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Dyah Hermiyanti; Pembimbing: Chandra Satrya; Penguji: Robiana Modjo, Hendra, Turmudi, Bagus B. Edvantoro
Abstrak:

Penelitian ini berfokus pada analisis penyebab kecelakaan kerja fatal jatuh dari kapal pada transportasi air dalam kegiatan survei seismik 2D PT. X di Simenggaris, Kalimantan Timur tahun 2010, dimana satu orang kru rintis #2 pada line 26 karyawan PT. SMK (mitra kerja) kehilangan nyawa karena korban terjatuh dari kapal saat akan mengambil pelampung yang diletakkan di atap kapal dan kemudian tenggelam. Penelitian dilakukan dengan pendekatan kualitatif berdasarkan data sekunder berupa dokumen laporan hasil investigasi kecelakaan dan foto kejadian mengenai kecelakaan kerja fatal jatuh dari kapal pada penggunaan transportasi air dalam survei seismik yang dilakukan oleh PT. X di Simenggaris, Kalimantan Timur. Adapun teknik yang digunakan untuk menganalisis penyebab kecelakaan adalah 5 Whys dan SCAT. Hasil analisa peneliti terkait penyebab kecelakaan fatal ini, mencakup dua hal, yaitu penyebab langsung berupa tindakan tidak aman korban yang tidak memperkirakan risiko yang dihadapi saat mengambil pelampung, dan kondisi tidak aman yaitu akses untuk menaiki dan menuruni kapal (bridging) yang belum disesuaikan dengan kondisi pasang-surut permukaan air sungai sehingga kondisi berlumpur, housekeeping yang buruk serta pengaman kapal yang tidak memadai. Sedangkan penyebab pedukung, mencakup: mitra kerja tidak memiliki SMK3, HSE Plan, dan Instruksi Kerja/SOP pekerjaan yang belum dilaksanakan secara konsisten oleh mitra kerja, tidak memadainya standar K3, serta kurangnya kesadaran dan pengawasan mandor. Kata kunci :  kecelakaan fatal, jatuh dari kapal, penyebab langsung, penyebab pendukung

This study focused on analyzing the causes of fatal accident man overboard on water transport in the 2D seismic survey activities of PT. X in Simenggaris, East Kalimantan in 2010. One crew of Rintis # 2 on line 26, employees of PT. SMK (partners) lost his lives because fell from the ship when took a life jacket which placed on the ship roof and then he sank. The study was conducted with a qualitative approach based on secondary data from the investigation report documents of the accident, as well as the documentation pictures.  The technique used to analyze the causes of accidents is 5 Whys and SCAT. The results of research analysis on the causes of this fatal accident, include two major; 1) direct cause of action; the victim did not conscious about the risk in front of him, by did not cleaned up the boot and use the life jacket before entering the boat) and unsafe conditions of access to up and down ship (bridging) that have not adapted to the conditions of the tidal river water surface, poor housekeeping, and minimum fence security on boat. While the contributing cause, including: sub-contractor did not have HSE system, HSE Plan, and Work Instructions / SOPs of work was not carried out consistently, minimum HSE, minimum training and controlling by PT X, as well as lack of supervision. Key words : fatal accidents, man overboard, direct causes, contributing causes

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T-3495
Depok : FKM-UI, 2012
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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Farhansyah Pratama; Pembimbing: Fatma Lestari; Penguji: Baiduri Widanarko, Mufti Wirawan, Propana Okionomus Ali, Herna Rosalin Manullang
Abstrak:
Industri pertambangan mineral dan batubara merupakan sektor berisiko tinggi yang masih mencatat kecelakaan fatal meskipun telah memiliki regulasi dan sistem manajemen keselamatan. Investigasi kecelakaan yang terlalu berfokus pada tindakan tidak aman pekerja berisiko mengabaikan faktor laten pada tingkat organisasi, pengawasan, kondisi kerja, dan sistem pengendalian. Penelitian ini bertujuan untuk mengeksplorasi accident archetypes atau pola kegagalan sistemik berulang pada kecelakaan fatal pertambangan mineral dan batubara di Indonesia melalui pendekatan Human Factors Analysis and Classification System for Mining Industry (HFACS-MI). Penelitian menggunakan desain kualitatif studi multi-kasus berbasis data sekunder berupa laporan investigasi kecelakaan tambang fatal tahun 2025 dari Kementerian ESDM. Dari 44 kasus fatalitas, tujuh kasus di regional Sumatera dan Kalimantan dipilih secara purposive berdasarkan kelengkapan data, keragaman aktivitas operasional, dan kompleksitas sistemik. Analisis dilakukan melalui directed content analysis, coding HFACS-MI, causal pathways, cross-case matrix, causal loop diagram, dan validasi expert judgement. Hasil penelitian menunjukkan bahwa organizational process, inadequate supervision, personnel factors, dan physical/technological environment muncul secara konsisten pada seluruh kasus yang dianalisis. Unsafe acts tidak berdiri sebagai penyebab tunggal, melainkan sebagai manifestasi akhir dari kondisi laten organisasi, pengawasan, kompetensi, dan lingkungan kerja. Penelitian ini mengidentifikasi empat accident archetypes, yaitu Cost-Driven Operational Normalization, Defense-in-Depth Collapse, Competence Illusion in High-Risk Engineering Tasks, dan Reactive Compliance Trap. Temuan ini menunjukkan bahwa pencegahan kecelakaan fatal perlu bergeser dari event-based intervention menuju structure-based intervention melalui penguatan pengawasan, critical control verification, preventive maintenance, verifikasi kompetensi, dan evaluasi efektivitas prosedur keselamatan di lapangan.
The mineral and coal mining industry is a high-risk sector that continues to experience fatal accidents despite the existence of safety regulations and management systems. Accident investigations that focus primarily on workers’ unsafe acts may overlook latent factors at the organizational, supervisory, working condition, and control-system levels. This study aimed to explore accident archetypes, or recurring patterns of systemic failure, in fatal mineral and coal mining accidents in Indonesia using the Human Factors Analysis and Classification System for Mining Industry (HFACS-MI). This research employed a qualitative multi-case study design based on secondary data from fatal mining accident investigation reports issued by the Ministry of Energy and Mineral Resources in 2025. Of 44 fatal accident cases, seven cases from the Sumatra and Kalimantan regions were purposively selected based on data completeness, operational diversity, and systemic complexity. Data were analyzed using directed content analysis, HFACS-MI coding, causal pathways, cross-case matrix, causal loop diagram, and expert judgement validation. The findings showed that organizational process, inadequate supervision, personnel factors, and physical/technological environment consistently appeared across all analyzed cases. Unsafe acts did not stand as single causes of accidents, but rather as final manifestations of latent organizational conditions, supervision, competence, and work environment. Four accident archetypes were identified: Cost-Driven Operational Normalization, Defense-in-Depth Collapse, Competence Illusion in High-Risk Engineering Tasks, and Reactive Compliance Trap. These findings suggest that fatal accident prevention should shift from event-based intervention toward structure-based intervention by strengthening supervision, critical control verification, preventive maintenance, competence verification, and evaluation of the actual effectiveness of safety procedures in the field.
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T-7588
Depok : FKM-UI, 2026
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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Theresia Iin Wulandari; Pembimbing: Zulkifli Djunaidi; Penguji: Abdul Kadir, Stevan Deby Anbiya Muhamad Sunarno, Imam Santoso, Machfud
Abstrak:
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.
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T-7693
Depok : FKM-UI, 2026
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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:: Pengguna : Pusat Informasi Kesehatan Masyarakat
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