overview accident causation model 2011
TRANSCRIPT
OVERVIEW ACCIDENT CAUSATION MODEL
Accident Investigation, YK, 11
ACCIDENT
AN UNPLANNED, UNEXPECTED EVENT THAT INTERFERES WITH OR INTERRUPTS NORMAL
ACTIVITY & POTENTIALLY LEADS TO PERSONAL INJURY OR DOLLAR LOSS
(EQUIPMENT DAMAGE).
TERMS
ACCIDENTResult 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 ACCIDENTNEAR-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!
4/28/2004 prosafe institute 9
Gunung Es Kecelakaan
$ 1Biaya Langsung
Pengobatan, kompensasi
Biaya Tidak Langsung
-Kerusakan
-Terhentinya produksi
-Claim masyarakat
-Biaya penggantian alat
-Citra
$5-50
LOSS
Nilaisaham
Peluangpasar
citra Ganti rugi
Kerugianproduksi
Kerusakanmateri
Cederamanusia
accidentincident
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
logisMenentukan pencegahan yang tepat
ACCIDENT CAUSATION MODELHeinrich Model Bird &Loftus Model The Damaging Energy ModelSurrey Model The Task - Demand ModelMORT (Management Oversight Risk Tree) The System TheoryEpidemiology Approach
HEINDRICH MODEL 1931Domino Theory
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Dengan 3E :
STRATEGI PENCEGAHAN
HEINDRICH MODEL 1931Domino Theory
Safe Place
Safe People2. Enforcement
3. Engineering
1. Education
BIRD AND LOFTUS MODELLACK OF MANAGEMENT CONTROL
Kelemahan fungsi-fungsi manajemen, Leadership, pengawasan, standard kerja, standard performance, correction error.
INDIRECT / Basic CausePersonal knowledge, skill, motivation, physical or capability work problems. Work standard
design, abnormal use
DIRECT / Immmediate CauseUNSAFE ACTS UNSAFE CONDITION
ACCIDENT
LOSS
BIRD AND LOFTUS MODEL
– poor work practices
– inadequate or careless maintenance contractors
– group norms
– information overload
– disain kerja yang buruk
– diluar kemampuan pekerja
Aktivitas pihak IIITugas diluar kapasitas mental
– faktor disain– Hemat waktu & tenaga
– Cegah cape , lelah
– tuntutan untuk bebas
– mencari perhatian
PeralatanKonflik Motivasi
– Purchasing practices gagal menetapkansafety equipment kedalam spesifikasi.
– Gagal supervisi, Menginformasikan danmenginstruksikan regulasi
– Kurang waspada thd hazard
– Pengetahuan ttg pekerjaan
– Ketrampilan kerja
– Instruksi yang sesuai
ManajemenPengetahuan & Ketrampilan
External FactorsPersonal Factors
The Damaging Ener gy Model
gravitasi- Orang jatuh- Objek jatuh
Listrik
Kinetic (motion)
- Kendaraan- Objek- Mesin
Potential
Chemical- Radiasi- Toksisitas
Heat
Light- UV- Laser- Visible
biomekanik- Kendaraan- Objek- Mesin
Radiation
Sur r ey ModelTAHAP DANGER BUILD UP
Yes
Yes
Yes
Yes
Yes
YesNoNoNoNoNo
No
Tanda bahaya muncul ?
Melihat bahaya itu ?
Tahu bahaya itu ?
Tahu cara menghindarinya ?
Persepsi
ProsesKognitif
Responfisiologik
No Hazard Hazard Imminent Danger
Keputusan utk menghindarinya ?
Sanggup menghindarinya ?
Sur r ey ModelTAHAP DANGER BUILD UP
Yes
Yes
Yes
Yes
Yes
YesNoNoNoNoNo
No
Tanda bahaya muncul ?
Melihat bahaya itu ?
Tahu bahaya itu ?
Tahu cara menghindarinya ?
Persepsi
ProsesKognitif
Responfisiologik
No Hazard Hazard Imminent Danger
Keputusan utk menghindarinya ?
Sanggup menghindarinya ?
Sur r ey ModelTAHAP EMERGENCY
Yes
Yes
Yes
Yes
Yes
YesNoNoNoNoNoNo
Tanda bahaya muncul ?
Melihat bahaya itu ?
Tahu bahaya itu ?
Tahu cara menghindarinya ?
Keputusan utk menghindarinya ?
Sanggup menghindarinya ?
Persepsi
ProsesKognitif
Responfisiologik
No Damage Injury / Damage
\
The Task – Demand Model
Performance
Demand of tasks1
2
MORT
Management Oversight and Risk TreeManagement Oversight and Risk Tree
AccidentsDamage
Loss
OversightOmmisions
Acceptedrisks
Control factors
Accident amelioration
And
Incident
Preceding incidents
Energyflow
Informationsystem
Design and planning
Operationalreadiness
Maintenance Supervision
Barriers People inEnergy channel
And
Or
Managementsystems
Riskassessment
ImplementationPolicy
Or
M ORT
PETERSON’S ACCIDENT/INCIDENT
THEORY
OVERLOAD• Pressure • Fatigue• Motivation • Drugs• Alcohol• Worry
OVERLOAD• Pressure • Fatigue• Motivation • Drugs• Alcohol• Worry
ERGONOMICS TRAPS
• Incompatible workstation• Incompatible expectations
ERGONOMICS TRAPS
• Incompatible workstation• Incompatible expectations
DECISION TO ERROR
• Misjudgment of the risk • Unconscious decision to err• Logical based on the situation
DECISION TO ERROR
• Misjudgment of the risk • Unconscious decision to err• Logical based on the situation
HUMAN ERRORHUMAN ERROR
ACCIDENT ACCIDENT
INJURY DAMAGE INJURY DAMAGE
SYSTEM FAILURE
• Policy • Responsibility • Training • Inspection • Correction • Standard
SYSTEM FAILURE
• Policy • Responsibility • Training • Inspection • Correction • Standard
EPIDEMIOLOGICAL THEORY
OVERLOAD• Susceptibility of People
• Perception
• Environmental Factors
OVERLOAD• Susceptibility of People
• Perception
• Environmental Factors
DECISION TO ERROR • Risk Assessment by Individual •Peer pressure • Priorities of the Supervisor
• Attitude
DECISION TO ERROR • Risk Assessment by Individual •Peer pressure • Priorities of the Supervisor
• Attitude
Can cause or Prevent Accident
Can cause or Prevent Accident
SYSTEM THEORY
MAN
MACHINE ENVIRONMENT
INFO
DECISION RISKTASK
SUCCESSFUL TASK FEEDBACK
SYSTEM THEORY
MAN
MACHINE ENVIRONMENT
STRESSSOR
INFO
DECISION RISK
TASK
ACCIDENT
UNSUCCESSFUL TASK FEEDBACK
