Ruptura Barragem Modelo

8/20/2019 Ruptura Barragem Modelo

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Modelo de acidente de ruptura de

barragem

Ildeberto Muniz de Almeida

Agradecimentos: AFT Mário Parreiras

AFT Ivone C Baumecker



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)



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


Equipamentos & entorno

Políticas epráticas da

empresa


Gerente da empresa


Min do MeioAmbiente

CREA

Aprovação e gestão dosprojeto de barragem e de

sua ampliação


Gestãode

SST




UniddeMA


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



Determinação das ações de

controle inadequadas e que

falharam em manter o necessárioconstrangimento de segurança



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


Equipamentos & entorno

Políticas epráticas da

empresa


Gerente da empresa


Min do MeioAmbiente

CREA

Aprovação e gestão dosprojeto de barragem e de

sua ampliação


Gestãode

SST




UniddeMA


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

*



Adaptation: Map of the accident analysisaccording Rasmussen suggestion.



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



Determine the various explanations for the

inadequate control based on the standard

components of a control loop



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

...



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.



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



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



Possible Partial Control Diagram to Dam project - 2

External Project developmentmanager

Model

ofprocess



Reports and formal


Process output:

Projects (partialor final)



Modelsofprocess







Demand

of project


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



Possible Partial Control Diagram to Dam project –Local adaptation

External Engineer hired to sign dam/ raising project

Model

ofprocess



Reports and formal


Process output:

Project signed byexternal engineer



signedModelsofprocess







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



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


Modelsof

process

Dam operation mngmnt

Models of thesystem

behaviour





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



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


Modelsof

process


Models of thesystem

behaviour





No

Demand

about

control


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



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


Process output:


procedures andpresent to dam

operation mngmnt orother responsible.


Oversight Health-Safety compliance

Are there healthand safety risks?

Modelsof

process


Models of thesystem

behaviour





Controls


conditions, infiltrations, stability of

dam wall, etc


nocompliance,





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



Oversight Health-Safety compliance

Are there healthand safety risks?

Modelsof

process


Models of thesystem

behaviour







dam wall, etc


No

Demand

about

control

Feed back:No reports

about nocompliancewith good


process

Process output:oversight of Health

and safetycompliance not

exploring technicalaspects of damraising process.



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


Process output:


procedures andpresent to dam

operation mngmnt orother responsible.


Project compliance

Are there health

and safety risks?Models

ofprocess

Company manager

Models of thesystem

behaviour





Controls



dam wall, etc


nocompliance,





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



Oversight ofproject compliance

Are there flaws or

risks?Models

ofprocess

Company manager

Models of thesystem

behaviour







dam wall, etc


No

Demand

about

control


about nocompliancewith good


process

Process output:No oversight ofgood techniques

compliance.



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





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.


projectdevelopment



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





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


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.



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

+

+

+

+

+

+



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.

++

+

+



Conclusions



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)



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



• 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:– ..




• 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).




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?




• 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?




• 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:




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.

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