Estudo de caso de dois acidentes do trabalho investigados com o método de árvore de causas

São apresentados dois acidentes do trabalho típicos, ocorridos em empresa de grande porte, investigados com o Método de Árvore de Causas ­ ADC, método que permite identificar o papel desempenhado por fatores gerenciais e de organização do trabalho no desencadeamento desses fenômenos. Os casos apresentados revelam a participação, na gênese dos acidentes, de fatores como designação temporária e improvisada de trabalhadores para funções e postos de trabalho, execução de tarefas deixadas à iniciativa e ao arbítrio dos trabalhadores, falta de ferramentas e de materiais apropriados à execução de tarefas e falhas na circulação de informações, entre outros. São também analisadas as indicações para o uso do método, suas potencialidades em termos de prevenção, bem como as implicações decorrentes de dificuldades de aplicação, de necessidades de treinamento e reciclagens e do dispêndio elevado de tempo para investigação de cada acidente.

Estudo da evolução dos acidentes do trabalho registrados pela Previdência Social no período de 1995 a 1999, em Botucatu, São Paulo

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

Da vigilância para prevenção de acidentes de trabalho: contribuição da ergonomia da atividade

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

Análise de barreiras e o modelo de ressonância funcional de acidentes de Erik Hollnagel

Partindo de apresentação da proposta de análise de acidentes baseada no modelo sistêmico e não linear de acidentes, dito de ressonância funcional, desenvolvido por Erik Hollnagel, este texto discute críticas às concepções deterministas de acidente e aos modelos lineares de representação desses eventos. Aspectos do modelo de ressonância funcional são usados como eixo definidor de proposta de agenda de discussões a ser desenvolvida pelos interessados no tema da análise de acidentes, destacando-se: a) a defesa do abandono da idéia de causas de acidentes e sua substituição pela de explicação desses eventos; b) apresentação dos conceitos de variabilidade de desempenhos e adaptações locais e a proposta de sua utilização como bases para a identificação de perfis ou aspectos típicos de acidentes. Por fim, discute-se a necessidade de incorporação dos conceitos apresentados no debate sobre novos caminhos para as práticas de análises e de prevenção de acidentes em nosso país.

Culpa da vítima: um modelo para perpetuar a impunidade nos acidentes do trabalho

Neste artigo analisam-se os laudos e dados obtidos das investigações de acidentes graves e fatais do trabalho efetuadas pelo Instituto de Criminalística (IC), Regional de Piracicaba. Foram analisados 71 laudos de acidentes ocorridos em 1998, 1999 e 2000. Os acidentes envolvendo máquinas representam 38,0%, seguido pelas quedas de altura (15,5%) e em terceiro lugar os causados por corrente elétrica (11,3%). Os laudos concluem que 80,0% dos acidentes são causados por atos inseguros cometidos pelos trabalhadores, enquanto que a falta de segurança ou condição insegura responde por 15,5% dos casos. A responsabilização das vítimas ocorre mesmo em situações de elevado risco em que não são adotadas as mínimas condições de segurança, com repercussão favorável ao interesse dos empregadores. Observa-se que estas conclusões refletem os modelos explicativos tradicionais, reducionistas, em que os acidentes são fenômenos simples, de causa única, centrada via de regra nos erros e falhas das próprias vítimas. A despeito das críticas que tem recebido nas duas últimas décadas no meio técnico e acadêmico, esta concepção mantém-se hegemônica prejudicando o desenvolvimento de políticas preventivas e a melhoria das condições de trabalho.

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.

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.

Armadilhas cognitivas: o caso das omissões na gênese dos acidentes de trabalho

Neste artigo discute-se o tema das omissões na gênese de acidentes do trabalho, tendo como referência contribuições de James Reason. Os autores descrevem três acidentes de trabalho ocorridos em atividades de manutenção, e nos quais a omissão de passos na execução da atividade foi apontada como causa nas análises efetuadas pelas empresas, acarretando atribuição de culpa aos acidentados. Nos três casos, a análise efetuada pelos autores revelou que, na seqüência de passos da atividade havia presença simultânea de pelo menos quatro das características apontadas por Reason como geradoras de omissões, caracterizando as denominadas armadilhas cognitivas.

Trajetória da análise de acidentes: o paradigma tradicional e os primórdios da ampliação da análise

A abordagem tradicional de acidentes pressupõe que a obediência a procedimentos e normas protege o sistema contra acidentes e que esses eventos decorrem de comportamentos faltosos dos trabalhadores, originados, em parte, de aspectos de suas personalidades. A identificação desses comportamentos baseia-se em comparação com o padrão que toma por base o jeito seguro de fazer, conhecido por antecipação pelos especialistas em segurança. Nas últimas décadas, surgem visões alternativas à abordagem tradicional, ampliando o perímetro das análises de acidentes e abrindo caminho para questionamentos de seus pressupostos relativos às concepções de ser humano e de trabalho. Os novos enfoques ajudam a evidenciar os resultados estéreis das práticas tradicionais: culpar e punir as vítimas, recomendar treinamentos e normas mantendo inalterados os sistemas em que ocorreram os acidentes. As novas abordagens sugerem o esgotamento do enfoque tradicional e ressaltam a importância da contribuição dos operadores para a segurança dos sistemas.

Effect of Mikania glomerata (Asteraceae) leaf extract combined with anti-venom serum on experimental Crotalus durissus (Squamata: Viperidae) envenomation in rats

Crotalic envenomation represents the highest number of deaths when compared to other snakebite envenomations of medical interest. Crotalic venom has important characteristics such as neurotoxicity, myotoxicity, nephrotoxicity, and clotting and hemolytic action. We evaluated the clinical and laboratory aspects of Crotalus durissus terrificus experimental envenomation in Wistar rats treated with antivenom and the aqueous extract of the plant mikania glomerata. The animals were divided into three groups: Group C (control); Group VS-venom and antivenom; Group VSM-venom, antivenom and aqueous extract of M glomerata. Crotalic poison caused clinical and laboratory alterations in Wistar mice. Significant clinical alterations were: temperature decrease, edema in the venom inoculated member, sedation and a locomotion decrease in groups VS and VSM when compared with group C. A faster recovery from sedation was observed only for animals of group VSM when compared to VS. There was an increase in the number of leukocytes, neutrophils and creatine kinase in the VS and VSM groups, compared to group C. Wistar rats showed a high resistance to crotalic venom. Additional studies with different doses, time of treatment, different administration methods and histopathological and immunological studies are necessary to understand the action of M glomerata in crotalic accidents. Rev. Biol. Trop. 57 (4): 929-937. Epub 2009 December 01.

Clinical and electrocardiographic evaluation during experimental toad poisoning in dogs

Accidents involving toad poisoning are frequent and dogs are the most common victims; they become poisoned by biting or ingesting a toad. When released in the organism, the venom is absorbed by both the oral mucosa and the digestive tract, initiating its toxic action. The aim of this work was to evaluate the clinical and electrocardiographic aspects of dogs subjected to experimental toad poisoning, as well as their response to treatment with propranolol. Twenty dogs were divided into two groups, a control group (n = 5) and a poisoned group (n = 15). After general anesthesia, the control group received a placebo, while the poisoned group received a venom aliquot through an orogastric tube. Results were tested through multivariate analysis (p < 0.05). The animals in the poisoned group had gastrointestinal symptoms including emesis, intense salivation, hyperemic or congested oral mucosa and pasty diarrhea. Non-responsive mydriasis, nystagmus, depression, stupor, tachypnea, opisthotonus and ataxia were also manifested by 100% of the poisoned animals. Affected dogs had an increase in blood pressure, statistically significant throughout study. Five poisoned animals developed ventricular tachycardia and were treated with propranolol (0.5 mg/kg IV). All propranolol-treated animals returned to normal sinus rhythm, which evidences the efficacy of this drug to treat ventricular arrhythmias caused by toad venom.

Knowledge of firefighters with special paramedic training of the emergency management of avulsed teeth

Immediate replantation into the socket is the ideal procedure in cases of accidental avulsion of permanent teeth. In Brazil, firefighters with special paramedic training are in charge of providing first-aid care to victims of road accidents and might have to deal with tooth avulsions. This study assessed the knowledge of firefighters regarding the emergency management of avulsed teeth. Information was collected from a questionnaire submitted to 110 volunteer firefighters in seven cities in the São Paulo State (Brazil). The results revealed that 70.9% of the respondents did not know what tooth avulsion was; 53.6% did not know what tooth replantation was or defined it incorrectly; 60% would not act properly in tooth avulsion cases; 20.9% did not consider replantation of the avulsed tooth into the socket as a treatment option; the ideal time interval for tooth replantation was unknown to 40% of the interviewees; 90% of the participants answered that they would not be able to perform tooth replantation. Among those who considered themselves unable to perform tooth replantation, 47.3% chose saline as the best storage medium for an avulsed tooth, 21.8% chose milk, 3.6% chose the patient's mouth and 20% reported not knowing where to store the tooth; 81.8% of the firefighters reported not to have ever received any specific directions on tooth replantation and 100% of them considered this knowledge a requirement for first-aid care to accident victims. In conclusion, the knowledge of the surveyed firefighters regarding emergency management after tooth avulsion was unsatisfactory in several aspects that are important for the success of replantation procedures. Firefighters with special paramedic training should be educated on how to proceed in cases of dentoalveolar traumas and tooth avulsions in order to improve treatment prognosis and increase the survival rate of replanted teeth.

Evaluating the knowledge of sports participants regarding dental emergency procedures

Dental trauma is a common consequence of sports practice to which emergency treatment is critical. The purpose of this study was to evaluate the knowledge of sports participants about dental trauma procedures, particularly tooth avulsion. A specific questionnaire concerning concepts, experiences and behaviors after dental trauma and the use of mouthguard was standardized and validated with 80 people. The validated questionnaire was then distributed to 310 sports participants. The results showed that 28.4% had experienced a kind of dental trauma; 42.6% would look for a dentist for treatment; 51.7% reimplanted or would reimplant the avulsed tooth; 6.5% would maintain the avulsed tooth in milk. Although 47.4% of the participants were aware of the possibility of accidents during sports practice, only 13.9% reported to use a mouthguard. This study showed an overall lack of knowledge of sportsmen and sportswomen with regards to tooth avulsion, thus reinforcing the need for educational campaigns to improve the immediate emergency treatment of tooth avulsion.

Occurrence of tooth injuries in patients treated in hospital environment in the region of Aracatuba, Brazil during a 6-year period

Dental trauma has been considered as a public health problem that affects mainly children and youngsters and due to its impact on the patient's quality of life. This study presents the results of a 6-year survey of the occurrence and characteristics of dental trauma in patients admitted to the Service of Surgery and Oral and Maxillofacial Traumatology of the School of Dentistry of Aracatuba (UNESP, Brazil) after emergency care in hospital facilities in the region of Aracatuba, SP, Brazil. For such purpose, the clinical files of patients treated at the Service between 1999 and 2005 were reviewed. Information regarding gender, age, number of traumatized teeth, etiology and diagnosis of the trauma was collected from the files of patients with tooth injuries and recorded in case report forms specifically designed for this purpose. The results showed that from a total of 4112 patients admitted to the Service within the surveyed period, 266 (6.5%) had tooth injuries (172 males - 64.7%; 94 females - 35.3%). The total number of traumatized teeth was 496. Most patients belonged to the 16-20 year-old age group (20.3%) and the most frequent causes of tooth injuries were bicycle accidents (28.6%), motorcycle accidents (19.2%) and falls (18.8%). Injuries to the periodontal tissues were the most frequent type of tooth injuries (408 teeth; 82.26%), occurring in 118 primary and 290 permanent teeth. Among the injuries to the periodontal tissues, avulsion was the most common (32.86%) (29.41% for primary and 34.0% for permanent teeth), followed by extrusive luxation (19.15%) (25.21% for primary and 17.24% for permanent teeth). In conclusion, in the surveyed population, cases of tooth injuries were more frequent in males aged 16-20 years old due to cyclist accidents with predominance of injuries to the periodontal tissues, in particular, avulsions.