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.

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.

Investigation of time series stations along a productivity gradient north of the Canary Islands

Three stations along a productivity gradient north of the Canary Islands were investigated for surface-water properties, particle flux, and composition (biogenic and lithogenic components, and stable nitrogen isotope composition, delta15N) and export production. Investigation sites along the east-west transect off the NW African upwelling margin included the European Station for Time-Series in the Ocean, Canary Islands (ESTOC), one location contiguous to the NW African upwelling zone in the Eastern Boundary Current (EBC) and one station north of the island La Palma (LP). The seasonality of surface-water properties along the transect was mainly influenced by the winter cooling and simultaneous phytoplankton maximum and, in addition at EBC, by nearby upwelling. Accordingly, particle flux and composition along the transect were closely linked to the winter bloom sedimentation and upwelling related enhanced plankton biomass stemming from the primary upwelling and the Cape Yubi filament at EBC. During all seasons, particle flux was highest at EBC and had the highest contribution of biogenic opal and lithogenic components, and the lowest delta15N compared to the offshore stations. But contrary to what would be expected from the productivity gradient, particle flux did not decrease from ESTOC to LP. Below the upper several hundred meters, particle flux was enhanced by additional particle input along the entire transect, manifested by an increase of flux with depth and lower delta15N values. We offer a scenario in which intermediate nepheloid layers originating from the primary upwelling as well as particle dispersion from upwelling filaments, mainly the Cape Ghir filament, impact on the trap stations as far as 700 km into the open ocean. This study contributes to our understanding of the poorly resolved biogeochemical transition between the productive shelf and subtropical gyre provinces.

Multivariate statistical analysis of highway accident and highway conditions. Final report.

Transportation Department, Office of University Research, Washington, D.C.

The effect of truck size and weight on accident experience and traffic operations. Volume 1: executive summary. Final report.

Federal Highway Administration, Washington, D.C.

The effect of truck size and weight on accident experience and traffic operations. Volume II: traffic operations. Final report.

Federal Highway Administration, Washington, D.C.

The effect of truck size and weight on accident experience and traffic operations. Volume III: accident experience of large trucks. Final report.

Federal Highway Administration, Washington D.C.

Tri-level study: modification. Task 3: validity assessment of police-reported accident data. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Tri-level study: modification. Task 4: final report on the relationships between driver characteristics and accident causation.

National Highway Traffic Safety Administration, Washington, D.C.

Tri-level study: modification. Task 5: an examination of driver characteristics and collision producing errors of accident and traffic violation repeaters. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Single vehicle accident study. Volume II: technical report. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

The effect of truck size and weight on accident experience and traffic operations. Volume IV: truck exposure classification by size and weight. Final report.

Federal Highway Administration, Washington, D.C.

Motorcycle accident cause factors and identification of countermeasures. Volume II: appendix/supplemental data. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Single vehicle accident study. Volume I: executive summary. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Single vehicle accident study. Volume III: appendices. Final report.

National Highway Traffic Safety Administration, Washington, D.C.