UNSAFE

ACTS

Errors Violations

Skill–based Rule–based Knowledge-

Routine Exceptional
Error Error based Errors

unconsciousness consciousness
 UNSAFE
ACTS

Errors Violations

Skill–based
Decision Rule–based Knowledge-
Routine Exceptional
Errors
Error Error based Errors

SKILL BASED ERROR

 Pelaksanaan aktivitas yang rutin
 Di luar kesadaran
 Attention & Memory
- Pengoperasian
- Postur kerja
- Ketepatan waktu
- Teknik/cara kerja

unconsciousness consciousness
 UNSAFE
ACTS

Errors Violations

Skill–based Skill-Based
Rule–based Knowledge-
Routine Exceptional
Error Errors
Error based Errors

RULE-BASED ERRORS
 Ketidaksesuaian penerapan prosedur
 Keputusan secara sadar
- Penggunaan alat/peralatan/APD
- Prioritas kerja
- Procedural
- Penilaian situasi
- Persepi
unconsciousness consciousness
 UNSAFE
ACTS

Errors Violations

Skill–based Rule–based Knowledge-

Perceptual
Routine Exceptional
Error Error based Errors
Errors

Knowledge-based
Error
 Situasi tidak dikenali
 incorrect action
- Proses informasi
- Pengetahuan
- Prosedur

unconsciousness consciousness
 UNSAFE
ACTS

Errors Violations

Skill–based Rule–based Knowledge-

Routine Exceptional
Error Error based Errors

ROUTINE

 Mengabaikan peraturan & prosedur secara sengaja

 Tergolong pelanggaran ringan
- Penggunaan pelindung
- Penggunaan alat/peralatan
- Peraturan & prosedur kerja
- Traffic management

Mis.: Tidak menggunakan APD, Menyalahgunakan peralatan

kerja, melewati batas kecepatan maksimal
unconsciousness consciousness
 UNSAFE
ACTS

Errors Violations

Skill–based Rule–based Knowledge-

Routine Exceptional
Error Error based Errors

EXCEPTIONAL

 Mengabaikan peraturan & prosedur secara sengaja

 Pelanggaran berat
- Penggunaan pelindung
- Penggunaan alat/peralatan
- Peraturan & prosedur kerja
- Traffic management

Mis.: Mengoperasikan unit tanpa Kimper atau SIO

unconsciousness consciousness
 PRECONDITIONS
FOR
UNSAFE ACTS

Condition of Environmental Personnel

Workers Factors Factors

Adverse Adverse Physical/

Coordination & Workers
Mental Physiological Mental
Communication Readiness
States States Limitations

Physical Technological
Environmental Environmental
 PRECONDITIONS
FOR
UNSAFE ACTS

Condition of Environmental Personnel

Workers Factors Factors

Adverse Adverse Physical/

Coordination & Workers
Mental Physiological Mental
Communication Readiness
States States Limitations

Physical Technological
Environmental Environmental

PHYSICAL ENVIRONMENT
 Kondisi lingkungan di area operasional
- Energi
- Instalasi
- Kondisi jalan/area kerja
- Kondisi lingkungan
- Housekeeping
- Ergonomik
- Kondisi lainnya (cuaca, confined space, banjir, dll)
 PRECONDITIONS
FOR
UNSAFE ACTS

Condition of Environmental Personnel

Workers Factors Factors

Adverse Adverse Physical/

Coordination & Workers
Mental Physiological Mental
Communication Readiness
States States Limitations

Physical Technological
Environmental Environmental

TECHNOLOGICAL ENVIRONMENT
 Ketersediaan dan desain perangkat-
perangkat kerja
- APD
- Pelindung & safety device
- Rambu/tanda peringatan
- Alat & peralatan
- Desain
 PRECONDITIONS
FOR
UNSAFE ACTS

Condition of Environmental Personnel

Workers Factors Factors

Adverse Adverse Physical/

Coordination & Workers
Mental Physiological Mental
Communication Readiness
States States Limitations

Physical Technological
Environmental Environmental
ADVERSE MENTAL STATE
 Penurunan kondisi mental dari
biasanya
- Psikologis
- Kesadaran
 PRECONDITIONS
FOR
UNSAFE ACTS

Condition of Environmental Personnel

Workers Factors Factors

Adverse Adverse Physical/

Coordination & Workers
Mental Physiological Mental
Communication Readiness
States States Limitations

Physical Technological
Environmental Environmental
ADVERSE PHYSIOLOGICAL
STATES
 Kondisi medis dan fisik yang
mengalami penurunan dari kondisi
biasanya
- Medis
- Fatigue
 PRECONDITIONS
FOR
UNSAFE ACTS

Condition of Environmental Personnel

Workers Factors Factors

Adverse Adverse Physical/

Coordination & Workers
Mental Physiological Mental
Communication Readiness
States States Limitations

Physical Technological
Environmental Environmental
PHYSICAL/MENTAL
LIMITATIONS
 keterbatasan/gangguan pada kondisi fisik
dan mental secara permanen
- Keterbatasan mental
- Kekurangan sensori
- Keterbatasan fisik
 PRECONDITIONS
FOR
UNSAFE ACTS

Condition of Environmental Personnel

Workers Factors Factors

Adverse Adverse Physical/

Coordination & Workers
Mental Physiological Mental
Communication Readiness
States States Limitations

Physical Technological
Environmental Environmental
COORDINATION & COMMUNICATION
 Proses interaksi dalam operasi kerja
- Koordinasi
- Komunikasi
 PRECONDITIONS
FOR
UNSAFE ACTS

Condition of Environmental Personnel

Workers Factors Factors

Adverse Adverse Physical/

Coordination & Workers
Mental Physiological Mental
Communication Readiness
States States Limitations

Physical Technological
Environmental Environmental
WORKERS READINESS
 Kesiapan karyawan untuk bekerja sesuai
ketentuan sebelum aktivitas pekerjaan di
mulai
- Kurang tidu
- Nutrisi tidak memadai
- Kebugaran fisik
- Berada di bawah pengaruh alkohol
- Berada di bawah pengaruh obat
 UNSAFE
LEADERSHIP

Planned
Inadequate Failed to Correct Leadership
Inappropriate
Leadership Known Problem Violation
Activities
 UNSAFE
LEADERSHIP
SUPERVISION

Planned
Inadequate Failed to Correct Leadership
Inappropriate
Leadership
Supervision Known Problem Violation
Activities

INADEQUATE LEADERSHIP
 Pembimbing/Pendamping
 Pelaksanaan Training
 Insentif
 Pengetahuan/Keterampilan Kepemimpinan
 Prosedur dan Kebijakan
 UNSAFE
LEADERSHIP
SUPERVISION

Planned
Inadequate Failed to Correct Leadership
Inappropriate
Leadership Known Problem Violation
Operations
Activities

PLANNED INAPPROPRIATE
ACTIVITIES
 Perencanaan Kerja/Tugas
 Penugasan Pekerja
 Perencanaan Keselamatan
 Pengawasan Kepemimpinan
 UNSAFE
SUPERVISION
LEADERSHIP

Planned Failed to Correct

Inadequate Leadership
Inappropriate Known Problem
Leadership Violation
Activities

FAILED TO CORRECT
KNOWN PROBLEM
 Bahaya & Risiko
 Kebijakan/Prosedur
 Perawatan/Tindakan Perbaikan
 UNSAFE
SUPERVISION
LEADERSHIP

Planned
Inadequate Failed to Correct Leadership
Inappropriate
Leadership Known Problem Violation
Activities

LEADERSHIP VIOLATIONS
 Pelanggaran peraturan dan prosedur
 Instruksi kerja tidak sesuai peraturan dan
prosedur
 Toleransi terhadap pelanggaran
 Penugasan pekerjaan
 Menyalahgunakan wewenang jabatan
 ORGANIZATIONAL
INFLUENCES

Resource Organizational Organization

Management Climate Process
 ORGANIZATIONAL
INFLUENCES

Resource Organizational Organization

Management Climate Process

RESOURCE MANAGEMENT
 Manusia
 Keuangan
 Peralatan/Fasilitas
 ORGANIZATIONAL
INFLUENCES

Resource Organizational Organization

Management Climate Process

ORGANIZATIONAL
CLIMATE
 Struktur
 Kebijakan
 Budaya
 ORGANIZATIONAL
INFLUENCES

Resource Organizational Organization

Management Climate Process

ORGANIZATION
PROCESS
 Operasional
 Prosedur
 Pengawasan