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INVESTIGATION REPORT
GENERAL INFORMATION
Incident Date
Time
Location
UNIT
Air-Marine/Contractor
Name of Contractor (if
applicable)
On/Off the job
Project

:
:
:
:
:
:

6th Of February 2014

1600 hrs
Air Marine (Lumut Yard)
12 Axles c/w 1 PPU
Air-Marine
NIL

:
:

Off the Job

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 operators 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
(1st 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.
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RESULTS OF INVESTIGATION AND REMEDIAL ACTIONS:

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 1 st trip re-schedule on
10th Feb (Mon) and following by 12 th 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

To brief all operation personnel on the

importance of safety and should listen opinion
from others during critical situation.

Ensure proper communication between the

operator and signal man such as the usage of
walkie talkie.

ACTION
PARTY
Air-Marine
Staff/Crew

TARGET
DATE
IMMEDIATE
EFFECT

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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