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Near Miss

Reporting

Improving the
Safety Culture
Greg McKeeman, EHS Professional

Near Miss Reporting Improving the Safety


Culture
What is a near miss and what caused it to
happen? Why should near misses be reported
and how can they pave the way to a better
safety culture? If you dont know the answers
to these questions, plan to attend this
presentation!
Near Miss Reporting -
Improving the Safety Culture

Contents
Introduction
Near Miss Reporting
Definitions
Examples
Benefits
Improving the Safety Culture
History and Theory
Implementing a Near Miss Program
Analyzing near misses (Eight Step Approach
to a successful near miss program)
Near Miss Reporting -
Improving the Safety Culture

Near Miss Reporting

Why isnt it called a near hit instead of a


near miss if it nearly missed, then didnt
it actually hit?
Near Miss Reporting -
Improving the Safety Culture
Near Miss Reporting -
Improving the Safety Culture

Definition of a Near Miss


A Near Miss? is an unplanned event that did not
result in injury, illness, or damage but had the
potential to do so (Wikipedia).
An event, circumstance, condition or behavior which
has the potential to cause-injury, illness, accidental
release or property/productivity loss but did not
actualize due to chance, corrective action and/or
timely intervention.

Other familiar terms for these events is a


"close call", or in the case of moving objects, "near collision" or a
near hit.
Near Miss Reporting -
Improving the Safety Culture

Near Miss Definitions


OSHA provides the following definition of
a near miss in an Accident Investigation
Fact Sheet:
incidents where no property was
damaged and no personal injury
sustained, but where, given a slight shift in
time or position, damage and/or injury
easily could have occurred.
Near Miss Reporting -
Improving the Safety Culture

Examples of a Near Miss


Near Miss Reporting -
Improving the Safety Culture

Examples of a Near Miss


1. A forklift brushes the bottom of a storage rack
column. The operator drives off. The racking
doesnt fall and doesnt appear damaged.
2. A pedestrian walks in front of a forklift operator. The
forklift operator slams on the breaks. There is no
collision and no one is injured.
3. A forklift operator is stacking a high load, the load
shifts forward and crashes to the ground. No one is
injured, but the product on the pallet is damaged.
4. A pedestrian slips on some fluid that had leaked
from a forklift. The pedestrian falls to the floor, but is
not injured.

http://www.youtube.com/watch?v=WHWJYaGO4DE
Near Miss Reporting -
Improving the Safety Culture

Benefits of Reporting a Near


Miss
There are several benefits to having a near-
miss reporting culture in place, including
these:
Enables pro-active resolution of hazards
Engages the workforce
Increases safety ownership and reinforces
workers self-esteem.
Exposes valuable information that otherwise
might not be discussed.
Develops a positive attitude surrounding safety.
Near Miss Reporting -
Improving the Safety Culture

Others Benefiting from Near


Miss Reporting
Aviation - The Aviation Safety Reporting System
(ASRS) has been collecting confidential
voluntary reports of close calls from pilots, flight
attendants, air traffic controllers since 1976.
Fire-rescue services In 2005 the National Fire
Fighter Near Miss Reporting System was
established.
Healthcare A US based professional
organization of Registered Nurses developed
SafetyNet
Near Miss Reporting -
Improving the Safety Culture

S afe ty Ic e be rg
Near misses must be given the same priority as accidents
Upper management

Major event Reactive


w ork
day
Re
(acute)
t
Los Firs str
ict
t ai ed
d
Medical

Day-
Day-to-
to-day management
Investigate
s
Proactive ar mis A major
Ne event?
(chronic) Un
saf
ec
on d
itio
n
Trend s
ct az ard
f ea h
Un
sa
o rted
rep
Un Behavioral-
havioral-based
safety management
Near Miss Reporting -
Improving the Safety Culture

Near Miss Reporting -


Improving the Safety Culture

The culture of an organization can be


defined as the way we do things around
here.
As such, culture provides a context for
action which binds together the different
components of an organizational system in
the pursuit of corporate goals (Improving
Safety Culture, A Practical Guide. Dr.
Dominic Cooper, 2001).
Near Miss Reporting -
Improving the Safety Culture

Improving the Safety Culture:


A look back in History
During the 19th and early 20th centuries
many safety practitioners took the view that
safety was all about controlling physical
work conditions.
Heinrichs Domino Theory (1931). Accidents
were caused by either an unsafe act, an
unsafe condition, or both.
Near Miss Reporting -
Improving the Safety Culture

Improving the Safety Culture


Near Miss Reporting -
Improving the Safety Culture
Incident Ratio Model
Heinrichs Theory

Serious Injury or Death


Most Accident 1
Investigations
Conducted
29 Biggest
Minor Injury percentage
of injury
Few Investigations causing
Conducted potential!
300
Near Miss

3,000
Unsafe Acts, Behaviors or Conditions
Near Miss Reporting -
Improving the Safety Culture

Improving the Safety Culture:


A look back
In 1976 E. Adams changed the emphasis of
the first three dominos to reflect
organizational rather than person features.
Near Miss Reporting -
Improving the Safety Culture

Improving the Safety Culture:


A look back
Although the above models have proved
useful in identifying the sequences of events
in the accident causation chain, they have
largely failed to specify how and under
what conditions each of the sequential
elements might interact to produce
accidents.
In 1988, Professor James Reason likened the
accident causation process to resident
pathogens in the human body.
Near Miss Reporting -
Improving the Safety Culture

Improving the Safety Culture:


A look back
Near Miss Reporting -
Improving the Safety Culture

Implementing a Near Miss


Program
A Near Miss Program can be defined as
an administrative tool to help reduce
accidents and injuries in the workplace.

Should address three disciplines in the


workplace.

1) Environmental
2) Safety
3) Health
Near Miss Reporting -
Improving the Safety Culture
Near Miss Reporting -
Improving the Safety Culture

Objectives of implementing a
Near Miss Program
Identifyrisks and prevent future accidents
Fix problems as they are identified
Make everyone an advocate of safety
Increase safety awareness
Near Miss Reporting -
Improving the Safety Culture

Options Of Implementation
There are several ways to ensure your near
miss program is executed and maintained.

Near
Miss Management Team
Comprised of a diverse team of employees,
managers, supervisors and workers.
Near Miss Reporting -
Improving the Safety Culture

Options, cont.
SafetyCommittee
Your safety committee can implement and
manage your near miss program.

Single
Person
You can designate a single person responsible to
manage the program
Near Miss Reporting -
Improving the Safety Culture

Training
There are two types of training associated
with a near miss program.

1) Administrative for administrators


2) Employee
Near Miss Reporting -
Improving the Safety Culture

Administrative Training

For the administrators, subjects should


include the guidelines at which the program
will function e.g., prioritizing, tracking and
responsibilities.
Near Miss Reporting -
Improving the Safety Culture

Employee Training should focus


on:
What are near misses
Why are near misses important and how they
can help
What is the role of each person in near miss
reporting
How will near misses be managed and by who
What is the near miss process (eight steps)
How do you report a near miss
How would you prioritize a near miss
Where to find near miss reporting forms
Near Miss Reporting -
Improving the Safety Culture

Employee Recriminations
Employees may be reluctant to report near
misses due to potential recriminations that
could result.

Such as:
Peer pressure
Disciplinary action
Unintended disciplinary action. For example, upon
incident investigation, additional job tasks or wearing
cumbersome PPE may be perceived as punishment for
reporting
Near Miss Reporting -
Improving the Safety Culture

Analyzing near misses: Eight Step


Approach to a successful near
miss program
Near Miss Reporting -
Improving the Safety Culture

Eight Steps
There are eight steps to an effective near
miss program.
Identification
Disclosure
Prioritization
Distribution
Root-cause analysis
Solution identification
Dissemination
Resolution
Near Miss Reporting -
Improving the Safety Culture

Step 1
Identification

The individual must recognize an incident


or condition as a near miss.
There must be a clear definition of what a
near miss is within your organization.
Near Miss Reporting -
Improving the Safety Culture

Step 2
Disclosure

Once a near miss is identified, it must be


disclosed, preferably in writing. Having a
simple procedure for reporting will encourage
this process. Having easy access to forms is
a key component to encouraging
participation.
Near Miss Reporting -
Improving the Safety Culture

Step 3
Prioritize

Once an incident has been reported it


must be prioritized. This very critical step
determines the path forward as to what
level of attention is needed. This should be
reviewed by management to help determine
the risk.
Near Miss Reporting -
Improving the Safety Culture

Step 4
Distribution

Distribute the near miss information to the


people that can help properly analyze the
cause of the incident. Ask for their
immediate feed back.
Near Miss Reporting -
Improving the Safety Culture

Step 5
Identification of Causes

Both direct and root-causes should be


determined. It could be a behavior based or
training based cause or other. Look at all
possible aspects of causes.
Near Miss Reporting -
Improving the Safety Culture

Step 6
Solution Identification

A solution for each identified cause should


be determined.
Near Miss Reporting -
Improving the Safety Culture

Step 7
Dissemination

Once solutions are identified, the information


should be communicated to the people who
will execute the solution.
Near Miss Reporting -
Improving the Safety Culture

Step 8
Resolution (Tracking)

Once solutions are identified and the


implementers are informed, it is important to
track all suggested changes to ensure that
they are properly executed.
Near Miss Reporting -
Improving the Safety Culture

Final Tips
A near miss in the workplace is a warning or
indication that something is wrong
Close calls or near misses on the job should be
corrected immediately
Constant safety awareness on everyones part is
the most important factor in accident prevention
Near Miss Reporting -
Improving the Safety Culture

Final Tips, cont.


Ifyou witness or are involved with a near miss
incident, stop and correct the problem or notify
the appropriate people immediately
Do not just shrug-off a near miss. Stop what you
are doing and report it.
Dont have the attitude that Thats the way we
have always done it.
Near Miss Reporting -
Improving the Safety Culture

Implementing a Near Miss


Program: OSHA regulations
In addition to making good business sense in terms of preventing
future accidents, there are OSHA requirements to investigate or take
action after certain near misses:
OSHAs Permit-Required Confined Spaces Standard, 29 CFR
1910.146, requires employers to review the entry program when
there is a near miss during entry.
OSHAs Powered Industrial Truck Standard, at 29 CFR 1910.178,
requires that refresher training in relevant topics be given to
operators involved in a near miss.
OSHAs Construction Fall Protection Standard, at 29 CFR 1926.502,
requires that employers investigate falls and near misses.
OSHAs non-mandatory Appendix A to the Process Safety
Management of Highly Hazardous Chemicals Standard, 29 CFR
1910.119, notes that OSHA expects employers to become aware of
and to investigate near misses that could have serious
consequences
J. J. Keller & Associates, Inc.,
Near Miss Reporting -
Improving the Safety Culture

THANKS

Greg McKeeman, EHS Professional


Corporation
1600 Perimeter Park Drive, Suite 400
Morrisville, NC 27560
Tel: 919.461.1210
Greg.McKeeman@urs.com