A carregar...
Publicação
Erro humano e erro organizacional nas atividades de manutenção das aeronaves na perspetiva da Grounded Theory : o caso nacional
| Nome: | Descrição: | Tamanho: | Formato: | |
|---|---|---|---|---|
| 8.84 MB | Adobe PDF |
Orientador(es)
Resumo(s)
Nos últimos anos ocorreram situações que demonstram que os acidentes em organizações de elevada fiabilidade têm consequências catastróficas que precisam de ser contidas ou evitadas. As medidas para a contenção e prevenção do erro estão estabelecidas nesse tipo de organizações, mas focalizam-se em evitar as consequências negativas dos erros, não analisando as consequências positivas dos mesmos (quando existem). A literatura aponta como consequências positivas a aprendizagem, a inovação e a resiliência. O trabalho conclui que de forma conceptual a consequência positiva dos erros é um aumento da Segurança Organizacional através de processos de melhoria associados à Aprendizagem Organizacional. O erro humano não deve ser primariamente entendido como a principal causa dos acidentes, mas antes como uma possível consequência da atividade organizacional. Foi necessário compreender como (How) ocorre e porque (Why) ocorre o erro organizacional; e, ainda, qual a relação entre os diferentes níveis de erro (humano, de equipa e organizacional) e os fatores organizacionais. Esta abordagem transportou o investigador para a necessidade de uma análise aprofundada do conceito de condições/erros latentes. O conhecimento das causas primárias de um incidente/acidente poderá levar a que se criem indicadores que sirvam de alertas em situações futuras e/ou se alterem essas mesmas condições para que se evitem situações idênticas. Verificou-se neste trabalho que cada incidente/acidente, depois de estudado, é uma fonte de informação absolutamente essencial para a melhoria do sistema. No entanto, existem outras fontes que necessitam de ser mais estimuladas, nomeadamente, o reporte de ocorrências e a correspondente análise e partilha de resultados na Organização. A investigação recorre a uma metodologia qualitativa e os resultados aplicam-se apenas à Organização em estudo. O modelo final explica como através do erro de manutenção aeronáutica, na Força Aérea Portuguesa, se aumenta a Segurança Organizacional.
In recent years, situations have occurred which demonstrate that accidents in High Reliability Organizations have catastrophic consequences that need to be restrained or avoided. Measures to contain and prevent errors are established in this type of organizations, but focus on avoiding the negative consequences of errors, thus not analyzing their positive consequences (when they exist). The literature points to positive consequences of learning, innovation and resilience. The study concludes that, in a conceptual way, the positive consequence of the errors is an increase of the Organizational Security through processes of improvement associated with the Organizational Learning. Human error should not be primarily understood as the main cause of accidents, but rather as a possible consequence of organizational activity. It is necessary to understand how and why organizational errors occur; and the relationship between the different levels of error (human, team and organizational) and organizational factors. This approach transported the researcher to the need for an in-depth analysis of the concept of latent conditions / errors. Knowing the root cause of an incident / accident may lead to the creation of indicators that serve as warnings in future situations and / or change the same conditions, so that similar situations are avoided. It was verified in this study that each incident / accident, once studied, is an absolutely essential source of information for the improvement of the system. However, there are other sources that need to be more stimulated, namely the reporting of occurrences and the corresponding analysis and sharing of results in the organization. The research uses a qualitative methodology and the results apply only to the organization being studied. The final model explains how the Organizational Safety is increased, through the aeronautical maintenance error in the Portuguese Air Force.
In recent years, situations have occurred which demonstrate that accidents in High Reliability Organizations have catastrophic consequences that need to be restrained or avoided. Measures to contain and prevent errors are established in this type of organizations, but focus on avoiding the negative consequences of errors, thus not analyzing their positive consequences (when they exist). The literature points to positive consequences of learning, innovation and resilience. The study concludes that, in a conceptual way, the positive consequence of the errors is an increase of the Organizational Security through processes of improvement associated with the Organizational Learning. Human error should not be primarily understood as the main cause of accidents, but rather as a possible consequence of organizational activity. It is necessary to understand how and why organizational errors occur; and the relationship between the different levels of error (human, team and organizational) and organizational factors. This approach transported the researcher to the need for an in-depth analysis of the concept of latent conditions / errors. Knowing the root cause of an incident / accident may lead to the creation of indicators that serve as warnings in future situations and / or change the same conditions, so that similar situations are avoided. It was verified in this study that each incident / accident, once studied, is an absolutely essential source of information for the improvement of the system. However, there are other sources that need to be more stimulated, namely the reporting of occurrences and the corresponding analysis and sharing of results in the organization. The research uses a qualitative methodology and the results apply only to the organization being studied. The final model explains how the Organizational Safety is increased, through the aeronautical maintenance error in the Portuguese Air Force.
Descrição
Doutoramento em Gestão
Palavras-chave
Aprendizagem organizacional Erro humano Erro organizacional Manutenção de aeronaves Segurança organizacional Organizational learning Human error Organizational error Aircraft maintenance Organizational safety
Contexto Educativo
Citação
Baltazar, Ana Rita Duarte Gomes Simões (2020). "Erro humano e erro organizacional nas atividades de manutenção das aeronaves na perspetiva da Grounded Theory : o caso nacional". Tese de Doutoramento, Universidade de Lisboa. Instituto Superior de Economia e Gestão.
Editora
Instituto Superior de Economia e Gestão