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"PT XYZ adalah perusahaan yang bergerak dibidang minyak dan gas, dimana memiliki anak perusahaan dengan karakteristik yang bervariasi. Karakteristik tersebut memunculkan risiko terjadinya kecelakaan kerja. Kasus kecelakaan kerja di PT XYZ selama 4 tahun terakhir meningkat. Penelitian ini dilakukan untuk untuk mengkaji kegagalan sistem pertahanan pada tingkat HFACS (Human Factor Analysis and Classification System) baik aktif maupun laten. Hasil penelitian ini menyebutkan bahwa fatality terjadi di tahun 2014 dengan lokasi insiden di onshore dan berada di Sumatera dan Sulawesi. Kemudian permasalahan terkait kegagalan dari sistem pertahanan HFACS yang banyak ditemukan adalah skill-based error, technological errors, coordination and communication, planned inappropriate operation, inadequate supervision, dan organizational process. Hasil analisis penelitian menyarankan tindakan perbaikan pada tingkat individu untuk kegagalan aktif dan tingkat organisasi untuk kegagalan laten untuk mengurangi atau menghilangkan kesalahan-kesalahan teridentifikasi sehingga akan memperkuat ketahanan sistem terhadap terjadinya kecelakaan.

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XYZ is a company engaged in oil and gas, which has subsidiaries with varying characteristics. These characteristics raise the risk of accidents. Cases of occupational accidents in XYZ during the last 4 years increased. This study was conducted to assess the failure of the defense system at the level of HFACS (Human Factor Analysis and Classification System), both active and latent. Results of this study stated that the fatality occurred in 2014 with the incident at onshore locations and are located in Sumatra and Sulawesi. Then the problems related to the failure of the defense system HFACS that are found are skill-based errors, technological errors, coordination and communication, planned Inappropriate operation, inadequate supervision, and organizational process. The analysis of research suggests corrective actions at the individual level for the failure of active and latent level of the organization for failure to reduce or eliminate the errors identified so that it will strengthen the resilience of the system against accidents."

"PT XYZ adalah perusahaan yang bergerak dibidang pertambangan, dimana memiliki lokasi kerja yang tersebar di Indonesia dengan karakteristik yang bervariasi. Karakteristik tersebut yang dapat memunculkan risiko terjadinya kecelakaan kerja. Penelitian ini bertujuan untuk mendapatkan gambaran tentang sistem pertahanan dalam mencegah kecelakaan sesuai dengan kerangka pikir Swiss Cheese Model. Peneliti mengkaji kegagalan sistem pertahanan dengan menggunakan metode Human Factor Analysis and Classification System in Mining Industry (HFACS-MI). Hasil penelitian ini menyebutkan bahwa kasus cedera tangan dan jari masih terjadi dan kejadiannya cenderung berulang. Berdasarkan analisis yang dilakukan terhadap 33 kasus kecelakaan, permasalahan yang banyak ditemukan diantaranya adalah decisions errors, adverse mental states, coordination and communication, planned inappropriate operations, dan organization process. Dapat disimpulkan bahwa sistem pertahanan yang ada untuk mencegah kecelakaan masih belum optimal. Oleh karena itu, perlu dilakukan perbaikan sistem pertahanan, baik yang ditargetkan kepada individu maupun organisasi, agar risiko kecelakaan dapat dikendalikan.

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XYZ is a company engaged in mining, which has several work sites in Indonesia with varied characteristics. This research aims to get an overview of the defense system in preventing accidents in accordance to the Swiss Cheese Model framework. This research examined the failure of the defense system by using the Human Factor Analysis and Classification System in Mining Industry (HFACS-MI) method. The result of this study mention that the case of hands and fingers injury still occurs. Based on the analysis of 33 cases of accident, the causes are mostly the decisions of errors, adverse mental states, coordination and communication, planned inappropriate operations, and organization process. It can be concluded that the defense system in XYZ company is still not optimal to prevent occupational accidents. Therefore, the defense system will need improvement, targeted to both individuals and organizations, so that the risk of accidents can be controlled."

"Tesis ini mengkaji kecelakaan kerja di PT XYZ tahun 2015 dengan menggunakan framework Human Factors And Classification System (HFACS). Penelitian ini adalah penelitian semi kuantitatif dengan desain studi deskriptif analitik. Hasil dari penelitian ini adalah lapisan dari HFACS yang paling banyak kelemahannya adalah unsafe act sebanyak 11 dari total 11 kecelakaan yang diteliti dengan elemen decision error menjadi faktor yang paling lemah, lalu disusul dengan precondition of unsafe act sebanyak 10 dengan elemen conditions of operator menjadi faktor yang paling banyak berkontribusi terhadap kecelakaan, lalu disusul dengan unsafe supervision sebanyak 7 dengan elemen inadequate leadership menjadi faktor yang paling banyak berkontribusi terhadap kecelakaan, dan yang terakhir organizational influences sebanyak 5 dengan elemen organizational climate dan resource management menjadi faktor yang paling banyak berkontribusi terhadap kecelakaan. Hasil analisis penelitian menyarankan tindakan perbaikan di tiap tingkatan HFACS baik pada perbaikan kegagalan aktif maupun laten dengan penekanan pada perbaikan di lapisan unsafe act.

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This thesis assess the accident in PT XYZ 2015 by using Human Factors And Classification System (HFACS) framework. This research is a semi-quantitative with design study analytical descriptive. Results from this study are a layer of HFACS most weakness is unsafe act at 11 from total 11 accidents with the elements of decision error becomes a factor of the number one weakness, then followed with a precondition of unsafe act at 10 with the elements of conditions of service to be the factors that most contribute to accidents, followed by unsafe supervision at 7 with inadequate leadership element is the factor that most contributed to the accident, and the latter as much as 5 of organizational influences with elements of organizational climate and resource management is the factor that most contributed to the accident. The analysis of research suggests corrective actions at each level of HFACS, not only for active failures but also latent failures with reinforcing corrective action at the unsafe act layer."

"Human Factors Analysis and Classification System in Mining Industry (HFACS-MI) merupakan suatu metode investigasi kecelakaan untuk mencari faktor-faktor penyebab kecelakaan pada industri pertambangan. Metode HFACS sendiri telah banyak digunakan untuk investigasi kecelakaan diberbagai industri seperti penerbangan, konstruksi, kereta api, dan industri lainnya. Metode ini terdiri dari 5 (lima) tingkatan yaitu unsafe act, precondition for unsafe act, unsafe leadership, organizational influences, dan outside factor. PT. XYZ merupakan salah satu perusahaan pertambangan di wilayah Kalimantan Timur. Kecelakaan yang sudah terjadi tentunya membuat perusahaan mengalami kerugian, perlunya dilakukan kajian proses analisis secara detail untuk mengetahui faktor penyebab kecelakaan bersifat aktif dan laten serta mengetahui keterkaitan penyebab kecelakaan dari berbagai tingkat dengan menggunakan metode HFACS-MI.

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Human Factors Analysis and Classification System in Mining Industry (HFACS-MI) is an accident investigation method to find the factors that cause accidents in the mining industry. The HFACS method itself has been widely used for accident investigations in various industries such as aviation, construction, railroads, and other industries. This method consists of 5 (five) levels, namely unsafe act, precondition for unsafe act, unsafe leadership, organizational influences, and outside factors. PT. XYZ is a mining company in the East Kalimantan region. Accidents that have occurred certainly make the company suffer losses, it is necessary to study the analytical process in detail to find out the active and latent causal factors and find out the interrelationships of the causes of accidents from various levels using the HFACS-MI method."

"Dalam setiap aktivitas pertambangan, terdapat potensi bahaya yang menimbulkan risiko terjadinya kecelakaan. Jenis kecelakaan menabrak merupakan kecelakaan yang banyak terjadi pada operasi lalu lintas tambang jobsite PT SS (41%) dan kejadiannya cenderung berulang. Maka dari itu, penelitian ini bertujuan untuk mendapatkan gambaran tentang sistem pertahanan dalam mencegah kecelakaan sesuai dengan kerangka pikir Swiss Cheese Model. Penelitian ini dilakukan dengan pendekatan kualitatif melalui analisis data kecelakan lalu lintas tambang di salah satu jobsite di PT SS, suatu perusahaan kontraktor pertambangan batubara terbuka, dengan menggunakan Human Factors Analysis and Classification System in Mining Industry (HFACS-MI). Berdasarkan analisis yang dilakukan terhadap 53 kasus kecelakaan lalu lintas tambang, permasalahan yang banyak ditemukan di antaranya adalah skill-based error, adverse mental states, coordination and communication, inadequate leadership, dan organization process. Dapat disimpulkan bahwa sistem pertahanan yang ada untuk mencegah kecelakaan lalu lintas tambang masih belum optimal. Oleh karena itu, perlu dilakukan perbaikan sistem pertahanan, baik yang ditargetkan kepada individu ataupun organisasi, agar risiko kecelakaan dapat dikendalikan.

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In mining process activities, there are potential hazards that poses a risk to be an accident. Collision is one of accident types that frequently happen on mining traffic operations jobsite PT SS (41%) and it has tendency to occur repeatedly. This study aimed to gain an overview of defences system in preventing accidents according to Swiss Cheese Model framework. The research was conducted with a qualitative approach through mining traffic accident data analysis in one of jobsite in PT SS, an open coal mining contractor company, using the Human Factors Analysis and Classification System in Mining Industry (HFACS-MI).

Based on the analysis of 53 cases of mining traffic accidents, revealed that the most common problems were skill-based errors, adverse mental states, coordination and communication, inadequate leadership, and organization process. It can be concluded that the existing defences system to prevent mining traffic accidents has not been optimal yet. Therefore, defences system improvement, either targeted to the individual or organizational, is needed to control accident risk."

"Tesis ini membahas studi kasus kecelakaan kerja akibat gas beracun di tambang bawah tanah PT Freeport Indonesia. Penelitian ini adalah penelitian desain deskriptif dan analisis dilakukan menggunakan metode Human Factor Analysis and Classification System (HFACS). Hasil penelitian mendapatkan bahwa terdapat 3 kasus kecelakaan akibat gas beracun di seluruh blok penambangan bawah tanah PTFI selama periode 2019-2022 dengan faktor risiko berasal dari tindakan tidak aman yang dikategorikan dalam Human Factor Analysis and Classification System (HFACS) yang terbagi menjadi empat yaitu organizational influences, unsafe leadership, precondition for unsafe acts, dan unsafe acts. Pada penelitian didapatkan hasil kegagalan sistem pertahanan pada pengaruh organisasi dalam kasus keracunan gas beracun di dominasi kategori resource management berjumlah 7 kegagalan (57%), faktor-faktor penyumbang kegagalan sistem management antara lain SOP, safety sign, Planned Inspection, PJO, Kebijakan K3, Database incident management system dan komunikasi saat penyampaian instruksi kerja. Tingkat Unsafe Supervision dalam kasus keracunan gas beracun berjumlah 11 kegagalan (55%) dengan dominasi oleh kategori Supervisory Violation, faktor-faktor penyumbang kegagalan sistem manajemen antara lain Neil George Checklist, Bulkhead Ventilation, Re-entry Checklist, Airlock Door, Vent bag, Supervisor Inspection, Alat Pelindung Diri, Pengawasan di lapangan, kelayakan sistem ventilasi di lokasi kerja, observasi pengawas ke pekerja terkait pengoperasian portable gas detector dan instruksi kerja. Tingkat Precondition for Unsafe Acts dalam kasus keracunan gas beracun didominasi kategori Personal Readiness berjumlah 8 kegagalan (38%), faktor-faktor penyumbang kegagalan sistem management antara lain peralatan blasting, PDA, pemahaman bahasa pengantar, emission test alat berat, ceklist stope vent dan ventilasi di area blasting, tidak mempedulikan alarm gas detector. Tingkat Unsafe Acts dalam kasus keracunan gas beracun berjumlah 11 kegagalan (46%) dari dominasi kategori Violation Routine, faktor-faktor penyumbang kegagalan sistem management antara lain chemical handling, prosedur yang tidak memadai, sign nilai ambang batas dalam satu bahasa, dumper vent terhalang lumpur dan vent bag rusak, fixed gas detector belum terkalibrasi dan tertutup lumpur, evaluasi pelatihan tidak konsisten dilakukan, barikade area, tidak mengikuti re-entry protocol. Perusahaan disarankan untuk melakukan evaluasi pada program penanganan kecelakaan akibat gas beracun.

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This thesis discusses case studies of work accidents due to toxic gas in PT Freeport Indonesia's underground mine. This research is a descriptive design research and the analysis was carried out using the Human Factor Analysis and Classification System (HFACS) method. The results of the study found that there were 3 cases of accidents due to toxic gas in all PTFI underground mining blocks during the 2019-2022 period with risk factors originating from unsafe actions which were categorized in the Human Factor Analysis and Classification System (HFACS), which was divided into four, namely organizational influences, unsafe leadership, precondition for unsafe acts, and unsafe acts. In the study, the results of the failure of the defense system on organizational influence in cases of poison gas poisoning were dominated by the category of resource management totaling 7 failures (57%), contributing factors to the failure of the management system including SOP, safety sign, Planned Inspection, PJO, K3 Policy, Database incident management system and communication when submitting work instructions. . The level of Unsafe Supervision in cases of poison gas poisoning amounted to 11 failures (55%) with dominance by the Supervisory Violation category, contributing factors to management system failure including the Neil George Checklist, Bulkhead Ventilation, Re-entry Checklist, Airlock Door, Vent bag, Supervisor Inspection, Personal Protective Equipment, Supervision in the field, feasibility of the ventilation system at the work site, supervisor's observation of workers regarding the operation of portable gas detectors and work instructions. The level of Precondition for Unsafe Acts in cases of poison gas poisoning was dominated by the Personal Readiness category with 8 failures (38%), contributing factors to management system failure including blasting equipment, PDA, understanding of the language of instruction, emission test of heavy equipment, stop vent checklist and ventilation in the blasting area, ignoring the gas detector alarm. The level of Unsafe Acts in cases of poison gas poisoning amounted to 11 failures (46%) from the dominance of the Violation Routine category, contributing factors to management system failure including chemical handling, inadequate procedures, sign threshold values ​​in one language, dumper vents blocked by mud and the vent bag is damaged, the fixed gas detector has not been calibrated and is covered in mud, inconsistent training evaluations are carried out, barricaded areas, do not follow the re-entry protocol. Companies are advised to evaluate the program for handling accidents caused by toxic gasses."

"ABSTRAKSkripsi ini membahas kasus kecelakaan Boeing 737-800 di Bandara Ngurah Rai, Bali tahun 2013 melalui investigasi HFACS Human Factors Analysis and Classification System . Tujuan penelitian ini untuk melihat kontribusi faktor manusia pada suatu kecelakaan di bidang aviasi. Penelitian ini adalah penelitian kualitatif dengan desain deskriptif. Hasil penelitian menyarankan upaya perbaikan terhadap faktor-faktor kontribusi kecelakaan seperti tindakan yang mengarah pada kecelakaan, pra-kondisi tidak aman, pengawasan yang kurang baik dan pengaruh organisasi.

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ABSTRACTThe focus of this study is investigating Boeing 737 800 accident in Ngurah Rai International Airport, Bali, 2013 using HFACS Human Factors Analysis and Classification System . The purpose of this study is to understand contributing of human factors in aviation accidents. This research is qualitative descriptive interpretive. The researcher suggests that corrective effort to contributing factors of accident such as unsafe acts, precondition for unsafe act, unsafe supervision and organizational influences."

"PT. XY perusahaan jasa pelayanan Dump Truck anak perusahaan semen di sektor tambang batu kapur, di PT. XY pernah terjadi kecelakaan kerja maka analisis kecelakaan dengan metode HFACS-MI perlu dilakukan. Penelitian ini bertujuan untuk menganalisis faktor-faktor yang berkontribusi latentdan active failures menyebabkan kecelakaan kerja pengoperasian dump truck. Pada penelitian ini menggunakan desain penelitian studi kasus dengan metode semi kuantitatif dengan pendekatan deskriptif. Populasi dalam penelitian ini adalah data laporan kecelakaan berupa hasil investigasi dari pengoperasian DT sebanyak 27 kasus kecelakaan kerja tahun 2019-2021. Hasil penelitian menunjukkan bahwa kategori dari HFACS-MI yang paling besar berkontribusi adalah organizational influences sebanyak 429 terkait dengan kurangnya analisis keselamatan kerja. Kemudian disusul unsafe leadership sebanyak 370 terkait dengan pengawasan pekerjaan yang tidak memadai. Precondition for unsafe act sebanyak 289 terkait dengan kondisi permukaan jalan licin. Unsafe act sebanyak 247 terkait dengan kegagalan mengenali bahaya. Dan yang paling kecil kategori berkontribusi ialah outside factor sebanyak 1 terkait dengan workshop diluar perusahaan. Disimpulkan bahwa framework HFACS-MI pada latent failures yang banyak berkontribusi ialah organizational influences dan pada active failures yang banyak berkontribusi ialah unsafe act, maka saran tindakan perbaikan di tiap kategori HFACS-MI pada perbaikan latent dan active failures dengan penekanan pada kategori organizational influences.

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PT. XY Dump Truck service company, a cement subsidiary in the limestone mining sector, at PT. XY has had a accident, so an accident analysis using the HFACS-MI method needs to be done. This research to analyze the factors that contribute laten and active failures to accidents in dump truck operations based on the HFACS-MI framework. This research uses a case study research design with a semi-quantitative method with a descriptive approach. The population in this study is accident report data in the form of investigation results from the operation of DT as many as 27 cases of work accidents in 2019-2021. The results showed that the category of HFACS-MI that contributed the most was organizational influences as many as 429 related to the lack of work safety analysis. Then followed by 370 Unsafe leadership related to inadequate work supervision. There are 289 preconditions for unsafe acts related to slippery road surface conditions. As many as 247 unsafe acts are related to failure to recognize hazards. And the smallest contributing category is the outside factor as much as 1 related to workshops outside the company. It is concluded that the HFACS-MI framework on latent failures that contributes a lot is organizational influences and on active failures that contributes a lot is unsafe act, then the suggestions for corrective actions in each HFACS-MI category are on repairing latent and active failures with an emphasis on the category of organizational influences."

"Industri pertambangan dipandang sebagai kategori industry dengan risiko tinggi. Jenis kecelakaan tambang lost time injury dan fatality merupakan kecelakaan dengan dampak major terhadap Grup Perusahaan X. Meskipun telah memiliki pedoman teknis pelaporan dan investigasi insiden serta dilakukan tindakan perbaikan, kecelakaan masih terus terjadi. Maka dari itu, penelitian ini bertujuan untuk mengidentifikasi tren penyebab kecelakaan tambang dan kelemahan sistem pertahanan berdasarkan konsep Human Factors Analysis Classification System in Mining Industry (HFACS-MI) di Grup Perusahaan X tahun 2021-2022. Penelitian ini merupakan penelitian deskriptif analitik dengan pendekatan semi kuantitatif. Hasil penelitian menunjukkan bahwa kelemahan sistem pertahanan active faiure yang sering ditemukan adalah tingkat unsafe acts kategori skill-based error. Sedangkan kelemahan sistem pertahanan latent failure yang sering ditemukan adalah tingkat unsafe leadership kategori inadequate leadership. Peneliti menyimpulkan bahwa masih banyak kelemahan pada sistem pertahanan active dan latent failure sehingga pencegahan kecelakaan masih belum optimal. Oleh karena itu, perlu dilakukan perbaikan di setiap tingkat sistem pertahanan, baik yang ditargetkan kepada individu maupun organisasi, agar kecelakaan dapat dicegah dan risiko kecelakaan dapat dikendalikan.

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The mining industry has been viewed as a high-risk industry. Types of mining accidents, such as lost time injuries and fatalities, have a significant impact at both the individual and organizational levels. Despite Group Company X having technical guidelines for incident reporting and conducting investigations with corrective actions, accidents continue to occur. Therefore, this study aims to identify trends in the causal factors of mining accidents and find weaknesses in defense systems based on the Human Factors Analysis Classification System in the Mining Industry (HFACS-MI) method. This research method uses an analytical descriptive approach with a semi-quantitative method. The results show that the most common weakness in the active failure defense system is the occurrence of unsafe acts in the skill-based error category. Additionally, the most common weakness in the latent failure defense system is inadequate leadership in the leadership category. The study concludes that there are still numerous weaknesses in the active and latent failure defense systems, which hinder optimal accident prevention. Improvements need to be made at all levels of the defense system, targeting both individuals and organizations, to prevent accidents and effectively control the risk of accidents."

"Proses pekerjaan konstruksi suatu bangunan dalam kegiatan operasionalnya selalu terdapat potensi bahaya yang dapat mengancam tenaga kerja berupa kecelakaan kerja, kebakaran, bahan kimia, ledakan, wabah penyakit dan penyakit akibat kerja yang bisa terjadi sewaktu-waktu. Penelitian ini merupakan kajian mengenai upaya pencegahan kecelakaan kerja bidang konstruksi. Penelitian ini dilakukan pada proyek pembangunan Teaching Hospital Universitas Indonesia kampus Depok oleh kontraktor pembangunan PT WIKA pada kurun waktu awal juni 2015. Penelitian ini menggunakan desain penelitian cross sectional dengan menggunakan pendekatan kuantitatif dan di dukung dengan metode kualitatif yang dalam menganalisis mendalam mengenai upaya pencegahan kecelakaan kerja bidang konstruksi menggunakan pendekatan model Human Factor Analysis Classification System (HFACS). Adapun yang menjadi hasil penelitian adalah sebagai berikut: Pelaksanaan resources management, organizational climate dan organizational process pada tingkat organizational influences / pengaruh organisasi sudah tinggi pelaksanaannya oleh pihak manajemen. Pelanggaran pada kegiatan inadequate supervision, planned inappropriate operations, failed to correct problems dan supervisory violations pada tingkat unsafe supervision / pengawasan tidak selamat termasuk dalam kategori rendah. Upaya untuk mencegah terjadi kecelakaan kerja masih terdapat lubang / celah kegagalan yang dapat mempengaruhi risiko terjadi kecelakaan kerja yakni pada condition of operators masih terdapat sebesar 9,3 %, crew resources management sebesar 5,2 % dan personal readiness sebesar 4,1 %. Potensi tinggi terjadi kegagalan upaya pencegahan kecelakaan kerja yang disebabkan oleh tindakan errors di sebesar 8,2 %, tindakan pelanggaran sekitar 5,2 %. Penelitian ini merekomendasikan beberapa hal antara lain, merealisasikan program K3, menegakkan peraturan, kebijakan dan komitmen perusahaan,mengadakan pelatihan K3, menjaga konsistensi implementasi K3L, melakukan pengadaan APD yang sesuai standard, mengalokasikan pembiayaan K3L, mengadakan pelayanan kesehatan, dan membangun leadership value.

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The process of building construction in the operations always any the potential hazard that can threaten the labor, such as occupational accidents, fire, chemicals, explosion, epidemic and occupational diseases that could occur at any time. This is a research study prevention construction workplace accidents. This study was perform on development projects Teaching Hospital, University of Indonesia campus in Depok by construction contractor PT WIKA during at June 2015. This study used cross sectional design with a quantitative approach and supported by qualitative methods, and for advance analyzing by using the model of Human Factor Analysis Classification System (HFACS). The results of this study are: Implementation of resources management, organizational climate and organizational process at the organizational influences have had implementating correctly by management. Infringement on the activities of inadequate supervision, planned Inappropriate operations, failed to correct problems and supervisory violations at the level of unsafe supervision is in the low category. Defense system for the prevention of occupational accidents is still a gap failures that can affect the risk of workplace accidents that occur on the condition of operators 9.3%, crew resources management 5.2% and 4.1% for personal readiness. High potential failure prevention of defense system for occupational accidents caused by errors 8.2%, and violations about 5.2%. Recommendation are: realize the HSE program, enforce regulations, policies and commitment of the company, HSE training, consistent for implementating HSE activities, procure appropriate PPE standards, HSE funding management, conduct the health services, and build leadership value."