how to increase near miss reporting

STEVE WISE

DECEMBER 2010

HOW to INCREASENEAR MISS REPORTING

HOW to INCREASE NEAR MISS REPORTING

Have you ever been involved in an

Accident Investigation –

where the contributing factors of the

Accident happened before but weren’t

reported?______________________________

Do you find that your People are

reluctant to report Near Misses?

Near Misses – Are Everywhere

Shock over workplace close callsPosted Tue Sep 14, 2010 3:27 pm AEST

Authorities are urging employers to ensure their workplaces are safe. (ABC News: Giulio Saggin).

Tasmania's workplace safety authority is investigating a series of electrical explosions involving young workers.

Workplace Standards is urging employers to ensure their workplaces are safe.

All of the recent incidents involved unsafe work practices.

In three of them, young tradesman were working on live switchboards.

The explosions caused extensive damage and one forced the closure of a Hobart primary school for a day.

Workplace Standards' general manager Roy Ormerod says the workers were lucky to escape serious injury.

"They were very, very lucky indeed. There was a similar incident on the mainland where a person received severe burns to his face working on a live switchboard and that person has been in hospital for months and months and will probably never work again," he said.

"That's how serious it could be.”

http://www.abc.net.au/news/stories/2010/09/14/3011531.htm

Near Misses can be very much a part of the Normal

Work Day




How to Increase Near Miss Reporting

This Safety Training Presentation – is directed to Safety Leaders of their Organization – whose mission is to Protect their People.

The Information that is contained herein – Is taken from the Safety Experience that I have

accumulated along my way. Along with various and worthwhile sources on

Near Miss Reporting from the Internet – which are so noted.

The Goal of this Presentation – is to give all Safety Leaders ideas on how to increase Near Miss Reporting – in order to Help Keep our People Safe.


What is a Near Miss?

Reasons Why Our People are Reluctant to Report

Benefits of Reporting Near Misses

How to Improve Near Miss Reporting

Actions Needed to Address Near Miss Reporting’s

Keeping the Process Flowing

WHAT IS A NEAR MISS?

If You were

asked to

define what

a Near

Miss is –

What would

You Say?

What Is a Near Miss?

A Near Miss –

Simply put – is a Close Call

Where the Individual(s) involved – were not Injured

But may have resulted in Damage to T&E

And if not attended to and corrected timely –

More than likely will result in one or more of your Employees being Injured

possibly severely or acquiring an Illness from its cause.

What is a Near Miss?

Examples of Near Misses that I have been exposed to –

Forklift tipped over while carrying a load that shifted on an uneven work surface – Driver escaped without a scratch by staying buckled inside the Cage.

Mechanic working under Railcar had just stepped away when the Car was struck by another Railcar being positioned on an active Work Track.

Forklift ran over Welder’s Foot which was protected by his Steel Toed Boots – when the Driver backed up and did not see him walking behind his Lift.

Examples of Escapes from Near MissesJICOSH - Japan International Center for Occupational Safety and Health

In the work of replacing the bucket securing pin, a mechanic hit the pinhead with a sledgehammer forcibly. The pin was driven out of the hole in a high speed and came near to hitting a fellow mechanic on

the opposite side. http://www.jniosh.go.jp/icpro/jicosh-old/english/cases/sacl/saigai03e/saigai03e_19.htm

http://www.jniosh.go.jp/icpro/jicosh-old/english/cases/sacl/saigai03e/saigai03e_19.htm

http://www.jniosh.go.jp/icpro/jicosh-old/english/cases/sacl/saigai03e/saigai03e_19.htm

From OSHA FATAL FACTS

• A carpenter apprentice was killed when he was struck in the head by a nail that was fired from a power actuated tool.

• The tool operator, while attempting to anchor a plywood form in preparation for pouring a concrete wall, fired the gun causing the nail to pass through the hollow wall.

• The nail travelled some twenty-seven feet before striking the victim.

• The tool operator had never received training in the proper use of the tool, and none of the employees in the area were wearing personal protective equipment.

BRIEF DESCRIPTION OF ACCIDENT

A NEAR MISS – is often only an Inch or two away from a Tragedy.http://www.osha.gov/OshDoc/data_FatalFacts/f-facts02.

html

http://www.osha.gov/OshDoc/data_FatalFacts/f-facts02.html

http://www.osha.gov/OshDoc/data_FatalFacts/f-facts02.html

REASONS WHY OUR PEOPLE ARE RELUCTANT TO REPORT NEAR MISSES

What % of

Near

Misses do

You think

are

actually

reported?


I would venture to say that

Near Miss Incidents in any

Organization – outnumber

Actual Injuries between 2:1 to 4:1

I would also venture to say that

Less than 20% ofNear Miss Incidents

are actually Reported

NEAR MISSES

What would You say?


There is No System for Near Miss Reporting.

Workers believe that their Supervisors will hold such Near Miss Reporting against them.

Generates Additional Work – i.e., paperwork, subsequent Investigation, etc.

Supervisors and/or Workers have Not Been Instructed How to Report Near Misses.

Once reported – Nothing is Done to Address or Correct what Caused the Near Miss.

NEAR MISSES


Upon reporting – there is No Follow-up Communicated to the Individual(s) who so reported the Near Miss.

Loss of Credibility for those that report such – may be viewed as a “Squealer.”

There is No Motivation for Organizational Employees to report Near Miss Incidents – nothing is gain Individually or Organizationally.1

Near Misses are so Frequent that they become common place and part of the everyday work life.

NEAR MISSES


Employees may Fear a Possible Job Loss or be Penalized – if they are found to be a contributing factor of the Near Miss Incident.

Form(s) Used may be too Complicated for Near Miss Reporting.2

There is No One Assigned to handle / direct the actions needed to correct what caused the Near Miss.

Workers have the Mindset that being Safe in the Workplace also includes Being Lucky.

NEAR MISSES

BENEFITS of REPORTING NEAR

MISSES

We MUST

find Ways

to Hear

and Learn

from our

Near

Misses

OSHA – Weekly Fatality / Catastrophe Report(Federal and State data tabulated week ending November

6, 2010)

Date of Incident Location Preliminary Description of Incident

10/10/10 Midland, TX.

Worker was changing the tire on a company truck using a small mechanical jack to lift the truck. The truck slipped off the jack and fell onto the worker.

10/27/10 Booneville, IN.

Workers were on a metal roof when the roof gave way and collapsed due to deterioration. One worker well through the roof.

11/1/10 Colton, CA. Worker was crushed between two pieces of steel K-Rails.

11/3/10 Jackson, MS.

Worker was riding on top of plywood that was on the forks of a rough terrain forklift. Worker fell off the plywood and was run over by the forklift.

http://www.osha.gov/dep/fatcat/fatcat_weekly_rpt_11062010.html

Wouldn’t You have wanted to make a Difference here?




As a Safety Leader – It is hard to argue with the fact that

a Near Miss Safety Incident – is a “Do Over” without a Cost or Penalty or Injury.

It is also hard to argue that Near Misses must not only be attended to and corrected timely – but that they must be Used as a Learning Experience.


A Real Life Example –

At one of our Facilities – a Mechanic was operating a Machine with a Rotary Mechanism.

When the Machine got clogged – the Mechanic reached inside to clear it without turning off and Locking Out – catching his Arm Sleeve on the rotating mechanism.

His initial reaction was to fall away from the Machine – resulting in his Arm Sleeve ripping from his Shirt.

The Mechanic received No Injury – and was very lucky that his Hand / Arm was not pulled into the Machine.


A Real Life Example (con’t) –

This Near Miss Incident was reported – and an Incident Investigation and Report were completed.

Corrective Actions included reviewing the Incident with all Personnel that use such a Machine – and the need to Lock Out any such Machinery before servicing.

A Safety Bulletin was issued that included a Picture of an Individual that suffered Fatal Injuries from such an Incident that was pulled into a Machine.

To see such – Google Image – “Machine Accidents”


Reporting of a Near Miss and

the subsequent Investigation of – will more than likely reveal – acts, conditions,

etc. that will need to be corrected.


EXISTING CONDITIONS – Do not be surprised when investigating Near Misses – to find Unsafe Conditions that have been present for some time.

NO STANDARD WORK PRACTICE – Near Miss Incidents are often caused by having no such standard practice or procedure in place – which results in having various and most likely unsafe ways to accomplish a task or responsibility.

LACK OF TRAINING – Another condition that leads to Safety Incidents – is the lack of Training of the Workers involved – i.e., How to Safely use a Come-Along.


USING IMPROPER or UNSAFE TOOLS – Can a Near Miss Incident ever be caused by Management?

How about when a Tool is given to an Employee that is either improper or unsafe to use for the Job that that they are asked to perform.

CUTTING CORNERS – Common place in the Work Place – will be Employees that “Cut Corners” – i.e., not following the steps that need to be performed in order.

Such may be due to Complacency and the belief that they will not get hurt – or it may include simply trying to speed up their work process.


LACK of SAFETY AWARENESS – A leading cause within my Organization – is the lack of Safety Awareness by our People involved in Near Misses and Accidents.

Such has included – not seeing Co-Workers in their immediate Work Area – to placing their Body Parts between Pinch Points – to not checking their work area prior to setting up or beginning their work.

OUTDATED PROCEDURES – Organizations must ensure that when their Processes change – that they update their Procedures to reflect such changes.

HOW to IMPROVE NEAR MISS REPORTING

It is

essential

for Safety

Leaders –

to hear and

know

about Near

Misses


Safety Leaders must create an environment –

where Near Misses are

reported timely – so that events such as this are stopped before

they occur.

Rig worker dies in workplace accident near Fort McMurray

Occupational Health and Safety investigating

By Journal Staff, edmontonjournal.com November 10, 2010

EDMONTON — A man is dead after a workplace accident in the Fort McMurray area on Tuesday.

A rig worker for Encore Coring and Drilling was killed during the assembly of an oil rig at a remote Devon Energy work site near Kirby Lake, about 350 kilometers northeast of Edmonton. Occupational Health and Safety is investigating.

"A piece of equipment fell and hit a worker in the head," said Occupational Health and Safety spokesman Chris Chodan.

The man was an experienced rig worker, said Rob Wilman, vice-president of health and safety for the parent company, Ensign Energy Services.

© Copyright (c) The Edmonton Journalhttp://www.edmontonjournal.com/health/worker+dies+workplace+accident+near+Fort+McMurray/3800911/story.html

http://www.edmontonjournal.com/health/worker+dies+workplace+accident+near+Fort+McMurray/3800911/story.html

http://www.edmontonjournal.com/health/worker+dies+workplace+accident+near+Fort+McMurray/3800911/story.html


There are three (3) important factors that must be present to ensure that Near Misses are reported –

1) There must be a Near Miss Reporting System in place that tracks the status of.

2) The Near Miss System must be understood by All Employees.

3) All Near Misses should be investigated and corrective actions taken if necessary to prevent their reoccurrence and/or more serious Injury.


In addition to these Factors – there are other important elements that should also be in place –

NO PENALTY – There should be No Penalty what-so-ever to any Employee that reports a Near Miss. As soon as such is experienced – all Near Misses will go

underground.

DRIVER OF THE SYSTEM – At each of your Locations – you need to have someone assigned to be the “Handler” of all Near Misses. Such duties will include Recording, leading the Near

Miss Investigation, and helping to determine and complete Corrective Actions to prevent any reoccurrence.


In addition to these Factors (con’t) –

PUBLICIZE YOUR EFFORTS – In order to make Near Miss Reporting successful – you must Publicize Your Efforts. You need to find a way to report how corrective actions taken

as a result of Near Misses – have helped the Organization and your People – by making their Workplace Safer.

You will have People reluctant to report Near Misses – until they see that they have something to gain from so reporting.

SHARE WITH OTHERS – Near Misses can and should be a Learning Tool for all applicable Organizational Employees. Make sure that you take time to not only share the Near Miss

Incident – but also how it occurred and what actions were taken to prevent its reoccurrence.



COMMUNICATE ACTIONS TAKEN – It is very important that you communicate any findings and actions taken to those involved with the Near Miss. This includes both the Individual(s) that reported the Near Miss – as well

as any Individual(s) that were actually involved in the Near Miss.

In addition, it would be beneficial to advise any Work Group Members that are involved in similar work actions.

USE AS A LEADING INDICATOR – Take time to track and record your Near Miss Incidents. Such can be used as an indicator of your Safety Performance to come. Various factors can be interpreted from Near Misses including – are they

major vs. minor in nature, is their primary cause from either lack of awareness or lack of training, etc.

Near Misses can point to what Safety Efforts are needed in the Workplace – to address what is causing them – and any negative trends in Performance



SENIOR MANAGEMENT SUPPORT – Sr. Management must support Near Miss Reporting in three aspects – First – it must support the Process of Near Miss Reporting and

expect it to be an integral part of the Company’s Safety Efforts.

Second – it must understand Near Miss Reporting and not react negatively to a spike in Near Misses reported for a particular area.

Third – they must know and accept that there is a Cost to Near Miss Reporting – such as the time needed to track and correct, incident investigation, etc.3

Sr. Management must let the necessary actions play out that should address any need that may be creating Near Misses.

ACTIONS NEEDED TO ADDRESS NEAR MISS

REPORTING’s

Once Near

Misses are

reported –

what will

You Do

with

them?

Actions Needed to Address NM Reporting’s

The Actions that we take in response to

Near Miss Reporting’s –

will determine how successful this Process

will be.


ACTIONS IN RESPONSE EXPLANATION / COMMENTS

KISS

Keep your actions Simple. Actions taken in response to a NM Reporting – should be basically a Streamlined Accident Investigation.

Act On in a Timely Manner

The severity of the Near Miss Incident – should dictate the type / level of response and the corrective actions taken and when.

Communicate Actions Needed

Upon being informed of a Near Miss – make sure that you or someone advise those so reporting – what actions will be taken & when.

Use as a Learning Tool

Your actions taken in response to a NM – should be to Learn from the Incident – and take actions to prevent any future or further events.



Don’t Take Near Misses

Lightly

As noted above – Near Misses should be considered a “Do Over.” By not giving the appropriate response to – could result in an Actual Injury next time such events occur.

Hold Someone

Responsible to Act On

With Near Misses – I would encourage you to get your People involved in the corrective actions needed – such as the Supervisor in charge.

Follow-up

As with any Safety Issue – Follow-up is critical to the success of your Safety Efforts – and from preventing Near Misses from becoming future Accidents that Injure Your People.



Act with Your People in

Mind

Especially with Near Misses – your People will be watching. If the reaction to is insignificant to correct possible Safety Problems – does you inaction communicate acceptance on your part?

Talk about Near Misses

Openly

Near Misses that are experienced within your Organization – should be discussed openly with Your People – so that all can learn from such Incidents and be Safer as a result of.

Communicate Your Findings and Actions

Take time to communicate what was found to be the Cause of Near Miss Incidents – and what Corrective Actions were taken to address.


Near Miss Incident

Reported to Supervisor /

Safety Leader

Near Miss Incident Report

Completed

Safety Leader Reviews for

Severity

Near Miss Incident is

Investigated

Root Cause(s) are

Determined

Corrective Actions are

Taken to Prevent

Reoccurrence

Near Miss Event and Actions are Recorded

Near Miss Corrective Actions are

Communicated

Suggested Flow Chart of Near Miss Actions Needed

Example of a Near Miss ReportWorkforce Safety & Insurance –

www.WorkforceSafety.com

NEAR MISS REPORTA near miss is a potential hazard or incident that has not resulted in any personal injury . Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and /or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations.Department/Location ________________________ Date: ________________ Time __________ am / pmPlease check all appropriate conditions:____ Unsafe Act ____ Unsafe Condition ____ Unsafe equipment ____ Unsafe use of equipment Description of incident or potential hazard: ______________________________________________________________________________________________________________________________________Employee Signature _____________________________ (optional) Date ___________________

NEAR MISS INVESTIGATION - Description of the near-miss event / condition: ______________________________________________________________________________________________________________________________________________________ Causes (primary & contributing) ___________________________________________________ ______________________________________________________________________________________________________________________________________________________Corrective action(s) taken (i.e., Remove the hazard, replace, repair, or retrain in the proper procedures for the task) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________Signed _________________________________________ Date Completed __________________ Not completed for the following reason: _____________________________________________________ Management ________________________________________ Date ___________________________

http://www.workforcesafety.com/safety/sops/NearMissReport.pdf

http://www.WorkforceSafety.com/

http://www.workforcesafety.com/safety/sops/NearMissReport.pdf

KEEP THE PROCESS FLOWING

Actions taken

in Response to

Near Misses –

will often

dictate the

type of

Accidents Your

Organization

Incurs

Keep the Process Flowing

The following Suggestions are offered to help ensure

the Success of your Near Miss Reporting Program –

Near Miss Reporting, Investigation, and Corrective

Action – should be considered an INTEGRAL PART of

your Organization’s Safety Program.

Be CONSISTENT with your response to and actions

taken regarding Near Miss Incidents.

Near Miss Incidents that are severe in nature – should

receive as much ATTENTION and CORRECTIVE

ACTION as an actual Accident / Injury.


The following Suggestions are offered (con’t) –

Put out the Message to all of your People – that Near

Miss NON-REPORTING is UNACCEPTABLE.

COMMUNICATION of both Near Miss Events and the

Corrective Actions taken – will be the key to its success.

The Reporting of Near Misses – should NEVER BE

INCENTIVEIZED. Let the Program prove its merit.

Employees should NEVER BE PENALIZED for

reporting Near Miss Incidents.


The following Suggestions are offered (con’t) –

LEARN – LEARN – LEARN – from your Near Miss Incidents and be Safer because of them.

Any and all Near Miss Incidents should be SHARED WITH OTHERS. Let others Learn too.

As with any Safety Effort – REVITALIZE from time to time to ensure such matches current Processes.

Engage your ENTIRE ORGANIZATION in your Near Miss Reporting. Senior / Local Management should know about Near Misses as well.


As Safety Leaders – we

must work with our

People to see events,

conditions, etc. – BEFORE they

turn into Accidents &

Injuries.

This Safety Training Presentation – was offered to give You Ideas on How to Increase Near Miss

Reporting.

How to Increase Near Miss ReportingReferences – Those Not Noted

1 - Forck, Matthew (2010). The S.T.O.R.M Model for Near-Miss Reporting. TDWorld.com. Retrieved December 26, 2010 from http://tdworld.com/overhead_distribution/storm-model-near-miss-reporting-20100201/

2 – Professional Safety (Nov 2010). Safety Management – Webinar Encourages Near-Miss Reporting. American Society of Safety Engineers. Retrieved December 10, 2010 from http://findarticles.com/p/articles/mi_hb5618/is_200911/ai_n42857768/

3 – Forck, Matt (Oct 2009). Near Miss Reporting – The Sounds of Silence. ISHN. Retrieved December 29, 2010 from http://www.ishn.com/Articles/Feature_Article/BNP_GUID_9-5-2006_A_10000000000000678682

http://tdworld.com/overhead_distribution/storm-model-near-miss-reporting-20100201/



http://findarticles.com/p/articles/mi_hb5618/is_200911/ai_n42857768/



http://www.ishn.com/Articles/Feature_Article/BNP_GUID_9-5-2006_A_10000000000000678682




SAFETY LEADERS

– Must be there

for Our People

– including those

that Do and Don’t

know better.

HOW TO INCREASE NEAR MISS REPORTING

Steve Wise

[email protected]

I welcome your Comments.

mailto:[email protected]

mailto:[email protected]

how to increase near miss reporting

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