@article{ref1,
title="Challenging the immediate causes: a work accident investigation in an oil refinery using organizational analysis",
journal="Work",
year="2018",
author="Beltran, Sandra Lorena and Vilela, Rodolfo Andrade de Gouveia and de Almeida, Ildeberto Muniz",
volume="59",
number="4",
pages="617-636",
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. <br><br>OBJECTIVE: This paper aims to debate the historical organizational aspects of a company whose policy was incubating an accident. <br><br>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. <br><br>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. <br><br>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.<p /> <p>Language: en</p>",
language="en",
issn="1051-9815",
doi="10.3233/WOR-182702",
url="http://dx.doi.org/10.3233/WOR-182702"
}