Analyse d'accident basée sur l'activité de travail : au-delà des erreurs humaines.

This article presents the analysis of an accident in the pearlification (production of urea pearls) sector of a nitrogen fertilizer plant. Unlike conventional analyses usually centered on the use of tools such as the "tree of causes" or the "Ishikawa diagram" which lead to the designation of those responsible for the human and / or technical errors identified, the analysis presented in this article focuses on the daily work carried out by workers in the sector in which the accident took place and also on how the daily activities carried out by these workers can contribute to, or avoid situations which can produce accidents. The accident analysis based on work activity was able to answer questions that remained unanswered after the official analysis produced by the company and, even more, it was able to elucidate the reasons why certain behaviors were adopted by the workers at the time of the accident. From this perspective, understanding the work activity reveals more concretely the actual causes of the accidents. This way, it responds better to what should be the main objective of any analysis: to promote learning and avoid new accidents. [ABSTRACT FROM AUTHOR]