Metodologia para análise de acidentes por meio da associação da técnica CAST e com as técnicas TRACEr e ABC: estudo de caso

Abstract

An accident can be understood as a sudden and unexpected event with undesirable results, leading to material damage, people's injury, environmental pollution, loss of mission, and financial losses. Once it happens, an investigation is necessary to understand its causes and responsibilities, which is done using causal models with different complexities. In general, the process of understanding the accidental dynamics has two main stages: (1) the development of the timeline of events; and (2) an exhaustive and systematic analysis of events to understand their cause. In the research under evaluation, the STAMP / CAST technique was used and associated with human factors methods through a formal procedure to study the accident case in the FPSO Cidade de São Mateus on 02/11/2015, which caused fatalities, injuries, and installation damage. It was concluded that the proposed methodology produced satisfactory results and contributed to the elucidation of aspects related to the origin and escalation of the accident. It was valid, in particular, in dealing with aspects related to decisions and faulty human actions, which were submitted to a classification process by means of the Human Error Identification/Analysis tool.