Activity-Based Accident Analysis: The Case of Nitrogenous Fertilizer Factory
摘要
Based on the analysis of an accident that occurred in the granulation sector of a nitrogen fertilizer factory, this article proposes a method of accident analysis based on work activity. Unlike classical analyses, which focus on the use of tools such as the “Cause Tree” or “Ishikawa Diagram” and assume human and/or technical failures as the stopping point, the analysis presented in this article seeks to bring everyday work performed by workers as the central axis. This work, represented by the activities they perform daily, can help recover or avoid accident-generating situations. For this, we are inspired by models that value both the knowledge of activity elements and historical and organizational aspects. The method of analysis developed and presented in this article was able to answer questions previously unanswered by the official analysis constituted by the company, and more than that, it was able to elucidate the reasons why certain behaviors were adopted by the operator at the time of the accident. From this perspective, removing the blame-focused approach of classical analyses, understanding work activity more accurately reveals the objective and subjective contributing factors of accidents, thus being more effective in achieving the main goal of any analysis: generating learning and advancing prevention.