Método para classificação de tipos de erros humanos: estudo de caso em acidentes em canteiros de obras
An algorithm for classifying error types of front-line workers: a case study in accidents in construction sites
Saurin, Tarcisio Abreu; Grando, Mara Lucia; Costella, Marcelo Fabiano
http://dx.doi.org/10.1590/S0103-65132012005000007
Prod, vol.22, n2, p.259-269, 2012
Resumo
Este trabalho tem como objetivo principal desenvolver melhorias em um método de classificação de tipos de erros humanos de operadores de linha de frente. Tais melhorias foram desenvolvidas com base no teste do método em canteiros de obras, um ambiente no qual ele ainda não havia sido aplicado. Assim, foram investigados 19 acidentes de trabalho ocorridos em uma construtora de pequeno porte, sendo classificados os tipos de erros dos trabalhadores lesionados e de colegas de equipe que se encontravam no cenário do acidente. Os resultados indicaram que não houve nenhum erro em 70,5% das 34 vezes em que o método foi aplicado, evidenciando que as causas dos acidentes estavam fortemente associadas a fatores organizacionais. O estudo apresenta ainda recomendações para a interpretação das perguntas que constituem o método, bem como modificações em algumas dessas perguntas em comparação às versões anteriores.
Palavras-chave
Investigação de acidentes. Erro humano. Segurança no trabalho. Construção civil.
Abstract
The objective of this study is to propose improvements in the algorithm for classifying error types of front-line workers. The improvements have been identified on the basis of testing the algorithm in construction sites, an environment where it had not been implemented it. To this end, 19 occupational accidents which occurred in a small construction company were investigated, and the error types of both injured workers and team members were classified. The results indicated that there was no error in 70.5% of the 34 times the algorithm was applied, providing evidence that the causes were strongly linked to organizational factors. Moreover, the study presents not only recommendations to facilitate the interpretation of the questions that constitute the algorithm, but also changes in some questions in comparison to the previous versions of the tool.
Keywords
Accident investigation. Human error. Safety. Construction.
References
BAKER, D.; KROKOS, K. Development and validation of aviation causal contributors for error reporting systems (ACCERS). Human Factors, v. 43, n. 2, p. 185-199, 2007. http://dx.doi.org/10.1518/001872007X312432
BASSOLS, F. F.; BALLARDIN, L.; GUIMARÃES, L. B. M. Análise dos tipos de erros em uma distribuidora de produtos derivados de petróleo. In: ENCONTRO NACIONAL DE ENGENHARIA DE PRODUÇÃO - ENEGEP, 27, 2007. Anais... ABEPRO, 2007.
COOPER, M. D. Towards a model of safety culture. Safety Science, v. 36, p. 111-136, 2000. http://dx.doi.org/10.1016/S0925-7535(00)00035-7
COSTELLA, M.; SAURIN, T. A. Proposta de método para identificação de tipos de erros humanos. In: ENCONTRO NACIONAL DE ENGENHARIA DE PRODUÇÃO - ENEGEP, 25., 2005. Anais... ABEPRO, 2005.
DEKKER, S. Just Culture: balancing safety and accountability. London: Ashgate, 2007.
DEKKER, S. The Field Guide to Human Error Investigations. London: Ashgate, 2002.
GRABOWSKI, M. et al. Human and organizational error data challenges in complex, large scale systems. Safety Science, v. 47, n. 8, p. 1185-1194, 2009. http://dx.doi.org/10.1016/j.ssci.2009.01.008
HINZE, J. Making zero injuries a reality. Gainesville: Construction Industry Institute, 2002. 110 p. Report 160.
RASMUSSEN, J.; PETERSEN, A.; GOODSTEIN, L. Cognitive Systems Engineering. New York: John Wiley & Sons, 1994.
REASON, J. Human Error. Cambridge: Cambridge University Press, 1990.
REASON, J. Managing the Risks of Organizational Accidents. Burlington: Ashgate, 1997. 252 p.
REASON, J. The Human Contribution: unsafe acts, accidents and heroic recoveries. Ashgate, 2008.
SANDERS, M.; McCORMICK, E. Human Factors in Engineering and Design. 7. ed. New York: McGraw-Hill, 1993.
SAURIN, T. A. et al. An algorithm for classifying error types of front-line workers based on the SRK framework. International Journal of Industrial Ergonomics, v. 38, p. 1067-1077, 2008. http://dx.doi.org/10.1016/j.ergon.2008.02.017
SAURIN, T. A.; FORMOSO, C. T.; CAMBRAIA, F. B. Analysis of a safety planning and control model from the human error perspective. Engineering, Construction and Architectural Management, v. 12, n. 3, p. 283-298, 2005. http://dx.doi.org/10.1108/09699980510600134
SURAJI, A.; DUFF, R.; PECKITT, S. Development of causal model of construction accident causation. Journal of Construction Engineering and Management, v. 127, n. 4, p. 337-344, 2001. http://dx.doi.org/10.1061/(ASCE)0733-9364(2001)127:4(337)
BASSOLS, F. F.; BALLARDIN, L.; GUIMARÃES, L. B. M. Análise dos tipos de erros em uma distribuidora de produtos derivados de petróleo. In: ENCONTRO NACIONAL DE ENGENHARIA DE PRODUÇÃO - ENEGEP, 27, 2007. Anais... ABEPRO, 2007.
COOPER, M. D. Towards a model of safety culture. Safety Science, v. 36, p. 111-136, 2000. http://dx.doi.org/10.1016/S0925-7535(00)00035-7
COSTELLA, M.; SAURIN, T. A. Proposta de método para identificação de tipos de erros humanos. In: ENCONTRO NACIONAL DE ENGENHARIA DE PRODUÇÃO - ENEGEP, 25., 2005. Anais... ABEPRO, 2005.
DEKKER, S. Just Culture: balancing safety and accountability. London: Ashgate, 2007.
DEKKER, S. The Field Guide to Human Error Investigations. London: Ashgate, 2002.
GRABOWSKI, M. et al. Human and organizational error data challenges in complex, large scale systems. Safety Science, v. 47, n. 8, p. 1185-1194, 2009. http://dx.doi.org/10.1016/j.ssci.2009.01.008
HINZE, J. Making zero injuries a reality. Gainesville: Construction Industry Institute, 2002. 110 p. Report 160.
RASMUSSEN, J.; PETERSEN, A.; GOODSTEIN, L. Cognitive Systems Engineering. New York: John Wiley & Sons, 1994.
REASON, J. Human Error. Cambridge: Cambridge University Press, 1990.
REASON, J. Managing the Risks of Organizational Accidents. Burlington: Ashgate, 1997. 252 p.
REASON, J. The Human Contribution: unsafe acts, accidents and heroic recoveries. Ashgate, 2008.
SANDERS, M.; McCORMICK, E. Human Factors in Engineering and Design. 7. ed. New York: McGraw-Hill, 1993.
SAURIN, T. A. et al. An algorithm for classifying error types of front-line workers based on the SRK framework. International Journal of Industrial Ergonomics, v. 38, p. 1067-1077, 2008. http://dx.doi.org/10.1016/j.ergon.2008.02.017
SAURIN, T. A.; FORMOSO, C. T.; CAMBRAIA, F. B. Analysis of a safety planning and control model from the human error perspective. Engineering, Construction and Architectural Management, v. 12, n. 3, p. 283-298, 2005. http://dx.doi.org/10.1108/09699980510600134
SURAJI, A.; DUFF, R.; PECKITT, S. Development of causal model of construction accident causation. Journal of Construction Engineering and Management, v. 127, n. 4, p. 337-344, 2001. http://dx.doi.org/10.1061/(ASCE)0733-9364(2001)127:4(337)
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