RESUMEN
This work presents the results of CAST (Causal Analysis using Systems Theory) application, technique initially created to understand the aerospace accidents root causes, to identify the main reasons that may have contributed to the considerable amount of human deaths caused by the Coronavirus pandemic in Brazil. Through the CAST process, it was possible to identify the dangers involved in safety control mechanisms related to the pandemic and its health implications, understanding the events that allowed this occurrence, identifying why the components related to the system's safety were not effective and, suggest mechanisms that reinforce safety controls at national and global levels, in order to avoid or mitigate similar losses related to pandemics in future events the steps established in the CAST structured approach, allowed to analyze the factors that contributed to the high number of human deaths, obtaining a greater amount of information and details, used in the elaboration of improvement proposals to face the problem, mainly with regard to the health system. © 2021 IEEE.