An investigation into the loss of the Brazilian space programme's launch vehicle VLS-1 V03

There has been a rapid increase in the complexity and integration of many safety-critical systems. In consequence, it is becoming increasingly difficult to identify the causes of incidents and accidents back through the complex interactions that lead to an adverse event. At the same time, there is a growing appreciation of the need to consider a broad range of contextual factors in the aftermath of any mishap. A number of regulators, operators and research teams have responded to these developments by proposing novel techniques to support the analysis of complex, safety-critical incidents. It is important to illustrate these different approaches by applying them to a number of common case studies. The following pages, therefore, show how STAMP and AcciMap might support the Serviço Público Federal investigation into the explosion and fire of the Brazilian launch vehicle VLS-1 VO3. © 2006 Elsevier Ltd. All rights reserved.

Semiparametric modeling of the spatial distribution of occupational accident risk in the casual labor market, Piracicaba, southeast Brazil

The objective of this study was to estimate the spatial distribution of work accident risk in the informal work market in the urban zone of an industrialized city in southeast Brazil and to examine concomitant effects of age, gender, and type of occupation after controlling for spatial risk variation. The basic methodology adopted was that of a population-based case-control study with particular interest focused on the spatial location of work. Cases were all casual workers in the city suffering work accidents during a one-year period; controls were selected from the source population of casual laborers by systematic random sampling of urban homes. The spatial distribution of work accidents was estimated via a semiparametric generalized additive model with a nonparametric bidimensional spline of the geographical coordinates of cases and controls as the nonlinear spatial component, and including age, gender, and occupation as linear predictive variables in the parametric component. We analyzed 1,918 cases and 2,245 controls between 1/11/2003 and 31/10/2004 in Piracicaba, Brazil. Areas of significantly high and low accident risk were identified in relation to mean risk in the study region (p < 0.01). Work accident risk for informal workers varied significantly in the study area. Significant age, gender, and occupational group effects on accident risk were identified after correcting for this spatial variation. A good understanding of high-risk groups and high-risk regions underpins the formulation of hypotheses concerning accident causality and the development of effective public accident prevention policies.

Log smoldering after an Amazonian deforestation fire

The characteristics of log smoldering after an Amazonian deforestation fire are described. The experiment was carried out in 2001 at the Caiabi farm, near the city of Alta Floresta, state of Mato Grosso, Brazil, as part of a set of tests that have been performed in the same area since 1997. A 200 x 200m(2) test area was slashed in the beginning of June and burned on 20 August. The area contained 507 logs with diameter at breast height (DBH) higher than 10 cm, per hectare. In the day following the main burn 59 logs were found to remain smoldering, a number that corresponds to 2.9% of the total in the area. We chose 11 of the 59 logs to have their smoldering process monitored. Their diameter, moisture content and CHN dry biomass composition after the plot burn and before smoldering were determined. Other parameters such as temperature distribution while smoldering, porosity, density and mass volatilized during thermogravimetric test were also determined. Average smoldering speeds were in the range from 0.8 to 1.5 cm h(-1) for logs that smoldered without transition to the flaming regime. The average speed increased to 2.1 cm h(-1) for those logs that oscillated between smoldering and flaming. The speeds were lower overnight as compared to values determined during daytime for the same log. Higher log moisture contents were found to produce decreased speeds. Micro-porous biomass was not observed in the set of the 11 selected logs. Smoldering was observed to occur at substantial intensity in crossing of logs, with no longitudinal propagation. (C) 2003 Elsevier Ltd. All rights reserved.

Biomass consumption and CO2, CO and main hydrocarbon gas emissions in an Amazonian forest clearing fire

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Pustular dermatosis caused by fire ant (Solenopsis invicta) stings in a dog

This paper reports a case of spontaneous fire ant sting dermatitis in canine. The skin lesions consisted of nonfollicular, grouped pustules in the abdominal region. Several fire ants were found attached to the lesional skin. Histopathological findings included an intraepidermal neutrophilic pustule and predominantly neutrophilic interstitial dermatitis. An extensive area of collagen degeneration was also observed below the epidermal pustule. These clinical and histopathological findings are remarkable similar to those observed in fire ant stings in humans.

Report of a human accident caused by Conus regius (Gastropoda, Conidae)

Conus regius is a venomous mollusc in the Conidae family, which includes species responsible for severe or even fatal accidents affecting human beings. This is the first report on a clinical case involving this species. It consisted a puncture in the right hand of a diver who presented paresthesia and movement difficulty in the whole limb. The manifestations disappeared after around twelve hours, without sequelae.

Acidente com material perfurocortante entre profissionais de enfermagem de um hospital universitário

Os riscos ocupacionais a que os profissionais da equipe de enfermagem estão sujeitos no desempenho de suas funções são consideráveis. Assim estabeleceu-se como objetivo deste estudo analisar os acidentes perfurocortantes no período de 2002 a 2006, envolvendo a equipe de enfermagem de um hospital universitário, para compreender o contexto em que ocorrem. A utilização destas informações pode ser ferramenta de prevenção. Estudo descritivo, retrospectivo quantitativo e qualitativo. Na análise quantitativa foi utilizada estatística descritiva e na qualitativa o discurso do sujeito coletivo. Por meio das fichas de notificação do Núcleo de Vigilância Epidemiológica do Hospital, foi possível identificar acidentes do gênero no período pesquisado. Entrevistas foram direcionadas às vítimas de acidentes que tiveram como paciente-fonte portador de Síndrome da Imunodeficiência Adquirida/ Vírus da Imunodeficiência Humana, hepatite B e C. Os achados demonstraram que ainda persiste um grau significativo do desconhecimento ou banalização dos acidentes entre profissionais da saúde.

Circuit board accident - organizational dimension hidden by prescribed safety

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.

Safety illusion and error trap in a collectively-operated machine accident

Workplace accidents involving machines are relevant for their magnitude and their impacts on worker health. Despite consolidated critical statements, explanation centered on errors of operators remains predominant with industry professionals, hampering preventive measures and the improvement of production-system reliability. Several initiatives were adopted by enforcement agencies in partnership with universities to stimulate production and diffusion of analysis methodologies with a systemic approach. Starting from one accident case that occurred with a worker who operated a brake-clutch type mechanical press, the article explores cognitive aspects and the existence of traps in the operation of this machine. It deals with a large-sized press that, despite being endowed with a light curtain in areas of access to the pressing zone, did not meet legal requirements. The safety devices gave rise to an illusion of safety, permitting activation of the machine when a worker was still found within the operational zone. Preventive interventions must stimulate the tailoring of systems to the characteristics of workers, minimizing the creation of traps and encouraging safety policies and practices that replace judgments of behaviors that participate in accidents by analyses of reasons that lead workers to act in that manner.

Hazards in non-pasteurized milk on retail sale in Brazil: prevalence of Salmonella spp, Listeria monocytogenes and chemical residues

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Tests of proportional hazards and proportional odds models for grouped survival data

In this paper, we derive score test statistics to discriminate between proportional hazards and proportional odds models for grouped survival data. These models are embedded within a power family transformation in order to obtain the score tests. In simple cases, some small-sample results are obtained for the score statistics using Monte Carlo simulations. Score statistics have distributions well approximated by the chi-squared distribution. Real examples illustrate the proposed tests.

Choosing between Cox proportional hazards and logistic models for interval-censored data via bootstrap

This work develops a new methodology in order to discriminate models for interval-censored data based on bootstrap residual simulation by observing the deviance difference from one model in relation to another, according to Hinde (1992). Generally, this sort of data can generate a large number of tied observations and, in this case, survival time can be regarded as discrete. Therefore, the Cox proportional hazards model for grouped data (Prentice & Gloeckler, 1978) and the logistic model (Lawless, 1982) can befitted by means of generalized linear models. Whitehead (1989) considered censoring to be an indicative variable with a binomial distribution and fitted the Cox proportional hazards model using complementary log-log as a link function. In addition, a logistic model can be fitted using logit as a link function. The proposed methodology arises as an alternative to the score tests developed by Colosimo et al. (2000), where such models can be obtained for discrete binary data as particular cases from the Aranda-Ordaz distribution asymmetric family. These tests are thus developed with a basis on link functions to generate such a fit. The example that motivates this study was the dataset from an experiment carried out on a flax cultivar planted on four substrata susceptible to the pathogen Fusarium oxysoprum. The response variable, which is the time until blighting, was observed in intervals during 52 days. The results were compared with the model fit and the AIC values.

Stem protective tissue in Erythroxylum tortuosum (Erythroxylaceae), a fire tolerant species from cerrado

The origin and structure are described of the secondary protective tissue in the stem of Erythorxylum tortuosum Mart., a fire tolerant shrubby species common in Brazilian cerrado. The highly tortuous stems are covered with thick bark which is more developed at the base of the stem. After fire in the cerrado, rhytidome fragments of the burned stem flake off, revealing newly formed cork. The first periderm appears near of the terminal buds and is iniated by periclinal divisions in subepidermal cells giving rise to radial rows of cells. The first phellogen is discernible only after the differentiation of the several radial rows of cork cells. Other phellogens have their origin in successively deeper layers of the cortex. The sucessive periderms are discontinuous around the circumference. The collapsed cells with phenolic substances and the accumulated dead cells cause the formation of discontinuous blackish lines, which delimit the sucessive periderms in the rhytidome. The rhytidome contains large quantities of sclereids developed from cell wall thickening of cortex cells. The occurrence of periderm, in the young parts of the stem and of rhytidome in the older parts represents pyrophytic characteristics and may explain, in part, the fire tolerance of this species.

General morphology and ultrastructure of the venom apparatus and convoluted gland of the fire ant, Solenopsis saevissima

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Proteomic View of the Venom from the Fire Ant Solenopsis invicta Buren

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)