Tesis ini mengkaji kecelakaan kerja aktivitas pengangkatan pada operasi rig darat di PT X. menggunakan metode Human Factor Analysis and Classification System (HFACS) periode tahun 2014 - 2018. Penelitian ini adalah penelitian kualitatif dengan desain deskriptif. Hasil analisis penelitian menunjukkan lapisan unsafe acts (tindakan tidak selamat) yang paling bekerja tidak efektif dengan paling banyak berkontribusi terhadap kecelakaan kerja sebanyak 45 dari total 49 kecelakaan kerja yang diteliti, dengan tipe errors (kesalahan) yang berkontribusi terbanyak dengan 39 kecelakaan kerja Lapisan organizational influences (pengaruh organisasi) tidak bekerja efektif dengan berkontribusi terbanyak kedua terhadap kecelakaan kerja sebanyak 26 dari total 49 kecelakaan kerja yang diteliti, dengan tipe organizational process (proses organisasi) yang berkontribusi terbanyak dengan 23 kecelakaan kerja. Lapisan unsafe supervisions (pengawasan tidak selamat) tidak bekerja efektif dengan berkontribusi terbanyak ketiga terhadap kecelakaan kerja sebanyak 16 dari total 49 kecelakaan kerja yang diteliti, dengan tipe inadequate supervision (pengawasan tidak memadai) dan planned inappropriate operations (perencanaan operasi yang tidak tepat) berkontribusi sama banyak yaitu masing-masing dengan 10 kecelakaan kerja. Lapisan preconditions for unsafe acts (prakondisi untuk tindakan tidak selamat) cukup bekerja efektif dengan berkontribusi paling sedikit dengan 8 kecelakaan kerja dari total 49 kecelakaan kerja yang diteliti, dengan tipe personnel factors (faktor personalia) berkontribusi terbanyak dengan 7 kecelakaan kerja. Hasil analisis penelitian menyarankan dilakukan tindakan perbaikan di setiap lapisan HFACS sebagai sistem proteksi keselamatan baik latent failures (kegagalan laten) dan active failures (kegagalan aktif) dengan penekanan perbaikan dimulai dahulu dari lapisan organizational influences (pengaruh organisasi) dilanjutkan dengan lapisan unsafe supervisions (pengawasan tidak selamat) dan kemudian lapisan unsafe acts (tindakan tidak selamat), sedangkan perbaikan lapisan preconditions for unsafe acts (prakondisi untuk tindakan tidak selamat) menjadi tahapan perbaikan terakhir, selain juga perbaikan pada organizational influences (pengaruh organisasi), lapisan unsafe supervisions (pengawasan tidak selamat), dan lapisan unsafe acts (tindakan tidak selamat) akan memberikan pengaruh positif pada lapisan preconditions for unsafe acts (prakondisi untuk tindakan tidak selamat)

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The focus of this research is to analyze all occupational accidents of lifting activities on land rig operations in PT ‘X’ using the Human Factor Analysis and Classifications System (HFACS) method in 2014 - 2018. The type of research methodology is qualitative research with a descriptive design. The final result shows that the unsafe act layer is the most ineffective layer that contributing to almost all occupational accident cases which is 45 of 49 total cases of occupational accidents. Error is the sub-layer of unsafe act which has the highest number of contributions to occupational accident cases with total 39 cases. On the other side, the organizational influences layer is the second layer that has high contribution to accident which is 26 of 49 total cases of occupational accidents. The organizational process is the sub-layer of organizational influences which contributing to 23 cases of occupational accident. The third layer which has contribution to accident is unsafe supervision. The unsafe supervision has contribution to accident which is 16 of 49 total cases of occupational accidents. Inadequate supervision and planned inappropriate operation are the sub-layer of inadequate supervision which contribute to the accident cases for 10 cases equally. The layer of preconditions for unsafe actions is the effective layer which has contribution to occupational accident cases which is 8 of 49 total cases of occupational accidents. Personnel factor is the sub-layer of preconditions for unsafe actions which contribute to 7 cases of occupational accidents. According to the result, researcher recommend that corrective action must be taken at each layer of HFACS as the safety protection system, both latent failures and active failures with the emphasis on improvement, which start from the organizational influences layer, followed by the unsafe supervisions layer, and then unsafe actions layer, while the improvement on the layer of precondition for unsafe actions becomes the last improvement. Improvement to organizational influences layer, unsafe act layer, and unsafe supervisions layer will have a positive influence on the layer of precondition for unsafe actions.

Industri minyak dan gas bumi merupakan sektor dengan tingkat risiko keselamatan kerja yang tinggi akibat kompleksitas operasi, penggunaan teknologi bertekanan tinggi, serta paparan energi berbahaya. Meskipun indikator kinerja keselamatan seperti Total Recordable Injury Rate (TRIR) menunjukkan tren perbaikan, kecelakaan dengan konsekuensi tinggi seperti fatality masih tetap terjadi. Kejadian fatality tidak hanya menyebabkan kehilangan nyawa, tetapi juga berdampak terhadap aspek operasional, finansial, dan reputasi perusahaan. Penelitian ini bertujuan untuk menganalisis faktor-faktor penyebab kejadian fatality pada Perusahaan X selama periode tahun 2021–2025 menggunakan metode Human Factors Analysis and Classification System (HFACS). Penelitian ini merupakan penelitian deskriptif analitik dengan pendekatan kualitatif dan kuantitatif menggunakan data sekunder berupa laporan investigasi kejadian fatality. Unit analisis penelitian terdiri atas 12 kejadian fatality yang terjadi pada periode tahun 2021–2025. Analisis dilakukan dengan mengklasifikasikan faktor penyebab kecelakaan ke dalam empat level HFACS, yaitu Unsafe Acts, Preconditions for Unsafe Acts, Unsafe Supervision, dan Organizational Influences. Hasil penelitian menunjukkan bahwa faktor yang paling dominan pada level Unsafe Acts adalah Routine Violations dan Perceptual Errors (83%) dan Decision Errors (50%). Pada level Preconditions for Unsafe Acts, faktor dominan adalah Communication, Coordination and Planning (83%), Tools/Technology (75%), dan Mental States (75%). Pada level Unsafe Supervision, faktor Inadequate Supervision ditemukan pada seluruh kasus (100%), sedangkan Planned Inappropriate Operations dan Failure to Correct Known Problem masing-masing ditemukan pada 92% kasus. Pada level Organizational Influences, faktor Operational Process dan Resource Management ditemukan pada seluruh kasus (100%), sedangkan Organizational Culture ditemukan pada 92% kasus. Hasil penelitian juga menunjukkan bahwa sebagian besar korban fatality merupakan pekerja kontraktor. Penelitian ini menyimpulkan bahwa kejadian fatality pada industri migas merupakan hasil interaksi berbagai faktor yang saling berkaitan mulai dari level organisasi, pengawasan, kondisi kerja, hingga tindakan individu. Pendekatan HFACS mampu mengidentifikasi faktor-faktor laten yang berkontribusi terhadap terjadinya fatality sehingga dapat menjadi dasar dalam pengembangan strategi pencegahan kecelakaan berkonsekuensi tinggi pada industri migas.

The oil and gas industry is recognized as a high-risk sector due to operational complexity, high-pressure technologies, and exposure to hazardous energy sources. Although safety performance indicators such as the Total Recordable Injury Rate (TRIR) have shown improvement trends, high-consequence incidents such as fatalities continue to occur. Fatal accidents not only result in the loss of life but also have significant operational, financial, and reputational impacts on organizations. This study aimed to analyze the contributing factors of fatal occupational accidents in Company X during the period 2021–2025 using the Human Factors Analysis and Classification System (HFACS). This study employed a descriptive-analytic design using qualitative and quantitative approaches based on secondary data obtained from fatal accident investigation reports. The unit of analysis consisted of 12 fatal incidents that occurred between 2021 and 2025. Accident contributing factors were classified according to the four HFACS levels: Unsafe Acts, Preconditions for Unsafe Acts, Unsafe Supervision, and Organizational Influences. The results revealed that the most dominant factor within the Unsafe Acts level were Routine Violations and Perceptual Errors (83%), followed by Decision Errors (50%). At the Preconditions for Unsafe Acts level, the dominant factors were Communication, Coordination and Planning (83%), Tools/Technology (75%), and Mental States (75%). Within the Unsafe Supervision category, Inadequate Supervision was identified in all fatal cases (100%), while Planned Inappropriate Operations and Failure to Correct Known Problem were identified in 92% of the cases. At the Organizational Influences level, Operational Process and Resource Management were found in all cases (100%), whereas Organizational Culture was identified in 92% of the cases. The study also found that most fatality victims were contractor personnel. This study concludes that fatal occupational accidents in the oil and gas industry are the result of interactions among organizational, supervisory, workplace, and individual factors. HFACS proved effective in identifying latent conditions contributing to fatal accidents and can therefore serve as a basis for developing high-consequence risk prevention strategies in the oil and gas industry.