(32bk) Santos Method: How Bowtie, in Conjunction with the "Brainstorming", "6M", and "5 Whys" Tools, Can Provide Agility and Precision in Investigating Unwanted Events.

The article presents a proposal for a new technique to investigate undesirable events in process safety, called the "Santos Method." With the premise that learning is the primary benefit derived from a process safety event, the new methodology aims to overcome challenges in information dissemination due to legal and psychological insecurity. The proposal involves comparing the performance of the new technique with traditional methods such as Cause Tree, Ishikawa, 5 Whys, and 5W2H.

The "Santos Method" uses the Bowtie model to structure the investigation, categorizing causes through the 6M and deepening the analysis with the "5 Whys," moving from the edges to the center of the Bowtie. Preliminary results indicate greater efficiency of the method compared to the Cause Tree, demonstrating a reduction in investigation time and a more focused approach to the failures in safety barriers. Despite the promising results, the technique still requires scientific validation through application in a broader range of events and by professionals from various fields, aiming to solidify its credibility as an effective tool in preventing recurrences.

The presented case study involves an incident with a steam boiler, highlighting the importance of efficient change management and the need for an investigative approach that integrates technical and operational knowledge, promoting a multidimensional analysis of events.