{"id":752,"date":"2025-12-31T21:15:18","date_gmt":"2025-12-31T21:15:18","guid":{"rendered":"https:\/\/swarm.craa.cz\/?p=752"},"modified":"2025-12-31T23:25:35","modified_gmt":"2025-12-31T23:25:35","slug":"vazny-pracovni-uraz-na-recyklacni-lince-plastu-v-rotacnim-zarizeni","status":"publish","type":"post","link":"https:\/\/swarm.craa.cz\/en\/vazny-pracovni-uraz-na-recyklacni-lince-plastu-v-rotacnim-zarizeni\/","title":{"rendered":"V\u00e1\u017en\u00fd pracovn\u00ed \u00faraz na recykla\u010dn\u00ed lince plast\u016f, v rota\u010dn\u00edm za\u0159\u00edzen\u00ed"},"content":{"rendered":"\n<div class=\"wp-block-uagb-container uagb-block-1e661f83 alignwide uagb-is-root-container\">\n<div class=\"wp-block-uagb-container uagb-block-734398ef\">\n\n\n<p class=\"wp-block-paragraph\">Year 2, Issue 3, 2025<br>swarm.craa.cz, ISSN 3029-7508<br>Safety, Work And Rescue Magazine<br>Pages 4-11, https:\/\/doi.org\/10.71319\/swarm2503.04-11<\/p>\n<\/div>\n\n\n\n<div class=\"wp-block-uagb-container uagb-block-c65675d8\"><\/div>\n<\/div>\n\n\n\n\n\n<h1 class=\"wp-block-heading has-text-align-center\"><strong>Serious occupational accident on a plastic recycling line involving rotating machinery<\/strong><\/h1>\n\n\n\n<p class=\"has-text-align-center has-medium-font-size wp-block-paragraph\"><strong><strong>V\u00edt Hofman<sup>1<\/sup><\/strong> <\/strong><sup><a href=\"https:\/\/orcid.org\/0009-0009-5232-4174\" target=\"_blank\" data-type=\"link\" data-id=\"https:\/\/orcid.org\/0000-0002-4804-0859\" rel=\"noreferrer noopener nofollow\"><img loading=\"lazy\" decoding=\"async\" width=\"22\" height=\"22\" class=\"wp-image-131\" style=\"width: 22px;\" src=\"https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/Bez-nazvu.png\" alt=\"\" srcset=\"https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/Bez-nazvu.png 22w, https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/Bez-nazvu-12x12.png 12w\" sizes=\"auto, (max-width: 22px) 100vw, 22px\" \/><\/a><\/sup><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><sup>1<\/sup> Ing. V\u00edt Hofman \u2013 SAWuh; info<img loading=\"lazy\" decoding=\"async\" width=\"23\" height=\"23\" class=\"wp-image-73\" style=\"width: 23px;\" src=\"https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/image.png\" alt=\"SWARM - Safety, Work And Rescue Magazine\" srcset=\"https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/image.png 23w, https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/image-12x12.png 12w\" sizes=\"auto, (max-width: 23px) 100vw, 23px\" \/>sawuh.cz<\/p>\n\n\n\n<div class=\"wp-block-uagb-container uagb-block-6844a9b5 alignwide uagb-is-root-container\">\n<div class=\"wp-block-uagb-container uagb-block-ba271e0f\">\n\n\n<p class=\"wp-block-paragraph\"><strong>Type of Paper<br><\/strong>Case Study<br><br><strong>Keywords<\/strong><br><em>Bale breaker, employer liability, human factor, occupational accident, occupational safety, plastic recycling, technical measures.<\/em><\/p>\n\n\n\n<p class=\"has-small-font-size wp-block-paragraph\"><em>Open Access \u010dl\u00e1nek s&nbsp;CC BY licenc\u00ed<\/em><br><img loading=\"lazy\" decoding=\"async\" width=\"88\" height=\"31\" class=\"wp-image-89\" style=\"width: 88px;\" src=\"https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/CC_BY_icon-88x31-1.webp\" alt=\"logo licence Creative Commons Attribution CC BY 4.0\" srcset=\"https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/CC_BY_icon-88x31-1.webp 88w, https:\/\/swarm.craa.cz\/wp-content\/uploads\/2024\/12\/CC_BY_icon-88x31-1-18x6.webp 18w\" sizes=\"auto, (max-width: 88px) 100vw, 88px\" \/><\/p>\n<\/div>\n\n\n\n<div class=\"wp-block-uagb-container uagb-block-3513f5a6\">\n\n\n<p class=\"wp-block-paragraph\"><strong>Abstract<\/strong><br><em><em>This article analyzes a serious occupationa accident that occurred in November 2022 at a Czech recycling facility. The injured worker, employed as a bale breaker operator sustained multiple injuries following the unexpected start-up of rotating machinery by a colleague beginning a work shift. The study identifies a convergence of technical, organizational and human failures that led to the accident. It critically evaluates the employer&#8217;s actions, the procedure of inspection authorities, and the adequacy of sanctions imposed. Particular attention is paid to the limitations of reliance on the human factor as opposed to technical safety measures? The article goes beyond the analysis od a single case, offering not only the reconstruction of the incident, but also a critical reflection on the current state of occupational safety in Czech industry and formulates systemic recommendations to improve its overall level.<\/em><\/em><\/p>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-uagb-container uagb-block-ba054a53 alignwide uagb-is-root-container\">\n<h2 class=\"wp-block-heading\"><strong>\u00davod<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Recykla\u010dn\u00ed pr\u016fmysl p\u0159edstavuje prost\u0159ed\u00ed, kde se ka\u017edodenn\u011b st\u0159et\u00e1vaj\u00ed t\u011b\u017ek\u00e1 strojn\u00ed za\u0159\u00edzen\u00ed, rota\u010dn\u00ed mechanismy &nbsp;s&nbsp;vysok\u00fdm kroutic\u00edm momentem a tlak na produktivitu. Ekonomick\u00e1 efektivita versus bezpe\u010dnost pr\u00e1ce jsou \u010dasto v konfliktu, kdy preventivn\u00ed opat\u0159en\u00ed jsou \u010dasto pova\u017eov\u00e1na za to, co \u201ebrzd\u00ed v\u00fdrobu\u201c a&nbsp;\u201ezdr\u017euje\u201c. Rozdru\u017eova\u010de pro rozbalov\u00e1n\u00ed bal\u00edkovan\u00e9ho odpadu jsou uk\u00e1zkov\u00fdm p\u0159\u00edkladem za\u0159\u00edzen\u00ed, kde se nedostate\u010dn\u00e9 technick\u00e9 zabezpe\u010den\u00ed m\u016f\u017ee prom\u011bnit v&nbsp;trag\u00e9dii.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">V listopadu 2022 do\u0161lo v \u010desk\u00e9m recykla\u010dn\u00edm z\u00e1vod\u011b k \u00farazu, kter\u00fd m\u011bl v\u0161echny p\u0159edpoklady k tomu, aby skon\u010dil smrteln\u011b. Po\u0161kozen\u00fd, 56 let, manipulant na rozdru\u017eova\u010di, utrp\u011bl v\u00e1\u017en\u00e1 zran\u011bn\u00ed pot\u00e9, co jeho kolega, R.P., nastupuj\u00edc\u00ed na sm\u011bnu spustil rota\u010dn\u00ed za\u0159\u00edzen\u00ed, ani\u017e by tu\u0161il, \u017ee se po\u0161kozen\u00fd nach\u00e1z\u00ed uvnit\u0159.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">P\u0159\u00edpad je n\u00e1zorn\u00fd v&nbsp;tom, \u017ee kombinuje n\u011bkolik rizikov\u00fdch faktor\u016f: nedostate\u010dn\u00e9 technick\u00e9 zabezpe\u010den\u00ed za\u0159\u00edzen\u00ed (absence vz\u00e1jemn\u00e9ho blokov\u00e1n\u00ed ovlada\u010d\u016f), organiza\u010dn\u00ed slabiny (chyb\u011bj\u00edc\u00ed m\u00edstn\u00ed provozn\u00ed bezpe\u010dnostn\u00ed p\u0159edpisy, ned\u016fsledn\u00e1 \u0161kolen\u00ed) a lidsk\u00fd faktor (komunika\u010dn\u00ed selh\u00e1n\u00ed mezi zam\u011bstnanci st\u0159\u00eddaj\u00edc\u00edmi se na sm\u011bn\u00e1ch).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Tato p\u0159\u00edpadov\u00e9 studie je nejen deskripc\u00ed a detailn\u00ed anal\u00fdzou p\u0159\u00ed\u010din \u00farazu, ale p\u0159edev\u0161\u00edm si klade za c\u00edl otev\u0159\u00edt diskusi o&nbsp;syst\u00e9mov\u00fdch Bez kritick\u00e9 reflexe, je\u017e m\u016f\u017ee b\u00fdt p\u0159\u00ednosn\u00e1 pro praktiky i&nbsp;teoretiky &nbsp;v&nbsp;oblasti bezpe\u010dnosti a ochrany zdrav\u00ed p\u0159i pr\u00e1ci (d\u00e1le jen BOZP), inspektory pr\u00e1ce, a&nbsp;zejm\u00e9na management pr\u016fmyslov\u00fdch podnik\u016f stoj\u00edc\u00edch p\u0159ed dilematem, jak vyv\u00e1\u017eit ekonomickou efektivitu s po\u017eadavky na bezpe\u010dnost zam\u011bstnanc\u016f bude k&nbsp;obdobn\u00fdm \u00faraz\u016fm doch\u00e1zet i nad\u00e1le.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>1 Popis p\u0159\u00edpadu a charakteristika pracovi\u0161t\u011b<\/strong><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>1.1 Charakteristika pracovi\u0161t\u011b a&nbsp;za\u0159\u00edzen\u00ed<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Incident se odehr\u00e1l v provozovn\u011b recykla\u010dn\u00ed spole\u010dnosti (d\u00e1le jen zam\u011bstnavatel, p\u0159\u00edp. spole\u010dnost) se s\u00eddlem na Morav\u011b. Jedn\u00e1 se o modern\u00ed recykla\u010dn\u00ed z\u00e1vod zam\u011b\u0159en\u00fd na zpracov\u00e1n\u00ed plastov\u00fdch odpadn\u00edch materi\u00e1l\u016f, vybaven\u00fd automatizovanou linkou \u010d\u00edslo 3 pro recyklaci plastov\u00e9ho odpadu. Kl\u00ed\u010dov\u00fdm prvkem t\u00e9to linky je rozdru\u017eova\u010d (rozbalova\u010d nebo t\u00e9\u017e turniket), viz obr\u00e1zek 1, kter\u00fd slou\u017e\u00ed k rozdru\u017eov\u00e1n\u00ed lisovan\u00fdch bal\u00edk\u016f plastov\u00e9ho odpadu na jednotliv\u00e9 odpadn\u00ed kusy p\u0159ed jejich dal\u0161\u00edm zpracov\u00e1n\u00edm. Za\u0159\u00edzen\u00ed m\u00e1 dv\u011b h\u0159\u00eddele s protib\u011b\u017en\u00fdmi no\u017ei, uvnit\u0159 kovov\u00e9ho tunelu, mezi kter\u00fdmi na p\u00e1sov\u00e9m dopravn\u00edku proch\u00e1z\u00ed lisovan\u00fd bal\u00edk. Za\u0159\u00edzen\u00ed m\u00e1 charakteristick\u00fd rota\u010dn\u00ed mechanismus s vysok\u00fdm kroutic\u00edm momentem, nezbytn\u00fdm pro rozbalen\u00ed pevn\u011b komprimovan\u00e9ho materi\u00e1lu.<\/p>\n\n\n\n<div class=\"wp-block-uagb-image aligncenter uagb-block-241e1e00 wp-block-uagb-image--layout-default wp-block-uagb-image--effect-static wp-block-uagb-image--align-center\"><figure class=\"wp-block-uagb-image__figure\"><a class=\"\" href=\"https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2.webp\" target=\"\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2.webp\" alt=\"Rozdru\u017eova\u010d\" class=\"uag-image-815\" width=\"682\" height=\"874\" title=\"Rozdru\u017eova\u010d\" role=\"img\" \/><\/a><figcaption class=\"uagb-image-caption\"><strong>Obr\u00e1zek 1: Rozdru\u017eova\u010d<\/strong><\/figcaption><\/figure><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">Rozdru\u017eova\u010d je vybaven dv\u011bma samostatn\u00fdmi ovl\u00e1dac\u00edmi panely: hlavn\u00edm ovlada\u010dem um\u00edst\u011bn\u00fdm na obslu\u017en\u00e9 plo\u0161in\u011b s vizu\u00e1ln\u00edm kontaktem na pracovn\u00ed prostor a bo\u010dn\u00edm ovlada\u010dem, kter\u00fd je um\u00edst\u011bn mimo p\u0159\u00edm\u00fd dohled do vnit\u0159n\u00edho prostoru rozdru\u017eova\u010de. Podle technick\u00e9 dokumentace byl bo\u010dn\u00ed ovlada\u010d navr\u017een prim\u00e1rn\u011b pro \u00fa\u010dely \u00fadr\u017eby a pro situace, kdy oper\u00e1tor pot\u0159ebuje zkontrolovat materi\u00e1l z doln\u00ed pozice. Kritick\u00fdm faktorem je skute\u010dnost, \u017ee oba ovlada\u010de ovl\u00e1daj\u00ed nejen rozdru\u017eova\u010d, ale sou\u010dasn\u011b i&nbsp;navazuj\u00edc\u00ed p\u00e1sov\u00fd dopravn\u00edk. Toto propojen\u00ed, a\u010dkoliv technologicky logick\u00e9 pro plynulost provozu, p\u0159edstavovalo v dan\u00e9m p\u0159\u00edpad\u011b z\u00e1sadn\u00ed bezpe\u010dnostn\u00ed riziko, nebo\u0165 spu\u0161t\u011bn\u00ed jednoho ovlada\u010de aktivovalo cel\u00fd syst\u00e9m bez mo\u017enosti zjistit z druh\u00e9 ovl\u00e1dac\u00ed pozice, zda je prostor rozdru\u017eova\u010de bezpe\u010dn\u00fd.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>1.2 Charakteristika zam\u011bstnanc\u016f<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Po\u0161kozen\u00fd i R.P. byli dlouholet\u00ed zam\u011bstnanci pracuj\u00edc\u00ed ve sm\u011bnn\u00e9m re\u017eimu, bez dolo\u017een\u00fdch pracovn\u00edch delikt\u016f. Z dostupn\u00fdch podklad\u016f vypl\u00fdv\u00e1, \u017ee oba byli obecn\u011b hodnoceni jako spolehliv\u00ed pracovn\u00edci. Ud\u00e1lost m\u011bla v\u00fdznamn\u00fd psychick\u00fd dopad i na zam\u011bstnance, kter\u00fd za\u0159\u00edzen\u00ed spustil; z dokumentace vypl\u00fdv\u00e1 do\u010dasn\u00e1 pracovn\u00ed absence a snaha o osobn\u00ed kontakt se zran\u011bn\u00fdm kolegou. Tyto skute\u010dnosti podporuj\u00ed z\u00e1v\u011br, \u017ee se jednalo o ne\u00famyslnou ud\u00e1lost v prost\u0159ed\u00ed s nedostate\u010dn\u011b nastaven\u00fdmi syst\u00e9mov\u00fdmi bari\u00e9rami. Policie \u010cR se zab\u00fdvala i mo\u017enost\u00ed, zda ne\u0161lo o \u00famysln\u00fd trestn\u00fd \u010din, co\u017e ale pozd\u011bji vylou\u010dila.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>1.3 Pr\u016fb\u011bh ud\u00e1losti<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Dne 10. listopadu 2022 m\u011blo doj\u00edt ke st\u0159\u00edd\u00e1n\u00ed sm\u011bn. Po\u0161kozen\u00fd si p\u0159ed koncem sm\u011bny (p\u0159ibli\u017en\u011b v 5:35) v\u0161iml, \u017ee se v rozdru\u017eova\u010di zasekl v\u00e1zac\u00ed dr\u00e1t, j\u00edm\u017e jsou lisovan\u00e9 bal\u00edky v\u00e1z\u00e1ny. Rozhodl se, \u017ee vstoup\u00ed do za\u0159\u00edzen\u00ed. Za\u0159\u00edzen\u00ed vypnul z ovl\u00e1dac\u00edho m\u00edsta obslu\u017en\u00e9 plo\u0161iny, vstoupil do n\u011bj a za\u010dal odstra\u0148ovat dr\u00e1t z h\u0159\u00eddel\u00ed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Kritick\u00fd moment nastal, kdy\u017e R.P., kter\u00fd m\u011bl nastoupit na sm\u011bnu v 6:00 hodin, p\u0159i\u0161el na pracovi\u0161t\u011b p\u0159ed\u010dasn\u011b \u2013 p\u0159ibli\u017en\u011b v 5:40. P\u0159esto\u017ee jeho sm\u011bna je\u0161t\u011b ani neza\u010dala (a sm\u011bna po\u0161kozen\u00e9mu je\u0161t\u011b nekon\u010dila), pot\u00e9, co si po p\u0159\u00edchodu k lince v\u0161iml, \u017ee linka neb\u011b\u017e\u00ed, ji ihned spustil prost\u0159ednictv\u00edm bo\u010dn\u00edho ovlada\u010de. A to ani\u017e by provedl jakoukoliv kontrolu linky nebo p\u0159evzal sm\u011bnu od \u00farazem posti\u017een\u00e9ho zam\u011bstnance. Pro p\u0159ipomenut\u00ed: z pozice bo\u010dn\u00edho ovlada\u010de nen\u00ed mo\u017en\u00e1 p\u0159\u00edm\u00e1 vizu\u00e1ln\u00ed kontrola vnit\u0159n\u00edho prostoru rozdru\u017eova\u010de, co\u017e je v\u00fdznamn\u00fd konstruk\u010dn\u00ed nedostatek.<br>Spu\u0161t\u011bn\u00ed rozdru\u017eova\u010de a sou\u010dasn\u011b p\u00e1sov\u00e9ho dopravn\u00edku m\u011blo za n\u00e1sledek zachycen\u00ed po\u0161kozen\u00e9ho rotuj\u00edc\u00edm mechanismem, kter\u00fd p\u016fsobil na t\u011blo zna\u010dnou mechanickou silou.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>2 Zji\u0161t\u011bn\u00ed \u0161et\u0159en\u00ed a n\u00e1sledky<\/strong><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>2.1 Rozsah zran\u011bn\u00ed a l\u00e9ka\u0159sk\u00e9 o\u0161et\u0159en\u00ed<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Po\u0161kozen\u00fd byl hospitalizov\u00e1n nejprve ve Fakultn\u00ed nemocnici Ostrava<sup data-fn=\"169f1f34-a7de-4bc2-801e-bb26281ae4c0\" class=\"fn\"><a id=\"169f1f34-a7de-4bc2-801e-bb26281ae4c0-link\" href=\"#169f1f34-a7de-4bc2-801e-bb26281ae4c0\">1<\/a><\/sup>, a&nbsp;na p\u0159elomu let 2022 a 2023 byl p\u0159evezen do jin\u00e9 nemocnice. Propu\u0161t\u011bn do dom\u00e1c\u00edho l\u00e9\u010den\u00ed byl a\u017e 13. b\u0159ezna 2023, tzn. p\u0159ibli\u017en\u011b \u010dty\u0159i m\u011bs\u00edce po \u00farazu. Jeho n\u00e1sledn\u00e1 pracovn\u00ed neschopnost trvala a\u017e do konce roku 2024.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">L\u00e9ka\u0159sk\u00e9 zpr\u00e1vy jednozna\u010dn\u011b potvrdily rozsah zran\u011bn\u00ed odpov\u00eddaj\u00edc\u00ed t\u011b\u017ek\u00e9mu polytraumatu. Po\u0161kozen\u00fd utrp\u011bl s\u00e9riovou zlomeninu \u017eeber (1.\u20139. vpravo a 9. a 11. vlevo) s pneumothoraxem, zlomeninu lopatky, zlomeniny trnov\u00fdch v\u00fdb\u011b\u017ek\u016f obratl\u016f a zejm\u00e9na Malgaigneovu zlomeninu<sup data-fn=\"5d262549-156c-466e-b2c5-0b58a07a820c\" class=\"fn\"><a id=\"5d262549-156c-466e-b2c5-0b58a07a820c-link\" href=\"#5d262549-156c-466e-b2c5-0b58a07a820c\">2<\/a><\/sup> p\u00e1nve [1].<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Z intern\u00ed komunikace veden\u00ed spole\u010dnosti vypl\u00fdv\u00e1, \u017ee v n\u011bkter\u00fdch f\u00e1z\u00edch nebyl rozsah zran\u011bn\u00ed spr\u00e1vn\u011b interpretov\u00e1n; veden\u00ed spole\u010dnosti se del\u0161\u00ed dobu domn\u00edvalo, \u017ee \u00farazem posti\u017een\u00fd zam\u011bstnanec m\u00e1 jen lehk\u00e1 zran\u011bn\u00ed \u2013 pohmo\u017ed\u011bniny. To bylo v rozporu s pozd\u011bji dolo\u017een\u00fdm klinick\u00fdm obrazem dle propou\u0161t\u011bc\u00ed zpr\u00e1vy [1]. Prob\u011bhl\u00e1 intern\u00ed dokumentace tak\u00e9 demonstruje nebezpe\u010d\u00ed podcen\u011bn\u00ed n\u00e1sledk\u016f pracovn\u00edch \u00faraz\u016f v mana\u017eersk\u00e9m rozhodov\u00e1n\u00ed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Bez ohledu na p\u0159esnou diagn\u00f3zu, d\u00e9lka hospitalizace jednozna\u010dn\u011b sv\u011bd\u010d\u00ed o&nbsp;z\u00e1va\u017enosti \u00farazu, kter\u00fd v&nbsp;p\u0159\u00edpad\u011b zachycen\u00ed hlav\u00ed nebo krku mohl m\u00edt fat\u00e1ln\u00ed n\u00e1sledky.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>2.2 Kontroln\u00ed zji\u0161t\u011bn\u00ed Oblastn\u00edho inspektor\u00e1tu pr\u00e1ce<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">V&nbsp;n\u00e1vaznosti na \u00faraz uskute\u010dnil &nbsp;Oblastn\u00ed inspektor\u00e1t pr\u00e1ce (d\u00e1le jen OIP) u zam\u011bstnavatele kontrolu. Ta prob\u011bhla s&nbsp;odstupem sedmi m\u011bs\u00edc\u016f od ud\u00e1losti (\u010derven 2023). Inspektor\u00e1t identifikoval n\u00e1sleduj\u00edc\u00ed kl\u00ed\u010dov\u00e1 pochyben\u00ed:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Absence vz\u00e1jemn\u00e9ho blokov\u00e1n\u00ed ovlada\u010d\u016f: <\/strong>Ovl\u00e1d\u00e1n\u00ed navazuj\u00edc\u00edho dopravn\u00edku a rozdru\u017eova\u010de nebylo \u0159e\u0161eno jako vz\u00e1jemn\u011b blokovan\u00fd syst\u00e9m pro technologick\u00fd celek, co\u017e OIP vyhodnotil jako nespln\u011bn\u00ed po\u017eadavku na bezpe\u010dn\u00fd provoz a&nbsp;pou\u017e\u00edv\u00e1n\u00ed za\u0159\u00edzen\u00ed pro plynulou dopravu n\u00e1klad\u016f (vz\u00e1jemn\u00e9 blokov\u00e1n\u00ed centr\u00e1ln\u00edho a m\u00edstn\u00edho ovl\u00e1d\u00e1n\u00ed za\u0159\u00edzen\u00ed) [2, p\u0159\u00edloha 4 bod 4]. Toto zji\u0161t\u011bn\u00ed je kl\u00ed\u010dov\u00e9, nebo\u0165 pr\u00e1v\u011b absence blokov\u00e1n\u00ed umo\u017enila spu\u0161t\u011bn\u00ed za\u0159\u00edzen\u00ed z&nbsp;jednoho ovlada\u010de bez v\u011bdom\u00ed osoby u&nbsp;druh\u00e9ho ovlada\u010de.<\/li>\n\n\n\n<li><strong>Absence akustick\u00e9ho nebo optick\u00e9ho signaliza\u010dn\u00edho za\u0159\u00edzen\u00ed:<\/strong> Za\u0159\u00edzen\u00ed nedisponovalo varovn\u00fdm syst\u00e9mem, kter\u00fd by upozornil osoby v&nbsp;okol\u00ed na bezprost\u0159edn\u00ed spu\u0161t\u011bn\u00ed stroje, co\u017e p\u0159edstavovalo poru\u0161en\u00ed povinnosti opat\u0159it za\u0159\u00edzen\u00ed varovn\u00fdm syst\u00e9mem v p\u0159\u00edpadech, kdy obsluha nem\u00e1 mo\u017enost vizu\u00e1ln\u00ed kontroly nebezpe\u010dn\u00e9ho prostoru [2, \u00a7 3 odst. 3].<\/li>\n\n\n\n<li><strong>Chyb\u011bj\u00edc\u00ed m\u00edstn\u00ed provozn\u00ed bezpe\u010dnostn\u00ed p\u0159edpis: <\/strong>Nebyl p\u0159edlo\u017een m\u00edstn\u00ed provozn\u011b bezpe\u010dnostn\u00ed p\u0159edpis (MPBP) pro bezpe\u010dn\u00fd provoz rozdru\u017eova\u010de, co\u017e p\u0159edstavovalo poru\u0161en\u00ed povinnosti vybavit za\u0159\u00edzen\u00ed provozn\u00ed dokumentac\u00ed [2, \u00a7 4 odst. 2] Spole\u010dnost disponovala pouze p\u0159edpisy pro dopravn\u00edky. MPBP pro rozdru\u017eova\u010d byl vytvo\u0159en a\u017e dodate\u010dn\u011b 19. ledna 2023.<\/li>\n\n\n\n<li><strong>\u0160kolen\u00ed BOZP: <\/strong>Posledn\u00ed p\u00edsemn\u011b dokumentovan\u00e9 \u0161kolen\u00ed BOZP prob\u011bhlo 20. kv\u011btna 2019, tedy v\u00edce ne\u017e 3 roky p\u0159ed \u00farazem. St\u00e1le to v\u0161ak bylo v&nbsp;souladu s&nbsp;intern\u00ed dokumentac\u00ed, kter\u00e1 stanovila periodicitu \u0161kolen\u00ed na 1 x 4 roky. Spole\u010dnost uv\u00e1d\u011bla, \u017ee zam\u011bstnanci byli pr\u016fb\u011b\u017en\u011b pro\u0161kolov\u00e1ni intern\u011b (nap\u0159. p\u0159i denn\u00edch porad\u00e1ch), av\u0161ak tyto aktivity nebyly p\u00edsemn\u011b zaznamen\u00e1v\u00e1ny. Pr\u00e1vn\u00ed p\u0159edpisy ponech\u00e1vaj\u00ed stanoven\u00ed periodicity \u0161kolen\u00ed v kompetenci zam\u011bstnavatele [3, \u00a7&nbsp;103 odst. 3], proto nebyla tato skute\u010dnost v z\u00e1v\u011bre\u010dn\u00e9m protokolu OIP klasifikov\u00e1na jako samostatn\u00e9 poru\u0161en\u00ed p\u0159edpis\u016f, by\u0165 byla p\u0159edm\u011btem intenzivn\u00edho vy\u0161et\u0159ov\u00e1n\u00ed jak ze strany OIP, tak i Policie \u010cR. Ani jeden z&nbsp;uveden\u00fdch org\u00e1n\u016f nakonec nevyhodnotil, \u017ee by perioda \u0161kolen\u00ed m\u011bla p\u0159\u00ed\u010dinnou souvislost s \u00farazem.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Spole\u010dnost d\u00e1le argumentovala, \u017ee v&nbsp;pracovn\u00edm postupu pro obsluhu rozdru\u017eova\u010de existoval v\u00fdslovn\u00fd z\u00e1kaz vstupu zam\u011bstnanc\u016f do za\u0159\u00edzen\u00ed. V\u00fdjimku tvo\u0159ila pouze \u00fadr\u017eba, kter\u00e1 mohla vstupovat a\u017e po vypnut\u00ed a zaji\u0161t\u011bn\u00ed hlavn\u00edho jisti\u010de. Podle vyj\u00e1d\u0159en\u00ed spole\u010dnosti byli v\u0161ichni zam\u011bstnanci, v\u010detn\u011b po\u0161kozen\u00e9ho, s t\u00edmto dokumentem a z\u00e1kazem pravideln\u011b seznamov\u00e1ni.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Vedouc\u00ed pracovi\u0161t\u011b nav\u00edc uvedl, \u017ee vstup po\u0161kozen\u00e9ho do za\u0159\u00edzen\u00ed byl zcela zbyte\u010dn\u00fd. D\u016fvodem vstupu byl \u00fadajn\u011b namotan\u00fd v\u00e1zac\u00ed dr\u00e1t, p\u0159i\u010dem\u017e tyto dr\u00e1ty se na za\u0159\u00edzen\u00ed namot\u00e1vaj\u00ed b\u011b\u017en\u011b a nebr\u00e1n\u00ed provozu. V r\u00e1mci standardn\u00ed \u00fadr\u017eby byly odstra\u0148ov\u00e1ny jednou t\u00fddn\u011b, co\u017e po\u0161kozen\u00fd dob\u0159e v\u011bd\u011bl.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Spole\u010dnosti se v\u0161ak v r\u00e1mci \u0161et\u0159en\u00ed nepoda\u0159ilo prok\u00e1zat, \u017ee by zam\u011bstnanci s&nbsp;pracovn\u00edm postupem byli prokazateln\u011b sezn\u00e1meni.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>2.3 Spr\u00e1vn\u00ed \u0159\u00edzen\u00ed a sankce<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Zam\u011bstnavatel podal proti kontroln\u00edmu protokolu n\u00e1mitky. Argumentovala, \u017ee po\u017eadavek na blokov\u00e1n\u00ed se vztahuje pouze na dopravn\u00edky, nikoliv na rozdru\u017eova\u010de, a \u017ee k \u00farazu do\u0161lo prim\u00e1rn\u011b poru\u0161en\u00edm pracovn\u00edch povinnost\u00ed ze strany po\u0161kozen\u00e9ho [3, \u00a7 106, odst. 4, p\u00edsm. d)] (p\u0159\u00edtomnost v za\u0159\u00edzen\u00ed). D\u00e1le spole\u010dnost tvrdila, \u017ee obsluha m\u00e1 povinnost se p\u0159ed spu\u0161t\u011bn\u00edm p\u0159esv\u011bd\u010dit o bezpe\u010dnosti, a proto nen\u00ed technick\u00e1 signalizace nutn\u00e1.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Inspektor\u00e1t n\u00e1mitky zam\u00edtl s&nbsp;od\u016fvodn\u011bn\u00edm, \u017ee rozdru\u017eova\u010d a dopravn\u00edk tvo\u0159\u00ed funk\u010dn\u00ed technologick\u00fd celek, nikoliv dv\u011b nez\u00e1visl\u00e1 za\u0159\u00edzen\u00ed. Pokud spu\u0161t\u011bn\u00ed jedn\u00e9 \u010d\u00e1sti (dopravn\u00edku) automaticky iniciuje pohyb nebezpe\u010dn\u00fdch \u010d\u00e1st\u00ed navazuj\u00edc\u00edho stroje (rozdru\u017eova\u010de), vztahuj\u00ed se na celou sestavu po\u017eadavky na vz\u00e1jemn\u00e9 blokov\u00e1n\u00ed [2, p\u0159\u00edloha \u010d. 4] OIP sou\u010dasn\u011b konstatoval, \u017ee prim\u00e1rn\u00ed bylo poru\u0161en\u00ed povinnosti zaji\u0161t\u011bn\u00ed obsluze mo\u017enost ov\u011b\u0159it, \u017ee se v&nbsp;nebezpe\u010dn\u00e9m prostoru nikdo nenach\u00e1z\u00ed; pokud to nelze, mus\u00ed bezpe\u010dnostn\u00ed syst\u00e9m p\u0159ed spu\u0161t\u011bn\u00edm (pop\u0159. zastaven\u00edm) za\u0159\u00edzen\u00ed vyd\u00e1vat zvukov\u00fd nebo i viditeln\u00fd v\u00fdstra\u017en\u00fd sign\u00e1l tak, aby byl \u010das nebezpe\u010dn\u00fd prostor opustit [2, \u00a7 3 odst. 3]. V\u00fdsledkem spr\u00e1vn\u00edho \u0159\u00edzen\u00ed byla pokuta ve v\u00fd\u0161i &nbsp;142.000 K\u010d.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Spole\u010dnost se rozhodla neodvol\u00e1vat. Z&nbsp;intern\u00ed komunikace vypl\u00fdv\u00e1, \u017ee veden\u00ed spole\u010dnosti vn\u00edmalo pokutu s \u00falevou (\u201e<em>\u010dekali jsme pokutu v rozmez\u00ed 100 \u2013 300 tis. K\u010d<\/em>\u201c). Ve srovn\u00e1n\u00ed s horn\u00ed hranic\u00ed pokut, kter\u00e9 z\u00e1kon umo\u017e\u0148uje ukl\u00e1dat za vybran\u00e9 p\u0159estupky zam\u011bstnavatel\u016f na \u00faseku BOZP (podle konkr\u00e9tn\u00ed skutkov\u00e9 podstaty a\u017e v&nbsp;\u0159\u00e1du milion\u016f K\u010d [4, \u010d\u00e1st \u010dtvrt\u00e1]), a se z\u00e1va\u017enost\u00ed ohro\u017een\u00ed \u017eivota se jednalo o&nbsp;\u010d\u00e1stku p\u0159i doln\u00ed hranici vn\u00edman\u00e9 sank\u010dn\u00ed praxe. Policie \u010cR p\u0159\u00edpad prov\u011b\u0159ovala pro podez\u0159en\u00ed z ubl\u00ed\u017een\u00ed na zdrav\u00ed z nedbalosti, av\u0161ak vy\u0161et\u0159ov\u00e1n\u00ed nevy\u00fastilo v obvin\u011bn\u00ed konkr\u00e9tn\u00ed osoby, co\u017e potvrzuje tezi o&nbsp;syst\u00e9mov\u00e9m selh\u00e1n\u00ed.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>3 Diskuse<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">N\u00e1sleduj\u00edc\u00ed kapitola p\u0159esahuje pouhou deskripci a nab\u00edz\u00ed kritickou anal\u00fdzu p\u0159\u00ed\u010din \u00farazu, odpov\u011bdnosti jednotliv\u00fdch akt\u00e9r\u016f a&nbsp;\u0161ir\u0161\u00edch implikac\u00ed pro syst\u00e9m bezpe\u010dnosti pr\u00e1ce.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>3.1 Technick\u00e9 p\u0159\u00ed\u010diny: p\u0159evl\u00e1daj\u00edc\u00ed faktor<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Anal\u00fdza ukazuje, \u017ee technick\u00e9 nedostatky nebyly jen dopl\u0148kov\u00fdm faktorem, ale p\u0159\u00edmou p\u0159\u00ed\u010dinou, kter\u00e1 umo\u017enila vznik \u00farazu. Absence vz\u00e1jemn\u00e9ho blokov\u00e1n\u00ed ovlada\u010d\u016f nen\u00ed jen ot\u00e1zkou \u201edobr\u00e9 praxe\u201c, ale p\u0159\u00edm\u00fdm poru\u0161en\u00edm po\u017eadavk\u016f pr\u00e1vn\u00edch p\u0159edpis\u016f [2, p\u0159\u00edloha \u010d. 4 bod 4] Extern\u00ed technik BOZP v intern\u00ed komunikaci p\u0159iznal: \u201e<em>faktem je, \u017ee ovlada\u010de vz\u00e1jemn\u011b blokovan\u00e9 b\u00fdt m\u011bly<\/em>.\u201c<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Stejn\u011b tak byla poru\u0161en\u00edm i absence varovn\u00fdch sign\u00e1l\u016f (sir\u00e9na, maj\u00e1k) [2, \u00a7 3 odst. 3] Argumentace spole\u010dnosti, \u017ee \u201eobsluha m\u00e1 povinnost se p\u0159esv\u011bd\u010dit\u201c, je z hlediska modern\u00edho \u201esafety engineeringu\u201c neudr\u017eiteln\u00e1. Podle Reasonova modelu \u0161v\u00fdcarsk\u00e9ho s\u00fdra (Swiss Cheese Model) je spol\u00e9h\u00e1n\u00ed se na jedinou vrstvu ochrany (pozornost obsluhy) cestou k hav\u00e1rii [5, s. 208]. Pokud z ovl\u00e1dac\u00edho m\u00edsta nen\u00ed vid\u011bt do stroje, nem\u016f\u017ee b\u00fdt bezpe\u010dnost postavena na vizu\u00e1ln\u00ed kontrole.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>3.2 Lidsk\u00fd faktor jako symptom, ne p\u0159\u00ed\u010dina<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">R.P. ud\u011blal chybu. P\u0159i\u0161el p\u0159ed\u010dasn\u011b a&nbsp;spustil stroj bez kontroly. Nicm\u00e9n\u011b, jak uv\u00e1d\u00ed Dekker, \u201e<em>human error is not a cause of failure. Human error is a symptom of trouble deeper in the system<\/em><sup data-fn=\"47111065-f9ee-4ffa-ae06-254b6a7bad27\" class=\"fn\"><a id=\"47111065-f9ee-4ffa-ae06-254b6a7bad27-link\" href=\"#47111065-f9ee-4ffa-ae06-254b6a7bad27\">3<\/a><\/sup>. [6<a>, <\/a>kapitoly 3 a 7]\u201c Syst\u00e9m dovolil, aby tato chyba nastala a&nbsp;m\u011bla fat\u00e1ln\u00ed n\u00e1sledky.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Selh\u00e1n\u00ed nastalo ve \u010dty\u0159ech rovin\u00e1ch:<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Absence procesu p\u0159ed\u00e1v\u00e1n\u00ed sm\u011bn:<\/strong> Neexistoval vynucen\u00fd protokol (osobn\u00ed setk\u00e1n\u00ed, podpis), kter\u00fd by zabr\u00e1nil situaci, kdy jeden pracovn\u00edk sm\u011bnu kon\u010d\u00ed a&nbsp;druh\u00fd za\u010d\u00edn\u00e1, bez vz\u00e1jemn\u00e9ho kontaktu.<\/li>\n\n\n\n<li><strong>Organizace pr\u00e1ce:<\/strong> Bylo umo\u017en\u011bno, aby zam\u011bstnanec za\u010dal pracovat 15 minut p\u0159ed za\u010d\u00e1tkem sm\u011bny, ani\u017e by \u010dinnost byla koordinovan\u00e1.<\/li>\n\n\n\n<li><strong>Design pracovi\u0161t\u011b:<\/strong> Konstrukce umo\u017e\u0148ovala ovl\u00e1d\u00e1n\u00ed bez vizu\u00e1ln\u00ed kontroly nebezpe\u010dn\u00e9ho prostoru.<\/li>\n\n\n\n<li><strong>Technick\u00e9 ji\u0161t\u011bn\u00ed:<\/strong> Chyb\u011blo blokov\u00e1n\u00ed, kter\u00e9 by \u201eodpustilo\u201c lidskou chybu.<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Oba zam\u011bstnanci byli hodnoceni jako vysoce spolehliv\u00ed. To, \u017ee i \u201espolehliv\u00fd\u201c zam\u011bstnanec ud\u011blal chybu, dokazuje, \u017ee bezpe\u010dnostn\u00ed syst\u00e9m mus\u00ed b\u00fdt navr\u017een pro \u201enejhor\u0161\u00ed mo\u017en\u00fd sc\u00e9n\u00e1\u0159\u201c (<em>worst case<\/em>&nbsp;<em>scenario<\/em>), nikoliv pro ide\u00e1ln\u00ed stav.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Nancy Leveson ve sv\u00e9 teorii syst\u00e9mov\u00e9ho p\u0159\u00edstupu k bezpe\u010dnosti zd\u016fraz\u0148uje, \u017ee \u00farazy nevznikaj\u00ed z&nbsp;izolovan\u00fdch komponent nebo chyb jednotlivc\u016f, ale z nebezpe\u010dn\u00fdch interakc\u00ed v syst\u00e9mu jako celku [7, kapitola 2]. V&nbsp;analyzovan\u00e9m p\u0159\u00edpad\u011b k \u00farazu nedo\u0161lo proto, \u017ee selhala jedna komponenta (\u010dlov\u011bk, stroj, nebo procedura), ale proto, \u017ee syst\u00e9m dovolil kombinaci faktor\u016f, kter\u00e9 spole\u010dn\u011b vytvo\u0159ily podm\u00ednky pro vznik \u00farazu. Jednalo se o:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>p\u0159ed\u010dasn\u00fd p\u0159\u00edchod,<\/li>\n\n\n\n<li>absence komunikace,<\/li>\n\n\n\n<li>konstruk\u010dn\u00ed nedostatek,<\/li>\n\n\n\n<li>chyb\u011bj\u00edc\u00ed technick\u00e9 z\u00e1brany.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>3.3 Reaktivn\u00ed versus proaktivn\u00ed p\u0159\u00edstup<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Spole\u010dnost po \u00farazu p\u0159ijala mnoh\u00e1 opat\u0159en\u00ed:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>technick\u00e1 blokace,<\/li>\n\n\n\n<li>zpracov\u00e1n\u00ed m\u00edstn\u00edho provozn\u00edho bezpe\u010dnostn\u00edho p\u0159edpisu pro linku,<\/li>\n\n\n\n<li>ro\u010dn\u00ed periodick\u00e9 \u0161kolen\u00ed zam\u011bstnanc\u016f + m\u011bs\u00ed\u010dn\u00ed d\u00edl\u010d\u00ed \u0161kolen\u00ed se z\u00e1znamem.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">V\u00fdkonn\u00fd \u0159editel spole\u010dnosti se osobn\u011b anga\u017eoval v komunikaci s kontroln\u00edmi org\u00e1ny (OIP, P\u010cR), v p\u00e9\u010di o po\u0161kozen\u00e9ho zam\u011bstnance, kter\u00e9ho pravideln\u011b nav\u0161t\u011bvoval v nemocnici, a v implementaci n\u00e1pravn\u00fdch opat\u0159en\u00ed v\u010detn\u011b dohledu nad pro\u0161kolen\u00edm zam\u011bstnanc\u016f. To je rozhodn\u011b chv\u00e1lyhodn\u00e9, ale z\u00e1rove\u0148 to vyvol\u00e1v\u00e1 ot\u00e1zku: pro\u010d to ne\u0161lo d\u0159\u00edve? V\u0161echna opat\u0159en\u00ed (blokace, signalizace) jsou standardn\u00ed, pom\u011brn\u011b levn\u00e1 a dostupn\u00e1 ji\u017e des\u00edtky let.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">P\u0159\u00edpad ilustruje klasick\u00fd reaktivn\u00ed p\u0159\u00edstup. Hopkins v knize <em>Safety, Culture and Risk<\/em> uv\u00e1d\u00ed, \u017ee \u201e<em>high reliability organizations learn before they fail<\/em><sup data-fn=\"2ef5ad6f-45af-4f55-b18b-2b636834d046\" class=\"fn\"><a href=\"#2ef5ad6f-45af-4f55-b18b-2b636834d046\" id=\"2ef5ad6f-45af-4f55-b18b-2b636834d046-link\">4<\/a><\/sup>\u201c [8, \u010d\u00e1st 1]. V&nbsp;tomto p\u0159\u00edpad\u011b se organizace u\u010dila a\u017e ze selh\u00e1n\u00ed. N\u00e1klady na prevenci by byly zlomkem n\u00e1klad\u016f spojen\u00fdch s \u00farazem (pokuta, l\u00e9\u010den\u00ed, odst\u00e1vka, reputace). Pokuta &nbsp;142.000 K\u010d se m\u016f\u017ee jevit jako n\u00edzk\u00e1, nicm\u00e9n\u011b jej\u00ed v\u00fd\u0161e odpov\u00edd\u00e1 \u010desk\u00e9 praxi, kter\u00e1 \u010dasto nereflektuje potenci\u00e1ln\u00ed fatalitu, ale pouze re\u00e1ln\u00fd n\u00e1sledek, spolupr\u00e1ci spole\u010dnosti p\u0159i \u0159e\u0161en\u00ed ud\u00e1losti a p\u0159ihl\u00ed\u017e\u00ed i&nbsp;k&nbsp;jej\u00ed ekonomick\u00e9 situaci.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u017de zm\u011bna bezpe\u010dnostn\u00ed kultury vy\u017eaduje v\u00edce ne\u017e jen reakci na jeden \u00faraz, potvrdila i n\u00e1sledn\u00e1 kontrola OIP proveden\u00e1 v \u010dervnu 2023. I p\u016fl roku po \u00farazu byly na pracovi\u0161ti zji\u0161t\u011bny z\u00e1va\u017en\u00e9 nedostatky, nap\u0159\u00edklad nezakryt\u00fd \u0161nekov\u00fd dopravn\u00edk ohro\u017euj\u00edc\u00ed zam\u011bstnance zachycen\u00edm, chyb\u011bj\u00edc\u00ed z\u00e1bradl\u00ed na ramp\u00e1ch \u010di nezaji\u0161t\u011bn\u00e9 tlakov\u00e9 l\u00e1hve v&nbsp;kabin\u00e1ch voz\u00edk\u016f. To nazna\u010duje, \u017ee a\u010dkoliv byla vy\u0159e\u0161ena konkr\u00e9tn\u00ed rizika spojen\u00e1 s&nbsp;\u00farazem po\u0161kozen\u00e9ho, komplexn\u00ed syst\u00e9m \u0159\u00edzen\u00ed rizik ve spole\u010dnosti st\u00e1le vykazoval z\u00e1vady.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>3.4 Intern\u00ed versus extern\u00ed odborn\u00e1 podpora BOZP: Syst\u00e9mov\u00e1 \u00favaha<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Spole\u010dnost zaji\u0161\u0165ovala odbornou podporu BOZP prost\u0159ednictv\u00edm extern\u00edho specialisty, co\u017e je v \u010cesk\u00e9 republice b\u011b\u017en\u00fd model, zejm\u00e9na u men\u0161\u00edch podnik\u016f. Tento p\u0159\u00edstup m\u00e1 nesporn\u00e9 v\u00fdhody (p\u0159\u00edstup k&nbsp;expert\u00edze bez pln\u00e9ho \u00favazku, \u0161ir\u0161\u00ed odborn\u00fd rozhled), ale z\u00e1rove\u0148 \u010del\u00ed objektivn\u00edm struktur\u00e1ln\u00edm omezen\u00edm. Extern\u00ed technik nen\u00ed p\u0159\u00edtomen denn\u011b, nem\u00e1 p\u0159\u00edm\u00fd p\u0159\u00edstup k neform\u00e1ln\u00ed komunikaci, nezachyt\u00e1v\u00e1 tzv. \u201e<em>near-miss<\/em>&#8220; situace v&nbsp;re\u00e1ln\u00e9m \u010dase.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Kritickou ot\u00e1zkou v\u0161ak nen\u00ed kvalita pr\u00e1ce extern\u00edho specialisty, ale rozsah mand\u00e1tu a&nbsp;podm\u00ednky, kter\u00e9 mu zam\u011bstnavatel vytv\u00e1\u0159\u00ed. M\u011bl pravideln\u00fd p\u0159\u00edstup do provozu? Disponoval rozpo\u010dtem na technick\u00e1 opat\u0159en\u00ed? Byla jeho doporu\u010den\u00ed (pokud byla vznesena) realizov\u00e1na, nebo skon\u010dila s&nbsp;pozn\u00e1mkou \u201ep\u0159\u00edli\u0161 drah\u00e9&#8220;? Absence z\u00e1kladn\u00edch bezpe\u010dnostn\u00edch opat\u0159en\u00ed p\u0159ed \u00farazem nevypov\u00edd\u00e1 o kompetenci technika, ale vyvol\u00e1v\u00e1 ot\u00e1zku, zda v\u016fbec m\u011bl prost\u0159edky a mand\u00e1t tyto nedostatky identifikovat a prosadit jejich odstran\u011bn\u00ed.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Kl\u00ed\u010dov\u00fdm faktorem nen\u00ed, kdo zabezpe\u010duje BOZP, ale jak je BOZP vn\u00edm\u00e1na v&nbsp;organiza\u010dn\u00ed kultu\u0159e. Pokud je bezpe\u010dnost priorita a management investuje do jej\u00edho zaji\u0161t\u011bn\u00ed, funguje jak\u00fdkoliv model. Pokud je BOZP vn\u00edm\u00e1na jako \u201enutn\u00e9 zlo&#8220;, nepom\u016f\u017ee ani intern\u00ed specialista. Uveden\u00fd p\u0159\u00edpad ukazuje selh\u00e1n\u00ed syst\u00e9mov\u00e9 integrace odborn\u00e9 podpory do re\u00e1ln\u00e9ho \u0159\u00edzen\u00ed bezpe\u010dnosti, nikoliv selh\u00e1n\u00ed modelu jako takov\u00e9ho.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>4 Shrnut\u00ed a z\u00e1v\u011br<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Analyzovan\u00fd pracovn\u00ed \u00faraz byl zbyte\u010dnou ud\u00e1lost\u00ed, kter\u00e9 bylo mo\u017en\u00e9 snadno p\u0159edej\u00edt. Nebylo pot\u0159eba vyv\u00edjet nov\u00e9 technologie, sta\u010dilo dodr\u017eet po\u017eadavky platn\u00fdch pr\u00e1vn\u00edch p\u0159edpis\u016f a technick\u00fdch norem a&nbsp;implementovat standardn\u00ed bezpe\u010dnostn\u00ed prvky (blokov\u00e1n\u00ed, signalizace). K \u00farazu v\u016fbec nemuselo doj\u00edt, sta\u010dilo jen, aby dot\u010den\u00e1 spole\u010dnost ne\u010dekala na nehodu, ale proaktivn\u011b \u0159\u00eddila rizika.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Z p\u0159\u00edpadu vypl\u00fdvaj\u00ed n\u00e1sleduj\u00edc\u00ed doporu\u010den\u00ed pro pr\u016fmyslovou praxi:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Implementace technick\u00e9ho blokov\u00e1n\u00ed:<\/strong> U v\u0161ech za\u0159\u00edzen\u00ed, kter\u00e1 je mo\u017en\u00e9 ovl\u00e1dat z v\u00edce m\u00edst, zav\u00e9st vz\u00e1jemn\u00e9 blokov\u00e1n\u00ed (hardwarov\u00e9 \u010di softwarov\u00e9) [9, \u010dl. 6.2], kter\u00e9 znemo\u017en\u00ed aktivaci bez potvrzen\u00ed ze druh\u00e9ho stanovi\u0161t\u011b.<\/li>\n\n\n\n<li><strong>Instalace varovn\u00fdch syst\u00e9m\u016f:<\/strong> V\u0161ude, kde nen\u00ed 100% viditelnost do nebezpe\u010dn\u00e9ho prostoru, instalovat akustickou a optickou signalizaci s&nbsp;prodlevou p\u0159ed spu\u0161t\u011bn\u00edm (minim\u00e1ln\u011b 5 sekund). Pomoci m\u016f\u017ee i instalace zrcadel na vhodn\u00e1 m\u00edsta.<\/li>\n\n\n\n<li><strong>Formalizace p\u0159ed\u00e1v\u00e1n\u00ed sm\u011bn:<\/strong> Zav\u00e9st p\u00edsemn\u00fd \u010di elektronick\u00fd protokol o p\u0159ed\u00e1n\u00ed sm\u011bny. Zak\u00e1zat spou\u0161t\u011bn\u00ed stroj\u016f p\u0159ed ofici\u00e1ln\u00edm za\u010d\u00e1tkem sm\u011bny bez dokon\u010den\u00e9ho p\u0159ed\u00e1n\u00ed sm\u011bny.<\/li>\n\n\n\n<li><strong>M\u00edstn\u00ed provozn\u00ed p\u0159edpisy (MPBP):<\/strong> Dokumentace nesm\u00ed b\u00fdt form\u00e1ln\u00ed. Mus\u00ed existovat pro ka\u017ed\u00e9 za\u0159\u00edzen\u00ed a&nbsp;popisovat re\u00e1ln\u00e9 situace (kontroly, zapnut\u00ed, vypnut\u00ed, \u00fadr\u017eba, \u010di\u0161t\u011bn\u00ed apod.).<\/li>\n\n\n\n<li><strong>Re\u017eim \u00fadr\u017eby\/\u010di\u0161t\u011bn\u00ed (zaji\u0161t\u011bn\u00ed proti spu\u0161t\u011bn\u00ed):<\/strong> Pro \u00fakony v&nbsp;nebezpe\u010dn\u00e9m prostoru zav\u00e9st jednozna\u010dn\u00fd postup zaji\u0161t\u011bn\u00ed za\u0159\u00edzen\u00ed proti neo\u010dek\u00e1van\u00e9mu uveden\u00ed do chodu (odpojen\u00ed\/uzam\u010den\u00ed\/ov\u011b\u0159en\u00ed beznap\u011b\u0165ov\u00e9ho stavu v&nbsp;z\u00e1vislosti na m\u00edstn\u00edch podm\u00ednk\u00e1ch) a jednozna\u010dn\u00e9 \u0159\u00edzen\u00ed opr\u00e1vn\u011bn\u00ed pro tyto z\u00e1sahy.<\/li>\n\n\n\n<li><strong>Kultura \u201e<em>Stop Work Authority<\/em>\u201c:<\/strong> Zam\u011bstnanci mus\u00ed m\u00edt pr\u00e1vo a&nbsp;povinnost zastavit pr\u00e1ci p\u0159i pocitu ohro\u017een\u00ed, ani\u017e by se b\u00e1li postihu.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Z\u00e1v\u011brem lze konstatovat, \u017ee a\u010dkoliv p\u0159\u00edm\u00fdm spou\u0161t\u011b\u010dem byla chyba jednotlivce, skute\u010dnou p\u0159\u00ed\u010dinou byla absence syst\u00e9mov\u00fdch z\u00e1bran. Dokud budou v&nbsp;procesu lid\u00e9, budou d\u011blat chyby. \u00dakolem zam\u011bstnavatele je zajistit, aby tato chyba nevedla k trag\u00e9dii.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Pou\u017eit\u00e1 literatura<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">[1] Propou\u0161t\u011bc\u00ed zpr\u00e1va \u00farazem posti\u017een\u00e9ho zam\u011bstnance, ze dne 13. 3. 2023.<br>[2] \u010cESKO. Na\u0159\u00edzen\u00ed vl\u00e1dy \u010d. 378\/2001 Sb., kter\u00fdm se stanov\u00ed bli\u017e\u0161\u00ed po\u017eadavky na bezpe\u010dn\u00fd provoz a pou\u017e\u00edv\u00e1n\u00ed stroj\u016f, technick\u00fdch za\u0159\u00edzen\u00ed, p\u0159\u00edstroj\u016f a n\u00e1\u0159ad\u00ed &#8211; zn\u011bn\u00ed od 1. 1. 2003. In: Z\u00e1kony pro lidi.cz [online]. \u00a9 AION CS 2010\u20132025. Dostupn\u00e9 z: <a href=\"https:\/\/www.zakonyprolidi.cz\/cs\/2001-378\" target=\"_blank\" rel=\"noreferrer noopener nofollow\">https:\/\/www.zakonyprolidi.cz\/cs\/2001-378<\/a>.<br>[3] \u010cESKO. Z\u00e1kon \u010d. 262\/2006 Sb., z\u00e1kon\u00edk pr\u00e1ce- zn\u011bn\u00ed od 1. 6. 2025. In: Z\u00e1kony pro lidi.cz [online]. \u00a9 AION CS 2010\u20132025. Dostupn\u00e9 z: <a href=\"https:\/\/www.zakonyprolidi.cz\/cs\/2006-262\" target=\"_blank\" rel=\"noreferrer noopener nofollow\">https:\/\/www.zakonyprolidi.cz\/cs\/2006-262<\/a>.<br>[4] \u010cESKO. Z\u00e1kon \u010d. 251\/2005 Sb., o inspekci pr\u00e1ce- zn\u011bn\u00ed od 1. 11. 2025. In: Z\u00e1kony pro lidi.cz [online]. \u00a9 AION CS 2010\u20132025. Dostupn\u00e9 z: <a href=\"https:\/\/www.zakonyprolidi.cz\/cs\/2005-251\" target=\"_blank\" rel=\"noreferrer noopener nofollow\">https:\/\/www.zakonyprolidi.cz\/cs\/2005-251<\/a>.<br>[5] REASON, James. Human Error. Cambridge: Cambridge University Press, 1990. ISBN 978-0-521-31419-0.<br>[6] DEKKER, Sidney. The Field Guide to Understanding &#8218;Human Error&#8216;. 3rd edition. Farnham: Ashgate Publishing, 2014. ISBN 978-1472439079.<br>[7] LEVESON, Nancy. Engineering a Safer World: Systems Thinking Applied to Safety. Cambridge: MIT Press, 2011. ISBN 978-0-262-01662-9.<br>[8] HOPKINS, Andrew. Safety, Culture and Risk: The Organisational Causes of Disasters. Sydney: CCH Australia Limited, 2005. ISBN 978-1921022258.<br>[9] \u010cSN EN ISO 12100 Bezpe\u010dnost strojn\u00edch za\u0159\u00edzen\u00ed &#8211; V\u0161eobecn\u00e9 z\u00e1sady pro konstrukci &#8211; Posouzen\u00ed rizika a sni\u017eov\u00e1n\u00ed rizika. Praha: \u00da\u0159ad pro technickou normalizaci, metrologii a st\u00e1tn\u00ed zku\u0161ebnictv\u00ed, 2011. T\u0159\u00eddic\u00ed znak: 833001.<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Tento \u010dl\u00e1nek analyzuje v\u00e1\u017en\u00fd pracovn\u00ed \u00faraz, k n\u011bmu\u017e do\u0161lo v listopadu 2022 v \u010desk\u00e9m z\u00e1vod\u011b. Po\u0161kozen\u00fd, pracuj\u00edc\u00ed jako obsluha rozdru\u017eova\u010de, byl t\u011b\u017ece zran\u011bn po ne\u010dekan\u00e9m spu\u0161t\u011bn\u00ed rota\u010dn\u00edho za\u0159\u00edzen\u00ed kolegou nastupuj\u00edc\u00edm na sm\u011bnu. Studie identifikuje soub\u011bh technick\u00fdch, organiza\u010dn\u00edch a lidsk\u00fdch selh\u00e1n\u00ed, kter\u00e1 vedla k \u00farazu. Kriticky hodnot\u00ed po\u010d\u00edn\u00e1n\u00ed zam\u011bstnavatele, postup inspek\u010dn\u00edch org\u00e1n\u016f i v\u00fd\u0161i ulo\u017een\u00fdch sankc\u00ed. Zvl\u00e1\u0161tn\u00ed pozornost je v\u011bnov\u00e1na limit\u016fm spol\u00e9h\u00e1n\u00ed se na lidsk\u00fd faktor versus technick\u00e1 opat\u0159en\u00ed. \u010cl\u00e1nek p\u0159esahuje r\u00e1mec jednotliv\u00e9ho p\u0159\u00edpadu, nab\u00edz\u00ed nejen rekonstrukci ud\u00e1lost, ale i kritickou reflexi sou\u010dasn\u00e9ho stavu bezpe\u010dnosti pr\u00e1ce v \u010desk\u00e9m pr\u016fmyslu a formuluje syst\u00e9mov\u00e1 doporu\u010den\u00ed ke zv\u00fd\u0161en\u00ed jej\u00ed \u00farovn\u011b.<\/p>","protected":false},"author":3,"featured_media":815,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_uag_custom_page_level_css":"","site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":"[{\"content\":\"V\u00a0nemocnici jej opakovan\u011b nav\u0161t\u00edvil v\u00fdkonn\u00fd \u0159editel spole\u010dnosti.\",\"id\":\"169f1f34-a7de-4bc2-801e-bb26281ae4c0\"},{\"content\":\"Zlomenina stydk\u00e9 kosti a k\u0159\u00ed\u017eov\u00e9 kosti s\u00a0poru\u0161en\u00edm p\u00e1nevn\u00edho kruhu.\",\"id\":\"5d262549-156c-466e-b2c5-0b58a07a820c\"},{\"content\":\"Lidsk\u00e1 chyba nen\u00ed p\u0159\u00ed\u010dinou selh\u00e1n\u00ed. Lidsk\u00e1 chyba je p\u0159\u00edznakem probl\u00e9mu hloub\u011bji v syst\u00e9mu.\",\"id\":\"47111065-f9ee-4ffa-ae06-254b6a7bad27\"},{\"content\":\"Vysoce spolehliv\u00e9 organizace se u\u010d\u00ed d\u0159\u00edve, ne\u017e sel\u017eou\",\"id\":\"2ef5ad6f-45af-4f55-b18b-2b636834d046\"}]"},"categories":[5],"tags":[17],"class_list":["post-752","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-bezpecnost-prace","tag-pripadova-studie"],"uagb_featured_image_src":{"full":["https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2.webp",682,874,false],"thumbnail":["https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2-150x192.webp",150,192,true],"medium":["https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2.webp",682,874,false],"medium_large":["https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2.webp",682,874,false],"large":["https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2.webp",682,874,false],"1536x1536":["https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2.webp",682,874,false],"2048x2048":["https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2.webp",682,874,false],"trp-custom-language-flag":["https:\/\/swarm.craa.cz\/wp-content\/uploads\/2025\/12\/3cl2-9x12.webp",9,12,true]},"uagb_author_info":{"display_name":"Ond\u0159ej Belica","author_link":"https:\/\/swarm.craa.cz\/en\/author\/obelicaseznam-cz\/"},"uagb_comment_info":0,"uagb_excerpt":"Tento \u010dl\u00e1nek analyzuje v\u00e1\u017en\u00fd pracovn\u00ed \u00faraz, k n\u011bmu\u017e do\u0161lo v listopadu 2022 v \u010desk\u00e9m z\u00e1vod\u011b. Po\u0161kozen\u00fd, pracuj\u00edc\u00ed jako obsluha rozdru\u017eova\u010de, byl t\u011b\u017ece zran\u011bn po ne\u010dekan\u00e9m spu\u0161t\u011bn\u00ed rota\u010dn\u00edho za\u0159\u00edzen\u00ed kolegou nastupuj\u00edc\u00edm na sm\u011bnu. Studie identifikuje soub\u011bh technick\u00fdch, organiza\u010dn\u00edch a lidsk\u00fdch selh\u00e1n\u00ed, kter\u00e1 vedla k \u00farazu. Kriticky hodnot\u00ed po\u010d\u00edn\u00e1n\u00ed zam\u011bstnavatele, postup inspek\u010dn\u00edch org\u00e1n\u016f i v\u00fd\u0161i ulo\u017een\u00fdch sankc\u00ed.&hellip;","_links":{"self":[{"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/posts\/752","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/comments?post=752"}],"version-history":[{"count":11,"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/posts\/752\/revisions"}],"predecessor-version":[{"id":871,"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/posts\/752\/revisions\/871"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/media\/815"}],"wp:attachment":[{"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/media?parent=752"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/categories?post=752"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/swarm.craa.cz\/en\/wp-json\/wp\/v2\/tags?post=752"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}