de Almeida Ildeberto Muniz, Filho José Marçal Jackson, Vilela Rodolfo Andrade Gouveia
School of Medicine of Botucatu, Department of Public Health, "Universidade Estadual Paulista "Júlio de Mesquita Filho" - Botucatu (SP), Brazil.
Jorge Duprat Figueiredo Occupational Safety and Medicine Foundation - Curitiba (PR), Brazil.
Rev Bras Med Trab. 2020 Jan 9;17(1):13-20. doi: 10.5327/Z1679443520190415. eCollection 2019.
Man-made disasters, such as tailings dam failures, raise countless questions. Such is the case of the Vale S.A. dam in Brumadinho, which failed on 25 January 2019. Based on the Accident Analysis and Prevention Model (AAPM), in the present essay we raise some issues deserving of consideration in an in-depth analysis of this disaster. Following AAPM four axes - analysis of the normal operation, barrier analysis, change analysis and conceptual broadening - we sought to contribute to the understanding of the human, technological and organizational dimensions of the disaster. Investigations restricted to technical explanations of the dam failure do not seem to be acceptable. In the present case, analysis should elucidate decision making at several levels of the company management that possibly culminated in normalization of deviance and migration of the system toward accidents. The company's influence on control and overseeing agencies evidences the weaknesses of the Brazilian disaster prevention model.
人为灾难，如尾矿坝溃坝，引发了无数问题。2019年1月25日发生溃坝事故的巴西布鲁马迪纽市淡水河谷公司（Vale S.A.）的大坝就是如此。基于事故分析与预防模型（AAPM），在本文中我们提出了一些在深入分析这场灾难时值得考虑的问题。按照AAPM的四个轴——正常运行分析、屏障分析、变化分析和概念拓展——我们试图为理解这场灾难的人为、技术和组织层面做出贡献。仅限于对大坝溃坝进行技术解释的调查似乎并不令人满意。在本案中，分析应阐明公司管理层多个层面的决策，这些决策可能最终导致偏差正常化以及系统向事故演变。该公司对控制和监管机构的影响证明了巴西灾难预防模式的弱点。
