
6. Gunakan Form HIRARC dan PENYIDIKAN INSIDEN yang disediakan.
7. Untuk presentasi, Laptop disediakan panitia.
8. Selamat berdiskusi dan bekerja.

608670349.doc
 ACCIDENT CASE STUDY (GROUP S)

ACCIDENT INVESTIGATION, ROOT CAUSE ANALYSIS, ACCIDENT REVIEW

AND CORRECTIVE IMPROVEMENT ACTION PLAN.

Please read thoroughly and make your accident investigation, your accident report to the
management, establish your line management root cause analysis, then perform your Project
Management review in accordance with this occurrence, and ensure that the CIAP is done as
committed.
Have a nice discussion and prepare your presentation; you are allowed to have 60
minutes time.
LOST WORKDAY CASE (LWC) ACCIDENT:
Occurrence time and place; Saturday, 25 November 2005 Steel Structure erection area
– somewhere in the world.
ACCIDENT OCCURRENCE REPORT.
5. Brief description of the accident occurrence
 According to the report submitted by the direct sub-contractor; PT XX, the
incident occurred on Saturday, 25 November 2005 at approximately 15.45 hours.
 The accident report stated that the victim was erecting a scaffold support, by
means of scaffold frame structure.
 The victim was standing on the third scaffold structure on a working platform
and fixing the third lift frame.
 Upon fixing the frames, he secured his body harness to one of the frame and
proceeded to cross-bracing to the frames.
 Upon putting the cross-bracing to one frame, victim proceeded to install cross-
bracing to the other frame.
 The report added that the victim could not secure the other side of the bracing to
the frame as it was not aligned.
 No life line was placed as reported by the investigator.
 As such, the victim needed to lift-up the one of the frame scaffold.
 While attempting to lift-out (or adjust) the frame scaffold, victim lost his balance
and fell down, together with the frame scaffold that his harness lanyard was
secured to.
 According to the report, the height that the victim fell off was about 13.5 meter.
 The victim was sent to General Hospital right after the accident.
 The victim suffered fractured left leg. He was warded for a day and discharged
on Monday, 27 November 2005.
 The victim was given a hospitalization leave from 26 Nov. 2005 to 15 December
2005.
6. Findings
Preliminary investigation revealed the following:
iv. Interview with site staff / management / sub contractor.

608670349.doc
No Site staff was present during the incident.
According to the site engineer, the sub-contractor, PT XX, did not submit application
for permit to work (PTW) to site management.
There was no comprehensive contractual clausal on the Quality, Health, and Safety and
Environment aspects as per regulated regulations requirements so it was not legally
stated in the work agreement.
Thus, no record from PT XX on who was working on that day.
Site staffs and workers work 6 days a week (08:00 – 17:00 hours).
Sunday is an off day.
v. Checks on documentation
Past PTW’s were checked during the investigation.
The forms were submitted by the Subcontractor to Site Management and approved by
site engineer and HSE engineer.
The findings of the condition that day were as follow:
 There were simultaneous work scopes done at the same time – concluded heavy
lifting, welding, and other small jobs activities.
 It was observed that 350 sub-contractor workers worked that day;
 Most of the PTW descriptions of work stated in the form were very brief with no exact
location or sketch of the area of work mentioned;
 PTW’s safety requirements were not verified in the submission of the present PTW
application e.g. erection work should come with working at height PTW
(statutory requirement).
 Competent person requirement not stated in the PTW form e.g. erection work requires a
safety supervisor to be present at site. Also, occasionally, the application did not include
safety supervisor’s name for safety supervision work.
 Other contractors and other scope of work sections were not informed.
vi. Physical inspection at site
Physical inspection at the scene area (proposed Treatment Plant Building)
conducted at site by Site Manager, HSE co-coordinator, Safety Officer and Site
Engineer, on Thursday, 23 November 2006 showed the following:
 Structure already completed;
 Scaffold still intact, with no access ladders on every lift;
 Working platform not secured on scaffold frame;
 Base plates (timber plates) where the formwork footings rested were at edge of
slope and suspected to be unstable.
 Proper erection of the base plates and footings of the scaffold cannot be verified as
the scaffold erection and design of the scaffold structure plan was not available.
 A metal working platform (next to the structure) vertically into the ground.
 This might be a sign of worker throwing material from above, which is not an
acceptable safety practices.
7. Analysis of gathered information
From the information gathered, the following can be deduced:

608670349.doc
viii.) The evidence sub-contractor had disregard safety rules was eminent, e.g. no
access ladder for each lift of the scaffold, working platform not secured, evident
of throwing material from height to the ground.
ix.) The violations of safety rules was eminent, again, upon observations made
during site QOHSE audit at the site, conducted on May 2006 i.e. workers not
wearing body harness when working at edge of structural beams (> 5 mtr) and
some of them removed their harness and put it on the floor, no barricade at open
edge of structure, scaffold for work access not certified by scaffold supervisor,
under height ladder placing against the vertical wall structure.
x.) No direct supervision work on erection work, although it is a statutory
requirement to appoint and conduct direct supervision to related to erection
activities.
xi.) The statutory requirement as stated (Safety Training Courses), where it requires
that the site management is to ensure that supervisor who must undergo the
approved course, be appointed. In this case, no evident of qualified Supervisor
supervising the work during the time of the accident.
xii.) PT XX also violates in-house requirement by not submitting PTW to Company
Site Management during the time of overtime work when accident occurred.
xiii.) From documentation assessment, the application form for sub-contractor to Site
management was not comprehensive and approving of the PTW application
requested by sub-contractor not verified properly, e.g. relevant PTW not
included a specific competent person requirement such as Lifting Supervisor,
Safety Supervisor, etc.
xiv.) Company Site Management did not set criteria as to when to assign a
supervisory and/or safety staff(s) to be around and monitors sub-contractor’s
work during overtime work.
8. Cause(s) of accident
iii.) From the accident notification report and interview/discussion with Company
Site staffs, the main cause of the accident was that the victim was not careful, i.e.
by securing his harness to the frame scaffold that he was adjusting. He should
secure his harness lanyard to another rigid structure (although the victim is
trained in rigging handling – he was a certified rigger).
iv.) The supervision of the erection work was not present at site.

End results required:

You must perform a complete Accident Investigation, Root Cause Analysis and
develop your Accident Review to make the Corrective Improvement Action Plan and
recommends your penalties.

608670349.doc
 STUDI KASUS GROUP E

PT. Cemerlang Engineering (PT CE) mendapatkan pekerjaan Tank Erection Works
yaitu:
1. Civil = Foundation Works for WBL Tank;
2. Mechanical = 35000 KL Fuel Oil Tank Erection;
3. Civil + Mechanical = Foundation and roofing works
Klien dari PT CE tersebut merupakan Produsen Pulp & Paper yang sudah
mengimplementasikan ISO 9001:2000, ISO14001:2004, OHSAS18001:1999 dan SMK3.
Semua kontraktor (bisnis partner) yang berada di lingkungan plant tersebut
diharuskan untuk memenuhi dan menerapkan persyaratan ketentuan dari system
tersebut.
Sebelum Proyek tersebut dimulai, maka PT. CE harus membuat dan menyerahkan ke
klien tentang HSE Plan & Program, yang tentunya memenuhi semua ketentuan
peraturan perundangan dan ketentuan yang berlaku.
Ruang lingkup pekerjaan yang akan dikerjakan oleh PT CE dan para subkontraktornya
adalah sebagai berikut:

No Lingkup Pekerjaan PT. C E Klien

1 Fabrication works V -
2 Tank erection, include
roofing and fire prevention V -
installation.
Scope yang akan diberikan kepada Sub Contractor:
1. Foundation concrete work
2. NDT
3. Sand Blasting & Painting
4. Water Test
Tugas Team:
1. Diskusikan dengan Team Saudara dan buatlah:
 HIRARC, HSE Objective, Target dan HSE Program,
 Kebutuhan-kebutuhan peralatan kerja yang berkaitan dengan Aspek HSE unutu
melaksanakan proyek ini.
3. Bagaimana saudara mengelola Sub Contraktor agar S/C tersebut juga
menerapkan HSE Management Sistem seperti yang dilakukan oleh PT. CE.
4. Gunakan Form HIRARC dan PENYIDIKAN INSIDEN yang disediakan.
5. Untuk presentasi, Laptop disediakan panitia.
6. Selamat berdiskusi dan bekerja.

608670349.doc
 ACCIDENT CASE STUDY (GROUP E)

ACCIDENT INVESTIGATION, ROOT CAUSE ANALYSIS, ACCIDENT REVIEW

AND CORRECTIVE IMPROVEMENT ACTION PLAN.

Please read thoroughly and make your accident investigation, your accident report to the
management, establish your line management root cause analysis, then perform your Project
Management review in accordance with this occurrence, and ensure that the CIAP is done as
committed.
Have a nice discussion and prepare your presentation; you are allowed to have 60
minutes time.
LOST WORKDAY CASE (LWC) ACCIDENT:
Occurrence time and place; Saturday, 25 November 2005 Steel Structure erection area
– somewhere in the world.
ACCIDENT OCCURRENCE REPORT.
9. Brief description of the accident occurrence
 According to the report submitted by the direct sub-contractor; PT XX, the
incident occurred on Saturday, 25 November 2005 at approximately 15.45 hours.
 The accident report stated that the victim was erecting a scaffold support, by
means of scaffold frame structure.
 The victim was standing on the third scaffold structure on a working platform
and fixing the third lift frame.
 Upon fixing the frames, he secured his body harness to one of the frame and
proceeded to cross-bracing to the frames.
 Upon putting the cross-bracing to one frame, victim proceeded to install cross-
bracing to the other frame.
 The report added that the victim could not secure the other side of the bracing to
the frame as it was not aligned.
 No life line was placed as reported by the investigator.
 As such, the victim needed to lift-up the one of the frame scaffold.
 While attempting to lift-out (or adjust) the frame scaffold, victim lost his balance
and fell down, together with the frame scaffold that his harness lanyard was
secured to.
 According to the report, the height that the victim fell off was about 13.5 meter.
 The victim was sent to General Hospital right after the accident.
 The victim suffered fractured left leg. He was warded for a day and discharged
on Monday, 27 November 2005.
 The victim was given a hospitalization leave from 26 Nov. 2005 to 15 December
2005.
10. Findings
Preliminary investigation revealed the following:
vii. Interview with site staff / management / sub contractor.

608670349.doc
No Site staff was present during the incident.
According to the site engineer, the sub-contractor, PT XX, did not submit application
for permit to work (PTW) to site management.
There was no comprehensive contractual clausal on the Quality, Health, and Safety and
Environment aspects as per regulated regulations requirements so it was not legally
stated in the work agreement.
Thus, no record from PT XX on who was working on that day.
Site staffs and workers work 6 days a week (08:00 – 17:00 hours).
Sunday is an off day.
viii. Checks on documentation
Past PTW’s were checked during the investigation.
The forms were submitted by the Subcontractor to Site Management and approved by
site engineer and HSE engineer.
The findings of the condition that day were as follow:
 There were simultaneous work scopes done at the same time – concluded heavy
lifting, welding, and other small jobs activities.
 It was observed that 350 sub-contractor workers worked that day;
 Most of the PTW descriptions of work stated in the form were very brief with no exact
location or sketch of the area of work mentioned;
 PTW’s safety requirements were not verified in the submission of the present PTW
application e.g. erection work should come with working at height PTW
(statutory requirement).
 Competent person requirement not stated in the PTW form e.g. erection work requires a
safety supervisor to be present at site. Also, occasionally, the application did not include
safety supervisor’s name for safety supervision work.
 Other contractors and other scope of work sections were not informed.
ix. Physical inspection at site
Physical inspection at the scene area (proposed Treatment Plant Building)
conducted at site by Site Manager, HSE co-coordinator, Safety Officer and Site
Engineer, on Thursday, 23 November 2006 showed the following:
 Structure already completed;
 Scaffold still intact, with no access ladders on every lift;
 Working platform not secured on scaffold frame;
 Base plates (timber plates) where the formwork footings rested were at edge of
slope and suspected to be unstable.
 Proper erection of the base plates and footings of the scaffold cannot be verified as
the scaffold erection and design of the scaffold structure plan was not available.
 A metal working platform (next to the structure) vertically into the ground.
 This might be a sign of worker throwing material from above, which is not an
acceptable safety practices.
11. Analysis of gathered information
From the information gathered, the following can be deduced:

608670349.doc
xv.) The evidence sub-contractor had disregard safety rules was eminent, e.g. no
access ladder for each lift of the scaffold, working platform not secured, evident
of throwing material from height to the ground.
xvi.) The violations of safety rules was eminent, again, upon observations made
during site QOHSE audit at the site, conducted on May 2006 i.e. workers not
wearing body harness when working at edge of structural beams (> 5 mtr) and
some of them removed their harness and put it on the floor, no barricade at open
edge of structure, scaffold for work access not certified by scaffold supervisor,
under height ladder placing against the vertical wall structure.
xvii.) No direct supervision work on erection work, although it is a statutory
requirement to appoint and conduct direct supervision to related to erection
activities.
xviii.) The statutory requirement as stated (Safety Training Courses), where it requires
that the site management is to ensure that supervisor who must undergo the
approved course, be appointed. In this case, no evident of qualified Supervisor
supervising the work during the time of the accident.
xix.) PT XX also violates in-house requirement by not submitting PTW to Company
Site Management during the time of overtime work when accident occurred.
xx.) From documentation assessment, the application form for sub-contractor to Site
management was not comprehensive and approving of the PTW application
requested by sub-contractor not verified properly, e.g. relevant PTW not
included a specific competent person requirement such as Lifting Supervisor,
Safety Supervisor, etc.
xxi.) Company Site Management did not set criteria as to when to assign a
supervisory and/or safety staff(s) to be around and monitors sub-contractor’s
work during overtime work.
12. Cause(s) of accident
v.) From the accident notification report and interview/discussion with Company
Site staffs, the main cause of the accident was that the victim was not careful, i.e.
by securing his harness to the frame scaffold that he was adjusting. He should
secure his harness lanyard to another rigid structure (although the victim is
trained in rigging handling – he was a certified rigger).
vi.) The supervision of the erection work was not present at site.

End results required:

You must perform a complete Accident Investigation, Root Cause Analysis and
develop your Accident Review to make the Corrective Improvement Action Plan and
recommends your penalties.

608670349.doc