Gestão Proativa

 Texts in English and Portuguese below. - Textos em Inglês e em Português a seguir. Video about Safety - René Amalberti, below: Vídeo sobre Segurança - René Amalberti, a seguir: Vídeo de uma entrevista de René Amalberti, pesquisador de destaque na Gestão de Riscos e da Safety Science. O destaque de René Amalberti, se dá pela linha de idéias e propostas, com boa aplicabilidade prática, na gestão das empresas. Se houver interesse, há a opção, de inserir legendas neste vídeo do you tube e configurar a tradução, para o português. Mais informações, vídeos, materiais complementares, sobre Segurança, acessar os links no final desta postagem.  Você quer aprimorar as questões essenciais para a Prevenção de Tragédias, na sua organização, empresa, serviço ou atividade? Importante se debruçar sobre estas questões, e aprofundar os estudos acadêmicos, com aplicação nas empresas, para desenvolver propostas para evitar estas tragédias. Primordial apresentar modelos, princípios e formas estruturadas,

Publicação de 25/08/2022, da coluna semanal Prevenir Tragédias da Revista Digital Norminha, de Segurança do Trabalho, de periodicidade semanal. Estou publicando semanalmente nesta revista, parte dos cases de tragédias e proposta de prevenção, que já divulgo aqui no Linkedin. Os cases estão hospedados no meu Blog da Segurança Proativa, e estão disponíveis para consulta on-line de forma gratuita. Minha contribuição para aprimorar a segurança das organizações. Mais informações, vídeos, materiais complementares, e outros artigos de acidentes e incidentes, acessar o link no final desta postagem. Será que estamos dando a atenção, as questões essenciais para a Segurança das Organizações? Quantas vidas, qual impacto social, ambiental, patrimonial, à imagem da organização e outros, seriam poupados? Importante se debruçar sobre estas questões, e aprofundar os estudos acadêmicos, com aplicação nas empresas, para desenvolver propostas para evitar estas tragédias. A seguir a proposta de prevenção e

  Figure - Challenger Explosion Challenger - Date Actions and latent failures Reference: James Reason – Human Error 1977 - During test firings of the solid–rocket booster, Thiokol engineers discover that casing joints expanded (instead of tightening as designed). Thiokol persuades NASA that this is “not desirable but acceptable.” It was also discovered that one of the two O – ring joint seals frequently became unseated, thus failing to provide the back – up for which it was designed. 1981 - NASA plans two lightweight versions of the boosters to increase payload. One is to be of steel, the other made of carbon filament. Hercules submits an improved design for the latter, incorporating a lip at the joint to prevent the O – ring from unseating (termed a “capture feature”). Thiokol continues to use unmodified joints for its steel boosters. November 1981 - Erosion (or “scorching”) was noticed on one of the six primary O – rings. This was the same joint that was later involved in the Challen

  Figure - Book Human Error Highlights of James Reason, Human Error: Chernobyl: The fundamental attribution error has been widely studied in social psychology. This refers to a pervasive tendency to blame bad outcomes on an actor’s personal inadequacies (i.e., dispositional factors) rather than attribute them to situational factors beyond his or her control. Such tendencies were evident in both the Russian and the British responses to the Chernobyl accident. Thus, the Russian report on Chernobyl (USSR State Committee on the Utilization of Atomic Energy, 1986) concluded that: “The prime cause of the accident was an extremely improbable combination of violations of instructions and operating rules.” Lord Marshall, Chairman of the U.K. Central Electricity Generating Board (CEGB), wrote a foreword to the U.K. Atomic Energy Authority’s report on the Chernobyl accident (UKAEA, 1987), in which he assigned blame in very definite terms: “To us in the West, the sequence of reactor operator error

Vídeo sobre Safety Differently - Sidney Dekker, a seguir: Vídeo de Sidney Dekker, pesquisador de destaque na Gestão de Riscos e da Safety Science. Dekker, foca na questão de uma Segurança menos burocrática e com menos regras, não propõe modelos estruturados para a Segurança e preconiza uma Segurança Diferente. Se houver interesse, há a opção, de inserir legendas neste vídeo do you tube e configurar a tradução, para o português. Centro de Estudos Prevenir Tragédias, através da Segurança Proativa e Gestão de Riscos, mais informações, vídeos e materiais complementares, acessar o link no final desta postagem.  Você quer aprimorar as questões essenciais para a Prevenção de Tragédias, na sua organização, empresa, serviço ou atividade? Importante se debruçar sobre estas questões, e aprofundar os estudos acadêmicos, com aplicação nas empresas, para desenvolver propostas para evitar estas tragédias. Primordial apresentar modelos, princípios e formas estruturadas, em conjunto com lições aprend

  Figure 1 - Loss of Air France 447 Off the Brazilian Coast Lessons learned from the Loss of Air France 447 Off the Brazilian Coast and ProSREM Reference: Organizational Accidents Revisited - James Reason Background On 1 June 2009, Air France Flight 447 (AF 447) took off from Rio de Janeiro with 228 passengers and crew on board. It was scheduled to arrive at Charles de Gaulle Airport, Paris, after an 11-hour flight, but it never arrived. Three hours later, it was at the bottom of the ocean. There were no survivors. Of all the case studies considered here, I find this one the most horrific, mainly because, unlike most of the others, the victims could be anyone. At three hours into a long-distance flight, it is likely that dinner had been served and that most of the passengers would have been composing themselves for sleep, reading, or watching videos. The flight crew comprised the captain and two co-pilots. The aircraft was an Airbus 330-200. In line with European Commission Regulations

  Figure - Deepwater Horizon in the Gulf of Mexico Lessons learned from the Deepwater Horizon in the Gulf of Mexico and ProSREM Reference: Organizational Accidents Revisited - James Reason Deepwater Horizon was a semi-submersible, mobile, floating, dynamically positioned oil rig, operated mainly by BP and, at the time of the explosion, was situated in the Macondo Prospect roughly 41 miles off the Louisiana coast. The disaster was in two parts: the explosion on 20 April 2010, killing 11 people, and an oil spill discovered on 22 April – the spillage continued for 87 days without pause and covered an area of the Gulf equivalent to the size of Oklahoma. This was the largest accidental oil spill in the story of petroleum exploration. After several failed efforts, the well was finally sealed on 19 September. Among others, two companies were involved in the event: Transocean, which owned/operated the drilling rig, and Halliburton, which carried out (among other things) essential cementing wor

  Figure 1 - Texas City Refinery Explosion 2005 Lessons learned from Texas City Refinery Explosion 2005 and ProSREM Reference: Organizational Accidents Revisited - James Reason Background In March 2005, a hydrocarbon vapor cloud exploded at BP’s Texas City refinery, killing 15 workers and injuring over 170 others. The site was designed to convert low octane hydrocarbons, through various processes, into higher octane hydrocarbons that could be blended into unleaded petrol. This was the second-largest oil refinery in Texas and the third-largest in the US. BP acquired the Texas City refinery as part of its merger with Amoco in 1999. The refinery was built in 1934 but had been badly maintained for several years. A consulting firm had examined conditions at the plant. It released its report in January 2005, which found many safety issues that included ‘broken alarms, thinned pipe, chunks of falling concrete, bolts falling 60ft and staff being overcome with fumes’. The refinery had had five