LAUSR

BACKGROUND In many companies, investigations of accidents still blame the victims without exploring deeper causes. Those investigations are reactive and have no learning potential. OBJECTIVE This paper aims to debate the historical organizational aspects of a company whose policy was incubating an accident. METHODS The empirical data are analyzed as part of a qualitative study of an accident that occurred in an oil refinery in Brazil in 2014. To investigate and analyse this case we used one-to-one and group interviews, participant observation, Collective Analyses of Work and a documentary review. The analysis was conducted on the basis of concepts of the Organizational Analysis of the event and the Model for Analysis and Prevention of Work Accidents. RESULTS The accident had its origin in the interaction of social and organizational factors, among them being: excessively standardized culture, management tools and outcome indicators that give a false sense of safety, the decision to speed up the project, the change of operator to facilitate this outcome and performance management that encourages getting around the usual barriers. CONCLUSIONS The superficial accident analysis conducted by the company that ignored human and organizational factors reinforces the traditional safety culture and favors the occurrence of new accidents.