Accident Investigation Report

Has occur an accident on the date of 8 October 2014 on an employee of the department facilities , where the eyes of the employees exposed to chemical splash COIL-100 at the time cleaning/wash the air conditioner at outsides washing room near store area; 8 October 2014 – at 10.50am.

- What happening…?- Why Can Occur…?- How to prevent…?

1

Name : Hariyono.Badge No : SPM-001400Position : Facility Technician.Sex : Male.

Superiors : Hasan (Ayong).

Data of victims

2

Investigation Team

No. NAME OCCUPATION

1 Fahrizal N Safety Officer

2 Burhan Manager

3 Sui Yin Admin Manager

4 Isman C OHS Committee

5 Verini HR

3

4

� Version of Victims (Haryono) :

� 10.40am – Haryanto start to do his job to cleaning/wash air conditioning FCU 9c use chemical COIL-100 together with his partner, Yulizar.

� 10.40am~11.00am : 1.Haryono up the stairs to the location of the air conditioner FCU 9c to

be cleaned while carrying a spray bottle containing cleaning chemicals COIL-100 with spray bottle ready to use.

2. Haryono finished cleaning the rear of compressor FCU 9c with stand at holder of compressor.

3. After the rear finished, then he continue to clean up the left side of the compressor. He can not do it from the same position because unreachable.

4. He told, to clean/wash that sides is not easy due to hindered and very narrow.

5. Therefore, He tried to climb onto the ducting by carrying spray bottle ready to use (chemicals Coil-100).

Chronology of Accident

5

6. Cause it’s difficult, Haryono tried to drop back with still holds the bottle7. At that time the eyes Haryono sprayed by chemicals Coil-100, by

inadvertently.8. After being exposed to chemicals, Haryono wash his eyes with water, using

water from a hose connected to tap water.9. After feeling better, Haryono down the stairs and toward the water tap

near the canteen to wash the eyes and face. 10. Haryono admitted that the incident was caused by his negligence11. According to Haryono, he is not allowed to do the job by Ayong because

still under recovers from illness. Who is told to wash is Yulizar, but since Yulizar declined because he objected to clean the AIR CONDITIONING in the living conditions, then Haryono still to do that job.

Note : Interviews with victims after his recovery and work as usual.

� 11.00am~11.15am – Due to Haryono still feel the pain, Afriandi (his partner)

immediately report to Burhan (Manager-Facility in charge), then Burhan told Afriandi report to Verini (HR) immediately.– After report to Verini (HR), then Verini (HR) initiative to immediately bring Haryono to the hospital (CaSa Hospital) to get help from a doctor.

� 11.35am –Verini contacted me while he was in hospital, inform that there was a work accident in our factory. Hearing that I was very surprised because no one is inform of the accident at that time.

� 11.35am ~11.55am – Hearing information, I immediately headed to the scene to take

pictures and interviews to his work partner.

6

Photo Location of accident

Ducting

AC-FCU 9c

7

The accident occur when cleaning up/washing the left side (Air filter

grilles) of the AC Compressor

Chemical Use & Spray Bottle

COIL – 100 CHEMICAL SPRAY

Spray Button

Spray valve, not locked.

8

�Direct Cause.1. Unsafe Act.- Work using chemical without PPE (e.g : safety googles). Safety googles

is provided, this is discipline issue.- Climbed with carrying chemical spray bottle ready to use without

locked.

�System Cause.1. Rush’s own employees impact from a tight of schedule.2. Lack of Control from superior, especially for the locations that are

difficult to reach and work at height.

Cause of the Accident

9

Another potential Hazard is discovered

� Chemical containers without a clear identification.

� Missing Chemical MSDS from Supplier (COIL-100).

10

Conclution

�Conclution :� The accident occur caused by negligence own employees and the lack of

control of his superiors and has meet 2 criteria causes of accidents; unsafe act; and system lack of control.

That’s not impact to the LDC in terms of the severity of the injuries inflicted were still in low category. In accordance to the rules, LDC will be impact if the accident caused one worker can't do his job following an accident during 2 X 24 hours.

Calculation :

2X24hrs means, start from the accident occur.Accident occur on 8 october’14 at 10.50am, 2 X 24hrs is until 10 october’14 at 10.50am

11

Recommendation

�Immediately recommendation :1. Use PPE when doing work.2. Ensure when bring a bottle of chemicals in a locked state, before they use.3. Aware and obedient to the safety warning include work partner.4. Switch off the power when clean/wash air conditioning.5. Review the use of chemicals to clean the AIR CONDITIONING compressor.

As an Safety officer; recommend to use chemicals once a year.6. Review schedule cleaning from 3 months to 6 months.

�Long-term recommendation:1. For all work that is at high risk should be made a work permit, the purpose is

to make superiors aware of and responsible for what is done by his subordinates. In case of an accident, the head of the department should be fully responsible.

2. Work permit must be check by a Safety Officer for eligibility.

12

13

Done by : Employee. Contractor. Supplier.

Company Name : Company Name :

PERMIT NUMBER (Nomor permit)

ORIGINATOR / DEPARTMENT(Asal / Departemen)

EMPLOYEE NAME(Nama pekerja)

LOCATION OF WORK(Lokasi pekerjaan)

DESCRIPTION OF WORK

(Deskripsi pekerjaan)

Helmet Barriers and Sign

Safety Shoes Respiratory Protection

Gloves and other hand protection Full Body Harness

Earplugs

Eye/Face Protection

I declare that I'm competent person to do the job as above and I agree to use safety equipment to maintain safety during the job done

(Saya menyatakan bahwa saya orang yang kompeten untuk melakukan pekerjaan seperti di atas dan saya setuju

untuk menggunakan peralatan keselamatan untuk mempertahankan keselamatan selama pekerjaan)

Submitted by,

Competent person names : Sign : Date : Time :

I declare that I have to know that the job will be done and safety equipment used by (subordinates/contractors/suppliers), I am fully responsible

for the consequences of non-compliance caused.

(Saya menyatakan bahwa saya telah mengetahui pekerjaan yang akan dilakukan dan alat keselamatan yang digunakan oleh

(bawahan/kontraktor/pemasok), saya bertanggung jawab sepenuhnya atas akibat dari ketidakpatuhan yang ditimbulkan).

Approved by,

Superiors (Spv, Managers): Sign : Date : Time :

I declare that I have verified the type of job, location and safety devices (PPE) are used and recommend some of the following points :

(Saya menyatakan bahwa saya telah memverifikasi jenis pekerjaan, lokasi dan alat keselamatan yang digunakan dan merekomendasikan

beberapa poin berikut) :

Hazards :

Risk/assesment :

Control Risk :

Verified by,

Safety Officer (OHS Expert) : Sign : Date : Time :

Ahli K3 PT. SP Manufacturing.

Note :

Permit To Work (PTW)- Request Form -

Others Equipment

not listed above

Issuing Permits - The issue of permits is strictly controlled, permits can only be issued by authorised personnel.

(Mengeluarkan ijin - masalah izin dikontrol ketat, izin hanya bisa dikeluarkan oleh personil yang berwenang)

PPE (Personal Protective Equipment) is required to complete the work safely :

(Number of permit control by Safety officer)

PT. SP Manufacturing

PTW Flow & Form

Prepared by : Fahrizal N

Permit To Work Flow

Work Activity/ Task Request(Own operation/Contractor/Supplier)

PTW (Permit To Work) submitted

Carry out Work Activity

Yes

No

All the required Fulfilled

All the required not Fulfilled

Competent Worker May Highlight potetial hazards

Evaluation of work activity and competentworker

Application of permit

Verified and approval of permit

Execution of work according to the permit

Verified/Asses

ment by safetyofficer (Hazards, Risk, Control Risk)

Work activity Evaluation (Superv isor/Managers); Competent worker, type of work, location, equipment, PPE, etc.

Mo

nito

ring

of W

ork

What should be done…?

� EVERYONE MUST ABIDE BY THE RULESAND PROCEDURE AS WELL AS K3 AT ANY TIME

� REMIND EACH OTHER TO PREVENT VIOLATIONS CAN RESULT IN THE OCCURANCE OF ACCIDENT.

� ALWAYS KEEP THE SAFETY; STOP IF YOU FEELDROWSINESS, NO PPE, etc.

� AVOID SHORTCUTSREMEMBER THERE IS NO WAY SHORTCUT FOR SAFETY!!!

� DISCIPLINE.

� SAFETY CAMPAIGN

14

Prepared By : Fahrizal NInvestigator

15