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.