Tragedy on grade crossing: driver failure or systemic fragility?
In 2010, an accident occurred in Americana-SP, Brazil, involving two trains and one bus on a Grade Crossing, when 10 people died and 17 were injured including workers. This paper aims to analyze the accident using the Model of Analysis and Prevention of Work Accidents (MAPA). The method provides observation of work, interviews and analysis of documents to understand precedents of the event in the following stages: to understand the usual work from the involved people, the changes occurred in the system, the operation of barriers, managerial and organizational aspects. By the end, measures are suggested to avoid new occurrences. The accident took place at night in a site with insufficient lighting. The working conditions of bus drivers, train operators and watchmen are inadequate. There were only symbolic barriers (visual and acoustic signals) triggered manually by watchman upon train operator radio communication. The fragility of the barrier system associated to poor lighting and short time to trigger the signaling seem to play a critical role in the event. Contrary to the official report which resulted in guilt of the bus driver, the conclusion of the paper emphasizes the fragility of the safety system and the need of level crossing reproject.
Post-Graduation in Public Health Program, School of Public Health of Universidade de São Paulo - FSP/USP, São Paulo, Brazil.
Manoela Gomes Reis
MG
Lopes
Rodolfo Andrade
RA
de Gouveia Vilela
Ildeberto Muniz
IM
de Almeida
Odilamar Lopes
OL
Mioto
Mara Alice Batista Conti
MA
Takahashi
Fernanda Oliveira
FO
Perin
D000063:Accidents, Traffic / Q000517:prevention & control; D001334:Automobile Driving; D001938:Brazil; D064088:Hazard Analysis and Critical Control Points; D006801:Humans; D015985:Precipitating Factors; D011890:Railroads; D012449:Safety