"Safety Beyond Numbers: Learning from Normal Work to Prevent Major Accidents"
"Safety Beyond Numbers: Learning from Normal Work to Prevent Major Accidents"
DOI:
https://doi.org/10.51473/rcmos.v1i2.2025.1369Keywords:
Occupational Safety; Normal Work; Human Factors; Risk Management; Safety Culture; Human Performance.Abstract
Occupational safety has traditionally been defined by the absence of accidents, creating the illusion that operations with low incident rates are intrinsically safe. This perspective proved inadequate in the face of disasters such as the Texas City refinery explosion (2005) and the Deepwater Horizon accident (2010), which occurred in operations considered safe by conventional metrics. This article proposes a paradigmatic shift through the concept of "Learning from Normal Work," which focuses on understanding successful daily activities rather than solely learning from failures. Using a qualitative methodology based on a systematic literature review and analysis of practical implementation cases in multinational companies, this study demonstrates how procedural deviations can be understood as necessary adaptations to actual work.
Downloads
References
CONKLIN, Todd. Pre-accident investigations: an introduction to organizational safety. Boca Raton: CRC Press, 2019. DOI: https://doi.org/10.4324/9781315246178
DEKKER, Sidney. O guia prático para entender o "erro humano". Boca Raton: CRC Press, 2017.
HEINRICH, Herbert William. Prevenção de acidentes industriais: uma abordagem científica. 1941.
HENDRICKS, Joseph W.; PERES, S. Camille. Beyond human error: an empirical study of the Safety Model 1 and Model 2 approaches for predicting workers’ behaviors and outcomes with procedures. Safety Science, v. 134, p. 105016, 2021. DOI: https://doi.org/10.1016/j.ssci.2020.105016
HOLLNAGEL, Erik. FRAM: o método de análise de ressonância funcional: modelagem de sistemas sociotécnicos complexos. Boca Raton: CRC Press, 2017.
HOLLNAGEL, Erik. Safety-I and Safety-II: the past and future of safety management. Boca Raton: CRC Press, 2014.
HOLLNAGEL, Erik. Safety-I and Safety-II: the past and future of safety management. 2. ed. Boca Raton: CRC Press, 2018. DOI: https://doi.org/10.1201/9781315607511
HOPKINS, Andrew. Failure to learn: the BP Texas City refinery disaster. Sydney: CCH Australia Ltd, 2008.
NORMAN, Donald A. A psicologia das coisas cotidianas. Rio de Janeiro: Livros Básicos, 1988.
REASON, James. Erro humano. Cambridge: Cambridge University Press, 1990.
VAUGHAN, Diane. The Challenger launch decision: risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press, 1996. DOI: https://doi.org/10.7208/chicago/9780226346960.001.0001
VICENTE, Kim J. Análise cognitiva do trabalho: rumo a um trabalho seguro, produtivo e saudável baseado em computador. Boca Raton: CRC Press, 1999.
WATER, Deep et al. The gulf oil disaster and the future of offshore drilling: report to the President National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling. 2011.
WOODS, David D.; HOLLNAGEL, Erik. Sistemas cognitivos conjuntos: padrões em engenharia de sistemas cognitivos. Boca Raton: CRC Press, 2006.
Downloads
Additional Files
Published
Issue
Section
Categories
License
Copyright (c) 2025 Felipe Abreu de Jesus , Félix Gustavo de Andrade Santos, Lis Quarantini de Souza Guimarães (Autor)

This work is licensed under a Creative Commons Attribution 4.0 International License.