Circuit board accident - organizational dimension hidden by prescribed safety


Autoria(s): Almeida, Ildeberto Muniz de; Buoso, Eduardo; do Amaral Dias, Maria Dionisia; Gouveia Vilela, Rodolfo Andrade
Contribuinte(s)

Universidade Estadual Paulista (UNESP)

Data(s)

20/05/2014

20/05/2014

01/01/2012

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.

Formato

3246-3251

Identificador

http://dx.doi.org/10.3233/WOR-2012-0590-3246

Work-a Journal of Prevention Assessment & Rehabilitation. Amsterdam: IOS Press, v. 41, p. 3246-3251, 2012.

1051-9815

http://hdl.handle.net/11449/13303

10.3233/WOR-2012-0590-3246

WOS:000306361803060

Idioma(s)

eng

Publicador

IOS Press

Relação

Work-a Journal of Prevention Assessment & Rehabilitation

Direitos

closedAccess

Palavras-Chave #occupational accidents #accident prevention #accident investigation #surveillance system
Tipo

info:eu-repo/semantics/article