ruptura barragem modelo
TRANSCRIPT
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 1/33
Modelo de acidente de ruptura de
barragem
Ildeberto Muniz de Almeida
Agradecimentos: AFT Mário Parreiras
AFT Ivone C Baumecker
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 2/33
Min do Trab eEmprego (MTE)
Setor deVigilância
MS - SUS
Auditoria doMTE
Hierarquia de Estruturas de Controle de Segurança
Governo, políticas& orçamento
Corporações reguladoras,sindicatos e associações
Planejamento, orçamentoe governo Local
Gestão e planejamento
da Empresa
Processo físicoe atividadesdos atores
Equipamentos
& em torno
Políticas epráticas daempresa
Sindicatos de Empresase empregados
Gerente da empresa
Min de Minas& Energia
Min do MeioAmbiente
CREA
Aprovação e gestão dosprojeto de barragem e
de sua ampliação
Gestão da construção eampliação da barragem
Gestãode SST
Gestão daoperação dabarragem
Motoristas de caminhões Operadores de escavadeiras e máquinas pesadas
Gestão daproduçãoda mina
Unidadede Meio
Ambiente
Unidade de MeioAmbiente (FEAM)
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 3/33
MTE
Setor deVigilância
MS - SUS
Auditoriado MTE
Hierarquia de Estruturas de Controle de Segurança e constragimentos
Governo,políticas &orçamento
Corporaçõesreguladoras, sindicatose associações
Planejamento, orçamentoe governo local
Gestão eplanejamento daEmpresa
Processo físicoe atividadesdos atores
Equipamentos & entorno
Políticas epráticas da
empresa
Sindicatos de Empresase empregados
Gerente da empresa
Min de Minas& Energia
Min do MeioAmbiente
CREA
Aprovação e gestão dosprojeto de barragem e de
sua ampliação
Gestão da construção eampliação da barragem
Gestãode
SST
Gestão daoperação dabarragem
Motoristas de caminhões Operadores de escavadeiras e máquinas pesadas
Gestão daproduçãoda mina
UniddeMA
Unidade de MeioAmbiente (FEAM)
PolíticaNacional
Legislação de M-A Legislação de SST
Concepçao de
polit. e estrat de
au
ditoria/ vigilânciaConcepçao de polit. e
estrat de auditoriaAprovação de projetos deconstruçao e ampliação
S
N
Pol. deSST
Audit externas, inspeções e anál. de acidentes
Pol local/reg de MA
RIMAARTSubmeter projetos
Boas técnicas
Dec.
internas,
superv,
audit, anál.
Acid. e vig.
Boas técnicas
Controle de Ql
Supervisão
da
percolagem
Supervisão
da injeção de
rejeitos
Condições da barragem,
superv de planos de
implementar /aumentar,
Aspectos boas técnicas: padrões de segurança, est. geotécnicos,
cálc estruturais, sist de percolagem, análise de riscos, etc.
Projeto
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 4/33
Determinação das ações de
controle inadequadas e que
falharam em manter o necessárioconstrangimento de segurança
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 5/33
MTE
Setor deVigilância
MS - SUS
Auditoriado MTE
Hierarquia de Estruturas de Controle de Segurança, constragimentos(“enforcements”) e adaptações locais
Governo,políticas &orçamento
Corporaçõesreguladoras, sindicatose associações
Planejamento,orçamento egoverno Local
Gestão eplanejamento daEmpresa
Processo físicoe atividadesdos atores
Equipamentos & entorno
Políticas epráticas da
empresa
Sindicatos de Empresase empregados
Gerente da empresa
Min de Minas& Energia
Min do MeioAmbiente
CREA
Aprovação e gestão dosprojeto de barragem e de
sua ampliação
Gestão da construção eampliação da barragem
Gestãode
SST
Gestão daoperação dabarragem
Motoristas de caminhões Operadores de escavadeiras e máquinas pesadas
Gestão daproduçãoda mina
UniddeMA
Unidade de MeioAmbiente (FEAM)
PolíticaNacional
Legislação de M-A Legislação de SST
Concepçao de
polit. e estrat de
au
ditoria/ vigilânciaConcepçao de polit. e
estrat de auditoriaAprovação de projetos deconstruçao e ampliação S
N
Pol. deSST
Audit externas, inspeções e anál. de acidentes
Pol local/reg de MA
RIMA
Projeto não
submetido
*
.
* Ausência de adesão a aspectos boas técnicas
Falha no leiaute de dutos de drenagem; elevação feita em cima de área já elevada
*
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 6/33
Adaptation: Map of the accident analysisaccording Rasmussen suggestion.
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 7/33
Government,policy &budgeting
Regulatory bodies,& Associations
Local Areagoverm, planning& budgets
Company
planning&Mngmnt
Physicalprocessandactoractivities
Equipment & surroundings
Nationalpolicy
General environmentprotection requirements
National Envir.Protection Policy
National work Health &Safety Guidelines & policy
Design of HS auditspolicy / strategies
Design of E auditspolicy / strategies
Dam construction/raisingproject approval?
Budgets Regional and local policy
(objectives, priorities, resources,
etc): audits, inspections and
accident analysis
Design ofHS policy /strategies
Dam raising safety planeffective?
Resourcesand staffeffective
NoYes
No Yes
Only architectonic
project had been
elaborated
Loc or regEnvir policy
Project not
submitted to Min Previous FEAM inspections
detects no problems in Damproject or execution
No HS inspection
during Dam raising
NoYes
Dam
instability
No
percolation
project
Critical event:
Dam raise is
made over area
already raised
Failure in
lay out of
drain tubes
Int Safety Env plans and
oversight effective?
NoYes
Crit event:
Dam wall
infiltration
Delay in problems
recognition
No study
about geo
techn stability
Dam’s percolation
isn’t supervised
Reject is being
bombed into trench 1
Trucks and “tracked
excavator” are over
dam’s wall
Dam
rupture
3 trucks, 1 tracked excavator are
destroyed
The river is affected
1 Km area is covered by rejects
5 workers died
Workers and equipmentover the dam’s wall
Mngnmt, Envir and Safety policyand practices effective?
No Yes
Wall heighted
13 m over the
planed
Competence &education
Worker’s plan effctive?
Yes No
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 8/33
Determine the various explanations for the
inadequate control based on the standard
components of a control loop
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 9/33
Alças de controle e falhas estabelecer e no“fazer cumprir” medidas de prevenção
1. Alça controle do projeto da barragem – nível deplanejamento e gestão da empresa:
1. Falha na solicitação de projetos (gestor de projeto)2. Falha na designação de responsável pelo projeto
1. Recém formada
3. Falha na supervisão/acompanhamento de projeto(UM-A; GSST; Gerência empresa ...)1. Projeto só arquitetônico2. Ausência: de cálculos estruturais; de estudo
geotécnico; de projeto de percolagem; de
análise de perigos e riscos4. Falha na definição de variáveis a serem
acompanhadas na execução do projeto e operaçãoda barragem:1. Ausência controle de percolagem e infiltrações
...
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 10/33
Falhas em alças de controle para fazercumprir medidas de prevenção
• Alça Governo–Empresa:
– Ausência de responsável pela aprovação doprojeto de barragem
• Alça Regulador (CREA)-Empresa:– Checa apenas profissão do responsável peloprojeto.
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 11/33
Falhas em alças de controle para fazercumprir medidas de prevenção
• Gestor da empresa / gestão de produção:
– Falha na explicitação de modelo de processo(quem designar e que pedir sobre barragem aconstruir?) e;
– Modelos de comportamento do sistema(Considera risco de ruptura? Como controla?)
– Falha da definição de feedback do processo.
• Gestor de desenvolvimento e execução de projetos– Falha na definição de variáveis a seremacompanhadas na construção, elevação eoperação da barragem
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 12/33
Possible Partial Control Diagram to Dam project - 1
Project development manager
Modelof
process
Model of interfaces:good techniques,
health, safety andenvironmentalcompliance
Reports and formal
communicationDisturbances
Process output:
Projects (partialor final)
Process inputs:press bottom
Damconstructionand raisingprojects
Modelsofprocess
Company manager or Damoperation mngmnt
Models of thesystembehaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Demand
of project
Feed back:reports about
projectdevelopment
and finalproject
Variables controlled: structuralcalculus, geotechnical analysis,
plans for percolation and control
of infiltrations, hazard analysis,
evaluation of stability of dam wall,
etc
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 13/33
Possible Partial Control Diagram to Dam project - 2
External Project developmentmanager
Model
ofprocess
Model of interfaces:good techniques,
health, safety andenvironmentalcompliance
Reports and formal
communicationDisturbances
Process output:
Projects (partialor final)
Process inputs:press bottom
Damconstructionand raisingprojects
Modelsofprocess
Company manager or Damoperation mngmnt
Models of thesystembehaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Demand
of project
Feed back:reports about
projectdevelopment
and finalproject
Variables controlled: structural calculus,geotechnical analysis, plans for
percolation and control of infiltrations,
hazard analysis, evaluation of stability of
dam wall, etc
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 14/33
Possible Partial Control Diagram to Dam project –Local adaptation
External Engineer hired to sign dam/ raising project
Model
ofprocess
Model of interfaces:good techniques,
health, safety andenvironmentalcompliance
Reports and formal
communicationDisturbances
Process output:
Project signed byexternal engineer
Process inputs:press bottom
Damconstructionand raisingprojects
signedModelsofprocess
Company manager or Damoperation mngmnt
Models of thesystembehaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Demand
of project
Feed back:reports
about finalproject
Variables controlled: structural calculus,geotechnical analysis, plans for
percolation and control of infiltrations,
hazard analysis, evaluation of stability of
dam wall, etc
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 15/33
Environmental controllers:
Model ofprocess:
emphasison Env.impact
Model of interfaces: “insitu” (mainly oversight
of environmental rulescompliance. Secondary(?) aspects may involve
percolation,infiltrations,
documentation analysis,etc
Reports and formalcommunicationDisturbances
Process inputs:press bottom
Modelsof
process
Dam operation mngmnt
Models of thesystem
behaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Demand
of control
Variables controlled: Percolation
conditions, infiltrations, hazard
analysis, stability of dam wall, etc
Environmental rulescompliance
Are thereenvironmental risks?
Feed back:reports aboutcompliance or
nocompliance,
possibleconsequences
Process output:
If Yes, establishrecommendations or
procedures and
present to damoperation mngmnt orother responsible.
Possible Partial Control Diagram to Damconstruction and oversight - 1
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 16/33
Environmental controllers:
Model ofprocess:
emphasison Env.impact
Model of interfaces: “insitu” (mainly oversight
of environmental rulescompliance. Secondary(?) aspects may involve
percolation,infiltrations,
documentation analysis,etc
Reports and formalcommunicationDisturbances
Process inputs:press bottom
Modelsof
process
Dam operation mngmnt
Models of thesystem
behaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
No
Demand
about
control
Variables controlled: Percolation
conditions, infiltrations, hazard
analysis, stability of dam wall, etc
Oversight Environmrules compliance
Are thereenvironmental risks?
Feed back:
No reportsabout nocompliancewith good
techniques indam raising
process
Process output:oversight of
environmental rulescompliance not
exploring technicalaspects of damraising process.
Possible Partial Control Diagram to Dam construction andoversight – 1: local adaptations
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 17/33
Safety manager controller:
Model ofprocess:emphasison Env.HS risks
Model of interfaces:“in situ” (mainly
oversight of healthand safety
compliance. Secondaryaspects may involve
percolation andinfiltrations analysis
Reports and formal
communicationDisturbances
Process output:
If Yes, establishrecommendations or
procedures andpresent to dam
operation mngmnt orother responsible.
Process inputs:press bottom
Oversight Health-Safety compliance
Are there healthand safety risks?
Modelsof
process
Dam operation mngmnt
Models of thesystem
behaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Controls
Variables controlled: Percolation
conditions, infiltrations, stability of
dam wall, etc
Feed back:reports aboutcompliance or
nocompliance,
possibleconsequences
Possible Partial Control Diagram to Damconstruction and oversight - 2
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 18/33
Safety manager controller:
Model ofprocess:emphasison Env.HS risks
Model of interfaces:“in situ” (mainly
oversight of healthand safety
compliance. Secondaryaspects may involve
percolation andinfiltrations analysis
Reports and formal
communicationDisturbances
Process inputs:press bottom
Oversight Health-Safety compliance
Are there healthand safety risks?
Modelsof
process
Dam operation mngmnt
Models of thesystem
behaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Variables controlled: Percolation
conditions, infiltrations, stability of
dam wall, etc
Possible Partial Control Diagram to Damconstruction and oversight - 2
No
Demand
about
control
Feed back:No reports
about nocompliancewith good
techniques indam raising
process
Process output:oversight of Health
and safetycompliance not
exploring technicalaspects of damraising process.
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 19/33
Dam operation controller:
Modelof
process
Model of interfaces: “insitu” direct oversight ofproject, H, S & E rules
compliance includinggood techniques
application, percolationand infiltrationsanalysis, etc.
Reports and formal
communicationDisturbances
Process output:
If Yes, establishrecommendations or
procedures andpresent to dam
operation mngmnt orother responsible.
Process inputs:press bottom
Project compliance
Are there health
and safety risks?Models
ofprocess
Company manager
Models of thesystem
behaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Controls
Variables controlled: Percolation
conditions, infiltrations, stability of
dam wall, etc
Feed back:reports aboutcompliance or
nocompliance,
possibleconsequences
Possible Partial Control Diagram to Damconstruction and oversight - 3
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 20/33
Dam operation controller:
Modelof
process
Model of interfaces: “insitu” direct oversight ofproject, H, S & E rules
compliance includinggood techniques
application, percolationand infiltrationsanalysis, etc.
Reports and formal
communicationDisturbances
Process inputs:press bottom
Oversight ofproject compliance
Are there flaws or
risks?Models
ofprocess
Company manager
Models of thesystem
behaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Variables controlled: Percolation
conditions, infiltrations, stability of
dam wall, etc
Possible Partial Control Diagram to Damconstruction and oversight - 3
No
Demand
about
control
Feed back:No reports
about nocompliancewith good
techniques indam raising
process
Process output:No oversight ofgood techniques
compliance.
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 21/33
Workers controllers (truckdrivers and others)
Model
ofprocess
Model of interfaces:
bring raw materialsusing trucks, control oftechnical aspects and
safety constraint, etc …
Reports and formalcommunication
DisturbancesProcess inputs:press bottom
Dam wall being
raisedModels
ofprocess
Dam operation manager ?
Models of thesystem
behaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Variables controlled: trucks and
excavators circulation, dam height,
qt of material used, etc
Possible Partial Control Diagram to Dam raising andoversight:
Demand
dam
raising
Process output:Dam reaches
planned height.
Feed back:reports about
projectdevelopment
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 22/33
Workers controllers (truckdrivers and others)
Model
ofprocess
Reports and formalcommunication
DisturbancesProcess inputs:press bottom
Dam wall raised
13 m over theplanned
Modelsof
process
Dam operation manager ?
Models of thesystem
behaviour
Actuators: No automatic devices
Hazards: dam rupture, material loss, environmental impact
Constraint: percolation monitoring, raising inspections, etc.
Process: dam raising
Variables controlled: flaws in
control of trucks circulation, dam
height and stability, etc
Possible Partial Control Diagram to Dam raising andoversight: Accident situation
Demand
dam
raising
Process output:Dam rupture
Feed back:No reports
about projectdevelopment
Model of interfaces:
lax control oftechnical aspects andsafety constraint, etc
…
Contextual aspects: no control of dampercolation, no detection of dam wall
infiltration, project has no structural calculus,etc. External Environmental protection Agency
audit detects no problem related to damstability.
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 23/33
Risk of damrupture
Risk of beingreached in caseof dam rupture
Dam raisingproject approval
Projectcompliance
to safety
standards
Projectcompliance to
hazards
analysis
Previous
Geotechnical
studies
Project with
previous
structural calculus
Percolation
oversightDam conditions
and raising plans
implementation
oversight
Project with
Percolation
system
Oversight dam
feed plans
(rejects
injection)
Oversight dam
conditions and dam
raising plans
Oversight
rejects
injection.
RIMA
approval
External
inspections
Compliance to
the project
Ad equation
ofinspections
plan
+++
+
+
+
Elaborationof (only)
architectonic
project
_
+
+
_
_ _
_
_
_
+ +
++
+
+
++
+
++
+
A system dynamics model for the dam raising.
+
+
+
+
Percolation
evaluation
plan
+
+
+
+
+
+
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 24/33
Risk of damrupture
+
A system dynamics model for the dam raising.
Raising dam
without
structural
project
RaisingDam
without
compliance
of safety
standards
Raising dam
without
hazards
analysis
Raising dam
without
geotechnical
studies
Raising dam
without structural
calculus
Raising dam
without project of
percolation
system
Raisingdam
without
RIMA
Dam raisingproject approval
_ _
_ _ _
_
No
percolation
oversight
No oversight of
Dam conditions
and raising plans
implementation
No plans about
oversight dam
feed (rejects
injection)
No plans about
oversight dam
conditions and dam
raising
No oversight
of rejects
injection.
No plan
about
percolation
evaluation.
External
inspections
Ad equation of
inspections
plan
Enterprise
fear of
punishment
Enterprisesafety culture
Dam raise is
made over area
already raised
Failure in
lay out of
drain tubes
Dam wall
infiltration
++
+ ++
++
Delay on
infiltration
detection
+
+
+ ++
++
+ ++
++
++
Cascade (Falls) of positive
influences going to the accident.
++
+
+
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 25/33
Conclusions
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 26/33
Conclusions
Control flaws leading to Hazards: Dam rupture• 1.2) Inappropriate, ineffective, or missing control actions for
identified hazard• 1.2.1 ) Design of control algorithm (process) doesn’t enforce constraint,
• Flaw(s) in creation process,
Min of Mines and energy
• Flaws in control of technical aspects of project: previous approval?
Specific guidelines?• Reason: Failure in model of process: Underestimation of risk of
HE? Risk “normalization”? (Brazilian aspect) Productionpressures?
Min of Environmental Protection
• Flaws in program to control risks/losses in Dam constructions
Min of Transport, Min of Health and Min of Labour:• Flaws in program or plan to control safety in Dam constructions.
• Reasons: Failure in model process. Cultural aspect: technicalrequirements of the process aren’t considered as safetyproblems.
CREA (engineer’s council)
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 27/33
Control flaws leading to Hazards: Dam rupture
• 1.2.1 ) Design of control algorithm (process) doesn’t enforce constraint,
• Flaws in creation process
Company manager
• There’s no enforcement to establish safety constraint during dam’sproject elaboration and implementation. Neither constraints(technical, safety and environmental requirements, trainings,
oversight …) nor responsibilities are clearly established.Construction and raising were developed only with anarchitectonical project.
• Incorrect modification or adaptation:
Company manager (Dam operation, Safety and Environment mngmnt)
• Project establishes dam raising over area already raised.
• Reason: Failure in model of process
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 28/33
• 1.2) Inappropriate, Ineffective or missing control actions for
identified hazards. (Cont):• 1.2.2) Process models inconsistent, incomplete, or incorrect (lack oflinkup)– Flaws in creation process:Min of Mines & Energy:– Dam construction and operation weren’t monitored.
• Reasons: inadequate mental model about the process?Contextual factors as lack of resources (budgets reductions?)Conflicting policies? …
– Flaws in updating process (asynchronous evolution):Company management:– ..
Control flaws leading to Hazards: Dam rupture
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 29/33
• 1) Inadequate enforcement of constraint (control actions) (cont).
• 1.2.3) Inadequate coordination among controllers and decision makers:Min of Labour, Min of Health and Min of Environmental Protection (federal,regional and local levels).
– Lack of constraint to establish oversight of the dam construction andraising. There’s overlap of attributions among national, regional and localHSE authorities without ways to coordinate the actions of these threeareas. None of these institutions oversights technical aspects of damconstruction or raising.
• Reasons: Contextual factors conflicting policies? Lack of resources? Noenforcement to coordinate actions …
Company management (Company manager, …)
– There’s overlap of attributions related do technical and safety complianceamong Dam operation, Safety and Environmental managements. None of themassumed the responsibilities maybe thinking that they belong to the others
• Reasons: Inadequate mental models about process (underestimation ofrisks?). Safety and environmental areas are not considered asinterlocutors during project elaboration and implementation(Organizational/cultural aspect).
Control flaws leading to Hazards: Dam rupture
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 30/33
2) Inadequate Execution of control action:
• 2.1) Communication flaw:Company management (Company manager, Dam operation
manager, safety and environment management …)• No enforcement to establish communication process
about the risk of dam rupture and ways of preventionMin of Labour, Min of Health and Min of Environmental
Protection (federal, regional and local levels)• There’s no exchange of information among them in
relation to dam construction/raising oversight.• Reasons: inadequate mental models about process and
about furnace operation? Safety culture problems?
Control flaws leading to Hazards: Dam rupture
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 31/33
• 2.2) Inadequate actuator (automatic and Human?) operation
Min of Labour, Min of Health and Min of Environmental Protection (federal,regional and local levels)– Audits from Environmental protection agency didn’t identify neither
projects problems nor implementation problems (no percolation evaluation, noinfiltration oversight, raising been made over areas already raised etc) ??
– Health and Safety area had no previous inspection on the dam area.Company management (Company manager, dam operation, Safety,
env ironmental management– Lack of enforcements to technical and safety constraints: dam wall raisedover area already raised; dam wall heighted 13 m over the planned; wallinfiltration not detected, percolation not oversighted …
• Reasons: Inadequate mental model about process. Safety cultureproblems?
Control flaws leading to Hazards: Dam rupture
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 32/33
• 3) Inadequate or missing feedback:Company management, Dam operation, safety and environmental
management– 3.1) Not provided in system design:– Design of control system didn’t establish percolation and infiltration
oversight as kinds of feedback managers and operators would receive.• Reasons: Inadequate mental model about the system? Competence/
training problems? Safety culture/organizational problems? Risknormalization (Brazilian aspect: normalization without risk analysis).
– 3.2) Communication flaw– In the region there were previous dam ruptures. Why the lessons
weren’t learned?• Reasons: Safety culture problems? Failure in accident analysis
practices? Cultural aspects: accidents tends to be explained astechnical phenomenon and as a consequence, managerial andorganizational aspects that are part of accidents origins aren’t
considered as causes.– 3.4) Inadequate sensor operation (incorrect or nor informationprovided)
– Warns about flaws in dam percolation and dam infiltration couldn’t bedetected. (discuss: 3.1 or 3.4???)
• Reasons:
Control flaws leading to Hazards: Dam rupture
8/20/2019 Ruptura Barragem Modelo
http://slidepdf.com/reader/full/ruptura-barragem-modelo 33/33
Comments
• Most important causes seem related to lack of enforcement enterprise to establish safetyconstraint since begin of dam project elaboration.
• Continuous degradation of safety during a long period without enforcement of safetyconstraint or good techniques of dam construction are in the origins of the accident.• Lack of supervision (oversight) of technical development of the project, lack of internal
safety or environmental inspections and audits related to the risk of dam rupturecontributes to avoid early detection of the problems. This problem is more importantbecause there were previous dam ruptures in the same state (region).
• This can be pointed as aspect of Brazilian heterogeneity of safety situation, maybe hisworst face. The persistence of enterprises handing with high risks technologies without any
compliance related do good techniques and legal safety constraint. In these kind ofenterprises Health and Safety management seems to be fragile (technical, organizationaland political) structures to face this kind of challenger. Mainly in situations where they livebesides these problems for long periods.
• Maybe flaws in external environmental protection agency audits of the dam raising hadcontributed to this process because they didn’t find any problem related do dam wallstability.
• This aspect points to the existence of flaws in government actions. Maybe there are
problems in competence / training programs and the need of better coordination among thedifferent agencies involved in audits/inspections of systems that are handling high riskstechnologies.