This article presents a methodology for accident analysis developed from the combination of CAST - Causal Analysis based on System Theory, derived from the STAMP (Systems-Theoretic Accident Model and Process) accident causation model and the human error analysis/investigation tool TRACEr (Technique for the Retrospective and Predictive Analysis of Cognitive Errors). This combination was proposed from the perceived need to structure one of the stages of the application of the CAST technique where unsafe control actions, or human errors, that occurred in the course of accidental events are analyzed, for which the application of the TRACEr technique proved extremely useful. From the application of the proposed combination to an accident that occurred in an oil production unit in operation on the coast of southeastern Brazil, it was possible to obtain a deeper understanding of the psychological phenomena that preceded one of the unsafe control actions, as well as the identification of performance shaping factors that contributed to its occurrence. These results demonstrated the conceptual cohesion and mutual complementarity of the associated techniques, which allowed a comprehensive understanding of the accidental event and, consequently, the elaboration of safety recommendations more appropriate to the findings of the analysis, better specified to the aspects of human factors involved.

本文介绍了一种基于系统理论的 CAST因果分析结合开发的事故分析方法，该方法源自 STAMP（系统理论事故模型和过程）事故因果模型和人为错误分析/调查工具 TRACEr（技术认知错误的回顾性和预测性分析）。这种组合是根据对构建 CAST 技术应用阶段之一的感知需求提出的，在该阶段分析意外事件过程中发生的不安全控制行为或人为错误，为此，TRACEr 技术的应用证明了这一点非常有用。将所提议的组合应用到巴西东南沿海某石油生产装置发生的事故中，可以更深入地了解其中一个不安全控制行动之前的心理现象，以及识别导致其发生的绩效塑造因素。这些结果证明了相关技术在概念上的凝聚力和互补性，