Análise da causa raiz aplicada a um incêndio em painel elétrico industrial: estudo de caso em uma empresa do Polo Industrial de Manaus

Abstract

Electrical panels used in industrial settings are essential for managing electrical power through the distribution, protection, and monitoring of the circuits necessary for production processes to operate. Therefore, the proper operation of these panels is essential to ensure worker safety, equipment availability, and the integrity of the facilities. However, problems in these systems can cause unexpected downtime, financial losses, and hazardous situations. In this context, this study proposes a structured approach to analyze incidents involving industrial electrical panels, using the \textit{5W2H} tool to organize information, determine the causes of problems, and identify improvements. The approach is applied to a real-world case of a fire in the electrical panel of an industrial machine at a company in the Manaus Industrial Complex, analyzing the power supply system, control and protection devices, cables, the environment, and maintenance routines, with the aim of understanding the factors involved and preventing a recurrence of the incident. The results indicate that the fire was caused by a combination of several factors, including heat-induced cable wear, the presence of oily residues, problems with protective mechanisms, and failures in maintenance procedures. Based on these findings, corrective and preventive measures are proposed to restore the system to proper operating conditions and prevent future incidents. Finally, the proposed methodology allows for a comprehensive assessment of the factors involved and provides a basis for implementing technical and organizational improvements. This, in turn, promotes the improvement of maintenance activities, increases equipment availability, and strengthens safety conditions in industrial environments.