Suparli, Suparli (2026) Analisis Efektivitas Implementasi Sistem Bekerja Selamat Dengan Pendekatan Swiss Cheese Model Di PT Berau Coal. Masters thesis, Institut Teknologi Sepuluh Nopember.
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Abstract
PT Berau Coal mengalami peningkatan kecelakaan kerja dari 2022-2024 meskipun telah menerapkan Layering Sistem Bekerja Selamat (SBS) 5 layer. Diperlukan analisis mendalam menggunakan Swiss Cheese Model untuk mengidentifikasi kelemahan sistem pertahanan dan memahami kegagalan berlapis yang menyebabkan kecelakaan. Oleh karena itu, diperlukan analisis penyebab kecelakaan kerja periode 2022 – 2024 berdasarkan layering SBS dengan pendekatan Swiss Cheese Model dan mengidentifikasi kontribusi setiap layer terhadap kecelakaan sebagai dasar perbaikan sistem keselamatan. Penelitian ini menggunakan metode semi kuantitatif dan kualitatif. Metode semi kuantitatif digunakan untuk melihat persentase frekuensi pada setiap variabel layering SBS, sedangkan metode kualitatif pada penelitian ini bertujuan untuk mengungkapkan gambaran faktor penyebab kecelakaan dari analisa framework layering SBS. Keabsahan data yang digunakan adalah dokumen resmi hasil investigasi kecelakaan PT Berau Coal periode 2022 - 2024. Hasil penelitian: Analisis terhadap 435 insiden dan 2.413 temuan kegagalan kontrol (2022–2024) menunjukkan bahwa Layer 3 (Work Readiness & Monitoring) merupakan kontributor terbesar (45,67%), diikuti Layer 2 (21,01%), Layer 1 (20,14%), Layer 5 (7,83%), dan Layer 4 (5,35%), dengan rasio rata-rata 5,55 temuan kegagalan per insiden. Analisis Pareto pada Layer 3 mengidentifikasi tiga sub-faktor vital few, yaitu Pelaksanaan Pekerjaan Sesuai SOP, Kondisi Area Kerja, dan Pengawasan Pekerjaan oleh Pengawas, yang menjadi prioritas utama perbaikan sistem keselamatan.
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PT Berau Coal experienced an increase in occupational accidents during the 2022 - 2024 period despite having implemented the five-layer Safe Work System (Sistem Bekerja Selamat – SBS) Layering. An in-depth analysis using the Swiss Cheese Model is therefore required to identify weaknesses in the defense system and to understand the layered failures that lead to accidents. Accordingly, this study analyzes the causes of occupational accidents during the 2022–2024 period based on the SBS layering framework using the Swiss Cheese Model approach, and identifies the contribution of each layer to accident occurrence as a basis for improving the safety system. This research employs semi-quantitative and qualitative methods. The semi-quantitative method is used to examine the percentage frequency of each SBS layering variable, while the qualitative method aims to reveal the description of accident causation factors through analysis of the SBS layering framework. Data validity is ensured through the use of official accident investigation documents issued by PT Berau Coal for the 2022–2024 period. Research results: Analysis of 435 incidents and 2,413 control-failure findings (2022–2024) shows that Layer 3 (Work Readiness & Monitoring) is the largest contributor (45.67%), followed by Layer 2 (21.01%), Layer 1 (20.14%), Layer 5 (7.83%), and Layer 4 (5.35%), with an average ratio of 5.55 failure findings per incident. Pareto analysis on Layer 3 identifies three vital-few sub-factors Compliance with SOP in Work Execution, Work Area Conditions, and Supervisor Oversight of Work, which are the top priorities for improving the safety system.
| Item Type: | Thesis (Masters) |
|---|---|
| Uncontrolled Keywords: | Kecelakaan kerja, Swiss Cheese Model, Layering Sistem Bekerja Selamat, Pertambangan batubara, Workplace accidents, Safe Working Layering System, Coal mining |
| Subjects: | H Social Sciences > HD Industries. Land use. Labor T Technology > T Technology (General) > T55 Industrial Safety T Technology > TN Mining engineering. Metallurgy |
| Divisions: | Interdisciplinary School of Management and Technology (SIMT) > 78201-System And Technology Innovation |
| Depositing User: | Suparli Suparli |
| Date Deposited: | 22 Jul 2026 03:28 |
| Last Modified: | 22 Jul 2026 03:28 |
| URI: | http://repository.its.ac.id/id/eprint/136678 |
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