Accident Investigation

Cinthya Theresia Tambunan M. Rosiawan Yulia Muhammad Rafiq Daulay Patricia Bebby Yolla Sistia Fitriana 1106087231 1106006801 1106017566 1106009974 1106006341

What is an Accident ??
An unplanned and unwelcome event which disrupts normal routine

Accident

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

Accident Investigation
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

Tahapan Investigasi Kecelakaan

Pengumpulan bukti

Analisa
Pengembangan kesimpulan Pelaporan

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)

Systematic Cause Analysis Technique (SCAT) Sequentially Timed Events

Human Reliability Analysis Event Plotting (STEP) Tree (HRA-ET)

Multiple-Cause
Systems-oriented Incident Investigation (MCSOII) Multi linear Events Sequencing (MES)

TapRoot Incident Investigation System Technique of Operations

Review (TOR)
Work Safety Analysis

Management Oversight Risk Tree (MORT)

Metode Investigasi Kecelakaan

Department of Energy (DOE) Amerika
menyebutkan metode investigasi kecelakaan lainnya sebagai berikut:
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.

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),

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

Syarat Investigasi Kecelakaan yang Baik

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

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
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

Contoh Kasus

Contoh kasus kebakaran di SPBU

Referensi
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-InvestigationMay-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