Group 1

Presented By:
Diego Putra Dewangga (02211540000050)
Mochammad Ircham Maulana (02211540000155)
Awaludin Rauf Firmansyah (02211640000001)
Provide participants with the basic skills
necessary to conduct an effective accident
investigation in your workplace.
 You will identify;
 Primary Reasons, Benefits, and
 Employer Responsibilities to
conducting an accident
investigation
 Three Steps for an
Effective Investigation
 Investigate and Analysis

CB106 Accident Investigation

The most important things in an accident are:

 When an accident happens, the most important

thing is taking care of the victim or victims.
◦ After that, the most important thing is finding
the causes of the accident.
◦ All of us, including employers, need help
and advice to identify the causes of
accidents.

CB106 Accident Investigation

Accidents also cause great economic losses
 Lost efficiency due to break-up of crew.
 Damage to tools and equipment.
 Damage from accident due to fire, water,
chemicals, spills, crashes, etc.
 Loss of customers because products and
services are not provided.
 Training costs for replacement worker.

CB106 Accident Investigation

What is an accident ?

An unwanted, unplanned event

that causes injuries, illnesses, or
property damage.

What is an incident ?

An unwanted, unplanned event

that almost causes injuries,
illnesses, or property damage.

CB106 Accident Investigation

 For each accident,
1
ACCIDENT • 300 incidents occurred, or
• you lost 300 chances to
300 INCIDENTS prevent the accident!

If we are going to
prevent accidents,
we have to investigate the
accidents and the incidents!

CB106 Accident Investigation

 Unsafe Conditions

◦ Poorly maintained machinery or equipment.

◦ Defective or missing personal protective equipment.
◦ Unguarded machinery or equipment.
◦ Missing or inadequate
warnings or safety and health
signs.
◦ Lack of housekeeping.

CB106 Accident Investigation

 Unsafe Acts
◦ Conduct work operations
without prior training
◦ Block or remove safety
devices.
◦ Clean, lubricate, or repair
equipment while its in
operation.
◦ Working without protection in
hazardous places.

CB106 Accident Investigation

 Investigate

 Analyze

 Report

CB106 Accident Investigation

 Seal the accident area.
 Interview witnesses.
 Draw and take
measurements of the
accident area.
 Take samples.

CB106 Accident Investigation

 Say what happened step-by-step.
 Analyze the events with the 6 key questions:
◦ Who? Who saw the crash?

◦ What? What happened to the

brakes?
◦ When? When did the brakes fail?
◦ Where? Where were the
replacement brakes?
◦ Why?
Why wasn’t the mechanic
◦ How? told?
How did the crash happen?
.

CB106 Accident Investigation

 Say what happened.
 Say which were the surface
causes.
 Say which were the root
causes.
 Say what needs to be done
so the accident doesn’t
happen again.

CB106 Accident Investigation

Accidents must be investigated and analyzed
from three different points of view:

1 . Direct cause of injury

2. Surface causes of
accident
3. Root causes of the
accident

CB106 Accident Investigation

A harmful transfer of energy
that produces injury or
illness.

 The worker suffered two

broken legs when the
truck crashed into the
wall.

CB106 Accident Investigation

Specific unsafe conditions or unsafe behaviors
that result in an accident.
 The truck crashed into the wall because the
brakes failed.

CB106 Accident Investigation

Common conditions and behaviors that
ultimately result in an accident.
 The company did not have a maintenance
program for its vehicles.

CB106 Accident Investigation

 Weed out the causes of injuries and
illnesses Strains
Burns
Direct Causes of
Cuts Injury/Illness

Surface
Causes of the
Accident

Conditions Behaviors
Lack of time Fails to enforce

Inadequate training

No discipline procedures Inadequate labeling procedures

No orientation process Outdated Procedures

Inadequate training plan

No accountability policy No inspection policy

- Accident Weed
Root Causes of the
Accident
CB106 Accident Investigation
 Secure the accident scene
 Collect facts about what happened
 Develop the sequence of events
 Determine the causes
 Recommend
improvements
 Write the report

CB106 Accident Investigation

Be ready when accidents happen
1. Write a clear policy statement.
2. Identify those authorized to notify
outside agencies (fire, police, etc.)
3. Designate those responsible to
investigate accidents.
4. Train all accident investigators.
5. Establish timetables for conducting
the investigation and taking
corrective action.
6. Identify those who will receive the
report and take corrective action.

CB106 Accident Investigation

 Accident investigation

 Let’s watch a video !!

CB106 Accident Investigation

This is the accident scenario:

An employee is working on a ladder and the

ladder seems to collapse.The employee falls off
the ladder and died.

CB106 Accident Investigation

The investigation reveals the following details:
 Employee had worked seven 12-hour shifts in a row.
 Accident happened at end of shift.
 Employee was standing on the top step of the ladder (an unsafe action).
 The employee was approximately 10 feet above floor level.
 No fall arrest or restraint system was used.
 A ladder inspection policy is in place, but there is no evidence that the ladder
has ever been inspected.
 Investigation reveals the ladder was damaged and did not provide a stable
working platform in any environment.
 Interview with facility manager reveals that he did not inspect the ladder
when it was due for inspection. He was aware that ladder needed to be
inspected.

CB106 Accident Investigation

Factors and Possible Causes Affecting Incident

Extended work hours may have caused employee to be tired and not clear-
headed.
 Employee violated safety rule (standing on top step).

 No fall arrest system in place (required at 6 feet above floor level).

 Ladder was defective and unusable.

 Ladder had not been inspected.

 Facility manager was aware that ladder needed to be inspected but did not
adhere to the existing policies and procedures for ladder inspections.

CB106 Accident Investigation

What is the Root Cause?

Which factor, if not present, could have prevented the accident?

If the facility manager had inspected the ladder and discovered the defect,
the ladder would not have been used, and this accident would have been
prevented.Failure to follow established ladder inspection procedures is the root
cause.

CB106 Accident Investigation

What about the Other Factors?

 Extended work hours might contribute, but there is no statistical evidence

available that indicates extended work hours increase the risk of accidents.
 The safety rule violation could be a contributory cause in this accident, but
not the root cause. However, if the ladder had been used properly, it is
possible that the incident might have been prevented.
 •The existence of a fall arrest system may have prevented or reduced injury.
This could be a contributory cause.
 The fact that the ladder was defective is certainly a contributory cause. But if
the facility manager had followed procedures and removed the ladder from
service, the accident would have been prevented.

CB106 Accident Investigation

The root cause of this accident could even be tracked deeper than just finding
the facility manager’s failure to inspect the ladder. With more in-depth analysis,
it might be found that the real cause was a failure in the system itself. Perhaps
the safety system in place had no means of ensuring the facility manager
actually carried out these inspections.

It is for reasons like this that accident investigations are best conducted by a
team. This can ensure that as many possibilities are explored until all causes are
discovered. It is easy to place blame on individuals when in actuality, the
problem may be with your management systems.

 .

CB106 Accident Investigation

Pertanyaan :
1. Kelompok II, Hendy : dari slide 5W + 1H , kenapa di pertanyaan tentang
why mengarah ke mecanic ?

Jawaban : disini pertanyaan why yang mengarah ke mekanik hanyalah contoh, inti
sesungguhnya pertanyaan why ditujukan untuk menanyakan penyebab sebuah
kecelakaan terjadi.

2. Kelompok III, Stevefanus : dari presentasi dijelaskan penyebab terjadinya

kecelakaan adalah tidak dilakukannya maintenance, kemudian apakah ada
penyebab lain ?

Jawaban :
Tentu ada, penyebab lain yang dapat menimbulkan kecelakaan sendiri adalah
kecerobohan pekerja semisal ketika bekerja mereka bercanda, kurang hati-hati
atau memang lalai menggunakan perlengkapan safety

CB106 Accident Investigation

Pertanyaan :
3. Kelompok IV, Naufal : tolong beri contoh triangle accident

Jawaban :
Triangle accident merupakan suatu konsep yang mendukung teori domino dari heinrich,
tercatat kontribusi terbesar penyebab kecelakaan kerja adalah berasal dari sikap dan kondisi
yang tidak aman. Terkait triangle accident, dalam kasus sehari-hari ketika seorang engineer
yang sedang mengerjakan sesuatu di bagian atas suatu bangunan, karena engineer tersebut
sedang tidak fokus atau ceroboh, palu yang berada di sebelahnya tersenggol hingga terjatuh
ke bawah. Dari kejadian itu dapat menimbulkan berbagai kemungkinan yakni palu yang
terjatuh tidak/hampir mengenai engineer lain yang berada dibawah (near miss), palu tersebut
mengenai kaki engineer yang berada dibawah dan membuat engineer tersebut cedera (minor
injury) atau bahkan palu tersebut mengenai kepala engineer yang ada dibawah hingga
membuat cedera yang cukup fatal dibagian kepala dan beresiko kematian (fatality)

CB106 Accident Investigation

Pertanyaan :
4. Kelompok V, Triven : dari study case yang telah dipaparkan, menurut
kelompok anda, peralatan apa yang paling safety untuk bekerja di ketinggian ?

Jawaban :
Menurut kelompok kami dari study case, piranti yang paling safety ialah tangga
hidrolik/ scafolding yang dapat bergerak naik turun dan dapat dikendalikan dan
diawasi oleh engineer/ pengawas

5. Kelompok VI, Nidhom : semisal di sebuah pabrik terjadi kecelakan sampai

kebakaran yang tidak menyisakan apapun , bagaimana cara menginvestigasinya ?
Jawaban :
Kejadian semacam itu mungkin untuk bisa terjadi, namun dari pengalaman yang
ada belum ada kejadian semacam itu, namun tindakan preventif dapat dilakukan
dengan adanya piranti-piranti yang tahan terhadap kejadian-kejadian seperti
kebakaran dll, yang mana dapat menjadi bukti ketika kemungkinan buruk diatas
terjadi, namun terlepas dari itu pihak kepolisian bersama tenaga ahli tentu
memiliki sistematika tersendiri dalam melakukan investigasi suatu kejadian

CB106 Accident Investigation

Pertanyaan :
6. Kelompok VIII, Irfan : berapa lama waktu yang dibutuhkan untuk investigasi ?

Jawaban :
Tidak ada tolak ukur yang pasti dalam penentuan waktu investigasi, namun dalam
sebuah case di industri pastinya butuh waktu yang sesegera mungkin, karena hal
tersebut tentu berpengaruh juga pada tatanan operasional suatu pabrik, selain itu
pemerintah pun juga akan menekan direktur pabrik bila investigasi berjalan lama,
karena pembuatan suatu SOP baru tentunya harus disegerakan mengingat bahaya
accident yang tak hanyas merugikan pihak perusahaan namun juga warga sekitar.

7. Kelompok IX, Ayu : bagaimana peran accident investigation dalam

menangani kasus-kasus di industri atau di ranah lain ?

Jawaban :
Accident investigation memiliki peran yang sangat penting , karena bertujuan untuk
kedepannya adalah dapat mencegah kecelakaan agar tidak terjadi kembali. Hasil dan
evaluasi dari accident investigation dapaty menjadi pertimbangan industri dalam
pembuatan atau perubahan SOP

CB106 Accident Investigation

Pertanyaan :
8. Kelompok X, Adelia : bila terjadi accident dalam sebuah perusahaan
kemudian konsumen menurun , bagaimana mengembalikan kepercayaannya ?

Jawaban : Apabila adanya accident mengakibatkan konsumen produk-produk

perusahaan menurun, maka langkah yang harus dilakukan yakni mengadakan
evaluasi, lalu jajak pendapat dengan konsumen juga perlu sebagai bagian dari
hubungan konsumen-produsen, hingga melakukan serangkaian inovasi-inovasi
pada produk sehingga mebuat kembalinya rasa percaya para konsumen terhadap
produk-produk suatu perusahaan yang dulunya sempat mengalami accident
9. Kelompok XI, Fitria : kecelakaan apa saja yang memerlukan investigasi ?

Jawaban :
semua kecelakaan memerlukan investigasi, karena di setiap pabrik pasti memiliki
kebijakan-kebijakan strategis untuk keberlangsungan pabrik kedepan, contohnya
adanya laporan harian, mingguan, dan bulanan dari pabrik itu sendiri.

CB106 Accident Investigation

Pertanyaan :
10. Kelompok XII, nabilah : adakah pihak eksternal yang membantu mencegah
kecelakaan ?

Jawaban : Pihak-pihak eksternal tentunya juga ikut andil dalam pencegahan

kecelakaan, selain perusahaan yang sudah pasti punya SOP sendiri-sendiri,
pemerintah pun juga menetapkan SOP yang diatur dalam undang-undang sebagai
tindakan preventif, selain itu pihak lain seperti badan sertifikasi seperti ISO, juga
turut andil dalm penjamin mutu melalui sertifikasi safety.
11. Kelompok XIII, Doni : contohkan 5W+1H dari case yang dibuat

Jawaban :
 - Who : siapa yang mengalami kecelakaan jatuh dari tangga ketika bekerja ?
 - What : apa yang terjadi dengan tangganya sehingga dapat terjadi ?
 - When : kapan kecelakaan itu terjadi ?
 - Why : kenapa tangga itu digunakan ?
 - Where : dimana kecelakaan itu terjadi ?
 - How : bagaimana kecelakaan itu bias terjadi ?

CB106 Accident Investigation

Thank you

CB106 Accident Investigation