ACCIDENT CAUSATION

MODEL

Accident Investigation, YK, 2010

ACCIDENT

AN UNPLANNED, UNEXPECTED EVENT THAT

INTERFERES WITH OR INTERRUPTS NORMAL
ACTIVITY & POTENTIALLY LEADS TO PERSONAL
INJURY OR DOLLAR LOSS (EQUIPMENT
DAMAGE).
TERMS
ACCIDENT
Result from contact with a substance or source of energy
above the threshold limit of the body or structure

INCIDENT
an undesired event which could or does result in a loss
TYPE OF ACCIDENT
MINOR ACCIDENTS :
Such as paper cuts to fingers or dropping a box of materials.

MORE SERIOUS ACCIDENT

more serious accidents that cause injury or damage to
equipment or property. Such as a forklift dropping a load or
someone falling off a ladder

ACCIDENT THAT OCCUR OVER AN EXTENDED TIME

FRAME
Accidents that occur over an extended time frame: such as
hearing loss or an illness resulting from exposure to
chemicals
THE ACCIDENT
NEAR-MISS

Also know as a “Near Hit”

An accident that does not quite result in injury or damage
(but could have).
Remember, a near-miss is just as serious as an accident!
 Gunung Es Kecelakaan
Biaya Langsung

$1 Pengobatan, kompensasi

Biaya Tidak Langsung

$5-50 -Kerusakan
-Terhentinya produksi
-Claim masyarakat
-Biaya penggantian alat
-Citra

4/28/2004 prosafe institute 9

LOSS

Cedera
Nilai manusia Kerusakan
saham materi
accident
Peluang incident Kerugian
pasar produksi
citra Ganti rugi
ACCIDENT CAUSATION MODEL
Digunakan “Accident Causation Model”  sebagai
metodologi ilmiah dalam investigasi kecelakaan
Tujuannya
Membantu menentukan penyebab kecelakaan sampai
pada ‘root causes’
Menentukan klasifikasi/jenis kecelakaan yang logis
Menentukan pencegahan yang tepat
ACCIDENT CAUSATION MODEL
Heinrich Model
Bird &Loftus Model
The Damaging Energy Model
Surrey Model
 The Task - Demand Model
MORT (Management Oversight Risk Tree)
The System Theory
Epidemiology Approach
 Ancestry
Environment

Fault of Person

Unsafe Condition
Unsafe Act
Domino Theory

ACCIDENT

LOSS
HEINDRICH MODEL 1931
 HEINDRICH MODEL 1931
Domino Theory

STRATEGI PENCEGAHAN
Dengan 3E :
Safe Place
1. Education
2. Enforcement
Safe People 3. Engineering
 BIRD AND LOFTUS MODEL
LACK OF MANAGEMENT CONTROL
Kelemahan fungsi-fungsi manajemen, Leadership, pengawasan, standard
kerja, standard performance, correction error.

INDIRECT / Basic Cause

Personal  knowledge, skill, motivation, physical or capability work problems. Work standard
design, abnormal use

DIRECT / Immmediate Cause

UNSAFE ACTS UNSAFE CONDITION

ACCIDENT

LOSS
 BIRD AND LOFTUS MODEL
Personal Factors
Pengetahuan & Ketrampilan
– Kurang waspada thd hazard
– Pengetahuan ttg pekerjaan
– Ketrampilan kerja
– Instruksi yang sesuai
Konflik Motivasi
– Hemat waktu & tenaga
– Cegah cape , lelah
– tuntutan untuk bebas
– mencari perhatian
Tugas diluar kapasitas mental
– information overload
– disain kerja yang buruk
– diluar kemampuan pekerja
External Factors
Manajemen
– Purchasing practices  gagal menetapkan
safety equipment kedalam spesifikasi.
– Gagal supervisi, Menginformasikan dan
menginstruksikan regulasi
Peralatan
– faktor disain
Aktivitas pihak III
– poor work practices
– inadequate or careless maintenance
contractors
– group norms
 Th e Da ma g i n g En e r g y Mo d e l
- Orang jatuh
gravitasi Heat
- Objek jatuh

- UV
Listrik Light - Laser
- Visible

Kinetic - Kendaraan - Kendaraan

(motion) - Objek biomekanik - Objek
- Mesin - Mesin

Potential
Radiation
- Radiasi
Chemical - Toksisitas
 Su r r e y Mo d e l
TAHAP DANGER BUILD UP
Su r r e y Mo d e l
TAHAP DANGER BUILD UP
Tanda bahaya muncul ?
Tanda bahaya muncul ?

Melihat bahaya
Melihat bahaya itu ?itu ? Yes
Persepsi Persepsi
Yes

Tahu bahaya itu ?

Tahu bahaya
Yes
itu ?
Proses
Tahu cara menghindarinya ?
Yes
Yes
Kognitif

Proses
Tahu cara menghindarinya
Keputusan utk menghindarinya ?
Yes ?
Respon
Sanggup menghindarinya ? Yes
Yes
Kognitif fisiologik
No No No No No
Keputusan utk menghindarinya
Yes No ?
Yes
No Hazard Hazard Imminent Danger

Respon
Sanggup menghindarinya ? Yes
fisiologik
No No No No No
Yes No

No Hazard Hazard Imminent Danger

 Su r r e y Mo d e l
TAHAP EMERGENCY
Tanda bahaya muncul ?

Melihat bahaya itu ?

Yes
Persepsi

Tahu bahaya itu ?

Yes

Proses Yes
Kognitif Tahu cara menghindarinya ?

Yes
Keputusan utk menghindarinya ?

Respon Yes
Sanggup menghindarinya ?
fisiologik No No No No No No
Yes
No Damage Injury / Damage
Th e Ta s k – De ma n d Mo d e l

Performance
2

1
Demand of tasks
 MORT

Management Oversight and Risk Tree

MOR T Accidents
Damage
Loss

Oversight Accepted
Ommisions risks

Control Management
factors systems
And Or

Accident amelioration Policy Implementation Risk

assessment
And
Incident Barriers People in
Energy channel
Preceding Energy
incidents flow
Or

Information Design and Operational

Maintenance Supervision
system planning readiness
 PETERSON’S
ACCIDENT/INCIDENT
THEORY

OVERLOAD
OVERLOAD ERGONOMICS
ERGONOMICS DECISION
DECISION TO TO
•• Pressure
Pressure TRAPS
TRAPS ERROR
ERROR
•• Fatigue
Fatigue •• Incompatible
Incompatible •• Misjudgment
Misjudgment of of
•• Motivation
Motivation workstation
workstation the
the risk
risk
•• Drugs
Drugs •• Incompatible
Incompatible •• Unconscious
Unconscious
•• Alcohol
Alcohol expectations
expectations decision
decision to
to err
err
•• Worry
Worry •• Logical
Logical based
based onon
the
the situation
situation

HUMAN
HUMAN ERROR
ERROR

SYSTEM
SYSTEM
FAILURE
FAILURE
•• Policy
Policy ACCIDENT
ACCIDENT
•• Responsibility
Responsibility
•• Training
Training
•• Inspection
Inspection
•• Correction
Correction INJURY
INJURY DAMAGE
DAMAGE
•• Standard
Standard
 EPIDEMIOLOGICAL
THEORY

OVERLOAD
OVERLOAD DECISION
DECISION TO TO ERROR
ERROR
•• Susceptibility
Susceptibility of
of •• Risk
Risk Assessment
Assessment by
by
People
People Individual
Individual

•• Perception
Perception ••Peer
Peer pressure
pressure

•• Environmental
Environmental •• Priorities
Priorities of
of the
the
Factors
Factors Supervisor
Supervisor

•• Attitude
Attitude

Can
Can cause
cause or
or
Prevent
Prevent Accident
Accident
 SYSTEM THEORY
SUCCESSFUL TASK FEEDBACK

MAN I
N T
F DECISION RISK A
MACHINE ENVIRONMENT O S
K
 SYSTEM THEORY
UNSUCCESSFUL TASK
FEEDBACK
S
T
MAN R I T
E N A
S DECISION RISK ACCIDENT
F S
MACHINE ENVIRONMENT S O K
S
O
R