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# 02 # 03 - Teori Kecelakaan Kerja
# 02 # 03 - Teori Kecelakaan Kerja
Ergosafety
Week 2&3
Accident
Causation
Theories
2
What is an Accident?
Number is Up
Carelessness People Error
ACCIDENT
Cost of doing
Act of God Business
PEOPLE PROBLEM
Nature Of Accidents
• Each accidents must be looked at in terms of having two components:
facility.
Class 3 accidents. Locally provided first aid, property damage of less
than $100, or the loss of less than eight hours of work time
Class 4 accidents. Injuries that are so minor that they do not require
the attention of a physician, result in property damage of $100 or
more, or cause eight or more work hours to be lost
Estimating the Cost of Accidents
1. Average uninsured costs for each class of accident can be
determined by pulling the records of all accidents that occurred
during a specified period and by sorting the records according
to class.
2. For each accident in each class, record every cost that was
not covered by insurance.
3. Compute the total of these costs by class of accident and
divide by the total number of accidents in that class to
determine an average uninsured cost for each class, specific
to the particular company.
Estimating the Cost of Accidents
Estimating the Cost of Accidents
• Calculating Lost Work Hours:
Calculating the direct costs associated with lost work hours involves compiling the
total number of lost hours for the period in question and multiplying the hours times
the applicable loaded labor rate. The loaded labor rate is the employee’s hourly
rate plus benefits. Benefits vary from company to company but typically inflate the
hourly wage by 20 to 35 percent.
Estimating the Cost of Accidents
DISCUSSION
1. Pilih salah satu diantara kasus kecelakaan yang
dibahas di minggu lalu
2. Bahas “cost of accident” yang terjadi di kasus
kecelakaan tersebut baik direct cost maupun
hidden cost.
3. Buat perkiraan besarnya biaya-biaya tersebut
dalam rupiah.
Why do we need to know how an accidents happened?
• To prevent accidents we must
know why they happened.
Unsafe Act
88%
Heinrich’s study laid the foundation
for his Axioms of Industrial
Safety and his theory of accident
causation, which came to be
known as the domino
theory.
Heinrich’s 10 Axioms of Industrial Safety
1. Injuries result from a completed series of factors, one of which is the accident
itself
2. An accident can occur only as the result of an unsafe act by a person and/or a
physical or mechanical hazard.
3. Most accidents are the result of unsafe behavior.
4. Unsafe acts and hazards do not always result in immediate accidents and
injuries.
5. Understanding why people commit unsafe acts helps to establish guidelines
for corrective actions.
6. The severity of the injury is largely fortuitous and the accident that caused it is
preventable.
Heinrich’s 10 Axioms of Industrial Safety
7. The best accident prevention techniques are analogous to best
quality/productivity techniques.
8. Management should assume safety responsibilities.
9. The supervisor is the key person in the prevention of industrial accidents.
10. Cost of accidents include both direct costs and indirect costs.
MISTAKES OF PEOPLE
• According to Heinrich, there are five factors in the sequence of events leading up
to an accident:
1.Ancestry and social environment - character traits that lead people to behave
in an unsafe manner can be inherited, or acquired as a result of social
environment ( ex: alcoholism).
Heinrich’s Domino Theory
39
Unsafe Act or
Working Condition ?
Unsafe Act or
Working Condition ?
Unsafe Act or Working Condition ?
43 Unsafe Act or Working Condition ?
Domino Theory in Practice
44
Domino Theory in Practice
45
Domino Theory in Practice
46
Modification Domino Theory
https://rlshumancare.com/frank-birds-domino-theory/
Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)
• Lack of control is the first domino and refers the fourth function of the
management (planning, organising, directing, controlling and coordinating, job
analysis, personal communication, selection and training, ‘standards’ in each
work activity identified measuring performance by standards and correcting
performance by improving the existing programmes.
• This first domino may fall due to inadequate standards, programmes and
follow up.
https://rlshumancare.com/frank-birds-domino-theory/
Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)
https://rlshumancare.com/frank-birds-domino-theory/
Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)
Immediate causes are only symptoms of the underlying problem. They are
substandard practices or conditions (known as unsafe acts and unsafe
conditions) that could cause the fourth domino to fall. These causes should be
identified, classified and removed by appropriate measures.
miningsafety.co.za
https://rlshumancare.com/frank-birds-domino-theory/
Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)
Accident or incident is the result of unsafe acts or/and unsafe conditions. This point
is the contact stage. Some counter measures employed are reinforcement, surface
modification, segregation, barricading, protection, absorption, shielding etc.
https://rlshumancare.com/frank-birds-domino-theory/
Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)
Pada dasarnya, terdapat empat layer yang menyusun terjadinya suatu accident, yaitu:
a. Organizational Influences (pengaruh pengorganisasian dan kebijakan manajemen dalam
terjadinya accident)
b. Unsafe Supervision (pengawasan yang tidak baik)
c. Precondition for Unsafe Act (kondisi yang mendukung munculnya unsafe act)
d. Unsafe Act (perilaku atau tindakan tidak aman yang dilakukan dan berhubungan langsung dengan
terjadinya accident)
Kronologi Jatuhya Pesawat Boeing 737-4Q8 Adam Air
CONTOH KASUS
ANALISIS DENGAN MENGGUNAKAN
SWISS CHEESE MODEL
Layer I : Organizational Influences
- Perusahaan melakukan penghematan dengan meminimisasi penggantian suku cadang
- Kurangnya kesadaran perusahaan tentang keselamatan penerbangan
Layer II : Unsafe Supervision
- Kurangnya pengawasan pada kerusakan IRS (Inertial Reference System) yang merupakan
alat pengindikasi posisi pesawat
- Kurangnya perhatian pada pemeliharaan perangkat pesawat
- Penggantian suku cadang tidak diawasi dengan baik
- Koreksi kemiringan pesawat akibat adanya angin hanya dilakukan sebentar
- Tidak ada satupun dari pilot atau ko-pilot yang menjaga arah pesawat selama 30 detik seperti
yang diharuskan oleh Quick Reference Handbook (buku yang berisi pedoman untuk kondisi
darurat)
Layer III : Precondition for Unsafe Act
- Pilot dan ko-pilot dalam kondisi panik
- Cuaca buruk
- Kehilangan situational awareness saat kemiringan pesawat melebihi batas
maksimum
- Kerusakan salah satu IRS
- Awak pesawat tidak mengetahui secara pasti IRS mana (Left IRS atau Right IRS)
yang masih berfungsi dengan baik.
Layer IV : Unsafe Act
- Kurang menanggapi dengan serius peringatan bahaya dari petugas Air Traffic
Controller (ATC)
- Pilot dan ko-pilot lebih fokus pada kerusakan IRS dari pada tingkat kemiringan
pesawat yang bermasalah
- Salah mengambil keputusan (decision error) saat kemiringan melebihi batas normal
TUGAS
Buat Ringkasan untuk teori penyebab kecelakaan lainnya:
• The domino theory
• Swiss cheese model
• The accident/incident theory.
• The systems theory.
• The combination theory.
• The human factors/error theory.
• The behavioral theory.
• The epidemiological theory.
• Drug, Depression and Obesity as Accident causation
• Management Failures and Accident causation
Referensi: Geotsch, L.D., 2014, Occupational Safety and Health for Technologists, Engineers,
and Managers, Prentice Hall. 61