Work-Related Accident on Petroleum Industry: Beyond Human Errors and Immediate Causes

Abstract

In 2005, there was an explosion during a repair at Barrancabermeja refinery in Colombia. The fire that followed caused the death of two people, left seven wounded and caused losses estimated at nine million dollars. The company presented a video with the description of this accident, pointing as immediate causes of the explosion a dripping of propane-butane mixture from a heat exchanger and a spark generated when a man lift was switched off. The analysis done by the company identified unsafe acts (the use of an inadequate tool to correct the dripping), unsafe conditions (inadequate cap installed on the heat exchanger) and also included in the assigned causes disregarding of rules (not using Safe Isolation System). The objectives of this paper are: to approach this accident analysis from a different perspective, discussing new hypothesis based on organizational factors; to formulate new recommendations in order to contribute to accidents prevention; to encourage an organizational approach for analyzing work-related accidents that goes beyond human errors, technical causes or standards perspectives. This paper used an Analysis and Prevention of Accidents Model (MAPA) based on ergonomics of activity and other concepts used in accident analysis. Info sources were taken from the video, the presentation that summarizes the research done by the company, some press articles and interviews.

Keywords: Work-related accident, Ergonomics, Petroleum industry, Accident analysis methodology.

DOI: 10.54941/ahfe100345