Tragedy on grade crossing: driver failure or systemic fragility? Manoela Gomes Reis Lopes a,b,* , Rodolfo Andrade de Gouveia Vilela b , Ildeberto Muniz de Almeida c , Odilamar Lopes Mioto d , Mara Alice Batista Conti Takahashi e and Fernanda Oliveira Perin b a Post-Graduation in Public Health Program, School of Public Health of Universidade de São Paulo – FSP/USP, São Paulo, Brazil b Environmental Health Department, School of Public Health- FSP/USP, São Paulo, Brazil c Public Health Department, Botucatu Medical School of Universidade Estadual Paulista -UNESP, Botucatu, Brazil d Workers’ Health Program (PST- Americana), Americana, Brazil e Reference Center for Workers’ Health (CEREST Piracicaba), Piracicaba, Brazil Abstract. In 2010, an accident occurred in Americana-SP, Brazil, involving two trains and one bus on a Grade Crossing, when 10 people died and 17 were injured including workers. This paper aims to analyze the accident using the Model of Analysis and Prevention of Work Accidents (MAPA). The method provides observation of work, interviews and analysis of documents to understand precedents of the event in the following stages: to understand the usual work from the involved people, the changes occurred in the system, the operation of barriers, managerial and organizational aspects. By the end, measures are suggested to avoid new occurrences. The accident took place at night in a site with insufficient lighting. The working condi- tions of bus drivers, train operators and watchmen are inadequate. There were only symbolic barriers (visual and acoustic sig- nals) triggered manually by watchman upon train operator radio communication. The fragility of the barrier system associated to poor lighting and short time to trigger the signaling seem to play a critical role in the event. Contrary to the official report which resulted in guilt of the bus driver, the conclusion of the paper emphasizes the fragility of the safety system and the need of level crossing reproject. Keywords: Health and Safety, Highway, Railway, Work Accidents, Level Crossing * Corresponding author. E-mail: lopes.manoela@usp.br. Faculdade de Saúde Pública – FSP/USP, Avenida Doutor Arnaldo, 715, 2 o andar, CEP: 01246-904, São Paulo – SP, Brasil. 1. Introduction The railway crossing with the road on the same level is called Grade Crossing (GC). Bearing in mind that railway composition has longer time of inertia to its total stopping, these crossings present high risk of accidents even with a lower incidence when com- pared to other modal roads, but the rate of severity is significant with loss of lives, injuries and material damages. That implies in people’s suffering, tax in- crease for society, burden with payment of indemni- ties to the victims or their relatives and deterioration of the company’s image [1]. A highway composition will only pass through a GC in a safe way if the installed safety systems are triggered automatically hindering totally the vehicle and people traffic [2]. The barriers are mechanisms whereby it is possible to prevent or to protect against uncontrolled transportation of mass, energy or infor- mation. They are used in the control of a certain situ- ation of risk or danger. They can be physical, func- tional, symbolic or immaterial. The physical barriers are the ones that physically block the propagation of potential energy, the functional barriers are the ones that operate in certain conditions of risk, for example, a system of power interlocking in a machine, and, the symbolic barriers that are the instructions of proce- Work 41 (2012) 3148-3154 DOI: 10.3233/WOR-2012-0576-3148 IOS Press 3148 1051-9815/12/$27.50 © 2012 – IOS Press and the authors. All rights reserved