loading operation incedent report (1)

INVESTIGATION REPORT (MOBILIZATION)

Tracing No: AMPE-FEB-01

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Rev. 00 07-02-2014

INVESTIGATION REPORT

GENERAL INFORMATION

Incident Date : 6th Of February 2014Time : 1600 hrsLocation : Air Marine (Lumut Yard)UNIT : 12 Axles c/w 1 PPU Air-Marine/Contractor : Air-MarineName of Contractor (if applicable) : NILOn/Off the job : Off the JobProject : Mobilization for Train 9 Project

EVENTS LEADING UP TO THE INCIDENT:

During loading operation of one unit 12axle liners loaded with miscellaneous items on deck to the trailer of Prime Mover, the beams that were being used as a ramp moved away due to the operator’s lack of concentration and over speeding the trailer without a good vision. This caused multiple damage to the trailer such as tires burst, rims damage, axle brake chamber damaged and etc. A figure is attached to this document for more clarity.

DESCRIPTION OF THE INCIDENT (CHRONOLOGY OF EVENTS):

On the 6th of February, Air-Marine crews received an order to carry out the mobilization for Train 9 Project. One unit 12 axle lines Goldhofer SPT c/w PPU carrying miscellaneous items (1 st Trip) to be loaded on top of the trailers of Prime Mover and delivered to Klang for shipment. The chronology of events is as below:

Air-Marine Crews was instructed to carry out loading operation by using 12 Axles c/w 1 PPU at Lumut Yard.

Setting up the SPT, beam, wedges and jacking timber for loading operation upon all miscellaneous items loaded on top of 12 axles.

Henry Bala is the operator during the operation. The operation was going on smoothly until the front 6 axle lines crossed the loading ramp.

The operator was looking for clearances and alignment on loading only on one side of the trailer. During the first 6axle lines moving up the ramp, the beams were slowly slipping to one side but the

operator failed to notice it. Once the bystander (Sobrie) notified the operator, he tried moving the trailer in reverse but the beams

slipped more and few axles started hanging. The bystander asked to stop the operation but the operator refused and continued to make the trailer

alignment correct by moving up and down, making the situation even worse. More personnel were called to the yard to assist and finally operator (Rizal) managed to bring the trailer

down to ground.

RESULTS OF INVESTIGATION AND REMEDIAL ACTIONS:

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Once the trailers brought down to ground level and PPU switched off, Operation Manager (Leong) instructed to offload all miscellaneous items and request the maintenance dept. carried out a thorough inspection.

After investigating & troubleshooting, the damages have been rectified such as: 1) 3 nos of tires burst and 3 rims damaged (PST/SL 60178)2) The 3rd Right Axle Break Chamber Damaged And Safety Bar Leaking (THP/SL 26388)3) The 2nd Left Axle Break Chamber Damaged And Safety Bar Leaking (THP/SL 26388)4) 2 of the drive axle are leaking (PST/SL 60178)5) 3rd cylinder leaking (THP/SL 26388)

For contingency plan of mobilization, trailer THP 26388 to be replaced with THP 26420. Maintenance department will carried out the repair on PST/SL 60178 within 2 days and loading to be commenced again on 9 th Feb (Sun). The mobilization of 1st trip re-schedule on 10th Feb (Mon) and following by 12th feb (2nd trip) to catch up the shipment advised by Shipping Agent.

CONCLUSION AND RECOMMENDATIONS: As conclusion, the incident happened due to misjudgment of the operator and lack of coordination with the signal man. More findings are required in order to avoid the same circumstance.

RECOMMENDATIONS TO PREVENT RECURRENCE:

No ACTION ACTION PARTY TARGET DATE1. To brief all operation personnel on the importance of safety

and should listen opinion from others during critical situation.

Air-Marine Staff/Crew

IMMEDIATE EFFECT

2. Ensure proper communication between the operator and signal man such as the usage of walkie talkie.

Air-Marine Staff/Crew

IMMEDIATE EFFECT

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ATTACHED PHOTO

Operator carry out the loading operation

First 6 axle lines moved up the ramp

Beams were slowly slipping to one side

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ATTACHED PHOTO

Safety Bar Leaking

Tires burst and rims damaged

Drive axle leaking

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ATTACHED PHOTO

Brake chamber damaged

Hydraulic jack leaking

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loading operation incedent report (1)

Documents

loading operation

trailer thp

trailer alignment

axle liners

drive axle

loading ramp

axle brake chamber damaged

miscellaneous items