Investigación conjunta de accidentes, incidentes y riesgos.

,19(67,*$&,Ï1&21-817$'($&&,'(17(6,1&,'(17(6< 5,(6*26 0LJXHO$QJHO0DULVFDO6DOGDxD (36GH%XUJRV$YGD&DQWDEULD61 PDULVFDO#XEXHV 0LJXHO$QJHO0DQ]DQHGRGHO&DPSR (36GH%XUJRV$YGD&DQWDEULD61 PPDQ]#XEXHV 6XVDQD*DUF D+HUUHUR (36GH%XUJRV$YGD&DQWDEULD61 VXVDQDJK#XEXHV -XDQ0DQXHO9DURQD$UQiL] (36GH%XUJRV$YGD&DQWDEULD61 MPYDURQD#XEXHV 5(680(1 /DLQYHVWLJDFLyQGHLQFLGHQWHV ULHVJRVMXQWRFRQORVDFFLGHQWHVHVXQDKHUUDPLHQWDUHODWLYDPHQWH UHFLHQWHHQODVHJXULGDGLQGXVWULDOSHURFX DLPSODQWDFLyQJDUDQWL]DODPHMRUDGHORVUHVXOWDGRV HQ VHJXULGDG /D UHFLHQWH LPSODQWDFLyQ HQ QXPHURVDV HPSUHVDV GH HVWD KHUUDPLHQWD VH YH DFRPSDxDGDGHXQFLHUWRGHVFRQRFLPLHQWRSDUDVXGLVHxR SDUDVXWUDWDPLHQWR3RUHVRHQHO SUHVHQWHGRFXPHQWR  VHUHDOL]DXQHVWXGLRVREUHODPDQHUDGHLPSODQWDUXQHVWXGLRGHHVWHWLSR DV FRPRGHORVIRUPXODULRVGLVHxDGRVKDVWDHOPRPHQWRSDUDWDOILQ /DXWLOL]DFLyQGHHVWDVQXHYDVKHUUDPLHQWDVSDUDODPHMRUDGHORVUHVXOWDGRVHQHOFDPSRGHOD VHJXULGDGLQGXVWULDOVXSRQHXQDUHYLVLyQSUHYLDGHORVFRQFHSWRVIXQGDPHQWDOHVGHODGLVFLSOLQD DTXHODVQXHYDVWHFQRORJ DV ODFRQVWDQWHHYROXFLyQGHODVH[LVWHQWHVIDYRUHFHODLQWURGXFFLyQ GH QXHYRV ULHVJRV $V  FRQ HVWDUHYLVLyQ VH ORJUDHVWDEOHFHU XQYRFDEXODULRFRP~QSDUDHVWD GLVFLSOLQDVLQHOFXDOQRHVSRVLEOHXQHQWHQGLPLHQWR 'HILQLFLyQGHFRQFHSWRV (Q ORV ~OWLPRV DxRV KD KDELGR XQ JUDQ GHVDUUROOR HQ HO iPELWR OHJLVODWLYR UHIHUHQWH D OD VHJXULGDG (VWH GHVDUUROOR QR HV VyOR QDFLRQDO VLQR TXH VH VLW~D HQ XQ PDUFR PXFKR PiV DPSOLR D QLYHO HXURSHR R LQFOXVR PXQGLDO  $O LQWHUpV H[LVWHQWH GHELGR D UD]RQHV WpFQLFDV FRPR OD DSDULFLyQ GH QXHYRV ULHVJRV LQGXVWULDOHV GHULYDGRV GH DSOLFDFLRQHV D OD WHFQRORJ D LQGXVWULDO HQ ODV HPSUHVDV VH XQH OD QHFHVLGDG GH LQYHVWLJDFLyQ HQ OD GLVFLSOLQD GH OD VHJXULGDG LQGXVWULDO DSUHPLDGD SRU OD UHFLHQWH LPSODQWDFLyQ HQ QXHVWUR SD V GH OD /H  GH 3UHYHQFLyQGH5LHVJRV/DERUDOHV (VWDQHFHVLGDGVHYHFRQILUPDGDSRUODVHVWDG VWLFDVVREUHODDFFLGHQWDOLGDGHQQXHVWURSD VODV FXDOHV PXHVWUDQ XQD WHQGHQFLD SUHRFXSDQWH HQ FXDQWR D Q~PHUR GH DFFLGHQWHV GH EDMDV ODERUDOHVHLQFOXVRGHPRUWDOLGDG  (VWHWUDEDMRVHGHULYDGHODSDUWLFLSDFLyQGHVXVDXWRUHVHQXQSUR HFWRGHLQYHVWLJDFLyQILQDQFLDGRSRUOD-XQWD GH &DVWLOOD  /HyQ FRQ UHIHUHQFLD %8  WLWXODGR ³0RGHOR SDUD OD PHMRUD GH OD SUHYHQFLyQ HQ ULHVJRV ODERUDOHVPHGLDQWHHOHVWXGLRGHLQFLGHQWHV´ &RQHVWHQXHYRPDUFRVHKDFHQHFHVDULRHOGHVDUUROORGHQXHYDVKHUUDPLHQWDVTXHD XGHQDO WpFQLFRGHSUHYHQFLyQDFRQWURODUUHGXFLUHLQFOXVR HOLPLQDUORVULHVJRVTXHSRVWHULRUPHQWH SXHGHQ JHQHUDU R DFDEDU HQ DFFLGHQWHV 3DUD ORJUDU HVWH GHVDUUROOR DV  FRPR DOFDQ]DU XQ HQWHQGLPLHQWRFRP~QHQPDWHULDGHVHJXULGDGVHKDFHQHFHVDULRILMDUFRQODPHMRUSUHFLVLyQ SRVLEOH ORV WpUPLQRV GH SHOLJUR ULHVJR LQFLGHQWH  DFFLGHQWH SDUD ORJUDU XQ YRFDEXODULR FRP~QGHWRGRVORVDJHQWHVLPSOLFDGRVHQHVWDiUHDFRQODGLILFXOWDGTXHHOORLPSOLFDSRUOD GLYHUVLGDGGHGHILQLFLRQHV FRQFHSWRVXVDGRVKDVWDHVWHPRPHQWR 'HVSXpVGHUHFRJHUPXFKDVGHODVPiVLPSRUWDQWHVDSRUWDFLRQHVDOHVFODUHFLPLHQWRGHWRGRV HVWRVFRQFHSWRVSURFHGHILMDUFRQODPHMRUSUHFLVLyQSRVLEOHORVWpUPLQRV GHSHOLJURULHVJR LQFLGHQWH  DFFLGHQWH UHOHYDQWHV SDUD FRPHQ]DU FXDOTXLHU LQYHVWLJDFLyQ HQ HO FDPSR GH OD VHJXULGDG 6LJXLHQGRHQJUDQSDUWHODGHILQLFLyQSURSXHVWDSRU&RUWpV OD81(SHOLJUR YDDVHUXQDVLWXDFLyQGHULHVJRLQPLQHQWHTXHSXHGDSURGXFLUXQGDxRRXQGHWHULRURGHOD FDOLGDGGHYLGDLQGLYLGXDORFROHFWLYDGHODVSHUVRQDVSRUODJHQHUDFLyQGHOHVLRQHVGDxRVD ODSURSLHGDGRDOPHGLRDPELHQWH 5LHVJR VHU D OD SRVLELOLGDG TXH SRU XQD FRPELQDFLyQ GH OD SUREDELOLGDG H[SRVLFLyQ  FRQVHFXHQFLDV DQWH XQ GHWHUPLQDGR SHOLJUR VH SURGX]FD XQ FLHUWR GDxR SXGLHQGR HQ FRQVHFXHQFLDFXDQWLILFDUVH(QHVWD GHILQLFLyQVHDSUHFLDTXHGHOSHOLJURVHSXHGHSDVDUDO ULHVJRFXDQGRVHFXDQWLILFDVXLPSRUWDQFLD$GHPiVHOULHVJRHV XQDSRVLELOLGDG  QRXQD PDWHULDOL]DFLyQHQXQKHFKRRVXFHVRFRPRHVHOFDVRGHOLQFLGHQWH ,QFLGHQWHHVXQKHFKRRVXFHVRQRSODQHDGRQLGHVHDGRTXHQRGDQGROXJDUDSpUGLGDVGHOD VDOXGROHVLRQHVDODVSHUVRQDVRFDVLRQDGDxRVDODSURSLHGDGHTXLSRVSURGXFWRVRDOPHGLR DPELHQWH SpUGLGDV GH OD SURGXFFLyQ R DXPHQWR GH ODV UHVSRQVDELOLGDGHV OHJDOHV &RQVLGHUDPRVSXHVODH[LVWHQFLDFLHUWDGHDOJ~QWLSRGHSpUGLGDV DVHDPDWHULDOHVRLQFOXVR GHSURGXFWLYLGDG/DDXVHQFLDGHHVWDFDUDFWHU VWLFD LPSOLFDU DTXHQRVHQFRQWUDPRVDQWHXQ VLPSOHULHVJR3RUWDQWRGHVFDUWDPRVODH[LVWHQFLDGHLQFLGHQWHVFU WLFRV  DFFLGHQWHVUDURV SURSXHVWRVSRU%DVHOJD 3RU~OWLPRSDUDGHILQLUDFFLGHQWHVHSXHGHDFXGLUDODUW FXORGHO7H[WR5HIXQGLGRGHOD /H *HQHUDOGHOD6HJXULGDG6RFLDO5HDO'HFUHWR/HJLVODWLYRGHGHMXQLRGRQGH VH FRQWHPSOD FRPR ³WRGD OHVLyQ FRUSRUDO TXH HO WUDEDMDGRU VXIUD FRQ RFDVLyQ R SRU FRQVHFXHQFLDGHOWUDEDMRTXHHMHFXWHSRUFXHQWDDMHQD´$V VHLQFOX HQFRPR DFFLGHQWHVGH WUDEDMRYDULRVVXSXHVWRVFRPRVRQORVTXHVXIUDHOWUDEDMDGRUDOLURDOYROYHUGHOOXJDUGH WUDEDMRORVUHODFLRQDGRVFRQHOGHVHPSHxRGHFDUJRVGHFDUiFWHUVLQGLFDORORVDFDHFLGRVHQ DFWRVGHVDOYDPHQWRHQWUHRWURV 6LQ HPEDUJR HV SUHFLVR GLVWLQJXLU ORV ³DFFLGHQWHV FRQ EDMD´ GH ORV ³DFFLGHQWHV VLQ EDMD´ ([LVWHQ QXPHURVRV FULWHULRV SDUD HOOR LQWHUHViQGRQRV HO DSRUWDGR SRU 1LYHQ   (O FULWHULRDXWLOL]DUHQQXHVWURFDVRYDDVHUODSpUGLGDGHXQG DGHWUDEDMRSDUDFRQVLGHUDUVH FRQ EDMD GHELGR D OD IDFLOLGDG SDUD VX PHGLFLyQ  0iV HQ FRQFUHWR VH FRQWDELOL]DUi XQ DFFLGHQWHFRPRFRQEDMDFXDQGRHOWUDEDMDGRUDFFLGHQWDGRQRDFXGDDWUDEDMDUDOG DVLJXLHQWH GHODFFLGHQWH )UXWRGHWRGDVHVWDVGHILQLFLRQHV H[SXHVWRGHXQDIRUPDYLVXDOHOSURFHVRGHODFFLGHQWHVH PXHVWUDHQODILJXUD &RQHVWDYLVLyQGHOHQWRUQRGHODFFLGHQWHVXUJHODLGHDGHHOLPLQDUHODFFLGHQWHDWUDYpVGHOD HOLPLQDFLyQGHORVLQFLGHQWHVRLQFOXVRGHORVULHVJRVLGHDHVWD DLQWURGXFLGDDWUDYpVGHOD /35/FRQODREOLJDFLyQGHUHDOL]DU(YDOXDFLRQHVGH5LHVJRV 7DPELpQFRQHVWDUHSUHVHQWDFLyQVHGDLGHDGHODH[LVWHQFLDGHXQDUHODFLyQSLUDPLGDOHQWUH ORVGLVWLQWRVWLSRVGHVXFHVRVODFXDO DKDE DVLGRDSXQWDGDSRUGLVWLQWRVDXWRUHVFRPR%LUG  +HLQULFK(VWRVDXWRUHVUHDOL]DQGLVWLQWRVHVWXGLRVSDUDSRQHUGHPDQLILHVWRODH[LVWHQFLDGH XQDUHODFLyQGHSURSRUFLRQDOLGDGHQWUHORVGLVWLQWRVWLSRVGHVXFHVRVDV FRPRSDUDPRVWUDUOD LPSRUWDQFLDGHOHVWXGLRGHORVULHVJRVLQFLGHQWHV DFFLGHQWHV &RQ HOHVWDEOHFLPLHQWRGHHVWDWHUPLQRORJ DTXHHVDSOLFDEOHDWRGRHVWXGLRRLQYHVWLJDFLyQGH VHJXULGDGVHFRQILUPDODQHFHVLGDGGHUHDOL]DUXQHVWXGLRFRQMXQWRGHULHVJRVLQFLGHQWHV  DFFLGHQWHVSDUDODPHMRUDGHORVUHVXOWDGRVHQVHJXULGDG 3HOLJURV 5LHVJRV ,QFLGHQWHV $FFLGHQWHV )LJXUD(OSURFHVRGHODFFLGHQWH)XHQWH(ODERUDFLyQSURSLD ,19(67,*$&,Ï1'(,1&,'(17(6<'(5,(6*26 7UDGLFLRQDOPHQWH VH KDQ HVWXGLDGR ORV DFFLGHQWHV D RFXUULGRV FRPR HMHPSORV FODURV GH GLVIXQFLRQDPLHQWRVGHOVLVWHPDVLQHPEDUJRODVWHQGHQFLDVDFWXDOHVVHFHQWUDQHQLQYHVWLJDU ORV LQFLGHQWHV LQFOXVR ORV TXH QR DFDEDQ HQ DFFLGHQWH FRPR KHUUDPLHQWD GH PHMRUD GHO VLVWHPD VXUJLHQGR GH HVWH PRGR OD SRVLELOLGDG IXWXUD GH LQYHVWLJDU RWURV FDPSRV FRPR SXHGDQVHUODFXOWXUDGHHPSUHVDHOOLGHUD]JRHWF 'H HVWD IRUPD VH DQDOL]D ODV SULPHUDV LGHDV GH LQYHVWLJDGRUHV FRPR %LUG  +HLQULFK ORV FXDOHVVLHQWDQODVEDVHVSDUD HOIXWXURGHVDUUROORGHODVHJXULGDG &RQHVWRVDQWHFHGHQWHV HQORVDxRVVXUJHXQDFRUULHQWHGHSHQVDPLHQWRTXHGHILHQGHHO HVWXGLRVHPHMDQWHSDUDDFFLGHQWHVHLQFLGHQWHVVLHQGRVXVPi[LPRVH[SRQHQWHVDXWRUHVFRPR 0DQ]DQHGR  6HQHFDO  %XUNH  .UDXVH  5XVHOO  16&   .LUNZRRG  *ROGEHUJ  *HOOHU  R /DNH  DOJXQR GH ORV FXDOHV IRUPXODPRGHORVGHUHFRJLGDHLQFOXVRGHDQiOLVLVGHLQFLGHQWHV 1R H[LVWH XQ PRGHOR QRUPDOL]DGR GH YDORU XQLYHUVDO  GH REOLJDGR FXPSOLPLHQWR QL HVWi WDPSRFRGHILQLGRVXFRQWHQLGRP QLPRRFRPRGHEHHVWUXFWXUDUVH  WUDWDUVHODLQIRUPDFLyQ UHFRJLGD6LPSOHPHQWHHOPRGHORDXWLOL]DUGHEHDMXVWDUVHDFDGDHPSUHVDWLSRHVWUXFWXUD RUJDQL]DFLyQHWFDILQGHTXHOHSHUPLWD OHIDFLOLWHFXPSOLUFRQVXVREOLJDFLRQHVOHJDOHV  D QLYHO HPSUHVDULDO ORV PRGHORV XWLOL]DGRV  ODV SHUVRQDV HQFDUJDGDV GH VX FXPSOLPLHQWR GHEHQVHUDFRUGHVFRQODRUJDQL]DFLyQGHFDGDHPSUHVD $FRQWLQXDFLyQVHPXHVWUDQHQODVILJXUDV GLYHUVRVPRGHORVXWLOL]DGRVSRUDOJXQRGH ORVDXWRUHVDQWHULRUPHQWHFLWDGRVSDUDVXHVWXGLR FRPSDUDFLyQFRQHOREMHWLYRGHHVWDEOHFHU XQRVUHTXLVLWRVP QLPRV XQDVHULHGHFRQVHMRVHQODHODERUDFLyQGHXQPRGHORGHIRUPXODULR SDUDHOHVWXGLRGHDFFLGHQWHVLQFLGHQWHV ULHVJRV )LJXUD,QIRUPHGH$FFLGHQWH)XHQWH%DVHOJD /DVP QLPDVFRQGLFLRQHVTXHGHEHVDWLVIDFHUXQPRGHORVHJ~QOD173VRQ x'HEHVHUVHQFLOORGHPRGRTXHVXXWLOL]DFLyQVHDIiFLO x'HEHVHUFRQFUHWRSDUDIDFLOLWDUODJHVWLyQGHORVGDWRVTXHHQHOPLVPRVHFRQWHQJDQ x'HEH VHU FODUR KDFLHQGR TXH HO DQDOLVWD QR WHQJD GXGDV R TXH KDFHU LQWHUSUHWDFLRQHV GXUDQWHVXFXPSOLPHQWDFLyQ )LJXUD0RGHORGH0LGDV)XHQWH6ZDUW]