Background Through in-depth identification of management system and specific control factor, the root cause of the accident can be determined. Had been an accident in the PT.X such as a first aid injury and loss time accident, and has conducted investigations and follow-up but similar accidents still happen. The purpose of this study was to identify the cause of the accident based on management system and specific control factor.

Methods This study used qualitative approaches to explore the root cause based on management system factor and specific control factor. Researchers used a qualitative approach, because researchers used a standard mini-MORT as a data collection tool and 5 whys method to explore the root causes.

Results Results of the analysis in the first case accident that crushed by c-canal, and the second case of an accident that falling from a ladder have in common causes, which is the cause of the accident was due to organisational influences. Influence of the organisation, such as resource management, organisational climate and organisational process. This relates to the allocation of limited resources, both human and financial, and material.

Conclusions Conclusion of this study is that there are elements of the management system and specific control factor was inadequate, and the root cause of the accident was on organisational Influences. The company had to consider the approach to safety behaviour that occupational safety and health programs can be done with an awareness of the whole management to workers who are believed to reduce the number of accidents.