Accident Investigation

Cinthya Theresia Tambunan

1106087231

M. Rosiawan Yulia 1106006801

Muhammad Rafiq Daulay 1106017566

Patricia Bebby Yolla 1106009974

Sistia Fitriana 1106006341

What is an Accident ??

Accident •An unplanned and unwelcome event which disrupts normal routine

Result•Death, injury, illness or a ‘near miss’•Damage to equipment or property•Disruption of work•Legal cost

NB: Most accidents are preventable by eliminating one or more causes

Definition• Determine not only what happend, but also how and

why these accident occur

Main aim• To prevent a recurrence of the same accident

and NOT to assign blame to individuals

Spesific aim• Prevent similar accidents occuring in the future• Revise and improve risk assessments• Enhance working environment and layout• Increase safety awareness

Accident Investigation

Tahapan Investigasi Kecelakaan

Metode Investigasi Kecelakaan

(Center for Chemical Process Safety (CCPS), antara lain:

Accident Anatomy method (AAM),

Action Error Analysis (AEA)

Accident Evolution and Barrier

Analysis (AEB)

Change Evaluation/Analysis,

Cause-Effect Logic Diagram (CELD)

Causal Tree Method (CTM)

Fault Tree Analysis (FTA)

Hazard and Operability Study (HAZOP)

Human Performance Enhancement System

(HPES)Human Reliability Analysis

Event Tree (HRA-ET) Multiple-Cause

Systems-oriented Incident Investigation (MCSOII)

Multi linear Events Sequencing (MES)

Management Oversight Risk Tree (MORT)

Systematic Cause

Analysis Technique

(SCAT)

Sequentially Timed

Events Plotting (STEP)

TapRoot Incident

Investigation System

Technique of Operations

Review (TOR)

Work Safety Analysis

Department of Energy (DOE) Amerika menyebutkan metode investigasi kecelakaan lainnya

sebagai berikut:

Events and Causal Factors Charting and Analysis, Barrier Analysis, Change Analysis, Root Cause Analysis, Fault Tree Analysis, Management Oversight and Risk Tree (MORT), Project Evaluation Tree Analysis (PET),

Specific Analytical Techniques,Human Factors Analysis, Integrated Accident Event Matrix, Failure Modes and Effects Analysis, Software Hazards Analysis, Common Cause Failure Analysis, Sneak Circuit Analysis, 72-Hour Profile, Materials and Structural Analysis, dan Scientific Modeling.

Metode Investigasi Kecelakaan

Daftar metode-metode kecelakaan lain yang belum tercantum di atas:

(Hu)Man-Technology and Organisation (MTO) analysis, Accident Analysis and Barrier Function (AEB) Method, TRIPOD-Delta, Acci-Map → digunakan di beberapa negara Eropa.

Syarat Investigasi Kecelakaan yang Baik

Melibatkan pihak-pihak yang relevan

Melibatkan tim investigasi yang relevan dan multi-disiplin ilmu

Mengumpulkan informasi yang relevan dan sebanyak mungkin

Human Reliability Associates sebagaimana dikutip Health and Safety Executive (HSE) Inggris dilaporan penelitian setebal 440 halaman yang berjudul “Accident

investigation - The drivers, Methods and Outcomes”

Mempunyai prosedur atau rencana investigasi terstruktur

Mengidentifikasi penyebab langsung maupun tidak langsung

Membuat rekomendasi dan menindaklanjuti penyebab kecelakaan

Human Reliability Associates sebagaimana dikutip Health and Safety Executive (HSE) Inggris dilaporan penelitian setebal 440 halaman yang berjudul “Accident

investigation - The drivers, Methods and Outcomes”

Syarat Investigasi Kecelakaan yang Baik

Human Reliability Associates sebagaimana dikutip Health and Safety Executive (HSE) Inggris dilaporan penelitian setebal 440 halaman yang berjudul “Accident

investigation - The drivers, Methods and Outcomes”

Syarat Investigasi Kecelakaan yang Baik

Menerapkan rekomendasi dan analisa resiko lanjutan setelah penerapan rekomendasi

Memastikan bahwa langkah-langkah pencegahan terbukti menurunkan resiko kecelakaan serupa

Membagikan pelajaran yang didapat dari sebuah kecelakaan (lesson learned) kepada pihak-pihak terkait

Mempunyai database kecelakaan yang mudah diakses

Contoh Kasus

Contoh kasus kebakaran di SPBU

• U.S. Department of Labor. Accident Investigation. Akses di

http://www.labtrain.noaa.gov/osha600/refer/menu16a.pdf pada 22 Oktober

2013

• University of Greenwich. Accident Investigation. Akses di

http://www.gre.ac.uk/__data/assets/pdf_file/0011/84746/Accident-Investigatio

n-May-2012.pdf

pada 22 Oktober 2013

• Sklet, Snorre. Methods for accident investigation. 2002. Norwegia

• Health and Safety Executive. Accident Investigation - The Drivers, Methods

and Outcomes. 2001. United Kingdom

• Benner Jr, Ludwig. Investigating Investigation Methodologies. 2003. Virginia,

Amerika

• Department of Energy (DOE). Workbook Conducting Accident Investigations.

1999. Washington, DC. Amerika

• Center for Chemical Process Safety (CCPS). Guidelines for Investigating

Chemical Process Incidents. 2003. Knovel online version. P

Referensi