This paper addresses actions implemented by Petrobras after the P-36 accident. The purpose of investigations following major accidents is to understand what exactly happened to avoid repetition. It is everyone’s responsibility to adopt practices that mitigate the risks even more in any activities. The P-36 accident was therefore analysed and discussed as transparently and deeply as possible in order that the lessons learned may be translated into safer operations. This is how it is done throughout the oil industry: the lessons learned from major accidents usually cause radical changes to the industry’s practices with regard to change in equipment, design, procedures, behaviours and attitudes. The P-36 Investigation Commission, with technical experts from Petrobras, universities and worker union representatives, audited by a company of international repute, produced several recommendations and identified areas for improvement. This paper discusses how Petrobras considered the commission report and how the areas for improvement are to be addressed. Many recommendations were immediately applicable but others, including some areas for improvement, requiring more detailed planning, were included in an Operational Excellence Programme (PEO – Programa de Exceleˆncia Operacional). This Programme shall be applied to every offshore unit of the company, while taking into account the peculiarities of each Business Unit. This Programme covers actions involving Petrobras design practices, operation, ballast and stability, maintenance, safety and human resources for offshore units and all those actions shall be concluded by December 2002. A detailed description of the actions which go beyond those required by current legislation will also be given, permitting Petrobras to achieve operational excellence in all its offshore units. Furthermore, Petrobras intends to contribute to the ongoing improvement of offshore oil industry practices through widespread dissemination of this Programme, which has already begun.

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