Tragedy on grade crossing: driver failure or systemic fragility?

In 2010, an accident occurred in Americana-SP, Brazil, involving two trains and one bus on a Grade Crossing, when 10 people died and 17 were injured including workers. This paper aims to analyze the accident using the Model of Analysis and Prevention of Work Accidents (MAPA). The method provides observation of work, interviews and analysis of documents to understand precedents of the event in the following stages: to understand the usual work from the involved people, the changes occurred in the system, the operation of barriers, managerial and organizational aspects. By the end, measures are suggested to avoid new occurrences. The accident took place at night in a site with insufficient lighting. The working conditions of bus drivers, train operators and watchmen are inadequate. There were only symbolic barriers (visual and acoustic signals) triggered manually by watchman upon train operator radio communication. The fragility of the barrier system associated to poor lighting and short time to trigger the signaling seem to play a critical role in the event. Contrary to the official report which resulted in guilt of the bus driver, the conclusion of the paper emphasizes the fragility of the safety system and the need of level crossing reproject.

Aircraft accident in Brazil: Boeing vs. Legacy?

Air accidents represent a small proportion of the flights registered worldwide. Airplane collisions in the air are rare. In September of 2006, a Boeing 737-800 collided in midair with a Legacy Jet. It was the largest accident registered in the history of Brazilian aviation until that time. The present study explores aspects of press coverage of the accident. Data and information reported in the media about the accident from September 2006 to August 2007 were collected and discussed. Media coverage called attention to two unusual aspects: politicisation of the discussion, culminating in the opening of congressional inquiries, and equally the concomitance of police investigations interfering in the work of agencies responsible for the official accident investigation. Emphasis on assigning guilt and establishing penalties may close the windows of opportunity an accident had opened for discussions on the improvement of air safety. In Brazil, political imperatives and organizational pressures have interfered and the possibilities of organizational learning from the accident have been drastically curtailed.

Operational safety: Development of electronic system for dynamic balance evaluation of farm tractors

The present study aimed at the development and evaluation of a low cost electronic device in order to provide safety for farm tractor users. The major accident occurrence in agricultural surroundings is from farm tractor side bending. Therefore, this sensor was designed to detect and alert about it. The results were satisfying. © 2013 Taylor & Francis Group.

Integrated sediment quality assessment in Paranagua Estuarine System, Southern Brazil

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Soil microbial biomass in organic farming system

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

APPLICATION of THE HAZARD ANALYSIS and CRITICAL CONTROL POINT (HACCP) SYSTEM on THE MUSHROOM PROCESSING LINE FOR FRESH CONSUMPTION

The Hazard Analysis and Critical Control Point (HACCP) is a preventive system that intends to guarantee the safety and harmlessness of food. It improves the quality of products as it eliminates possible defects during the process, and saves costs by practically eliminating final product inspection. This work describes the typical hazards encountered on the mushroom processing line for fresh consumption. Throughout the process, only the reception stage of mushrooms has been considered a critical control point (CCP). The main hazards at this stage were: the presence of unauthorised phytosanitary products; larger doses of such products than those permitted; the presence of pathogenic bacteria or thermo-stable enterotoxins. Putting into practice such knowledge would provide any industry that processes mushrooms for fresh consumption with a self-control HACCP-based system for its own productions.

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.

Microbiological Evaluation of Chicken Carcasses in an Immersion Chilling System with Water Renewal at 8 and 16 Hours

Since 2004, Brazil has been the leading exporter of chicken. Because of the importance of this sector in the Brazilian economy, food safety must be ensured by control and monitoring of the production stages susceptible to contamination, such as the chilling process. The goal of this study was to evaluate changes in microbial levels on chicken carcasses and in chilling water after immersion in a chilling system for 8 and 16 h during commercial processing. An objective of the study was to encourage discussion regarding the Brazilian Ministry of Agriculture Livestock and Food Supply regulation that requires chicken processors to completely empty, clean, and disinfect each tank of the chilling system after every 8-h shift. Before and after immersion carcasses were collected and analyzed for mesophilic bacteria, Enterobacteriaceae, conforms, and Escherichia coli. Samples of water from the chilling system were also analyzed for residual free chlorine. The results do not support required emptying of the chiller tank after 8 h; these tanks could be emptied after 16 h. The results for all carcasses tested at the 8- and 16-h time points indicated no significant differences in the microbiological indicators evaluated. These data provide both technical and scientific support for discussing changes in federal law regarding the management of immersion chilling water systems used as part of the poultry processing line.

Assessment of pharmacotherapeutic safety of medical prescriptions for elderly residents in a long-term care facility

The present study aimed to estimate the prevalence of elderly using potentially inappropriate medications (PIM) and with occurrence of potentially hazardous drug interactions (PHDI), to identify the risk factors for the prescription of PIM and to evaluate the impact of pharmaceutical intervention (PI) for the prescription of safer therapeutic alternatives. Therefore, a cross-sectional study was performed in a long-term care facility in São Paulo State, between December/2010 and January/2011. The medical records of the patients >= 60 years old who took any drugs were consulted to assess the pharmacotherapeutic safety of the medical prescriptions, in order to identify PIM and PHDI, according to the Beers (2003) and World Health Organization criteria, respectively. PI consisted of a guidance letter to the physician responsible for the institution, with the suggestions of safer equivalent therapeutics. Approximately 88% of the elderly took at least one drug, and for 30% of them the PIM had been prescribed. Most of the PIM identified (53.4%) act on the central nervous system. Among the 13 different DI detected, 6 are considered PHDI. Polypharmacy was detected as a risk factor for PIM prescription. After the PI there was no change in medical prescriptions of patients who had been prescribed PIM or PHDI. The data suggests that PI performed by letter, as the only interventional, method was ineffective. To contribute it a wide dissemination of PIM and PHDI among prescriber professionals is necessary for the selection of safer treatment for elderly. Additionally, a pharmacist should be part of the health care team in order to help promote rational use of medicines.

Development of a low-cost mobile mapping system: A South American experience

This paper presents the prototype of a low-cost terrestrial mobile mapping system (MMS) composed of a van, two digital video cameras, two GPS receivers, a notebook computer, and a sound frame synchronisation system. The imaging sensors are mounted as a stereo video camera on top of the vehicle together with the GPS antennae. The GPS receivers and the notebook computer are configured to record data referred to the vehicle position at a planned time interval. This position is subsequently transferred to the road images. This set of equipment and methods provide the opportunity to merge distinct techniques to make topographic maps and also to build georeferenced road image databases. Both vector maps and raster image databases, when integrated appropriately, can give spatial researchers and engineers a new technique whose application may realise better planning and analysis related to the road environment. The experimental results proved that the MMS developed at the São Paulo State University is an effective approach to inspecting road pavements, to map road marks and traffic signs, electric power poles, telephone booths, drain pipes, and many other applications important to people's safety and welfare. A small number of wad images have already been captured by the prototype as a consequence of its application in distinct projects. An efficient organisation of those images and the prompt access to them justify the need for building a georeferenced image database. By expanding it, both at the hardware and software levels, it is possible for engineers to analyse the entire road environment on their office computers.

GIS_EM (Geographic information system for environmental monitoring) - A software implemented at Paulínia refinery (REPLAN) for management of environmental data

The computational program called GIS_EM (Geographic Information System for Environmental Monitoring), a software devised to manage geographic information for monitoring soil, surface, and ground water, developed for use in the Health, Safety, and Environment Division of Paulinia Refinery is presented. This program enables registering and management of alphanumeric information pertaining to specific themes such as drilling performed for sample collection and for installation of monitoring wells, geophysical and other tests, results of chemical analyses of soil, surface, and groundwater, as well as reference values providing orientation for soil and water quality, such as EPA, Dutch List, etc. Management of such themes is performed by means of alphanumeric search tools, with specific filters and, in the case of spatial search, through the selection of spatial elements (themes) in map view. Documents existing in digital form, such as reports, photos, maps, may be registered and managed in the network environment. As the system centralizes information generated upon environmental investigations, it expedites access to and search of documents produced and stored in the network environment, minimizing search time and the need to file printed documents. This is an abstract of a paper presented at the AIChE Annual Meeting and Fall Showcase (Cincinnati, OH 10/30/2005-11/4/2005).

Bio-safety technology in production of bovine herpesvirus type 5 (BoHV-5) using an alternative serum-free medium

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

Transmission network expansion planning for the Colombian electrical system: Connecting the Ituango hydroelectric power plant

The hydroelectric power plant Hidroltuango represents a major expansion for the Colombian electrical system (with a total capacity of 2400 MW). This paper analyzes the possible interconnections and investments involved in connecting Hidroltuango, in order to strengthen the Colombian national transmission system. A Mixed Binary Linear Programming (MBLP) model was used to solve the Multistage Transmission Network Expansion Planning (MTEP) problem of the Colombian electrical system, taking the N-1 safety criterion into account. The N-1 safety criterion indicates that the transmission system must be expanded so that the system will continue to operate properly if an outage in a system element (within a pre-defined set of contingencies) occurs. The use of a MBLP model guaranteed the convergence with existing classical optimization methods and the optimal solution for the MTEP using commercial solvers. Multiple scenarios for generation and demand were used to consider uncertainties within these parameters. The model was implemented using the algebraic modeling language AMPL and solved using the commercial solver CPLEX. The proposed model was then applied to the Colombian electrical system using the planning horizon of 2018-2025. (C) 2014 Elsevier B.V. All rights reserved.

Feasibility and safety of intrathecal transplantation of autologous bone marrow mesenchymal stem cells in horses

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