{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T10:33:24Z","timestamp":1777890804979,"version":"3.51.4"},"reference-count":0,"publisher":"SAGE Publications","issue":"S1","license":[{"start":{"date-parts":[[2012,1,1]],"date-time":"2012-01-01T00:00:00Z","timestamp":1325376000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["WORK: A Journal of Prevention, Assessment &amp; Rehabilitation"],"published-print":{"date-parts":[[2012,3]]},"abstract":"<jats:p>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 conditions of bus drivers, train operators and watchmen are inadequate. There were only symbolic barriers (visual and acoustic signals) 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.<\/jats:p>","DOI":"10.3233\/wor-2012-0576-3148","type":"journal-article","created":{"date-parts":[[2019,12,3]],"date-time":"2019-12-03T00:08:35Z","timestamp":1575331715000},"page":"3148-3154","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Tragedy on grade crossing: driver failure or systemic fragility?"],"prefix":"10.1177","volume":"41","author":[{"given":"Manoela Gomes Reis","family":"Lopes","sequence":"first","affiliation":[{"name":"Post-Graduation in Public Health Program, School of Public Health of Universidade de S\u00e3o Paulo \u2013 FSP\/USP, S\u00e3o Paulo, Brazil"},{"name":"Environmental Health Department, School of Public Health- FSP\/USP, S\u00e3o Paulo, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rodolfo Andrade","family":"de Gouveia Vilela","sequence":"additional","affiliation":[{"name":"Environmental Health Department, School of Public Health- FSP\/USP, S\u00e3o Paulo, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ildeberto Muniz","family":"de Almeida","sequence":"additional","affiliation":[{"name":"Public Health Department, Botucatu Medical School of Universidade Estadual Paulista -UNESP, Botucatu, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Odilamar Lopes","family":"Mioto","sequence":"additional","affiliation":[{"name":"Workers\u2019 Health Program (PST- Americana), Americana, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mara Alice batista Conti","family":"Takahashi","sequence":"additional","affiliation":[{"name":"Reference Center for Workers\u2019 Health (CEREST Piracicaba), Piracicaba, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fernanda Oliveira","family":"Perin","sequence":"additional","affiliation":[{"name":"Environmental Health Department, School of Public Health- FSP\/USP, S\u00e3o Paulo, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2012,1]]},"container-title":["WORK: A Journal of Prevention, Assessment &amp; Rehabilitation"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.3233\/WOR-2012-0576-3148","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.3233\/WOR-2012-0576-3148","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T05:46:24Z","timestamp":1777614384000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.3233\/WOR-2012-0576-3148"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2012,1]]},"references-count":0,"journal-issue":{"issue":"S1","published-print":{"date-parts":[[2012,3]]}},"alternative-id":["10.3233\/WOR-2012-0576-3148"],"URL":"https:\/\/doi.org\/10.3233\/wor-2012-0576-3148","relation":{},"ISSN":["1051-9815","1875-9270"],"issn-type":[{"value":"1051-9815","type":"print"},{"value":"1875-9270","type":"electronic"}],"subject":[],"published":{"date-parts":[[2012,1]]}}}