O acidente da plataforma de petróleo P-36 revisitado 15 anos depois: da gestão de situações incidentais e acidentais aos fatores organizacionais

Abstract

The accident with the P-36 oil rig in the Campos Basin in Rio de Janeiro State, Brazil, was one of the petroleum industry's worst international disasters. Based on this specific case, the article aims to (a) verify the role of the human dimension in the reliability of highly complex systems, with a focus on the management of incidental and accidental situations with the potential to lead to large-scale accidents. The analysis should help (b) shed light on some of the organizational factors that can increase the risk level in offshore activities, beyond the so-called immediate causes. The methodology involves mainly document research (especially the reports produced by Petrobras, ANP/DPC, and CREA-RJ) and interviews with three professionals that worked on the P-36 rig. The results indicate that the management of incidental and accidental situations in which emergency decisions are made should take advantage of contribution by the workforce, who can identify gaps in the process and discuss them with managers. This involves shared and more flexible decisions and collective analysis of risk situations. The findings also suggest that certain organizational factors contributed to the accident, corroborating domestic and international studies of major accidents and pointing to the need for a shift in the focus adopted by oil companies' management.

Major accident prevention illustrated by hydrocarbon leak case studies: A comparison between Brazilian and Norwegian offshore functional petroleum safety regulatory approaches

“…However, in 2000, two major environmental accidents related to pipeline failures increased concerns about the reliability of Petrobras safety self-regulation. These concerns were highlighted by the P-36 platform accident in 2001, which caused 11 fatalities and the platform sinking (Figueiredo et al, 2018). After an extensive study about different regulatory models, the Brazilian Offshore Safety Regime (BSR) was established by ANP in 2007.…”

Perfil dos acidentes de trabalho fatais em empresa de petróleo no período de 2001 a 2016

“…Em 2015, das 16 mortes ocorridas, 9 foram em um único acidente no estado do Espirito Santo: a explosão do Navio-Plataforma Cidade de Sao Mateus, em um período que a empresa vivenciava uma grave crise em decorrência dos escândalos de corrupção e alto endividamento 21 . Este acidente reacende o debate quanto ao peso das falhas na gestão de situações incidentais e dos fatores de caráter organizacional como elementos causais contribuintes para a ocorrência do acidente e suas graves consequências 22 do mesmo modo que no acidente marco deste estudo, o da plataforma P-36.…”

Human Performance Analysis of Processes for Retrieving Beidou Satellite Navigation System During Breakdown

“…Researchers using a larger data set of incidents also found a link between shift handover and accidents. For example, deficient handover can increase transmission errors and related accidents in the offshore oil industry (Gordon, 1998). Similarly, incomplete or non-handover can result in patient safety issues in medical settings (Pezzolesi et al, 2010(Pezzolesi et al, , 2012Riesenberg, 2012).…”