One hundred times ForumAT!

On September 10, 2024, the Occupational Accidents Forum (FórumAT – Fórum Acidentes do Trabalho) celebrated its 100th meeting! The forum was created in 2008 to foster pluralistic discussions, broaden the debate on occupational safety, and encourage the replacement of traditional accident investigation practices.

ForumAT was structured as a permanent education activity, creating a technical and scientific agenda that discusses the construction of a concept of accidents - how to understand these events - and how to deal with them as systemic socio-technical phenomena.

The replacement of investigations into occupational accidents (AT) concluded by attributing blame to the victims and explanations such as uni-causal events were motivating and permanent topics on the agenda of the ForumAT¹, as already highlighted in this Brazilian Journal of Occupational Health (RBSO – Revista Brasileira de Saúde Ocupacional).

The ForumAT and the Model of Analysis and Prevention of Accidents (MAPA)² were born together, receiving support from the São Paulo Research Foundation (Fapesp – Fundação de Amparo à Pesquisa do Estado de São Paulo), through a Public Policy Research Project, which aimed, among other things, to answer why companies inspected on the basis of Health and Safety Standards did not reduce AT rates³? With the support of Activity Ergonomics⁴,⁵, a network of organizational aspects was uncovered in the city of Piracicaba-SP, which were systematically hidden by Occupational Health and Safety (SST) services, anchored in the hegemonic approach in technical and professional circles in the field.

The group that created the Forum included a core group of professors and researchers from São Paulo and other states, professionals from the Health Surveillance Centers or Workers’s Health Reference Centers - Cerest (especially the one in Piracicaba), auditors, labor inspectors, prosecutors, and occupational health and safety professionals from the Federal Prosecution Service of Labour and others. The Forum was helped by the Botucatu Medical School, the São Paulo State University Júlio de Mesquita Filho (Unesp), Piracicaba’s Cerest and Methodist University of Piracicaba (Unimep), the School of Public Health at the University of São Paulo (USP), the Federal Prosecution Service of Labour, and Fapesp. The Environmental Health and Sustainability Association (ASAS – Associação de Saúde Ambiental e Sustentabilidade) currently supports and maintains the ForumAT Portal.

ForumAT in numbers

Throughout its existence, the Forum has involved foreign researchers and authors in face-to-face and virtual events, and interviews and works have been translated and made available on the Portal and YouTube channel. During the pandemic, it held virtual meetings broadcast live.

In the last 12 months (until August 2024), forumat.net.br had 22,520 visits, with an average of 62 visits per day. The data from 2008-2024 shows that the website is consulted regularly, as follows:

• 3,012 active users;

• 3,322 posts/articles published;

• 1,497 files available, including 671 in pdf format;

• 7,100 accesses in 2024; and

• the search update also showed 12,000 visits in the last 12 months.

The www.youtube.com/ForumAcidentes channel has 2,280 subscribers and 310 videos related to the field of occupational health and safety.

A journey marked by methodological pluralism

Methodological pluralism has become a hallmark of ForumAT’s understanding of accidents. New concepts and reflections, especially the articulation of theoretical research with projects to transform realities and the people involved, were produced and disseminated in the activities of ForumAT and the YouTube channel. This process stimulated reflections on work, accidents, human behavior in work situations, etc. as social processes.

On the other hand, we come up against impasses. Uncomfortable moments emerge when investigations that were considered rich and stimulating end up being “shelved” and do not result in interventions that transform the realities studied, as was the case before with the use of the causal tree and MAPA applications. Although the methodologies encourage workers to participate in the whole process, it was possible to recognize the political nature of the challenges, which mirrored the resistance and legal defenses of organizations that avoid at all costs recognizing the accident as a systemic event, with origins rooted in the history of the systems studied.

Forum as a space for debate and dissemination of new perspectives

Gradually, the understanding of accidents as a historical phenomenon was established, represented by the bowtie or three-dimension⁶ model: causes, risks, and consequences.

The first practical development of this approach was to encourage accident analysis that explored in depth the “causes of the causes”, the left side of the bowtie. This happened both with the concepts proposed by MAPA and with the dissemination of investigation techniques such as vertical maps (AcciMaps)⁷,⁸. The application of MAPA concepts has changed over time, for example with the study of real work, of activities whose interaction can contribute to the origins of accidents. New concepts have been incorporated: cognitive management and commitment, understanding, impeded work, situated action, meaning and significance of work, error traps, among others, in the exploration of accident origins and consequences. The paths suggested for prevention have changed.

The second development highlights the issue of the country’s social debt in relation to recognizing the delayed consequences of accidents. Our learning in this regard was fueled by several cases, especially those in which the victim was part of the excluded group, without the protection of public and social policies⁹. Occupational health services need to go beyond the management of injuries and disabilities, exploring the impact of accidents on the identity, self-esteem, and social recognition of workers who are often classified as people with disabilities and doubly discriminated against.

On this path, ForumAT interacted with emerging themes that highlight the need to deal with prevention before accidents happen. Highlights include dialogues with the literature on high-reliability organizations, system resilience, Safety II, the new vision of safety, accident warnings, among others.

From the accident to the activity and the activity system

The learning journey on health and safety at work was strongly influenced by Ergonomics studies developed in France. More recently, another finding has become important. This is the Change Laboratory (CL) proposal¹⁰, which was developed in Finland and which we saw as an ideal tool for the designing - or social construction – of transformative interventions in work realities.

The cultural-historical activity theory (CHAT) and the CL approach have gained prominence on the Forum’s website and YouTube channel, stimulating changes in the ways we have historically dealt with the role of the specialist in intervention. The CL brings notions of co-learning and collaborative development of workers’ health¹¹. The approach presupposes that internal actors participate intensively in the expansive learning cycle to be concluded with the implementation and testing of the new activity system model.

Accidents persist as a subject of study, seen in a broader, historical perspective. The hybridization of methods has been recognized as part of our DNA and has been taken up as a subject of recent studies. The new challenges and threats of a multi-crisis era, of impasses associated with social and technological innovations in a context of negationism, are also invading our agenda. This process is stimulated by the direction taken in the production of knowledge by other actors who interact with the Forum.

ForumAT’s challenges for the next 100 meetings

A first idea is to recognize that the accident demonstrates the failure of prevention. If accidents give warnings before they happen, sending out precursor signals that can be detected¹²,¹³, why do we need to arrive after the disaster to start the investigation process? Would it be possible to encourage or prioritize the development of consistent, collaborative, and systematic actions to identify warning signs and contradictions in their origin, which make it possible to build in-depth defenses against accidents and other losses and damages?

A second objective is to join forces to replace the reductionist view that still rests intact in NBR 14.280¹⁴, which is widely used in organizations to transform a complex, multi-causal phenomenon into an event centered on an individual with a “low perception of risk”, adept at “non-standard behavior”, etc. After the removal of the “unsafe act” from the MTE’s Regulatory Standard No. 1, this is certainly one of the last institutional strongholds that hinder prevention.

Another front that keeps knocking on our door is the issue of mental health in its dimensions of surveillance, prevention, and comprehensive care. ForumAT has already been dealing with this issue, but concentrated efforts are needed to support professionals who are dealing with the difficulties and complexity of the subject.

The multiple interactions that have arisen reinforce the idea that prevention must begin with approaches to the development of systems and their professional activities. But also, with the understanding that many of the new ways of approaching old challenges reflect aspects of the historical development of our group. The old commitments persist, however, we have come to see nuances not seen with the first lenses used in the past.

References

• ¹ Jackson Filho JM, Vilela RA G, Garcia EG, Almeida IM. Sobre a "aceitabilidade social" dos acidentes do trabalho e o inaceitável conceito de ato inseguro. Res. Bras. Saúde Ocup. 2013 jan;38(127):6-8. https://doi.org/10.1590/S0303-76572013000100001
  » https://doi.org/10.1590/S0303-76572013000100001
• ² Almeida IM, Vilela RAG. Modelo de análise e prevenção de acidentes. Piracicaba: Centro de Referência em Saúde do Trabalhador; 2010.
• ³ Vilela RAG. Ações interinstitucionais para o diagnóstico e prevenção de acidentes do trabalho: aprimoramento de uma proposta para a Região de Piracicaba: Relatório de Pesquisa em Políticas Públicas. São Paulo: Fapesp; 2012.
• ⁴ Guérin F, Laville A, Daniellou F, Duraffourg J, Kerguelen A. Compreender o trabalho para transformá-lo: a prática da ergonomia. São Paulo: Edgard Blücher; 2004.
• ⁵ Wisner A. O trabalhador diante dos sistemas complexos e perigosos. In: Wisner A. A inteligência no trabalho. São Paulo: UNESP; 1994. p. 53-70.
• ⁶ Hale AR, Ale BJM, Goossens LHJ, Heijer T, Bellamy LJ, Mud ML et al. Modeling accidents for prioritizing prevention. Reliab Eng Syst Safe. 2007 Dec;92(12):1701-15. https://doi.org/10.1016/j.ress.2006.09.025
  » https://doi.org/10.1016/j.ress.2006.09.025
• ⁷ Rasmussen J. Risk management in a dynamic society. Safety Sci. 1997;27(2-3):183-213. https://doi.org/10.1016/S0925-7535 (97)00052-0
  » https://doi.org/10.1016/S0925-7535 (97)00052-0
• ⁸ Rasmussen J, Svedung I. Proactive risk management in a dynamic society. Karlstad: Swedish Rescue Services Agency; 2000.
• ⁹ Almeida IM, Takahashi M. Consequências tardias de acidentes e desastres de causas externas relacionadas ao trabalho. In: Mendes R, organizador. Patologia do trabalho: o essencial, o novo e a prática. 4a ed. Rio de Janeiro: Atheneu; 2024. p. 683-94.
• ¹⁰ Virkkunen J, Newnham DS. Laboratório de mudanças: uma ferramenta de desenvolvimento colaborativo para o trabalho e a educação. Belo Horizonte: Fabrefactum; 2015.
• ¹¹ Vilela RAG, Querol MAP, Beltran-Hurtado SL, Cerveny GCO, Lopes MGR. Desenvolvimento colaborativo para a prevenção de acidentes e doenças relacionadas ao trabalho. São Paulo: Ex-Libris; 2020.
• ¹² Llory M. O custo do silêncio. Rio de Janeiro: MultiMais; 1999.
• ¹³ Llory M, Montmayeul R. O acidente e a organização. Belo Horizonte: Fabrefactum; 2014.
• ¹⁴ Associação Brasileira de Normas Técnicas. NBR-14280: Cadastro de acidente do trabalho: procedimento e classificação. Rio de Janeiro: Associação Brasileira de Normas Técnicas; 2001.

Publication Dates

• Publication in this collection
  02 Dec 2024
• Date of issue
  2024