FMEA APPLIED AT SAFETY WORKS MANAGEMENT – A CASE STUDY

This paper presents a method that aims to put the management of occupational hazards in optimization models of production processes. The use of the proposed tool seeks both to reduce the frequency with which accidents happen as to minimize the severity of these accidents. The tool also assesses the probability of potential accidents aiming to reduce them. The genesis of this work is an issue of practical research, which seeks the interaction of production and safety, where he implemented the FMEA tool (Failure Modes and Effects Analysis) with the focus on the management of occupational hazards, under the mapping production flow. The activity was considered the modification in a cutting plasma area in a metallurgical company. The application of FMEA tool focused on safety was conducted following methodological procedures for the use of the tool by applying risk analysis concepts aimed at eliminating the causes that could potentially result in accidents. Finally, it was found that the integrated approach using this quality tool with focus on security is a viable alternative for organizations that seek to evaluate the various failure modes that may occur during a process, may cause accidents to workers, so the use of the tool can evaluate the risks and prevent accidents.


INTRODUCTION
"The company has the obligation to adopt risks control measures that may affect directly or indirectly the safe and health of the worker".(Brazilian Ministry of Labor and Employment, 2016).This way it is necessary to perform for each activity a risk analysis to identify the risks and the control measures to minimize or eliminate this risks.
The risk analysis it is a systematic method of examining and evaluation all the steps and elements of a determined work to develop and rationalize all sequences the worker performs, identifying the potential risks of accidents that may cause damage to workers or property, written by Muniz (2011).
Therefore it is a critical tool of the activity or situation, with great utility to identify and prevent undesirable events, making possible the adoption of measures to prevent the safe and health of the worker.
The problem to be solved is an improvement in the occupational safety and health management through implementation of a quality tool with focus in safety, to improve the detection level of failure in the process, decreasing the probability of occurrence accident rate and occupational diseases, with the goal of introduce the FMEA (Failure Modes and Effects Analysis) concepts applied to safety, evaluating the benefits arising from its application.The FMEA with safety focus should prevent the occurrence of failures/risks that could potentially cause accidents.For that, a methodology is developed a methodology that allows analyzing and conceive actions that act preventively about the possible causes of accidents in a productive process.

THE APLIED STUDY FIELD INDUSTRY: MAXION CRUZEIRO
The company analyzed is active in the automotive segment, divided into: Maxion Wheels that is world leader in wheels productions automotive and off-road wheels, Maxion Structural Components which is one of the main producers of automotive structural components in the Americas.(Maxion, 2016)

U N I S A L -U n i d a d e L o r e n a -C a m p u s S ã o J o a q u i m
The Safety and Health system of the Cruzeiro plant has certified OHSAS 18001 granted by Bureau Veritas Certification.It is an effectively implemented system that permanently seeks the best practices among its daily activities of product manufacturing, aiming to guarantee the well-being of its direct or indirect employees, thus ensuring the operational continuity of the company.
The company has a pyramid of decision hierarchy, as shown in the picture 1.

MANAGEMENT AND ANALYSIS OF HAZARD AND RISK
All Activity in a company has included risks that must be managed.The process of management of risks assist the making decision, taking into account the uncertainties and the possibilities of circumstances or future events (be intentional or unintentional) and the effects on the agreed objects.(ABNT NBR ISO/IEC 31010:2012) The company is responsible for manage its risks by proposing preventive measures to neutralize or eliminate such risks "The Risk Analysis involves two steps: Qualitative evaluation, in this step the risk is identified, described and estimated, and the quantitative evaluation the risks are measured and then treated".(Muniz, 2011) Picture 1: Pyramid of Decision Hierarch

U N I S A L -U n i d a d e L o r e n a -C a m p u s S ã o J o a q u i m
The process of qualitative risk analysis is the process of evaluation the impact and the probability of the identified risks.This process prioritizes the risks in accordance the potential effects of them.
The quantitative analysis the risk has the objective perform a numeric analysis of the probability of each risk and their respective consequence, through a risk survey attributing values to each consequence, identifying the more serious risks, it is prioritized in the process of risk control.
Therefore, in the risk analysis leaves registered all the types of hazards and risks existing in a workplace, as well the preventive measures and control to minimize or neutralize the exposition of the worker to these risks.
To start an effective risk analysis program, the following questions are usually posed: Which level ensure the worker safety?What makes a safe task?The processes ensure the safety of the worker?
The process of risk analysis allow obtain answers to each questions, identifying the potential risks (or hazards), determining the probability of this happen (the frequency) qualifying and quantifying the consequence (Severity).
"Risk is the combination of the probability of occurrence of a hazardous event or exposure with the severity of the injury or illnesses that may caused by the event or exposure" (OHSAS 18001:2007).
The standard define that "hazard is a source or situation or an act with potential to cause damage to worker, or a combination of them.(OHSAS 18001:2007).
The risk management is the systematic application of policies, procedures and practices for the establishment of contexts for the identification, analysis, evaluation, monitoring and communication of risks.(AS/NZS 4360:2004).This evaluation allows determine the origin, the nature and the effects of the risks, making possible the adoption of risk measures control that must be developed from the planning, leading to possible elimination of risks or the reduction of them an acceptable levels through engineering measures.
"The risk assessment, involves two steps: qualitative evaluation, in this step the risk is identified, described and estimated, quantitative evaluation, in this case the risk is measured for subsequent treatment."Muniz (2011).The Picture 2 presents the main policy elements for the implantations of a safety management system.The Picture 3 presents a risk management model that is included: identified, assess, analysis, and risk management.The Failure Modes and Effects Analysis is a technique that offers three distinct functions: is a tool to problems prognosis, is a procedure to develop and execution of project, process or new services or to review it; in the last, is a diary of the project, process or services.(PALADY, 2004 p.5) MORETTI (2006), "The use of FMEA tool enables define a set of corrective and preventive measures, besides propose method that help minimize the potential failure modes".

U N I S
Although it was developed with the focus of new products projects and process, the FMEA methodology for its great utility came to be applied in several ways.Therefore it is currently used to decrease process and product failure and decrease the probability of failure in administrative process.Has also been employed in specifics applications as risk analysis in work's safety engineering and food industry.(TOLEDO; AMARAL, 2006 p.2) The development and execution of FMEA produce costs, however, when done effectively they can result in a significant return of reliability and quality.This return is obtained trough of the cost reduction with failure, gathering a collective knowledge with all the team that comprising how the project may fail.(PALADY, 2004 p.5)According Aguiar and Salomon ( 2007) "when a company invest in prevention effectively in terms of implementation the returns are right in reducing costs with failure.
Five basic elements should be included in all successful FMEA, that are: 1) Planning of FMEA; 2) List of the failure modes and their effects; 3) Prioritization and isolation of the most important failure modes; and 5) Monitoring of the actions necessary to develop an efficient FMEA and the actions suggested by it.(PALADY, 2004 p.21).The FMEA tool é basically developed in two major stages: in the first stage the failure mode is identified.In the second stage the Number of Priority Risk -NPR is determined, that is, the number score of these failure.(PUENTE, 2002).The FMEA include many of charts that are used in the assess of three criterion on a scale of 1 to 10, the higher number assigned to the criterion, the greater the risk.The interpretation of these values is done by calculation the Risk Priority Number, it is obtained through the result the multiplication of the analyzed factors that are: Severity, Occurrence and Detection.(CARPINETTI, 2012) The charts 1, 2 and 3 presents a model with the relation of the severity, occurrence and detection, while the picture 5 presents a FMEA form.

FMEA WITH SEFETY FOCUS
The FMEA is a tool used to detect Failure before that happens, proposing corrective and preventive measures for each failure modes identified by FMEA.
Making an analogy of failures with accident, since as cited by the legislation the accident is an unwanted event that can bring consequences to the worker, therefore we an consider the accident a fail.
To apply the tool with safety focus specifically in safety management, the accident independent of injury will be treated as an effect of failure modes.
Similarly to FMEA of process or product, the FMEA with safety focus should follow the methodology procedures written by Carpinetti (2012), Palady (2004) and Puente (2002).
Adapt the charts of severity, occurrence and detection suggested by Palady (2004) so that reflect questions about safety and occupational health has developed the charts 4 to 6.The Severity, Occurrence and Detection index, was developed according to the company's need, making an analogy to the methodology written by Carpinetti ( 2012).
The Picture 6 presents an adaptation of the FMEA form to be used with the focus on safety through the risk management. .

HOW TO ELABORATE THE FMEA WITH SAFETY FOCUS:
In according to the model proposed by Palady (2004) has an adapted header so that it contains the work place evaluated by FMEA, a description of the machines and equipment used on the work place, and finally a description of the activity, developed by the worker.
The FMEA form with Safety focus is composed by: • Risk Code: in this first step after the completing the header the person responsible for the FMEA should codify the risks evaluated in the work place, this action aims to facilitate and catalog the possible risk situation that can be found in each task developed in the work place.
• Process: In this step the responsible of the work should be described what process is being evaluated; • Task: This step is very important because should be described the project phases in analyze.
• Hazard: Description of the hazard coming from the exposure to risk.
• Possible Damages: Description of the possible damages coming from the exposure to the hazard/risk, that is, what is the consequence to the exposure.
• Severity: Used to assess the nature of the damage.
• Cause of the Fail: The cause of the hazard/risk by which the fail may be occurring described in terms of something that can be corrected or controlled.
• Occurrence Degree: It is the probability that a failure will occur.
• Control Measures: It is the measures adopted to control of the risk and hazard coming from each activity, these measures can be, risk elimination, engineering control, administrative measures and finally as last option the use of Protective Personal Equipment according to current legislations.
• Detection Degree: it the probability assessment that process control will detect hazards / risks.
• RPN -Risk Priority Number: It is the product by Severity, Occurrence and Detections.The bigger the RPN more critical the risk, what makes it a priority in taking action for its control.
• Legal Requirements: It is the standards, procedures, regulations, instructions when applicable to the hazard.
• Preventive Actions Recommended: Describe which actions will necessary to minimize or eliminate the risk.
• Responsible to the action: Person responsible to making action, describe in this item the deadlines to each action proposed.
• Action Taken: Describe all actions effectively taken to minimize and/or eliminate the risk.
The evaluate of severity, occurrence and detection of FMEA must be remade after the implementation of the improve, since there is an improvement implemented the degree of detection improve and the probability of occurrence of the problem will decrease, therefore a new RPN is calculated.
The severity degree remains unchanged when the new RPN is calculated, because if an accident will happen the severity of damage will not be altered, there is no change in the severity of the injury.

METHODOLOGY OF RISK ASSESSMENT -BEFORE THE IMPLEMENTATION OF
FMEA TOOL.
The work place where the methodology FMEA with safety focus was applied is a process of plasma cutting.
The Plasma is the fourth state of matter.For the best known substance, water, you have ice, water and steam.If we add energy in the form of heat to the solid (ice), we will have the change of state to the liquid (water) and if more heat is added we have the gas (vapor).When a substantial amount of heat is added to the gas, it becomes Plasma.
CNC thermal cutting machines require a table of support to hold the metal plate where the shapes are cut.
To reduce the level of emission of pollutants, it is necessary that the table of cutting be fitted with a system of absorption or exhaustion of these pollutants.In this way, the most common types of tables used in Brazil are wet table, or tables of water (wet cutting) and he aspirated tables (downdraft tables).(Manual Esab, 2016).
In the line of Plasma Cutting at the company where the FMEA was applied, the Because of some problems with the plasma cutting process in the use of wet cutting, the Industrial Engineering of the company did a study and proposed a change in the process of the plasma cutting tables, initially the change would occur in two of the tables that use water for aspiration model, since the first meeting when the Industrial Engineering proposed the changed the safety area was involved starting the first FMEA with Safety focus into the company.
As determined by the current legislation, the company is required a risk assessment for each activities performed by the employees and issue Service Orders with the preventive measures to avoid accidents and occupational Illness.
The company performs the risk analysis of the activities performed by the employee during a production process, this risk analysis was carried out superficially, once the employee described their activities and automatically the risks were qualified, with the effects of risk exposure and solutions that is the measures controls of risk.
This model was developed in a summarized way, as follows: 1-Description of the activity 2-Risk 3-Effect

4-Solutions
The Picture 9 presents a model of the method used at the company, it is possible to analyze that the risk was qualified but this method does not consider the additional risks in the process, the peripheral risks.That is the risk around the place work that may influence the activity and potentially cause an accident, for example, the need to perform a Lockout at the energy source when setup is performed, the risk of involuntary actuation or performed by someone else does not included in the activity of setup.This risk was not considered in the actual method of risk assessment.
The model adopted before the implementation of the improve leaves some gaps in the analysis whereas the measures to control of additional risks just was taken after the occurrence of some unwanted event.
Picture To leverage a steel plate with the help of a lever it escaped and hit the employee's right ear causing injury.

Removal of the leverage of the process
When the employee was handling the steel sheet it hit against his right hand holding his little finger between the steel and the table causing a small fracture.
Change the system of Movement steel sheet.
When the employee put the steel sheet on the cutting table the scrap hit against his right hand causing fracture with stitches Include gloves of Kevlar in the process.
When the employee was taking the scrap of the table it hit against his forearm causing cut with stitches.
Include sleeves of Kevlar in the process.
According the regulatory standard deal with Protective Personal Equipment, in the risk assessment and adoption of preventive measures, the indication of Protective Personal Equipment should be the last resort to be used for control of Occupational Risks.
(Brazilian Ministry of Labor, 2016) If the accidents had been analyzed and the corrective measures had been adopted this accidents wouldn't happened.It can be estimated that all accidents would be predictable if the risk analysis was elaborated together maintenance, engineering and production areas, starting the process analysis using some tools risk analysis as "What If", this methodology presuppose possible fail in the process it could be realized with a Brainstorming with the areas involved to solve a problem.A L -U n i d a d e L o r e n a -C a m p u s S ã o J o a q u i m 5.2 RISK ANALYSIS METHODOLOGY -AFTER THE IMPLEMENTATION OF FMEA TOOL According proposed in the chapter 4, similarly to process or product FMEA, the FMEA with safety focus should follow the methodology procedures written by Carpinetti (2012), Palady (2004) and Puente (2002).

U N I S
The work began in January of 2016 with a multidisciplinary team to develop a project to change one of the plasma cutting tables with water for the aspiration system; the safety was involved in order to perform the risk analysis of the project still in its initial phase.
The multidisciplinary team was composed of: Industrial Engineering, responsible for the project, Manufacturing Engineering, Industrial Safety, Civil Maintenance and Machinery and Equipment Maintenance.The picture 10 presents the drawn of the project of the table with aspiration system.

Picture 8: Plasma Cutting with Aspiration System
Source: Maxion, 2016 During the presentation of the Project it was necessary to perform a Brainstorming of the possible safety failures in the process, were considered the past occurrences of accidents and the occurrence that could happen with the implantation of the new project, the chart 8 presents the Brainstorming developed by the multidisciplinary team.After the identification of the possible damages, was attributed to each hazard a severity degree of the damage, it means how severe the injury could be if it happened.
After it was identified the possible failure modes, in others words the possible cause that could cause damage.Identifying the failure modes it was possible to analyze the occurrence degree, in this case the indices was assigned in accordance the chart 5, considering the accidents occurred in 2015, therefore, the failure modes that had not registered occurrence was assigned the index 1 and the failure modes that had registered occurrence assigned the indices in accordance the quantity of accident.This to approximate the document as well as possible to reality before the process start.
Following with the analysis after to determinate of the occurrence degree, the measures of control was suggested, it could be Eliminate, Engineering Measures or adopt a Personal Protective Equipment -PPE, it is the last resource which should be adopted when trying to control a risk.
After was realized the identification of the detection degree of the problem, in others words the risk factor, the company established based on the literature about FMEA that the detection would be evaluated as follows: "the greater the probability of the occurrence of an incident the higher the detection rate" (Maxion, 2016), on this way the engineering department developed the chart number 6 to determinate the detection index.
With the severity, occurrence and detection index, the Risk Priority Number was calculated, which should indicate to the project and safety managers which activity is more dangerous to the worker identifying which the actions in this area should be prioritized.
In the safety area, the control measure usually will have a legal requirement, so the next step of the safety FMEA is determine which legal requirement must be complied.
After analyzing the legal requirement, preventive actions should be recommended for the eliminations of possible potential cause.Then determine the area responsible for taking the recommended actions and the deadline for implementation.
After the person responsible for the actions taken finish this actions the FMEA form must be completed, identifying which actions have been effectively implemented, this actions must be evaluated and approved by the safety department.
Finishing the analysis of the actions taken a new RPN is calculated as described in Chapter 4.
The Annex 1 shows the safety FMEA performed by multidisciplinary team.

RESULTS
With the application of the FMEA tool with safety focus there was a decrease in the probability of occurrence of failures, such as incidents and / or accidents, this was possible through the study of the main causes of accidents happened at this work place.
The tool made it possible to increase the level of fault detection that could possibly cause an accident.
With the application of the tool, there were any accidents in the work place since February 2016, when the work place was released for production.
The picture number 11 shows the new model of the plasma cutting table with aspiration system, already installed and in operation.
The picture 12 shows a risk prioritization graph with the following classification criteria: the higher Risk Priority Number NPR makes the risk a priority in the process of take measures for control of these risks.In Annex 1 is available the Safety FMEA elaborated with all the identified risks.

Picture 9 PLASMA CUTTING -ASPIRATION SYSTEM
risks of operations by monitoring and controlling the possible causes that may lead to an accident or occupational illness.The work of risk analyze is necessary because besides being able to be worked with data of events occurred, it is also possible to work with data of incidents or events that are possible to happens.
After of the risk analyze has the Risk Priority Number -RPN, shown in this study, this RPN allows the risk management by the company, because this number presents to the company which risk should be prioritized in the process of management.The occupational risk management as presented in this work does not finish in the RPN, it must also act on the actions to be taken, after this step, must be planed the investments to perform each action reported in the safety FMEA, the document (FMEA) should be kept constantly update to seek a continuous improvement.
The FMEA must be applied within the company to assess new projects or process change to analyze the aspects referents the safety, keeping on this way an alive tool within the company.
The evaluation of the FMEA methodology allowed the verification of a preventive tool in the actions generated and their degrees of priority within the risk analysis, however, the tool would not had the positive results for the company if it had not been developed by a multidisciplinary team.

REFERENCES
AGUIAR, Dimas C. de, SALOMON, Valério A. P., Avaliação da prevenção de falhas em processos utilizando métodos de tomada de decisão.Prod.[online]. 2007[online]. , vol.17, n.3, pp.502-519. ISSN 1980-5411-5411 U N I S A L -U n i d a d e L o r e n a -C a m p u s S ã o J o a q u i , equipments, tools, used in the process: Plasma Cutting, Suction Cup, Crane, electromagnetic system, industrial scissors, hand tools Impact suffered by person (Risk of Accident) Description of the activity: Production of plate through plasma cutting Inhalation, ingestion, absorption by contact of harmful chemical substance (Chemical Hazard) U N I S A L -U n i d a d e L o r e n a -C a m p u s S ã o J o a q u i m

Chart 1: Severity Scale
U N

Chart 3: Severity Scale
months away).E.g. surgery caused by fall / electrical shock Moderate Accidents with moderate injuries (01 month away).E.g. finger loss Low Accident with small lesions (15 days away).E.g.Cuts, burns Very Low Accident with risk of absence from work (01 week away).E.g. small cuts.Smaller Accident with small risk of absence from work (03 days away).E.g.Small cuts U N I S A L -U n i d a d e L o r e n a -C a m p u s S ã o J o a q u i m

Plasma Cutting Picture 6: Wet Table
table cutting is wet table, as shown in the Picture 7 and 8. Picture 5: Source: Maxion.

7: Model of Risk Assessment -Before of the Improve
After the realization of Brainstorming, was started the process of risk analyze of the work place.Was analyzed each activity performed by employee in the work place, in accordance the activity, was identified the hazard and possible damage.The chart 9 presents the risks identified during this analysis. .
CORTE A PLASMA.Manual Esab, Mesas de Corte -Água Vs.Aspiração.Disponível em: http://www.esab.com.br/br/pt/education/blog/loader.cfm?csModule=security/getfile&pageid =11598 acessado em: 10/06/2016. m of person of the same level (Risk of Accident) Imprisonment in, under, or between objects (Risk of Accident) Friction, abrasion, puncture or cutting (Risk of Accident) Repetitive effort uncomfortable and lack of organization (Ergonomic Risk) Contact with high temperature materials (Risk of Accident) Atmosphere electrical Discharge (Risk of Accident) Non Atmosphere Electrical discharge (short-circuit) (Risk of Accident) Accident in the movement of material (Manually or mechanic movement) (Risk of Accident) Fall