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There is a need for changing the methods with which work accidents are analyzed, if we truly wish to use what we uncover from them to learn and enrich our knowledge base of organizational management. The goal is to relinquish the broadly adopted and rather simplistic paradigm that accepts the search for human error and unsafe acts performed by workers, and produces “guilt diagnostics”. Instead, we use a systemic accident analysis methodology, based on the socio-technical principle of understanding the real operating conditions in which accidents take place.
Methods
We compare the analyses of an Anhydrous Ammonia gas leakage accident in a fish processing plant using the traditional accident analysis model based on unsafe acts and the proposed systemic method. In the systemic method, we track down the accident to the essence of its organizational context. The data are obtained using multiple sources and methods such as work documents, field observations, interviews – including first off ones obtained at the scene of an accident – looking for norms and procedures that may indicate ambiguity, complexity and other cognitive constraints.
Results
The results of the comparison favor the systemic approach because instead of finish the analysis blaming a worker, the systemic method provided useful recommendations to safety management processes in the use of Anhydrous Ammonia gas over the fish processing industry that goes beyond the organizations itself, reaching changes in Brazilian occupational health system procedures.
Discussion
The systemic method of accident analysis described in this article, balks at the traditional methodology’s focus on searching for failures, both technical and especially human, and it bases itself on the idea that accidents are truly a systemic phenomenon emerging from within a work system, in a scenario and in a specific context and time, providing a powerful set of useful recommendations for accident prevention.