At around 22.00 WITA on 13 June 2024, two workers were injured near a ferronickel furnace at a nickel smelter in Morowali, Central Sulawesi. According to information received by the Ministry of Industry, an employee accidentally sprayed water onto freshly cut slag, causing a burst of hot steam. The Minister of Industry said the ministry had asked for comprehensive repairs since late 2023 (Bisnis.com, 2024b), after a furnace explosion at the same smelter in December 2023 (Bisnis.com, 2024a).
Accounts still differ. The industrial park operator said the event was not a furnace explosion but a burst of hot steam while employees were cleaning steel slag from the plant floor (CNBC Indonesia, 2024), while the workers' union called it a repeat explosion and said no meaningful repairs had been made since December 2023 (Bisnis.com, 2024a). No official investigation report has been published, so we make no judgement on the cause. What can be discussed is the system question: how does an organisation that has already investigated one event end up with a similar one? This review reads one main study on the stages of learning from incidents, supported by a literature review from the same research group.
The Study Reviewed
Drupsteen et al. (2013) built a learning from incidents model of 11 steps in four stages: investigating and analysing incidents, planning interventions, intervening, and evaluating. They used it in a survey of safety professionals in the Netherlands. Invitations went to around 2,200 members of a professional safety association, 649 surveys came back, and 303 complete responses from seven sectors were analysed: chemicals, construction, energy and waste, food, government, metal and transport. For each step, respondents were asked whether it was formally organised in their organisation and how well it worked in practice. Three exploratory case studies complemented the survey.
Main Findings
Almost every organisation formally organised incident reporting (98 percent of respondents), but only 57 percent organised the intervention step and 53 percent organised evaluation. Evaluation was most often named as the main bottleneck (20 percent), followed by reporting (19 percent). Respondents commented that where evaluation existed, it often only confirmed that actions had been carried out rather than judging whether they prevented recurrence (Drupsteen et al., 2013).
The share of respondents who said each stage worked well fell from 65 percent for investigation to 60 percent for planning, 51 percent for intervening and 38 percent for evaluation. Multiplied in sequence, the learning potential actually used was below 10 percent. The case studies showed the pattern behind the numbers: corrective actions were lost among the many actions coming from incident analyses and audits, priorities were set mainly by available time and money so short-term actions won, actions on more complex underlying causes were often left unattended, and lessons were rarely applied in other parts of the organisation with similar causes (Drupsteen et al., 2013).
A follow-up literature review by Drupsteen and Guldenmund (2014) describes the sub-processes of learning, namely formulating, sharing, storing and applying lessons, along with factors that influence them such as trust, the severity of an incident's consequences and the people involved in learning.
Study Limitations
The survey reflects the views of safety professionals, not managers or workers, and the researchers acknowledge the results may be biased even though the case studies supported them. The Dutch context and survey method limit how far the findings can be generalised, and the data are more than ten years old. We have not found a comparable study in Indonesia.
Meaning for SMK3
Indonesia's Government Regulation No. 50 of 2012 on the Implementation of Occupational Safety and Health Management Systems includes an element on reporting and correcting deficiencies. Criterion 8.3 calls for a procedure to examine and review accidents, reports that state causes, effects, recommendations and a timetable for corrective action, a named person responsible for each action, informing workers at the accident location about corrective actions, and monitoring, documenting and communicating their implementation to all workers (Pemerintah Republik Indonesia, 2012). The management review in the same regulation asks for an evaluation of how effectively the SMK3 is implemented and lists accident review findings as one of its inputs. ISO 45001:2018 clause 10.2 likewise requires organisations to review the effectiveness of corrective action taken (International Organization for Standardization [ISO], 2018).
In our reading, criterion 8.3 covers the investigation, planning and intervention stages of the Drupsteen et al. (2013) model well, but its monitoring requirement is easily read as "the action has been done". That is the trap the survey found: complete documents, a passed audit, yet nobody checks whether the risk actually went down. A repeat event at the same location is a strong signal that the evaluation stage deserves scrutiny. We draw no such conclusion about the Morowali event, because its report is not yet available.
Practical Steps
- Separate "completed" from "proven effective" in the corrective action register, and set an effectiveness review date when each action is raised.
- Give priority to actions on underlying causes, not only the cheap and quick ones.
- Share lessons with other units that run similar processes or equipment, in the spirit of criterion 8.3.6 on informing all workers.
- Take repeat events and actions not yet proven effective to the management review.
- Measure the learning process itself, for example the share of actions whose effectiveness has been verified.
How Nusa Safety Helps
Nusa Safety helps companies test the reporting and correction element through an SMK3 Internal Audit, tracing corrective actions through to evidence that they worked. Internal investigation teams can be strengthened through Incident Investigation and RCA training, and action registers can be tracked through HSE Digitalization.
This article is general information and not legal or professional advice for any specific case.
References
- Bisnis.com. (2024a, June 14). Buruh bongkar penyebab tungku smelter ITSS Morowali meledak lagi [Workers reveal the cause of the repeat ITSS Morowali smelter furnace explosion]. https://ekonomi.bisnis.com/read/20240614/44/1774143/buruh-bongkar-penyebab-tungku-smelter-itss-morowali-meledak-lagi
- Bisnis.com. (2024b, June 14). Kemenperin buka suara terkait insiden tungku smelter nikel ITSS di Morowali [Ministry of Industry responds to the ITSS nickel smelter furnace incident in Morowali]. https://ekonomi.bisnis.com/read/20240614/257/1774323/kemenperin-buka-suara-terkait-insiden-tungku-smelter-nikel-itss-di-morowali
- CNBC Indonesia. (2024, June 14). Bukan meledak, PT IMIP ungkap kronologi di smelter PT ITSS Morowali [Not an explosion, PT IMIP sets out the chronology at the PT ITSS Morowali smelter]. https://www.cnbcindonesia.com/news/20240614134014-4-546678/bukan-meledak-pt-imip-ungkap-kronologi-di-smelter-pt-itss-morowali
- Drupsteen, L., & Guldenmund, F. W. (2014). What is learning? A review of the safety literature to define learning from incidents, accidents and disasters. Journal of Contingencies and Crisis Management, 22(2), 81-96. https://doi.org/10.1111/1468-5973.12039
- Drupsteen, L., Groeneweg, J., & Zwetsloot, G. I. J. M. (2013). Critical steps in learning from incidents: Using learning potential in the process from reporting an incident to accident prevention. International Journal of Occupational Safety and Ergonomics, 19(1), 63-77. https://doi.org/10.1080/10803548.2013.11076966
- International Organization for Standardization. (2018). Occupational health and safety management systems: Requirements with guidance for use (ISO Standard No. 45001:2018). https://www.iso.org/standard/63787.html
- Pemerintah Republik Indonesia. (2012). Peraturan Pemerintah Nomor 50 Tahun 2012 tentang Penerapan Sistem Manajemen Keselamatan dan Kesehatan Kerja [Government Regulation No. 50 of 2012 on the Implementation of Occupational Safety and Health Management Systems]. https://peraturan.go.id/files/pp50-2012bt.pdf
