Building an EHS Management System from Scratch After a Day-4 Fatality: A Corrective-to-Preventive Turnaround Case in a 100-Employee Pharmochemical Plant (2019-2022)

This paper reports a field case study led by the author as EHS Coordinator in a 100-employee pharmochemical plant in Brazil (2019-2022). At hiring, the plant had no formal EHS Management System and operated in a purely corrective model. On Day 4, a fatal accident (death) occurred. Objective: Describe the turnaround methodology from corrective to preventive. Methodology implemented:- SIF-focused fatality investigation and diagnosis of system absence- Implementation of high-energy focused Risk Assessment (RA)- Development of operational procedures and Operational Risk Analysis (ORA)- Robust action plan with leadership accountability- EHS training for leadership and operational teams- Implementation of EHS planning and management system- Occupational Hygiene program with multidisciplinary team and Tactical Plan- Behavior-based safety and high-energy controls Results: During 3 years of leadership (2019-2022), zero fatalities after the initial event and zero lost-time incidents of 5, 10 and 15 days. Severity reduced to practically zero. Conclusion: Absence of EHS systems is common in SMEs in Brazil and in construction SMEs in Utah. A SIF-focused implementation with leadership commitment is feasible and replicable without increasing headcount. Note: Company name omitted due to confidentiality agreement. Author: Jailton da Silva, Founder - EkoSeg Consultoria Ambiental e Segurança do Trabalho (Brazil) & EkoSeg EHS US LLC - Salt Lake City, UT, USA. 27 Years Experience (1999-2026). Specialist in EHS turnaround for construction and chemical industries. Keywords: EHS, Safety Management System, SIF, Fatality Prevention, Corrective to Preventive, Risk Assessment, Pharmochemical, OSHA, Utah Construction

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Publication Details

Journal
Zenodo (CERN European Organization for Nuclear Research)
Published
2026-10-08
DOI
https://doi.org/10.5281/zenodo.23229156
Primary Topic
Occupational Health and Safety Research
Type
article
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article

Building an EHS Management System from Scratch After a Day-4 Fatality: A Corrective-to-Preventive Turnaround Case in a 100-Employee Pharmochemical Plant (2019-2022)

JAILTON DA SILVA
Zenodo (CERN European Organization for Nuclear Research)
Occupational Health and Safety Research
article

Building an EHS Management System from Scratch After a Day-4 Fatality: A Corrective-to-Preventive Turnaround Case in a 100-Employee Pharmochemical Plant (2019-2022)

JAILTON DA SILVA
article en

Abstract

This paper reports a field case study led by the author as EHS Coordinator in a 100-employee pharmochemical plant in Brazil (2019-2022). At hiring, the plant had no formal EHS Management System and operated in a purely corrective model. On Day 4, a fatal accident (death) occurred. Objective: Describe the turnaround methodology from corrective to preventive. Methodology implemented:- SIF-focused fatality investigation and diagnosis of system absence- Implementation of high-energy focused Risk Assessment (RA)- Development of operational procedures and Operational Risk Analysis (ORA)- Robust action plan with leadership accountability- EHS training for leadership and operational teams- Implementation of EHS planning and management system- Occupational Hygiene program with multidisciplinary team and Tactical Plan- Behavior-based safety and high-energy controls Results: During 3 years of leadership (2019-2022), zero fatalities after the initial event and zero lost-time incidents of 5, 10 and 15 days. Severity reduced to practically zero. Conclusion: Absence of EHS systems is common in SMEs in Brazil and in construction SMEs in Utah. A SIF-focused implementation with leadership commitment is feasible and replicable without increasing headcount. Note: Company name omitted due to confidentiality agreement. Author: Jailton da Silva, Founder - EkoSeg Consultoria Ambiental e Segurança do Trabalho (Brazil) & EkoSeg EHS US LLC - Salt Lake City, UT, USA. 27 Years Experience (1999-2026). Specialist in EHS turnaround for construction and chemical industries. Keywords: EHS, Safety Management System, SIF, Fatality Prevention, Corrective to Preventive, Risk Assessment, Pharmochemical, OSHA, Utah Construction

Zenodo (CERN European Organization for Nuclear Research)
Openalex Percentile: Top 8%
Occupational Health and Safety Research
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Building an EHS Management System from Scratch After a Day-4 Fatality: A Corrective-to-Preventive Turnaround Case in a 100-Employee Pharmochemical Plant (2019-2022) — JAILTON DA SILVA · Zenodo (CERN European Organization for Nuclear Research) (2026) | TGRS Research Map | TGRS