Affiliations: [a]
Department of Environmental Health, School of Public Health, University of São Paulo, São Paulo, Brazil
| [b]
Department of Public Health, School of Medicine, São Paulo State University “Júlio de Mesquita Filho”, Botucatu, São Paulo, Brazil
Correspondence:
[*]
Address for correspondence: Sandra Lorena Beltran, Department of Environmental Health, School of Public Health, University of São Paulo, Av. Dr. Arnaldo 715, Cerqueira César, São Paulo, SP, 01246-904, Brazil. E-mail: [email protected].
Abstract: BACKGROUND:In many companies, investigations of accidents still blame the victims without exploring deeper causes. Those investigations are reactive and have no learning potential. OBJECTIVE:This paper aims to debate the historical organizational aspects of a company whose policy was incubating an accident. METHODS:The empirical data are analyzed as part of a qualitative study of an accident that occurred in an oil refinery in Brazil in 2014. To investigate and analyse this case we used one-to-one and group interviews, participant observation, Collective Analyses of Work and a documentary review. The analysis was conducted on the basis of concepts of the Organizational Analysis of the event and the Model for Analysis and Prevention of Work Accidents. RESULTS:The accident had its origin in the interaction of social and organizational factors, among them being: excessively standardized culture, management tools and outcome indicators that give a false sense of safety, the decision to speed up the project, the change of operator to facilitate this outcome and performance management that encourages getting around the usual barriers. CONCLUSIONS:The superficial accident analysis conducted by the company that ignored human and organizational factors reinforces the traditional safety culture and favors the occurrence of new accidents.
Keywords: Accident prevention, oil refinery, oil and gas industry
