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Hasil Penelitian menunjukkan bahwa faktor-faktor penyebab kecelakaan kebakaran yang terjadi pada industri migas di Indonesia pada tahun tersebut adalah disebabkan faktor manusia sebesar 41,67% atau 15 kejadian, faktor peralatan 41,67% atau 15 kejadian, faktor alam (gempa bumi) 1 kejadian atau 2,78% dan faktor lain sebesar 13, 89% atau 5 kejadian. Sedangkan akar penyebab (root cause) utama kecelakaan kebakaran tersebut pada faktor manusia adalah tidak adanya pengawasan (11 kejadian) dan untuk faktor peralatan disebabkan kurangnya program pemeliharaan yang bersifat pencegahan/ prediksi (10 kejadian).
Every year always happened a fire accident on the oil and gas industry in Indonesia and caused huge losses both on the material, equipment, environment and people and disruption of the production process too. Therefore, efforts need to be done to prevent the occurrence of fire accidents is by finding the root cause. This study aims to analyze the root causes of fire accidents. This study is a qualitative research design with descriptive analytic. The study was conducted in a fire accident years 2006-2010 in the territory of Indonesia by taking a secondary data from the Directorate General of Oil and Gas.
Research results indicate that these factors cause a fire accident that occurred on oil and gas industry in Indonesia for the year was caused by human performance difficulty of 41.67% or 15 events, equipment difficulty 41.67% or 15 incidents, natural disaster factors (earthquakes) 1 incidents or 2.78%, and other factors of 13, 89% or 5 events. While the root cause a major fire accident on the human factor is the lack of supervision (11 events) and to factor due to lack of equipment maintenance programs that are preventive/predictive (10 events).
Industri pertambangan merupakan kegiatan industri yang mempunyai risiko tinggi. Faktor manusia telah diidentifikasi sebagai penyebab paling umum terjadinya kecelakaan besar di industri pertambangan. Oleh karena itu, penelitian ini bertujuan menganalisis data kecelakaan di PT. X dengan menggunakan kerangka analisis faktor manusia dan sistem klasifikasi industri pertambangan (HFACS-MI). Metode penelitian ini melibatkan pengumpulan data kualitatif untuk 322 kasus kecelakaan di PT. X yang terjadi pada tahun 2018-2022 dari basis data Sistem Manajemen Insiden yang dikategorikan sebagai cedera yang dapat dicatat. Faktor penyebab kecelakaan ini diberi kode menggunakan kerangka HFACS-MI. Data kecelakaan dianalisis menggunakan statistik deskriptif. Temuan penelitian menunjukkan bahwa 84% dari seluruh kecelakaan melibatkan pekerja kontraktor dan 16% melibatkan pekerja tetap PT. X. Hasil analisis menggunakan kerangka HFACS-MI menunjukkan bahwa setiap lapisan atau tingkatan memberikan kontribusi terhadap kecelakaan, yaitu faktor luar (44%), pengaruh organisasi (68%), kepemimpinan tidak aman (90%), prasyarat tindakan tidak aman (99%), dan tindakan tidak aman (99,7%). Temuan ini menekankan perlunya fokus pada pengurangan jumlah kesalahan manusia selama operasi penambangan untuk mengurangi tren kecelakaan saat ini. Kerangka kerja HFACS-MI telah terbukti menjadi alat penting untuk analisis kecelakaan yang kuat terhadap faktor manusia di pertambangan.
The mining industry is an industrial activity with high risks. Human factors have been identified as the most common cause of major accidents in the mining industry. Therefore, this research aims to analyze accident data at PT. X using the human factors analysis and classification system-mining industry framework (HFACS-MI). This research collected qualitative data for 322 accident cases at PT. X occurring from 2018 to 2022 from the Incident Management System database categorized as recordable injuries. Factors causing the accidents were coded using HFACS-MI framework. Accident data were analyzed using descriptive statistics. The study findings revealed that 84% of all accidents involved contractor workers and 16% involved the PT. X permanent workers. The results of analysis using the HFACS-MI framework show that each layer or level contributes to accidents, namely outside factors (44%), organizational influences (68%), unsafe leadership (90%), preconditions of unsafe acts (99%), and unsafe acts (99.7%). These findings emphasize the need to focus on reducing the number of human errors during mining operations to reduce the current accident trend. The HFACS-MI framework has proven to be a valuable tool for robust accident analysis of human factors in mining.
This thesis discusses case studies of work accidents due to toxic gas in PT Freeport Indonesia's underground mine. This research is a descriptive design research and the analysis was carried out using the Human Factor Analysis and Classification System (HFACS) method. The results of the study found that there were 3 cases of accidents due to toxic gas in all PTFI underground mining blocks during the 2019-2022 period with risk factors originating from unsafe actions which were categorized in the Human Factor Analysis and Classification System (HFACS), which was divided into four, namely organizational influences, unsafe leadership, precondition for unsafe acts, and unsafe acts. In the study, the results of the failure of the defense system on organizational influence in cases of poison gas poisoning were dominated by the category of resource management totaling 7 failures (57%), contributing factors to the failure of the management system including SOP, safety sign, Planned Inspection, PJO, K3 Policy, Database incident management system and communication when submitting work instructions. . The level of Unsafe Supervision in cases of poison gas poisoning amounted to 11 failures (55%) with dominance by the Supervisory Violation category, contributing factors to management system failure including the Neil George Checklist, Bulkhead Ventilation, Re-entry Checklist, Airlock Door, Vent bag, Supervisor Inspection, Personal Protective Equipment, Supervision in the field, feasibility of the ventilation system at the work site, supervisor's observation of workers regarding the operation of portable gas detectors and work instructions. The level of Precondition for Unsafe Acts in cases of poison gas poisoning was dominated by the Personal Readiness category with 8 failures (38%), contributing factors to management system failure including blasting equipment, PDA, understanding of the language of instruction, emission test of heavy equipment, stop vent checklist and ventilation in the blasting area, ignoring the gas detector alarm. The level of Unsafe Acts in cases of poison gas poisoning amounted to 11 failures (46%) from the dominance of the Violation Routine category, contributing factors to management system failure including chemical handling, inadequate procedures, sign threshold values in one language, dumper vents blocked by mud and the vent bag is damaged, the fixed gas detector has not been calibrated and is covered in mud, inconsistent training evaluations are carried out, barricaded areas, do not follow the re-entry protocol. Companies are advised to evaluate the program for handling accidents caused by toxic gasses.
Kata kunci:Kecelakaan, analisis kecelakaan, Human Factors And Classification System, HFACS, Comprehensive List Of Causes, CLC
This thesis assess the accident in PT XYZ 2015 by using Human Factors AndClassification System (HFACS) framework. This research is a semi-quantitativewith design study analytical descriptive. Results from this study are a layer ofHFACS most weakness is unsafe act at 11 from total 11 accidents with theelements of decision error becomes a factor of the number one weakness, thenfollowed with a precondition of unsafe act at 10 with the elements of conditions ofservice to be the factors that most contribute to accidents, followed by unsafesupervision at 7 with inadequate leadership element is the factor that mostcontributed to the accident, and the latter as much as 5 of organizationalinfluences with elements of organizational climate and resource management isthe factor that most contributed to the accident. The analysis of research suggestscorrective actions at each level of HFACS, not only for active failures but alsolatent failures with reinforcing corrective action at the unsafe act layer.
Key words:Accident, accident analysis, Human Factors And Classification System, HFACS,Comprehensive List Of Causes, CLC
Occupational accident cases in the cement industry, especially the packer area, are a serious problem that can have an impact on many things including productivity, safety, and worker welfare. Data shows that occupational accidents in the Packer area of the PT X Cement Industry in 2024 have increased compared to 2023, making it the area with the highest accident frequency in 2024. Occupational accident investigations and corrective actions have been conducted, but accidents continue to recur. This may be due to the absence of human factor analysis during the investigation process. Therefore, this study was conducted to determine contribution of human factors specifically latent conditions and active failures to occupational accidents that occurred in the PT X packer area during 2023-2024. This study was conducted using a descriptive analytical method using the Human Factor Analysis Classification System (HFACS) method. The results of the study showed that latent conditions contributed more to occupational accidents than active failures. The latent condition factors that contributed the most to occupational accidents included organizational climate, organizational process, resource management, and inadequate supervision. Meanwhile, the active failure factor that contributed the most was decision error. PT X needs to improve latent conditions at the organizational level and implement control to mitigate active failures in the packer area.
Learning from accident means accident is learned to identify the causes and weaknesses of the system so the future accidents be prevented. Although accidents are studied, accidents with similar scenarios still occur at PT X. Therefore, research is conducted which aims to study the process of "learning from accidents" implemented by PT X. The study was conducted using qualitative descriptive method. To maintain the validity of the results, triangulation was carried out using data triangulation, method triangulation, and source triangulation. The learning from accidents that implemented by PT X starts from recognizing events, reporting events, recording and classifying events, collecting data to support the investigation process, finding root causes, making recommendations/corrective actions, communicating learning, monitoring closure of corrective actions, and verifying and validating corrective actions. The study shows that workers have understood events that are categorized as accidents, but a small proportion of workers are still confused in distinguishing between near miss with unsafe conditions or act. Accidents and near miss are reported through e-mail or SharePoint but the reporting of near miss is still relatively lack when compared to the number of accidents. Events are classified based on standard guidelines and recorded in the IT Tool even though the follow-up of reporting event in SharePoint is still lacking. Investigation is begun by gathering the information that grouped into 4Ps, namely people, positions, paper, and parts. Data collection for level 3 investigations tends to review accidents with a similar scenario in the previous cases. The root cause of an accident is determined using the five why or why tree method that starts by determining the top event and progressing to find the root cause of accident. It is found human root causes instead of systemic root causes for the investigation involving motor vehicle crash that is classified as level 1. Recommendations/corrective actions are developed based on SMART criteria i.e., specific, measurable, accountable, relevant, and time limits. However, the sustainability of corrective actions is not emphasized enough. Learning is spread through alerts and bulletins that are distributed to workers through e-mail and other media. However, the making of alerts and bulletins are less consistent and the mechanism of dissemination is less effective. Corrective actions are monitored and completed on time and the sponsor verifies and validates the completion of corrective actions to check the effectiveness. With the advantages and disadvantages that exist, but the learning from accidents that is implemented by PT X was able to reduce the trend of accidents in the period from 2015 to 2019.