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teori kecelakaan kerja #1

Dr. Adithya Sudiarno, ST, MT., IPM

Laboratorium Ergonomi dan Perancangan Sistem Kerja
Departemen Teknik Industri - ITS
what is an accident - incident?
– An unintended or unplanned
– Characterized by unacceptable
consequences e.g. injury to
persons, damage to assets.
– Any unwanted event that
causes harm to people,
property, or processes.
– Incident is any observable
human activity that is an
unwanted event that MIGHT
HAVE had a negative impact on
the people, property or process
involved (near miss incident).
fatal injury rates by industry
causes of traffic accidents
accident in shipping
why do we need to know how an accidents happened?

― To seek not only the immediate

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

― To prevent accidents we must

know why they happened.

― The focus should be on “how

could similar incidents/accidents
be prevented”.
nature of accidents
Each accidents must be looked at in terms of having two components :
― The final loss resulted
― It is the event that is to
e.g. injury, death,
be prevented, because if
disease, ill health,
the event does not take
place there can be no
consequences. ― The consequences are

― There is also concern for not always

“near misses” where immediately apparent.
there is no actual
accident causation theories
- Explain why accidents happen.
- The purpose of these theories are:
1. To provide a classification system : logical, objective and universal
system that aids analysis and control
2. To assist in hazard identification : logical framework for hazard
3. To aid accident investigation and prevention : ensure investigation is
based on logical and reasoned arguments.
accident causation theory
The most widely known theories of accident causation are:
– The Heinrich’s domino theory.
– The accident/ incident theory.
– The systems theory.
– The combination theory.
– The human factors/ error theory.
– The behavioral theory.
– The epidemiological theory.
#1 The Heinrich’s domino theory.
heinrich’s 10 axioms of industrial safety

1. Injuries result from a series of preceding factors.

2. Accidents occur as the result of a physical
hazard or an unsafe act.
3. Most accidents are the result of unsafe
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
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
8. Management should assume safety
9. The supervisor is the key person in the
prevention of industrial accidents.
10. Cost of accidents include both direct costs and
indirect costs.

Note : Heinrich’s study laid the foundation for his

Axioms of Industrial Safety, and it is now outdated
theory of accident causation
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.
#2 Fault of person - negative traits, inherited or acquired, are why
people behave in an unsafe manner and why hazardous conditions
#3 Unsafe act/mechanical or physical hazard – acts by people, and
mechanical/physical hazards are the direct causes of accidents.
#4 Accident - typically, injury accidents are caused by falling or being hit
by moving objects.
#5 Injury - typical injuries resulting from accidents include lacerations
and fractures.
domino theory (heinrich, 1920s)

Injuries are caused by the action of preceding

factors. Removal of the central factor (unsafe mistake of people
act/hazardous condition) negates the action of
the preceding factors and prevents accidents and
unsafe condition - unsafe action
unsafe conditions unsafe acts
– Defective tools and equipment ― By-passing safety devices
– Defective/incomplete design ― Failure to wear PPE
– Ungrounded ― Wearing unsafe clothing
– Un-insulated ― Failure to secure/to warn
– Improper or inadequate clothing ― Unauthorised deviation from SOP
– Improper stacking or piling ― Using defective/ improper equip.
– Inadequate space or clearance for ― Entering confined spaces without
moving objects clearance
– Excessive noise ― Horseplay
– Lack or poor of ventilation, lighting, ― Working on equipment in operation
illumination etc. ― Throwing materials/tools instead of
carrying or passing them
corrective action sequence (the three “e”s)
heinrich’s theory

#1 enforcement

#2 education

#3 engineering
the weakness of domino theory by heinrich

― Too much emphasis on human error (human error)

― Do not take into account the failure of the management
(management error)
― Only a single approach, but in the actual conditions there is
more than one factor.
the strengths of domino theory by heinrich

― Simple applications
― Easy to understand
― Easy handling problem solving
bird’s domino theory
Frank E. Bird Petersen (1967) : modifying the domino theory by putting
MANAGEMENT THEORY that contain of five sequence factor of accident.
bird’s domino theory

lack immediate
Basic cause incident loss
of control cause

inadequate substandard
personal contact with people,
program, acts,
factor, energy or property,
standard, substandard
job factor substance process
compliance condition
case study

― CPC adalah distributor kayu, pipa, produk beton. Konsumen CPC secara
umum adalah kontraktor kecil bangunan, dengan operasi yang kecil maka
order yang diminta juga kecil. Pekerja gudang CPC menggunakan tangan
untuk mengangkat beban yang diantaranya sulit karena ukurannya besar
dan tidak praktis untuk dipegang sehingga pekerja dilengkapi dengan alat
perlindungan helm, gloves, sepatu, dan sebagainya.
― Selama musim panas terjadi penambahan minor injury seperti luka,
memar, tergores dan terdapat 2 pekerja menderita back injuries sehingga
perusahaan akan mengeluarkan cost untuk kompensasi.
case study (cont’d)

― Setelah musim panas maka kondisi ini akan berbeda dimana setelah
dianalisa maka penyebab injury adalah kondisi suhu yang panas pada
saat musim panas menyebabkan pekerja sering melepas/melalaikan
alat perlindungan diri karena tidak nyaman dipakai.
― Management berkomitmen untuk membuang yang menyebabkan
injury pekerja gudang dengan membentuk comite yang terdiri dari
satu executive manager, satu supervisor gudang, dan tiga pekerja
case study (cont’d)

Rekomendasi yang dihasilkan komite ini:

1. Memberikan pelatihan kepada seluruh
personel gudang agar mengerti arti
penting APD sehingga dapat
menggunakan APD secara benar.
2. Menugaskan supervisor gudang agar
memonitor penggunaan APD.
3. Menegakkan disiplin dalam penggunaan
4. Memberikan pendingin ruang pada saat
musim panas

Analisalah, apakah rekomendasi yang

dihasilkan komite sudah tepat! Jelaskan
dalam bentuk narasi argumentasi!
Unsafe Act or Working Condition ?
Unsafe Act or Working Condition ?
Unsafe Act or Working Condition ?
Unsafe Act or Working Condition ?
Unsafe Act or Working Condition ?
[thank you]