Circuit board accident - organizational dimension hidden by prescribed safety

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dc.contributor.authorAlmeida, Ildeberto Muniz de [UNESP]
dc.contributor.authorBuoso, Eduardo
dc.contributor.authordo Amaral Dias, Maria Dionisia [UNESP]
dc.contributor.authorGouveia Vilela, Rodolfo Andrade
dc.contributor.institutionUniversidade Estadual Paulista (Unesp)
dc.contributor.institutionUniversidade de São Paulo (USP)
dc.date.accessioned2014-05-20T13:38:21Z
dc.date.available2014-05-20T13:38:21Z
dc.date.issued2012-01-01
dc.description.abstractThis 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.en
dc.description.affiliationUniv Estadual Paulista, UNESP, Botucatu Med Sch, Dept Publ Hlth, São Paulo, Brazil
dc.description.affiliationUniv São Paulo, Dept Environm Hlth, Sch Publ Hlth, BR-05508 São Paulo, Brazil
dc.description.affiliationUnespUniv Estadual Paulista, UNESP, Botucatu Med Sch, Dept Publ Hlth, São Paulo, Brazil
dc.format.extent3246-3251
dc.identifierhttp://dx.doi.org/10.3233/WOR-2012-0590-3246
dc.identifier.citationWork-a Journal of Prevention Assessment & Rehabilitation. Amsterdam: IOS Press, v. 41, p. 3246-3251, 2012.
dc.identifier.doi10.3233/WOR-2012-0590-3246
dc.identifier.issn1051-9815
dc.identifier.lattes2734132298792788
dc.identifier.urihttp://hdl.handle.net/11449/13303
dc.identifier.wosWOS:000306361803060
dc.language.isoeng
dc.publisherIOS Press
dc.relation.ispartofWork-a Journal of Prevention Assessment & Rehabilitation
dc.relation.ispartofjcr0.902
dc.relation.ispartofsjr0,463
dc.rights.accessRightsAcesso restrito
dc.sourceWeb of Science
dc.subjectoccupational accidentsen
dc.subjectaccident preventionen
dc.subjectaccident investigationen
dc.subjectsurveillance systemen
dc.titleCircuit board accident - organizational dimension hidden by prescribed safetyen
dc.typeArtigo
dcterms.licensehttp://www.iospress.nl/service/authors/author-copyright-agreement/
dcterms.rightsHolderIOS Press
unesp.author.lattes2734132298792788
unesp.campusUniversidade Estadual Paulista (Unesp), Faculdade de Medicina, Botucatupt

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