A Work Accident Analysis Using Fishbone Diagram and Systematic Cause Analysis Technique (Scat) as A Basis for Improving Worker Supervision at PT XYZ

Abstract

Work accidents in manufacturing industries remain an important occupational safety issue because production activities involve manual handling, lifting operations, moving materials, heavy equipment, and work environments with potential pinch points. PT XYZ is a precast concrete utility pole manufacturer that experienced five work accident cases during July-August 2025, including hands caught between objects, a concrete pole striking a crane cabin, a hand crushed by a wire coil, and a palm punctured by wire. This study aimed to identify accident-contributing factors, analyze their root causes, and formulate improvements to worker supervision to prevent recurrence. A descriptive qualitative approach was applied using observation, interviews with injured workers, witnesses, and Health, Safety, and Environment personnel, Focus Group Discussion, company accident reports, and source triangulation. The Fishbone Diagram was used to classify contributing factors, while the Systematic Cause Analysis Technique (SCAT) was used to trace accident events from contact, immediate causes, basic causes, to recommended controls. The findings show that the five accidents were influenced by human, method, machine/equipment, environmental, material, and management factors. The dominant problems were weak supervision, absence of detailed standard operating procedures, inadequate communication and confirmation during lifting and transport activities, unsafe work positioning, insufficient warning devices, and inadequate preventive maintenance. The SCAT results indicate that unsafe acts and unsafe conditions were strongly linked to job factors, particularly inadequate work standards, equipment maintenance, task observation, and safety control. This study recommends an integrated worker supervision system consisting of pre-operational supervision, operational supervision, and post-operational supervision supported by toolbox meetings, standardized communication signals, safe work procedures, critical equipment inspection, preventive maintenance, warning systems, exclusion zones, and continuous incident learning.