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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.
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
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.
Resiko bekerja di perusahaan migas PT X yang berlokasi di offshore Natuna adalah relatif tinggi. Sepanjang tahun 2018 – 2023 terjadi fluktuasi kecelakaan kerja di PT. X. Bahkan setelah dua tahun (tahun 2020 dan 2019) tidak terjadi kecelakaan kerja untuk kategori recordable injury (kasus di atas FAC), di tahun 2021 terjadi lagi 3 kasus (1 RWDC dan 2 MTC) dan di tahun 2022 terjadi 4 kasus (1 LWDC, 1 RWDC, dan 2 MTC). Di tahun 2023 terjadi 1 kasus (1 RWDC). Korban kecelakaan kerja di tahun 2021 didominasi oleh pekerja kontrak dan pekerja tetap sedangkan kecelakaan kerja di tahun 2022 dan 2023 semuanya terjadi pada pekerja kontrak. Sebagian besar kecelakaan yang terjadi penyebab langsungnya adalah unsafe acts. Sampai saat ini belum ada analisis menyeluruh dari data investigasi kecelakaan-kecelakaan yang telah dilakukan PT X untuk mendapatkan faktor-faktor penyebab dasar dari semua kecelakaan tersebut. Dengan demikian, penelitian perlu dilakukan, dan karena berhubungan dengan human factor, maka pada penelitian ini akan dianalisis faktor-faktor yang menyebabkan kecelakaan kerja tersebut dengan metode Human Factor Analysis and Classification System (HFACS). Tujuan: Menganalisis faktor-faktor yang memengaruhi kecelakaan kerja di PT X antara tahun 2018 – 2023 dengan metode HFACS. Metode: Penelitian ini adalah penelitian deskriptif analitik dengan pendekatan kualitatif. Data sekunder yang digunakan berupa rekaman kejadian kecelakaan dan laporan investigasi atas 41 kecelakaan di PT X. Data sekunder tersebut kemudian diklasifikasikan sesuai dengan empat (4) tahapan kegagalan di metode HFACS, yaitu unsafe acts, precondition of unsafe acts, unsafe supervision, dan organizational influence. Pengklasifikasian ini divalidasi oleh dua ahli keselamatan kerja, di mana hasil validasinya relatif tinggi (96%). Hasil: Hasil penelitian menjelaskan bahwa faktor-faktor HFACS yang mempengaruhi kecelakaan terbesar berturut-turut adalah adverse mental state (51,2%), skill-based error (39%), routine violations (34,1%), dan tools/technological dan resource management (masing-masing 31,7%). Kemudian disusul oleh decision error (29,3%), inadequate supervision (22%), failed to correct problem dan organizational process masing-masing (17,1%), lalu supervisory violation dan organizational climate masing-masing (9,8%). Kesimpulan: Faktor-faktor HFACS yang memengaruhi kecelakaan kerja di PT X dapat digunakan sebagai masukan untuk perbaikan program K3 perusahaan guna menurunkan angka kecelakaan dengan memprioritaskannya pada faktor HFACS yang bersifat latent failure baru kemudian pada faktor active failure-nya, karena latent failure - jika diperbaiki- akan menjadi kunci untuk mencegah berulangnya kecelakaan.
The risks of working for the PT X , an oil and gas company located offshore Natuna are relatively high. Throughout 2018 – 2023 there were fluctuations in work accidents at PT. X. Even after two years (2020 and 2019) there was no work accident for the recordable injury category (cases above FAC), in 2021 there were 3 cases (1 RWDC and 2 MTC) and in 2022 there were 4 cases (1 LWDC, 1 RWDC, and 2 MTC). In 2023 there was 1 case (1 RWDC). Work accident victims in 2021 are dominated by contract workers and permanent workers, while work accidents in 2022 and 2023 all occur in contract workers. Most of the accidents that occur are directly caused by unsafe acts. Until now there has been no comprehensive analysis of accident investigation data that has been carried out by PT X to obtain the basic causal factors of all these accidents. Thus, research needs to be carried out, and because it is related to human factors, this research will analyze the factors that cause work accidents using the Human Factor Analysis and Classification System (HFACS) method. Objective: Analyzing the factors that influence work accidents at PT X between 2018 – 2023 using the HFACS method. Method: This research is descriptive analytical research with a qualitative approach. The secondary data used is in the form of recordings of accidents and investigation reports on 41 accidents at PT X . This classification was validated by two occupational safety experts, where the validation results were relatively high (96%). Results: The research results explain that the HFACS factors that influence the biggest accidents are adverse mental state (51.2%), skill-based errors (39%), routine violations (34.1%), and tools/technological and resources, respectively. management (31.7% each). Then followed by decision errors (29.3%), inadequate supervision (22%), failed to correct problems and organizational processes respectively (17.1%), then supervisory violations and organizational climate respectively (9.8%). Conclusion: The HFACS factors that influence work accidents in PT X can be used as input for improving the company's H&S program to reduce the number of accidents by prioritizing the HFACS factors which are latent failures and then the active failure factors, because latent failures - if corrected - will become key to preventing recurrence of accidents.
Pendahuluan: Di dalam industri hulu migas, cedera tangan dan jari merupakan tantangan besar. Setidaknya 50% dari kasus cedera di dalam industri migas merupakan cedera tangan dan jari. Di beberapa perusahaan, proporsi tersebut dapat menjadi lebih besar. Dalam analisis yang pernah dilakukan terhadap kecelakaan di perusahaan anggota IOGP, lebih dari delapan puluh persen diakibatkan karena factor manusia, baik yang disebabkan oleh faktor pribadi ataupun faktor organisasi. Studi ini dilakukan untuk menganalisis factor manusia di dalam kasus cedera tangan dan jari yang teradi di PT. X sepanjang tahun 2014 hingga 2020 dengan menggunakan kerangka HFACS. Metode: Penelitian dengan metode deskriptif kualitatif dengan menggunakan data sekunder berupa data kasus cedera tangan dan jari di PT. X dari tahun 2014 hingga 2020. Hasil: Cedera tangan dan jari paling banyak disebabkan oleh skill-based errors dan routine violations. Kasus cedera yang diakibatkan skilled-based errors juga diperparah oleh pelanggaran aturan yang dilakukan bersama secara terus menerus (routine violations). Kondisi yang menjadi prekondisi dari tindakan tidak aman yang berkontribusi dalam cedera tangan dan jari paling banyak terkait crew/ resource management. berbagai faktor yang termasuk ke dalam kategori ini di antara lain komunikasi, koordinasi, perencanaan dan kerja tim yang mempengaruhi kinerja. Pengawasan yang tidak aman yang paling banyak terjadi adalah failed to correct known problems dan inadequate supervision. Inadequate supervision terkait dengan pengelolaan personil dan sumber daya termasuk pelatihan, panduan professional dan kepemimpinan operasional. Sedangkan failed to correct known problems terkait dengan kekurangan pada individu, peralatan, pelatihan atau area keselamatan lain “diketahui” oleh supervisor, namun dibiarkan tidak dikoreksi. Di level 4, pengaruh organisasi yang terbesar adalah Organisational Process. Organisational process adalah proses formal di mana visi sebuah organisasi dijalankan termasuk operasi, prosedur, dan kesalahan di antaranya. Kesimpulan: Gambaran HFACS pada kasus cedera tangan dan jari di PT. X sejalan dengan gambaran umum HFACS yang ada dalam industri hulu migas, kecuali di level 2 yakni preconditions for unsafe acts. Sistem pembelajaran kejadian di PT. X masih dipengaruhi oleh teori domino dan belum mengintegrasikan konsep faktor manusia secara menyeluruh. Kerangka HFACS dapat membantu PT. X dalam menelaah lebih dalam defisiensi di dalam faktor manusia untuk dapat menetapkan tindakan perbaikan yang lebih tepat.
Introduction: Hand and finger injuries have always been major challenges in upstream oil and gas industry. At least 50% of injuries in upstream oil and gas impacting hand and fingers. In some companies, the proportion could be larger. More than 80% of incidents in IOGP members were caused by human factors, both personal and organizational factors. This study aims to analyze human factors in hand and finger injuries at PT. X by using HFACS framework. Methodology: The study was conducted by applying qualitative descriptive analysis by using secondary data, investigation report of hand and finger injures from 2014 to 2020. Results: Skill-based errors and routine violations contributed in most of hand and finger injuries in PT.X. Routine violations were found as aggravating factors in skill-based errors injuries/ crew resource management were dominating level 2, preconditions for unsafe acts, it consists of coordination, communication, planning and team work that impacting performance. Unsafe supervision that occurred the most are inadequate supervision and failed to correct known problems. Inadequate supervision related to personnel and resources management including trainings, professional guidance and operational leadership. Failed to correct known problems related to deficiencies in individual, equipment, training or the safety area “known” to supervisor but left uncorrected. In level 4, Organizational process was the weak chain of organizational influences. Organizational process is a formal process where organization’s vision is implemented on Site, including operations, procedures. Conclusion: HFACS of hand and finger injuries in PT. X is in line with general HFACS description in upstream oil and gas industry, except for level 2, pre-conditions for unsafe acts. Learning from incident system in PT. X was still highly influenced by domino theory and has not yet integrated human factors. HFACS framework can help PT. X to dig deeper in human factors deficiencies in organization so PT. X can define more effective mitigation & preventive measures.
This research examines work-related accidents in the mining industry categorized as injury cases, using the Human Factors Analysis and Classification System in Mining Industry (HFACS-MI). The mining industry is known as a high-risk sector, where serious incidents such as major injuries and fatalities frequently occur despite investigations and preventive measures. The study aims to identify the main causal factors of workplace accidents based on the HFACS-MI framework, which classifies human errors and systemic weaknesses within mining organizations. Using data from injury-related accident cases in 2024, both qualitative and quantitative analyses were conducted to assess contributing factors from the operator level up to the organizational level.The findings reveal that the majority of accidents were triggered by unsafe acts, particularly skill-based errors, indicating deficiencies in workers' basic competencies. Additionally, latent failures, such as inadequate supervision and organizational inefficiencies, were also found to play a significant role.