Scene 4 / 5 · FINAL 11:00 WITA — 15/5/2026 · 3 hari setelah near-miss DT-007, Ir. Bambang lead investigation meeting. 5-Why analysis identifikasi root cause. 4 CAPA assigned: 2 permanent (mirror + JSA update), 2 procedural (speed limit + radio comm). Tracked di Foxel sampai verified effectiveness. 11:00 WITA — 15/5/2026 · 3 days after DT-007 near-miss, Mr. Bambang leads the investigation meeting. 5-Why analysis identifies root cause. 4 CAPAs assigned: 2 permanent (mirror + JSA update), 2 procedural (speed limit + radio comm). Tracked in Foxel until effectiveness verified.
Investigation Report · INC-2026-0512-NM-007
DT-007 Near-miss Blind Spot · 5-Why Analysis · 4 CAPA

5-Why Root Cause Analysis

Metode ISO 45001ISO 45001 method
1
Apa yang terjadi?What happened?
DT-007 hampir tabrak LV di haul road KM 2 curve 14:23 WITA 12/5/2026
2
Kenapa bisa terjadi?Why did it happen?
DT-007 tidak melihat LV di tikungan curve sampai 8m sebelumDT-007 didn't see LV in the curve until 8m away
3
Kenapa tidak terlihat?Why wasn't it visible?
Blind spot karena tikungan tajam + tumpukan OB 3m tinggi di sisi dalam curveBlind spot from sharp curve + 3m OB pile on inner side
4
Kenapa tidak ada mitigasi untuk blind spot?Why no mitigation for the blind spot?
JSA haul road tidak mencantumkan blind spot sebagai hazard — assumed clear line-of-sightHaul road JSA didn't list blind spot as a hazard — assumed clear line-of-sight
5
Kenapa JSA tidak catat ini? (ROOT CAUSE)Why didn't JSA capture this? (ROOT CAUSE)
JSA dibuat 2024 saat haul road linear. Setelah extend Bench 3 (Jan 2026), tikungan baru terbentuk TAPI JSA tidak di-re-review. Gap di change management JSA.JSA drafted 2024 when haul road was linear. After extending Bench 3 (Jan 2026), the new curve appeared BUT the JSA wasn't re-reviewed. A change-management gap in JSA.
✓ Systemic finding:Systemic finding: Bukan salah operator Pak Imam atau LV driver Pak Dedi. Isu ada di JSA change management. Fix ini permanen (mirror + JSA update) akan prevent similar di semua curves lain yang akan terbentuk di masa depan. Neither Mr. Imam (DT-007) nor Mr. Dedi (LV) was at fault. The issue is in JSA change management. This permanent fix (mirror + JSA update) will prevent similar events for all future curves.

4 CAPA · Corrective + Preventive4 CAPA · Corrective + Preventive

1
Corrective · Convex mirror install KM 2Corrective · Convex mirror install KM 2
Pak Suparjo · Pak Kusno · IDR 4 jt
Done 18/5
✓ DONE
2
Preventive · Convex mirror KM 4 junctionPreventive · Convex mirror KM 4 junction
Identifikasi blind spot serupa · IDR 4 jtSimilar blind spot identified · IDR 4M
Due 30/5
IN PROGRESS
3
Corrective · Update JSA-HAUL-03 v2.1Corrective · Update JSA-HAUL-03 v2.1
Blind spot hazard added · speed limit 30km/h · radio comm mandatoryBlind spot hazard added · 30 km/h speed · radio comm mandatory
Done 14/5
✓ DONE
4
Preventive · Sistemik JSA Change ManagementPreventive · Systemic JSA Change Management
Quarterly JSA re-review · any layout change trigger JSA update. Owner: Ir. BambangQuarterly JSA re-review · any layout change triggers update. Owner: Mr. Bambang
Policy 30/6
IN PROGRESS
Effectiveness verification:Effectiveness verification: Schedule 30-day (30/6/2026). Ir. Bambang akan audit haul road, survey operator, verify zero similar incident. Jika OK, CAPA closed. Scheduled 30-day (30/6/2026). Mr. Bambang will audit haul road, survey operators, verify zero similar incidents. If OK, CAPA closed.

Investigation ReportInvestigation Report

BSrE signed
K
PT KTS HSE Division
Incident Investigation Report
INC-2026-0512-NM-007
ClassificationNear-Miss (Type 1 · No harm)
Date & Time12/5/2026 14:23 WITA
LocationHaul road KM 2 curve
PersonnelPak Imam (DT-007), Pak Dedi (LV)
WitnessesPak Suparjo (reporter)
Root causeJSA change mgmt gap
CAPA issued4 (2 done, 2 in-progress)
Classification ESDMTier 1 – no mandatory reporting
Investigation leadIr. Bambang Setyo
Approved by KTTIr. Budi Santoso ✓
SHA-256: 7f3a1e9c2b8d5f64a890c5e2f7d4... · BSrE 15/5 11:42 · Immutable
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