Resumo:
Work accidents remain a significant public health issue and a persistent challenge for safety management in industrial organizations. The way these events are investigated directly influences the effectiveness of preventive measures and the organization’s capacity to learn from system failures. This dissertation aims to analyze the accident investigation method adopted by a metal-mechanical company, identifying whether the approach used is predominantly reactive or proactive, and comparing it with traditional and systemic methods in order to understand how this perspective affects prevention potential and working conditions. Grounded in a constructivist epistemological perspective, the study employed a qualitative methodology based on documentary analysis of records produced after a severe accident. The findings revealed a relevant discrepancy between the institutionally declared method (Fault Tree, Ishikawa Diagram, and Cause Tree) and the method actually applied in the case study, which relied on Fault Tree Analysis and aligned with traditional assumptions. A predominantly linear and technical approach was observed, focused on isolated failures and individual behaviors, with limited consideration of organizational, human, and contextual factors widely recognized in systemic literature. The results indicate that such an investigative orientation reduces the organization’s learning potential and restricts the preventive capacity of the analyses, favoring reactive interventions implemented only after the event, even when technically relevant. At the same time, the study highlights opportunities for improvement, suggesting that the effective adoption of systemic methods can broaden the understanding of real working conditions and strengthen a safety culture based on learning, anticipation of risks, and integrated analysis of sociotechnical factors. It is expected that this research contributes to the enhancement of investigative practices and to the advancement of more comprehensive approaches in the field of occupational safety.
