LABORATORIUM

ERGONOMI & PERANCANGAN SISTEM KERJA

TEKNIK INDUSTRI – ITS SURABAYA

Photo: sarote pruksachat/Getty Images

Ergosafety
Week 2&3
Accident
Causation
Theories

2
What is an Accident?

• An unintended or Incident is any observable

unplanned event. human activity that is an
• Characterized by unwanted event that
unacceptable might have had a
consequences e.g. negative impact on the
injury to persons, people, property or
damage to assets. process involved.
• Any unwanted event
that causes harm to
people, property, or
processes.
What is an Accident?
 Industrial Revolution

Factory managers reasoned that workers were hurt because ….

Number is Up
Carelessness People Error

ACCIDENT
Cost of doing
Act of God Business

PEOPLE PROBLEM
 Nature Of Accidents
• Each accidents must be looked at in terms of having two components:

THE EVENT THE CONSEQUENCES

• It is the event that is to be
prevented, because if the event
does not take place there can be
no consequences.
• There is also concern for “near
misses” where there is no actual
damage.
 The final loss resulted e.g. injury,
death, disease, ill health,
productivity/material damage.
 The consequences are not
always immediately apparent.
About Consequences Of Accidents

Sinking of ship results in

Fatalities, asset loss,
environmental impact and
reputation loss.
https://www.ethos3.com/wp-content/uploads/2017/08/iStock-693474546.jpg
 COST OF ACCIDENTS
• The overall cost of accidents in the United States is approximately $150
billion.
• These costs include such factors as lost wages, medical expenses,
insurance administration, fire-related losses, motor vehicle property
damage, and indirect costs.
COST OF ACCIDENTS
 COST OF ACCIDENTS
The number injured in industrial
place accidents in a typical year
is 7,128,000.
• 3 per 100 persons per year.
• There is an accidental
workplace death about every
51 minutes, and one injury
every seconds.
 COST OF ACCIDENTS
Workplace accidents cost employers millions every year. Consider the
following examples from the recent past.
• Arco Chemical Company was ordered to pay $3.48 million in fines as a result
of failing to protect workers from an explosion at its petrochemical plant in
Channelview, Texas.
• The steel-making division of USX paid a $3.25 million fine to settle numerous
health and safety violation citations.
• BASF Corporation agreed to pay a fine of $1.06 million to settle Occupational
Safety and Health Administration (OSHA) citations associated with an
explosion at a Cincinnati chemical plant that caused two deaths and 17
injuries.
 Work Injuries by Type of Accident
The most common causes of work injuries are:
• Overexertion: the result of employees working beyond their physical limits, is the
leading cause of work injuries. According to the NSC, almost 31 percent of all work
injuries are caused by overexertion.
• Impact accidents: involve a worker being struck by or against an object.
• Falls
• Bodily reaction (to chemicals)
• Compression
• Motor vehicle accidents
• Exposure to radiation or caustics
• Rubbing or abrasions
• Exposure to extreme temperatures
 Death Rates by Industry
Occupations that typically have the highest rate of fatalities on the job are as
follows (not necessarily in order since the order changes from year to year):

Fishing Aircraft pilots, flight engineers, and

Logging maintenance
Mining/quarrying Refuse and recycling collectors
Agriculture Law enforcement
Construction Professional and business services
Transportation and warehousing Retail
Manufacturing Public administration/government
 Parts of the Body Injured on the Job
Typically, the most frequent injuries to specific parts of the body are as
follows (from most frequent to least):
1. Back
2. Legs and fingers
3. Arms and multiple parts of the body
4. Trunk
5. Hands
6. Eyes, head, and feet
7. Neck, toes, and body systems
Estimating the Cost of Accidents
Accident prevention are expensive.
Estimating the Cost of Accidents
Accident prevention are expensive. However, to be successful, safety
and health professionals must be able to show that accidents are more
expensive than prevention. To do this, they must be able to estimate the
cost of accidents.

costs associated with an

Cost-Estimation Method
(Professor Rollin H. Simonds of
accident
Michigan State College working
in conjunction with the Statistics insured uninsured
Division of the NSC)
Estimating the Cost of Accidents

Determining the insured costs of

accidents is a simple matter of
examining accounting records.
Estimating the Cost of Accidents
Class 1 accidents. Lost workdays, permanent partial disabilities, and
temporary total disabilities
Class 2 accidents. Treatment by a physician outside the company’s
accidents

facility.
Class 3 accidents. Locally provided first aid, property damage of less
than $100, or the loss of less than eight hours of work time

Class 4 accidents. Injuries that are so minor that they do not require
the attention of a physician, result in property damage of $100 or
more, or cause eight or more work hours to be lost
Estimating the Cost of Accidents
1. Average uninsured costs for each class of accident can be
determined by pulling the records of all accidents that occurred
during a specified period and by sorting the records according
to class.
2. For each accident in each class, record every cost that was
not covered by insurance.
3. Compute the total of these costs by class of accident and
divide by the total number of accidents in that class to
determine an average uninsured cost for each class, specific
to the particular company.
Estimating the Cost of Accidents
Estimating the Cost of Accidents
• Calculating Lost Work Hours:
Calculating the direct costs associated with lost work hours involves compiling the
total number of lost hours for the period in question and multiplying the hours times
the applicable loaded labor rate. The loaded labor rate is the employee’s hourly
rate plus benefits. Benefits vary from company to company but typically inflate the
hourly wage by 20 to 35 percent.
Estimating the Cost of Accidents
 DISCUSSION
1. Pilih salah satu diantara kasus kecelakaan yang
dibahas di minggu lalu
2. Bahas “cost of accident” yang terjadi di kasus
kecelakaan tersebut baik direct cost maupun
hidden cost.
3. Buat perkiraan besarnya biaya-biaya tersebut
dalam rupiah.
Why do we need to know how an accidents happened?
• To prevent accidents we must
know why they happened.

• To seek not only the immediate

causes but also the prior
conditions and underlying
causes of accidents.

• The focus should be on “how

could similar incidents/accidents
be prevented”.
Accident Causation Theories
Why care about “theories”?
• “The scientific approach is based on the principle that
theory is the bridge between experiment and practice”
• Accident theories : Good accident theories can help identify
the sources of problems, which can lead to targeted
prevention efforts.
• Think of accidents as being caused, rather than occurring by
chance as such, we can break them apart, apply engineering
techniques, identify the contributing factors, and prevent
them from occurring again.
Accident Causation Theories

The purpose of these theories are:

• To provide a classification system : logical, objective
and universal system that aids analysis and control
• To assist in hazard identification : logical framework
for hazard identification
• To aid accident investigation and prevention : ensure
investigation is based on logical and reasoned
arguments.
The most widely known theories of accident
causation are:
 The domino theory
 Swiss cheese model
 The accident/incident theory.
 The systems theory.
 The combination theory.
 The human factors/error theory.
 The behavioral theory.
 The epidemiological theory.
 Drug, Depression and Obesity as Accident
causation
 Management Failures and Accident
causation
DOMINOTHEORY
The Origin of Domino Theory
• Herbert W. Heinrich an official with the Travelers Insurance Company
• In the 1920s doing research on the causes of 7500 industrial accident,
and the result is :
Unsafe Can not be
Condition avoided
10% 2%

Unsafe Act
88%
Heinrich’s study laid the foundation
for his Axioms of Industrial
Safety and his theory of accident
causation, which came to be
known as the domino
theory.
Heinrich’s 10 Axioms of Industrial Safety
1. Injuries result from a completed series of factors, one of which is the accident
itself
2. An accident can occur only as the result of an unsafe act by a person and/or a
physical or mechanical hazard.
3. Most accidents are the result of unsafe behavior.
4. Unsafe acts and hazards do not always result in immediate accidents and
injuries.
5. Understanding why people commit unsafe acts helps to establish guidelines
for corrective actions.
6. The severity of the injury is largely fortuitous and the accident that caused it is
preventable.
Heinrich’s 10 Axioms of Industrial Safety
7. The best accident prevention techniques are analogous to best
quality/productivity techniques.
8. Management should assume safety responsibilities.
9. The supervisor is the key person in the prevention of industrial accidents.
10. Cost of accidents include both direct costs and indirect costs.

So much of Heinrich’s theory has been discounted by more contemporary

research that it is now considered outdated. However, because some of
today’s more widely accepted theories can be traced back to Heinrich’s theory,
students of industrial safety should be familiar with his work
 Domino Theory (Heinrich, 1920s)

“Industrial Accident Prevention”

Social Fault of the Unsafe Act

Environment Person or Accident Injury
and Ancestry (Carelessness) Condition

MISTAKES OF PEOPLE

Injuries are caused by the action of preceding factors.

Removal of the central factor (unsafe act/hazardous condition) negates the
action of the preceding factors and prevents accidents and injuries.
 Heinrich’s Domino Theory

• According to Heinrich, there are five factors in the sequence of events leading up
to an accident:
1.Ancestry and social environment - character traits that lead people to behave
in an unsafe manner can be inherited, or acquired as a result of social
environment ( ex: alcoholism).
 Heinrich’s Domino Theory

2.Fault of person - negative traits, inherited or acquired, are why people

behave in an unsafe manner and why hazardous conditions exist. Ex: clumsy,
careless, impatient
3.Unsafe act/mechanical or physical hazard – acts by people and
mechanical/physical hazards are the direct causes of accidents.
 Unsafe Acts
•By-passing safety devices
•Failure to wear PPE
•Wearing unsafe clothing
•Failure to secure/to warn
•Unauthorised deviation from SOP
•Using defective or improper
equipment
•Entering confined spaces without
clearance
•Horseplay
•Working on equipment in
operation
•Throwing materials/tools instead
of carrying or passing them
Unsafe Conditions
•Defective tools and equipment
•Defective/incomplete design
•Ungrounded
•Un-insulated
•Improper or inadequate clothing
•Improper stacking or piling
•Inadequate space or clearance for
moving objects
•Excessive noise
•Lack or poor of ventilation,
lighting, illumination etc.
 Unsafe Act or
Working Condition ?

39
Unsafe Act or
Working Condition ?
Unsafe Act or
Working Condition ?
Unsafe Act or Working Condition ?
43 Unsafe Act or Working Condition ?
Domino Theory in Practice

44
Domino Theory in Practice

45
Domino Theory in Practice

46
Modification Domino Theory

• The first update of the Domino Theory was presented

by Bird & Loftus [ Heinrich et al, 1980; Bird & Germain,
1986]. This update introduced two new concepts;
1.The influence of management and managerial
error;
2.Loss, as the result of an accident could be production
losses, property damage or wastage of other assets,
as well as injuries.
Modification Domino Theory

Frank Bird (1967)  modified

the domino theory by
incorporating management
theory. This theory also consists
of five sequence factors of
accident :

https://rlshumancare.com/frank-birds-domino-theory/
 Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)

• Lack of control is the first domino and refers the fourth function of the
management (planning, organising, directing, controlling and coordinating, job
analysis, personal communication, selection and training, ‘standards’ in each
work activity identified measuring performance by standards and correcting
performance by improving the existing programmes.
• This first domino may fall due to inadequate standards, programmes and
follow up.

https://rlshumancare.com/frank-birds-domino-theory/
 Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)

Basic Causes (origins) are consisted of

• Personal factors – Lack of knowledge or skill, improper motivation and
physical or mental problems.
• Job factor – Inadequate work standards, design, maintenance, purchasing
standards, abnormal usage etc.

These basic causes are origin of substandard

acts and conditions and failure to identify
them permits the second domino to fall,
which initiates the possibility of further chain
reaction.

https://rlshumancare.com/frank-birds-domino-theory/
 Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)

Immediate causes are only symptoms of the underlying problem. They are
substandard practices or conditions (known as unsafe acts and unsafe
conditions) that could cause the fourth domino to fall. These causes should be
identified, classified and removed by appropriate measures.

miningsafety.co.za

https://rlshumancare.com/frank-birds-domino-theory/
 Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)

Accident or incident is the result of unsafe acts or/and unsafe conditions. This point
is the contact stage. Some counter measures employed are reinforcement, surface
modification, segregation, barricading, protection, absorption, shielding etc.

https://rlshumancare.com/frank-birds-domino-theory/
 Proses Terjadinya Kecelakaan Kerja
(the Bird Domino Theory)

Injury includes traumatic injury, diseases

accidents.co.za
https://rlshumancare.com/frank-birds-domino-theory/
and adverse mental neurological or
systemic effects resulting from workplace
exposures. ‘Damage’ includes all types of
property damage including fire.
The severity of losses involving physical
harm and property damage can be
minimised by prompt reparative action
salvage in the case of property damage and
fire control devices and trained personnel.
SWISS CHEESE MODEL
Tentang Swiss Cheese Model

James T. Reason (1997) menggambarkan proses terjadinya kecelakaan

melalui ilustrasi potongan-potongan keju Swiss. Swiss Cheese Model
memberikan informasi perihal bagaimana suatu tindakan tidak
aman dapat terjadi. Lapisan-lapisan (layers) keju tersebut
menggambarkan hal-hal yang terlibat dalam suatu sistem
keselamatan, sedangakan lubang-lubang yang terdapat pada tiap
lapisan tersebut menunjukkan adanya kelemahan yang berpotensi
menimbulkan terjadinya kecelakaan.
Jenis Kegagalan • Active failure dampaknya segera dirasakan
dan pada umumnya diasosiasikan dengan
operator front-liner (Reason, 1990).
Disebabkan oleh komunikasi, kerusakan
fisik, faktor psikologis, dan interaksi manusia
dengan peralatan. Unsafe Act merupakan
Active failure.
• Latent failure sebagai bentuk kegagalan
sistem yang tersembunyi, dan sesudah
sekian lama baru terbukti menimbulkan
kecelakaan bila dikombinasikan dengan
berbagai faktor lainnya (Reason, 1990).
Organizational Influences, Unsafe
Supervision, dan Precondition for Unsafe Act
merupakan latent failure.
4 Layer Penyusun Terjadinya Kecelakaan

Pada dasarnya, terdapat empat layer yang menyusun terjadinya suatu accident, yaitu:
a. Organizational Influences (pengaruh pengorganisasian dan kebijakan manajemen dalam
terjadinya accident)
b. Unsafe Supervision (pengawasan yang tidak baik)
c. Precondition for Unsafe Act (kondisi yang mendukung munculnya unsafe act)
d. Unsafe Act (perilaku atau tindakan tidak aman yang dilakukan dan berhubungan langsung dengan
terjadinya accident)
 Kronologi Jatuhya Pesawat Boeing 737-4Q8 Adam Air
CONTOH KASUS
ANALISIS DENGAN MENGGUNAKAN
SWISS CHEESE MODEL
Layer I : Organizational Influences
- Perusahaan melakukan penghematan dengan meminimisasi penggantian suku cadang
- Kurangnya kesadaran perusahaan tentang keselamatan penerbangan
Layer II : Unsafe Supervision
- Kurangnya pengawasan pada kerusakan IRS (Inertial Reference System) yang merupakan
alat pengindikasi posisi pesawat
- Kurangnya perhatian pada pemeliharaan perangkat pesawat
- Penggantian suku cadang tidak diawasi dengan baik
- Koreksi kemiringan pesawat akibat adanya angin hanya dilakukan sebentar
- Tidak ada satupun dari pilot atau ko-pilot yang menjaga arah pesawat selama 30 detik seperti
yang diharuskan oleh Quick Reference Handbook (buku yang berisi pedoman untuk kondisi
darurat)
Layer III : Precondition for Unsafe Act
- Pilot dan ko-pilot dalam kondisi panik
- Cuaca buruk
- Kehilangan situational awareness saat kemiringan pesawat melebihi batas
maksimum
- Kerusakan salah satu IRS
- Awak pesawat tidak mengetahui secara pasti IRS mana (Left IRS atau Right IRS)
yang masih berfungsi dengan baik.
Layer IV : Unsafe Act
- Kurang menanggapi dengan serius peringatan bahaya dari petugas Air Traffic
Controller (ATC)
- Pilot dan ko-pilot lebih fokus pada kerusakan IRS dari pada tingkat kemiringan
pesawat yang bermasalah
- Salah mengambil keputusan (decision error) saat kemiringan melebihi batas normal
TUGAS
Buat Ringkasan untuk teori penyebab kecelakaan lainnya:
• The domino theory
• Swiss cheese model
• The accident/incident theory.
• The systems theory.
• The combination theory.
• The human factors/error theory.
• The behavioral theory.
• The epidemiological theory.
• Drug, Depression and Obesity as Accident causation
• Management Failures and Accident causation
Referensi: Geotsch, L.D., 2014, Occupational Safety and Health for Technologists, Engineers,
and Managers, Prentice Hall. 61