Challenging the immediate causes: A work accident investigation in an oil refinery using organizational analysis

• Autor(a) principal: Beltran, Sandra Lorena
• Data de Publicação: 2018
• Outros Autores: Vilela, Rodolfo Andrade De Gouveia, De Almeida, Ildeberto Muniz [UNESP]
• Tipo de documento: Artigo
• Idioma: eng
• Título da fonte: Repositório Institucional da UNESP
• Texto Completo: http://dx.doi.org/10.3233/WOR-182702; http://hdl.handle.net/11449/164148
• topic: Accident prevention; oil refinery; oil and gas industry

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.