Circuit board accident - organizational dimension hidden by prescribed safety
Nenhuma Miniatura disponível
Data
2012-01-01
Autores
Almeida, Ildeberto Muniz de [UNESP]
Buoso, Eduardo
do Amaral Dias, Maria Dionisia [UNESP]
Gouveia Vilela, Rodolfo Andrade
Título da Revista
ISSN da Revista
Título de Volume
Editor
IOS Press
Resumo
This study analyzes an accident in which two maintenance workers suffered severe burns while replacing a circuit breaker panel in a steel mill, following model of analysis and prevention of accidents (MAPA) developed with the objective of enlarging the perimeter of interventions and contributing to deconstruction of blame attribution practices. The study was based on materials produced by a health service team in an in-depth analysis of the accident. The analysis shows that decisions related to system modernization were taken without considering their implications in maintenance scheduling and creating conflicts of priorities and of interests between production and safety; and also reveals that the lack of a systemic perspective in safety management was its principal failure. To explain the accident as merely non-fulfillment of idealized formal safety rules feeds practices of blame attribution supported by alibi norms and inhibits possible prevention. In contrast, accident analyses undertaken in worker health surveillance services show potential to reveal origins of these events incubated in the history of the system ignored in practices guided by the traditional paradigm.
Descrição
Palavras-chave
occupational accidents, accident prevention, accident investigation, surveillance system
Como citar
Work-a Journal of Prevention Assessment & Rehabilitation. Amsterdam: IOS Press, v. 41, p. 3246-3251, 2012.