ANALISYS ROOT CAUSE

TERHADAP INSIDEN-
Satrio Pratomo July 17, 2020.
CONTENT

§ OBJECTIVE
§ PROCESS FLOW : aplikasi

§ 1. Lessons Learned – fatality Case tahun 2000

§ Kritical factor
§ Analysis.

§ 2. Examples of 5 whys, dan case

§ Kritital Factor
§ Contoh Analysis- Link to SMKM Substansi
§ Contoh Rekomendasi – Link to SMKM Substansi,

§ KESIMPULAN & SUGGESTION

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Objective:

§ Objective : Mencari Fakta dan menganalisa fakta guna menentukan

penyebab dasar suatu kecelakaan shg dapat diambil tindakan
koreksi/ rekomendasi agar kecelakaan serupa tdk terulang kembali.

§ Prinsip Investigasi Kecelakaan :

• Tidak mencari siapa yang salah (no blaming), namun apa yang salah
• Tidak memberikan sanksi / hukuman (no Judicial).
• Tidak mencari siapa yang bertanggung jawab menanggung kerugian (no
Liability).
• Transparan.

4. Apa yang dapat dilakukan

1. Apa Yg 2. Bagamanai 3. Mengapa
untuk mencegah terulangnya
Terjadi bisa terjadi bisa terjadi
kejadian

Pedoman Investigasi Kecelakaan Migas: SK 0107.K/18/DMT/2019

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 3. Mengapa CLC / SCAT Link to SMKM
PROCES INVESTIGASI bisa terjadi System/ Substansi
Lack of Control
System Management Managemen
Improvement Needed Keselamatan
Data/ Evidence MIGAS
gathering- 4P’s
System/Basic
Cause
Personal Factor & Job
Factor

1. Apa Yg Immediate/Direct
Cause
Terjadi Fact Findings Unsafe Act & Unsafe
Condition
REKOMENDASI
Contact/ Incident Contact/ Incident

Loss Contact/ Incident

2. Building Block
Technique to built a time 4. Apa yang dapat dilakukan
Bagamanai
untuk mencegah terulangnya
bisa terjadi line and Key events kejadian
(Chronology of incident
based fact findings).
Analyzing each
critical Factor that
is identified by
Identify Critical using the CLC
Factors- from the (SCAT)- Based on 5 Why’s
chronology Domino Theory

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Brief Event (insiden 20 tahun yg lalu)
§ Sekitar pukul 21.15 waktu setempat pada 30 September 2000,
sebuah kecelakaan fatal terjadi pada sebuah Barge yang
ditambatkan di samping anjungan produksi gas baru di sebuah
operasi Perusahaan (CPY) lepas Pantai di Indonesia dan terlibat
dalam pekerjaan pemasangan dan hook up.

• Tongkang tersebut disubkontrakkan ke kontraktor utama Perusahaan

untuk proyek tersebut, yang mengelola lokasi.
• Inspeksi MWS & wajib sebelum mobilisasi di mana staf Perusahaan
telah berpartisipasi.
• Ini adalah pekerjaan 6 minggu dan hampir selesai.
• Selama waktu itu, hanya satu “Near Miss” telah dilaporkan, meskipun
penyelidikan menunjukkan sejumlah kecelakaan telah terjadi
• Kehadiran Representative Perusahaan CPY di kapal terbatas pada dua
perwakilan, yang keduanya dikontrak untuk pekerjaan ini saja. Mereka
adalah mantan staf Perusahaan yang akrab dengan lepas pantai tempat
Perusahaan beroperasi.

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Description :
§ Korban: SSX, 40 thn, rigers (Dia punya dua anak, 8 thn dan 3 thn)
§ Lokasi: DLB- Shillelagh-1, platform LES
§ Kontraktor: P.T. MS
§ Kronologi singkat :
§ 30 September 2000
§ 21:10: Pekerjaan selesai di LES p / f untuk Coffee break
§ 21:15: Jatuh kelaut dari jalan (walkway).di sisi kanan di stasiun Pipeline
no: 5 diatas Barge.
§ 22:30: Kapal Penyelamat (Abeer-26) tiba 1 Oktober 2000
§ 2:45: Diving Vessell tiba
§ 04:00: Penyelam pertama turun - Tidak berhasil
§ 06: 25-06:30: Penyelam kedua turun dan menemukan korban
§ 08:30: Tubuhnya tiba di permukaan- (No Vital Sign)
§ 11:30: Mengevakuasi jenazah ke Jakarta
§ Hasil Insiden: FATALITY,.

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Tim Investigasi

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Evidence Gathering - Scene Photograph:

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Evidence Gathering - House Keeping:

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Timelime/ Kronologi–
berdasarkan fakta
§ Log peristiwa dan kondisi berikut dibuat dalam bentuk tabel –
timeline, chronology, yang ditransformasikan dari “building block”
yang dikembangkan dari bukti/fakta 4P’s yang dikumpulkan selama
investigasi oleh tim investigasi awal dan tim investigasi kecelakaan
fatal.

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13
Critical Factors
§ Tim investigasi sepenuhnya meninjau bukti / Fakta dan
menggunakan proses “Building Block” untuk menetapkan urutan
timeline, peristiwa (Event) dan kondisi. (Condition) Dari sini , tiga
“faktor kritis” diidentifikasi:

1. Inspeksi pra-mobilisasi tongkang/barge tidak memadai - tidak

adanya pegangan tangan (hand rail), di celah (opening) ini tidak
diindahkan. Bahkan pernah ada Pagar tetapi itu telah mereka
pindahkan (E).

2. Tidak ada “tantangan aktif” (active challenge) untuk efektivitas

Sistem Manajemen Keselamatan di tongkang/barge . Ada budaya
keselamatan yang sangat buruk di tongkang; Kepemimpinan
keselamatan kurang dan tindakan tidak aman ditoleransi oleh
manajemen lokasi (C).

3. Tidak ada penghalang pelindung (protection barrier) yang

dipasang pada pembukaan. (opening) (C).

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TIPKM
Parts
Comprehensive List of Causes People Parts

A TOOL FOR ROOT CAUSE ANALYSIS Solution

Solutions
DESCRIPTION OF IMPLEMENTATION & RESEARCH PHASES: ANALYSIS PHASE:
INCIDENT EVIDENCE GATHERING IDENTIFICATION OF CRITICAL FACTORS
• Document the type / severity of • Gather relevant evidence • Organise all evidence Position
event Positions Paper
• Implementation phase = direct evidence (scene and witnesses) • Map evidence
• Cover the who / what / when / • Research phase = indirect evidence (written sources) • Identify critical factors
where / how as known at the
time • Consider People / Parts / Position / Paper • Use CLC to identify all immediate and root causes

POSSIBLE IMMEDIATE CAUSES

ACTIONS CONDITIONS
1. Following Procedures 2. Use of Tools or Equipment 3. Use of Protective Methods 4. Inattention / Lack of Awareness 5. Protective Systems 6. Tools, Equipment & Vehicles 7. Work Exposures to 8. Work Place Environment / Layout
1-1 Violation by individual 2-1 Improper use of equipment 3-1 Lack of knowledge of hazards present 4-1 Improper decision making or lack of judgment 5-1 Inadequate guards or protective devices 6-1 Defective equipment 7-1 Fire or explosion 8-1 Congestion or restricted motion
1-2 Violation by group 2-2 Improper use of tools 3-2 Personal protective equipment not used 4-2 Distracted by other concerns 5-2 Defective guards or protective devices 6-2 Inadequate equipment 7-2 Noise 8-2 Inadequate or excessive illumination
1-3 Violation by supervisor 2-3 Use of defective equipment (aware) 3-3 Improper use of proper personal protective equipment 4-3 Inattention to footing and surroundings 5-3 Inadequate personal protective equipment 6-3 Improperly prepared equipment 7-3 Energized electrical systems 8-3 Inadequate ventilation
1-4 Operation of equipment without authority 2-4 Use of defective tools (aware) 3-4 Servicing of energized equipment 4-4 Horseplay 5-4 Defective personal protective equipment 6-4 Defective tools 7-4 Energized systems, other than electrical 8-4 Unprotected height
1-5 Improper position or posture for the task 2-5 Improper placement of tools, equipment or materials 3-5 Equipment or materials not secured 4-5 Acts of violence 5-5 Inadequate warning systems 6-5 Inadequate tools 7-5 Radiation 8-5 Inadequate work place layout
1-6 Overexertion of physical capability 2-6 Operation of equipment at improper speed 3-6 Disabled guards, warning systems or safety devices 4-6 Failure to warn 5-6 Defective warning systems 6-6 Improperly prepared tools 7-6 Temperature extremes • controls less than adequate
1-7 Work or motion at improper speed 2-7 Servicing of equipment in operation 3-7 Removal of guards, warning systems or safety devices 4-7 Use of drugs or alcohol 5-7 Inadequate isolation of process or equipment 6-7 Defective vehicle 7-7 Hazardous chemicals • displays less than adequate
1-8 Improper lifting 2-8 Other 3-8 Personal protective equipment not available 4-8 Routine activity without thought 5-8 Inadequate safety devices 6-8 Inadequate vehicle for the purpose 7-8 Mechanical hazards • labels less than adequate
1-9 Improper loading 3-9 Other 4-9 Other 5-9 Defective safety devices 6-9 Improperly prepared vehicle 7-9 Clutter or debris • locations out of reach or sight
1-10 Shortcuts 5-10 Other 6-10 Other 7-10 Storms or acts of nature • conflicting information is presented
1-11 Other 7-11 Slippery floors or walkways 8-6 Other
7-12 Other

POSSIBLE SYSTEM CAUSES

PERSONAL FACTORS JOB FACTORS
1. Physical Capability 2. Physical 3. Mental State 4. Mental Stress 5. Behavior 6. Skill Level 7. Training / Knowledge 8. Management / 9. Contractor Selection 10. Engineering / 11. Work Planning 12. Purchasing, Material 13. Tools & Equipment 14. Work Rules / Policies / 15. Communication
1-1 Vision deficiency Condition 3-1 Poor judgment 4-1 Preoccupation with 5-1 Improper performance is 6-1 Inadequate Transfer Supervision / Employee & Oversight Design 11-1 Inadequate work planning Handling & Material 13-1 Inadequate assessment Standards / Procedures (PSP) 15-1 Inadequate horizontal
1-2 Hearing deficiency 2-1 Previous injury or 3-2 Memory failure problems rewarded assessment of 7-1Inadequate knowledge Leadership 9-1 Lack of contractor pre- 10-1 Inadequate technical 11-2 Inadequate preventive Control of needs and risks 14-1 Lack of PSP for the task communication between
1-3 Other sensory illness 3-3 Poor coordination or 4-2 Frustration • saves time or effort required skills transfer 8-1 Conflicting roles / qualifications design maintenance 12-1 Incorrect item received 13-2 Inadequate human •lack of defined responsibility for peers
deficiency 2-2 Fatigue reaction time 4-3 Confusing directions / • avoids discomfort 6-2 Inadequate practice • inability to comprehend responsibilities 9-2 Inadequate contractor • design input • assessment of needs •inadequate factors / ergonomics PSP 15-2 Inadequate vertical
1-4 Reduced respiratory •due to workload 3-4 Emotional demands • gains attention of skill • inadequate instructor • unclear reporting pre-qualifications obsolete • lubrication / specifications to considerations •lack of job safety analysis communication between
capacity •due to lack of disturbance 4-4 Conflicting directions / 5-2 Improper supervisory 6-3 Infrequent qualifications relationships 9-3 Inadequate contractor • design input not servicing vendor 13-3 Inadequate standards or •inadequate job safety analysis supervisor and person
1-5 Other permanent rest 3-5 Fears or phobias demands example performance of skill • inadequate training • conflicting reporting selection correct • adjustment / •inadequate specifications 14-2 Inadequate development of PSP 15-3 Inadequate
physical disabilities •due to sensory 3-6 Low mechanical 4-5 Meaningless or 5-3 Inadequate identification 6-4 Lack of coaching on equipment relationship 9-4 Use of non-approved • design input not assembly specifications on 13-4 Inadequate availability •inadequate coordination with communication between
1-6 Temporary disabilities overload aptitude degrading activities of critical safe behaviors skill • misunderstood • unclear assignment of contractor available • cleaning / requisition 13-5 Inadequate adjustment / process / equipment design different organizations
1-7 Inability to sustain body 2-3 Diminished 3-7 Low learning aptitude 4-6 Emotional overload 5-4 Inadequate reinforcement 6-5 Insufficient review of instructions responsibility 9-5 Lack of job oversight • design output resurfacing •inadequate control on repair / •inadequate employee 15-4 Inadequate
positions performance 3-8 Influenced by 4-7 Extreme judgment / of critical safe behaviors instruction to 7-2Inadequate recall of • conflicting assignment of 9-6 Inadequate oversight inadequate 11-3 Inadequate repair changes to orders maintenance involvement in the development communication between
1-8 Restricted range of •due to medication decision demands • proper performance is establish skill training material responsibility 9-7 Other • design input • communication of •unauthorized 13-6 Inadequate salvage and •inadequate definition of corrective work groups
body movement temperature 3-9 Other 4-8 Extreme criticized 6-6 Other • training not reinforced • improper or insufficient infeasible needed repair substitution reclamation actions 15-5 Inadequate
1-9 Substance sensitivities extremes concentration / • inappropriate peer on the job delegation of authority q Not Applicable • design output • scheduling of work •inadequate product 13-7 Inadequate removal / •inadequate format for easy use communication between
or allergies •due to oxygen q Not Applicable perception demands pressure q Not Applicable • inadequate refresher 8-2 Inadequate leadership unclear • examination of parts acceptance replacement of unsuitable 14-3 Inadequate implementation of PSP, shifts
1-10 Inadequate size or deficiency 4-9 Extreme boredom • inadequate training frequency • standards of performance • design output not • parts substitution requirements items due to deficiencies 15-6 Inadequate
strength •due to 4-10 Other performance feedback 7-3 Inadequate training effort missing or not enforced correct 11-4 Excessive wear and tear •no acceptance 13-8 No equipment record •contradictory requirements communication methods
1-11 Diminished capacity atmospheric • inadequate • inadequate training • inadequate accountability • design output • inadequate planning verification performed history •confusing format 15-7 No communication
due to medication pressure q Not Applicable disciplinary process program design • inadequate or incorrect inconsistent for use 12-2 Inadequate research on 13-9 Inadequate equipment •more than one action per step method available
1-12 Other variation 5-5 Inappropriate aggression • inadequate training performance feedback • no independent • extension of service materials / record history •no check-off spaces provided 15-8 Incorrect instructions
2-4 Blood sugar 5-6 Improper use of goals / objectives • inadequate work site design review life equipment 13-10 Other •inaccurate sequence of steps 15-9 Inadequate
q Not Applicable insufficiency production incentives • inadequate new walk-through 10-2 Inadequate standards, • improper loading 12-3 Inadequate mode or •confusing instructions communication due to
2-5 Impairment due to 5-7 Supervisor implied haste employee orientation • inadequate safety specifications, and / or • use by untrained route of shipment q Not Applicable •technical error / missing steps job turnover
drug or alcohol use 5-8 Employee perceived • inadequate initial promotion design criteria people 12-4 Improper handling of •excessive references 15-10 Inadequate
2-6 Other haste training 8-3 Inadequate correction of prior 10-3 Inadequate assessment • use for wrong purpose materials •potential situations not covered communication of safety
5-9 Other • inadequate means to hazard / incident of potential failure 11-5 Inadequate reference 12-5 Improper storage of 14-4 Inadequate enforcement of PSP and health data,
q Not Applicable determine if qualified for 8-4 Inadequate identification of 10-4 Inadequate ergonomic materials or publications materials or spare parts •inadequate monitoring of work regulations or guidelines
q Not Applicable job worksite / job hazards design 11-6 Inadequate audit / 12-6 Inadequate material •inadequate supervisory 15-11 Standard terminology not
7-4 No training provided 8-5 Inadequate management of 10-5 Inadequate monitoring inspection / monitoring packaging knowledge used
• need for training not change system of construction • no documentation 12-7 Material shelf life •inadequate reinforcement 15-12 Verification /
identified 8-6 Inadequate incident reporting 10-6 Inadequate assessment • no correction exceeded •non-compliance not corrected repeat back techniques
• training records / investigation system of operational readiness responsibility assigned 12-8 Improper identification of 14-5 Inadequate communication of PSP not used
incorrect or out of date 8-7 Inadequate or lack of safety 10-7 Inadequate monitoring • no accountability for hazardous materials •incomplete distribution to work 15-13 Messages too long
• new work methods meetings of initial operation corrective action 12-9 Improper salvage groups 15-14 Speech interference
introduced without 8-8 Inadequate performance 10-8 Inadequate evaluation 11-7 Inadequate job placement and / or waste disposal •inadequate translation to 15-15 Other
training measurement & assessment and / or documentation • appropriate personnel 12-10 Inadequate use of safety appropriate languages
• decision made not to of change not identified and health data •incomplete integration with q Not Applicable
8-9 Other
train 10-9 Other • appropriate personnel 12-11 Other training
q Not Applicable not available •out of date revisions still in use
7-5 Other
q Not Applicable • appropriate personnel q Not Applicable 14-6 Other
q Not Applicable not provided q Not Applicable
For each identified critical factor, consider if any 11-8 Other
of the listed root cause categories apply. If 'yes,' q Not Applicable

circle the specific root cause.

If none of the root causes in the category apply,
then check the 'not applicable' box at the bottom
of the column.

CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION

• Align with ‘Getting HSE Right’ elements

ELEMENTS OF HSSE Management System

Leadership and Risk Assessment and People, Training and Working with Facilities Design and Operations and Management of Information and Customers and Community and Crisis and Emergency Incidents Analysis and Assessment,
Accountability Management Behaviours Contractors and Construction Maintenance Change Documentation Products Stakeholder Awareness Management Prevention Assurance and
Others Improvement
SP Form 3862 Rev 1 3/99
16
TIPKM
System Causes-inc. thn 2000
Ke 3 Faktor Kritis diatas dianalisa dengan menggunakan CLC lalu di
petakan dengen SMS Elements CPY:

1. Leadership & Accountability:

Harapan kinerja HSE CPY tidak dipahami pada tingkat apa pun di
atas barge tsb.. Manajemen barge tidak terlibat aktif dalam
penerapan Sistem Manajemen Keselamatan CTR Ada ”Inadequate
enforcement and communication” thd kebijakan, standard,
prosedure & KPI oleh CPY dan manajemen CTR baik di kantor
pusat Jakarta maupun lapangan.

2. Risk Assessment and Management:

Identifikasi bahaya yang tidak memadai terkait dengan pembukaan
(opening) yang tidak terlindungi di sisi tongkang. Secara umum, sementara
risiko spesifik proyek secara jelas diidentifikasi dalam Analisis Keselamatan
Kerja pra-mobilisasi, risiko yang terkait dengan pelaksanaan “marine
operation” dan dek oleh kontraktor tidak ditangani dengan baik.

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System Causes-
§ Standar manajemen bidang-bidang seperti kualitas perancah,
penyimpanan pelumas, kontrol kerja, izin kerja panas dan prosedur
darurat tidak dapat diterima. (unacceptable).

3. People,Training and Behaviours

Tidak ada identifikasi dan penguatan perilaku aman yang kritis (Critical safe
behaviour). Iklim 'pekerjaan lebih penting daripada jaminan SMS' lazim di
tongkang, yang mengarah ke persepsi tergesa-gesa dalam pelaksanaan
pekerjaan. “Key Staff” tidak cukup terlatih dalam “Safety Leadership” dan
penggunaan ”behavioural safety tools”. Konsekuensinya , dapat diterima
bagi orang untuk menggunakan jalan setapak (walkway) (dan, selama fase
pipelay, bekerja) di area dengan “opening” yang tidak diberi pembatas/
barrier dan melangkah ke dek samping untuk buang air kecil di samping -
tanpa mengenakan Life Vest, Life Jacket..

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System Causes
4. Working with Contractors and Others
Pra-kualifikasi dan seleksi kontraktor yang tidak memadai, dan
pengawasan kinerja kontraktor yang sepenuhnya tidak memadai oleh
perwakilan/ Representative di lokasi. Juga tidak ada verifikasi CPY yang
efektif bahwa perwakilannya di tongkang/ barrge secara efektif
menegakkan standar CPY

Sistem Manajemen Keselamatan Kontraktor (CSMS) yang diterapkan di BU

Indonesia –CPY (di tahun 1998-1999, memiliki banyak fitur bagus, tetapi standar
kepatuhan terhadap sistem rendah. Ada area spesifik di mana CSMS dapat
ditingkatkan, termasuk standar HSE minimum yang lebih tinggi pada tahap pra-
kualifikasi dan evaluasi site HSE (evaluation Audit), dari peserta lelang pada tahap
evaluasi teknis.

5. Operations and Maintenance:

Audit pra-mobilisasi tidak memadai. Tidak ada daftar periksa audit
terpadu untuk memastikan penilaian komprehensif atas “marine operation
capability” dan Persyaratan “key staff”. Perwakilan HSE dan Marine
representative melakukan inspeksi pada hari yang berbeda, karena
ketersediaan personel yang terbatas
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EXAMPLES

CASE- Milenial

Root Case dan Rekomendasi

Link kepada Substansi SMKM (System Management
Keselamatan MIGAS)- SK Direktur Teknik & Lingkungan
Migas- no. 0196.K/18/DMT/2018

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TIPKM
 CONTOH MENGGUNAKAN 5WHY’S
5 WHY’s
Fatality Accident @ Anjungan Sumur Lepas Pantai
FATAL ACCIIDENT
FELL Down from 4
Mtr.Height

Bekerja di atas benda (IH) Benda (IH) Yg akan Diangkat

yang akan diangkat tinggi Roboh
3 4 mtr

Mengikat body Harness
tdk pada titik permanen
SWA tdk berjalan Incompetent Crew
Bermaksud mengaitkan Tertabrak Crane hook Improper Guy Line Barge Pitching & Rolliing
Crane Hook yg mengyun kr. Ombak
Ke Master Link yg terlalu
pendek,.
Pertimbangan Rolling &
2 Blind Lifting
1 Guy Line terpasang pada Pitching
Tdk ada dlm Lifting
titik yg tdk permanen
IH tdk terpasang Procedurte.
Extention Sling, as Signalman untuk Dinamic Lifting
per contract. incompete
nt

1 No Inspection as
Per Contract Requirement
No system Verification & Validasi Poor
No MK & Judgement &
JSA MK/JSA
No SWA
No Pre Job & Pre Mob approval
Poor Judgement
NO Approved & Formal HSE Plan
No CSMS IMplementation Inadequate For CTU Contract. No Independent HSE Assurance
assessment
required skill
(c
SWA: Stop Work Authorithy Leadership & Accountability ompetency) LACK of Pre Job activity & Premob Audit-CSMS

TIPKM
Identified Critical Factors (CF):- Case Milenial
(identik dengan case Fatality than 2000 diatas).

1. Tidak ada Inspeksi/ Audit sebelum memobilisasi

Kontraktor ke site (wilayah kerja tambang).

2. Kegagalan Melakukan Blind Lifting

3. Bekerja di Ketinggian secara tidak aman (unsafe

WAH)).

23
 Examples

Kritikal Faktor 1:
Tidak ada Inspeksi dan Audit sebelum Memobilisasi Kontraktor Ke
site (daerah tambang)

Direct Cause Indirect Cause/ Basic Cause

6.6. Improperly Prepared 11.1 Inadequate Work Planning

equipment
SMKM substansi 3.4

8.2 Inadequate Leadership,

standard performance missing or
not enforced, inadequate
accountability
SMKM substansi 1.12; 3.13

23
24
Kritikal Faktor 2:

Kegagalan Melakukan “Blind Lifting”

Direct Cause Indirect Cause/ Basic Cause

3.1 Lack of knowledge of hazard 11.1 Inadequate work Planning
Present. SMKM substansi 2.1.4; 2.3 ; 2.6 : 3.3

6.1 Inadequate assessment of

requirement skill
SMKM substansi.5..1.3

4.1 Improper Decision making/ lack 8.2 Inadequate Leadership, standard

of judgement performance missing or not enforced,
inadequate accountability
SMKM substansi 1.12; 3.13

14.3. Inadequate Enforcement

procedure.
SMKM Substansi 2.3

14.4 Inadequate procedure, related

with Lifting Operation.
(no.B3/014/KT1330/2019/S9)
SMKM Substansi 3.2.3 25
REKOMENDASI
1. Leadership & Control
§ Melaksanakan amanat tanggung jawab Keselamatan Migas di Area
Pertambangan di wilayah tanggung jawabnya, untuk memastikan tidak ada
Kontraktor yang yang bekerja di areanya tanpa Persiapan dan Perencanaan
Keselamatan Migas yang memadai.
SMKM Substansi 1.12 dan 3.13

§ Menyediakan kecukupan SDM yang kompeten dan independen

untuk melakukan verifikasi dan validasi setiap Metoda Kerja dan
Kajian Risiko pekerjaaan yang memiliki risiko tinggi.
SMKM Substansi 1.9

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REKOMENDASI

2. Manajemen Risiko
§ Perencanaan Keselamatan & Keteknikan Migas yang baik harus
dilaksanakan kepada setiap kontraktor sebelum Mobilisasi dan bekerja di
wilayah kuasa pertambangan. Antara lain Kajian Risiko, Inspeksi dan Audit,
kompetensi check dan Mengkomunikasikan semua Persyaratan yang
dituangkan dalam dokument HSE Plan yg disetujui kepala Teknik.
SMKM Substansi 2.3; 2.5; 2.6; 3.1.3; dan 3.4

§ Rencana Kerja dan Kajian Risiko untuk pekerjaan yang berisiko tinggi harus
diverifikasi dan divalidasi oleh Spesialis yang kompetent dan independent
(bisa unsur internal yg kompeten namun tdk dlm satu organisasi ekskusi).
SMKM Substansi 2.3

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REKOMENDASI

3. Prosedur

§ Melakukan Audit “Sistim Ijin Kerja” secarta Berkala oleh pihak

independen (dapat internal resourses yang kompetent namun bukan
dalam organisasi eksekusi.)
SMKM Substansi 3.3.4

§ Memastikan dalam Prosedur Perencanaan Pekerjaan dan Kajian Risko

dilakukan oleh tenaga Verification Specialist yang independent (dapat
inyernal resources) untuk semua pekerjaan yang berisiko tinggi sebelum
diijinkan untuk dieksekusi.
SMKM Substansi 2.3.4

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 3. Mengapa CLC / SCAT Link to SMKM
PROCES INVESTIGASI bisa terjadi System/ Substansi
Lack of Control
System Management Managemen
Improvement Needed Keselamatan
Data/ Evidence MIGAS
gathering- 4P’s
System/Basic
Cause
Personal Factor & Job
Factor

1. Apa Yg Immediate/Direct
Cause
Terjadi Fact Findings Unsafe Act & Unsafe
Condition
REKOMENDASI
Contact/ Incident Contact/ Incident

Loss Contact/ Incident

2. Building Block
Technique to built a time 4. Apa yang dapat dilakukan
Bagamanai
untuk mencegah terulangnya
bisa terjadi line and Key events kejadian
(Chronology of incident
based fact findings).
Analyzing each
critical Factor that
is identified by
Identify Critical using the CLC
Factors- from the (SCAT)- Based on 5 Why’s
chronology Domino Theory

SP-TIPKM 29
Kesimpulan
§ Konsistensi Menggunakan “tools/ methode Investigasi”, sangat disarankan
dan penting- karena ini juga dpt meningkatkan kapabilitas organisasi- dengan
mengenal sistimatika investigasi- bisa sebagai awareness dan pencegahan
kecelakaan.

§ Root Cause Analysis (RCA) suatu kecelakaan ,(tanpa menghiraukan kapan

dan dimana terjadi) yg. credible, merupakan “harta karun” yang bernilai
tinggi, dipakai sebagai Referensi untuk Planning Pekerjaan ”Learning from
event” yang dapat digunakan secara terus menerus, bersanding dengan
Kajian Risiko (HIRADC,JSA, PHA, MAHA), CSMS Pre-Job Activity workshop
(HSE plan, Methode Kerja), dan review terhadap existing operasi/ kegiatan
yang relevan.

§ Repetitive Insident dng Root Cause yang sama, merupakan suatu indicator
kegagalan system “learning from event” tempat kerja.

§ “Learning from event” atau “lesson learned” process dapat digunakan dan
dipertimbangkan sebagai Leading indicator dalam membuat annual KPI.

§ Investigasi di Industri Migas Indonesia- sebaiknya Root atau system cause

dan management improvement di Link kan juga kpd Substansi SMKM (2018).
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 SEMOGA BERMANFAAT

TERIMA KASIH

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