NEAR MISS REPORTING

A proactive HSE management system

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A NEAR MISS TODAY

COULD BE AN ACCIDENT
TOMORROW
It is better to report near miss
rather than accident report

REPORT ALL
NEAR MISSES!

“Start Reporting Near Miss for Prevention of Accident”

Author:

Eng. Salim Ali Al Harthy

BSc Electrical Engineering (USA), MSc (Mechanical
Industrial Engineering –SQU Oman)
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Download HSE Docs hseprof.com NEAR MISS REPORTING

About the Author

Qualification:
Bachelor in Electrical Engineering (USA), Master in Industrial Engineering -
Sultan Qaboos University,

Member of:
member of many professional organizations and partnership councils with some universi-
ties in the Sultanate of Oman and abroad.

Experience:
He worked in the field of Engineering, Maintenance, Firefighting, Operation, Health, Safety
and Environment in the Oil and Gas sector, Refinery and Petrochemicals and Airports
Operation and Management.

Speaker:
A speaker at many national and international conferences in the fields of engineering,
maintenance, management, health, safety and the environment.

Author:
Eng. Salim Ali Al Harthy
BSc Electrical Engineering (USA), MSc (Mechanical Industrial Engineering -
SQU Oman)

Disclaimer
The information provided in this book is designed to provide helpful information on the subjects discussed. This
book is not meant to be used, nor should it be used, to diagnose or treat any medical condition. For diagnosis or
treatment of any medical problems, consult your own physician. The publisher and author are not responsible for
any specific health or allergy needs that may require medical supervision and are not liable for any damage or
negative consequences from any treatment, action, application or preparation, to any person reading or following
the information in this book. References are provided information purpose only and do not constitute endorsement
of any website or other sources.

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 NEAR MISS REPORTING

CONTENTS
Introduction ............................................................................................. 5

Definitions ................................................................................................ 5
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Loss causation Model.............................................................................. 7

Benefits of Near Miss reporting................................................................ 8

Analysis of Near Miss incidents............................................................... 8

Barriers to report accident / incidents...................................................... 9

Typical examples of Near Miss................................................................ 9

Near Miss reporting procedure ............................................................. 11

Near Miss reporting form ...................................................................... 12

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 NEAR MISS REPORTING

INTRODUCTION
It has been established by studies that before an accident occurs, it gives sufficient systems
in terms of near miss incidents. Studies in several industries indicate that there are between 50
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to 100 near misses for every accident.

Traditionally in mostly industries scope of accident / incident investigation is limited to physical

injury and property damage. So as a pro- active approach, managements should encourage
the employees to report Near Miss reported and investigated to avoid accidents at workplace.

DEFINITIONS
TERM DEFINITION

1. Accident: An undesired event that results in harms to people, damage to property, loss
to process or harm to the environment
2. Incident: An incident is an unplanned event and chain of events that had or could have,
resulted in injury or illness or damage too assets, the environment or company’s image
/ reputation.
3. Near Miss: An undesired event or situation that could have resulted in personnel harm,
property damage or other loss such as environment damage, but did not do so due to
chance, corrective action and / or timely intervention.
4. High potential Near Miss Incident or dangerous occurrence: An undesired event,
which under slightly different circumstances could have resulted in major injury, major
property damage, major environment damage, major reputation damage. E.g. Crane
failing and no one get hurt.
5. First Aid Injury: Any one time treatment and subsequent observation of minor
scratches, cuts, burns, splinters, etc. which do not ordinarily require medical care by a
physician. Such treatment and observation are considered first aid even if provided by
a physician or registered professional personnel.
6. Medical treatment case : A medical treatment case is any reportable injury that
involves neither lost workdays nor restricted workdays but which requires treatment
by, or under the specific order of, a physician or could be considered as being in the
province of a physician. Medical treatment does not include first aid even if this is
provided by a physician or registered professional personnel.
7. Lost time injury: Lost time injuries are the sum of fatalities, permanent total disabilities,
permanent partial disabilities, and lost workday cases, but excluding restricted work
cases and medical treatment cases. Note. If, in a single incident give people receive
injuries, which are falls in LTI, then it shall be counted as 5 LTI.
8. Lost workday case: A lost workday case is any reportable injury other than a
permanent partial disability which renders the injured person temporarily unable to
perform any regular job or restricted work on any day after the day on which the injury
was received. Medical coordinator reports shall be used to decide whether particular
incident falls under lost time work case or not, regardless of next working days falls
as rest day, weekend day, scheduled holiday, public holiday or subsequent day after
ceasing employment or person proceed on leave or business trip.

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 NEAR MISS REPORTING

9. Restricted work case (RWC): A restricted work case is any work injury which results
in awork assignment after the day the incident occurred that does not include all the
normal duties of the person’s regular job. The restricted work assignment must be
meaningful and pre- established or a substantial part of a regular job.
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10. Lost work days: The number of lost work days is the total number of calendar days
on which the injured or ill person was temporarily unable to work as a result of a lost
workday case, illness or a permanent Partial disability.
11. Serious Injury: (Definition as per Oman government MD No. 19 of 1982)
An accident shall be deemed serious according to the following criteria.
• Every accident which leads to the death of worker or causes him 50% or more
disability.
• Fire accident, collapse or explosion which results in the loss of machines
• Accident which result in injury to more than one person.
12. Immediate causes: The substandard acts / practices or condition which directly
contributes to the occurrences of accident / incident. This is frequently referred as
unsafe act or condition.
13. Basic Causes: The job and personnel factors, such as inadequate engineering,
lack of knowledge or skill etc., from which the substandard acts / condition originate.
Basic causes may be referred as underlying, root or real cause, system defects or
contributing causes. Basic causes are most frequently the result of an inadequate
safety system, in adequate system standards and / or inadequate compliance with
standard.

Figure 1 & 2 has been produced below to understand definition concept of near miss.

Incidents

Near miss

Accidents

Figure1

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 NEAR MISS REPORTING

Analogy between Near Miss and cold & cough

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Something Correct the safety

Near Miss wrong in safety management
Organisation
incidents management system before
system accident occurs.

See the doctor

Something wrong
before any
Human body Cold – cough in human body
diseases
system.
developed.

Figure 2

LOSS CAUSATION MODEL

Figure 3: are produced below to understand the process of near miss occurrence through loss
causation model.
Figure 4: indicate ratio of accident & near miss, the ratio varies from study to study but struc-
ture remain same. The numbers (1, 10, 30 & 600) indicated here are notional, but structure of
accident ratio remains same.

Near Miss
Accident

Lack of Basic Immediate Incident Loss

control causes causes

Inadequate Personal substandard

Unintended
Factors acts / practices
harm
• System Event or
• Standards job / system damage
Substandard
• Compliance factors
Conditions

Threshold Limit Value

Figure 3

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 NEAR MISS REPORTING

Figure: 4 indicate ratio of accident & near miss, the ratio varies from study to study but struc-
ture remain same. The numbers (1, 10, 30 & 600) indicated here are notional, but structure of
accident ratio remains same.
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ACCIDENT RATIO

1
Major Accident

10
Minor Injury

30
Property Damages

600
Incidents

Figure 4
Our efforts should be directed to the many significant opportunities of Near
Miss for control of accidental losses.

BENEFITS OF NEAR MISS REPORTING

It has been experienced that the industries where near miss incidents are reported,
investigated & recommendation are implemented the rates of accidents are very low compare
to industries they don’t report on near misses’ incidents.
We must learn from accidents and near miss to prevent recurrence. The first step in the
learning process is investigation of to determine the causes and underlying reasons and
why accident and near miss occurs. A thorough investigation to root cause will identify the
management weakness. Learning which management system weaknesses are leading to near
miss and accident is one of the highest value activities in which company can invest. And
learning from near misses is much cheaper than learning from accident.
NEAR MISS PROVIDE GOLDEN OPPORTUNITY TO IMPROVE HSE PERFORMANCE.

ANALYSIS OF NEAR MISS INCIDENTS

The analysis is done by applying the principle of multiple causes: “problems and loss
producing” events are seldom, if ever the result of a single cause. Analyze for:-
• Unsafe / substandard acts
• Unsafe / substandard conditions
• Personal facts.

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 NEAR MISS REPORTING

• Job factors.
• System deficiencies.

Avoid the satisfaction of each syndrome, i.e. don’t stop the analysis when you first find some
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evidence to support your favorite hypothesis. Explore alternatives.

Process should include all contributing factor. Apply principle of critical few. The investigation
team decides which, critical few immediate & basic causes contributed to the accident or near
miss.

BARRIERS TO REPORT ACCIDENT / INCIDENTS

Experience research & experience indicate that due of following reasons employees generally,
not report the accident / incidents.
• Fear of disciplinary action
• Concerned about the record.
• Concerned about reputation
• Fear of medical treatment
• Desire to avoid work interruption.
• Desire to keep personnel record clear.
• Avoidance of paper work.
• Poor understanding of importance.

TYPICAL EXAMPLES OF NEAR MISS

An incident / accident having the potential for either personal / property damage of
environmental impact or both are termed as a near miss. Examples are:
• Non – relieving of a relief value at set pressure.
• Relieving of relief value before set pressure.
• Non – working of emergency appliances.
• Non – working shutdown / trip systems.
• Violation of safety regulation (e.g. Working without valid work permit)
• Free failing of objects from height
• Bursting / disconnection of pressure hoses

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 NEAR MISS REPORTING

DIFFERENCE BETWEEN NEAR MISS INCIDENT & INCIDENT

Before reporting near miss you must understand between near miss incident & incident, as it is
matter of interpretation of individual. However, following example incidents have been provided
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for better understanding of concept.

NO. NEAR MISS ACCIDENT

When a person was walking in a

A man walking in a warehouse, tripped
warehouse, he stumbled over the loose
1 over loose wires, fell on his face and
electrical wires and he fell, but he didn’t
injured his forehead with a bloody wound.
have any injuries.

One car collided with another car and

One vehicle collided with another, but
2 both car drivers and passengers were
there were no major injuries or damage.
injured

While working at a height, a tool slipped
from the worker’s hand and fell on
3 someone’s head standing below, there
was no injury because he wore a safety
helmet on his head.
While a man working on a height, tool
slipped out of his hand and fell on a
person’s head, standing below, although
he was wearing a helmet, the tool hit his
shoulder and injured him.

A trip occurred when a worker attempts
to walk through packaging materials
4
dispersed across the floor and nothing
happened
A trip occurred when a worker attempts
to walk through packaging materials
dispersed across the floor and had a
fracture in his finger

A load lifted on the deck fell due to a A load fell on to the deck due to a sling
5 broken rope but nothing happened to collapse and injured the workers working
anyone below.

While tightening the bolt your hand slips

While tightening the bolt your hand slips
from the tool because of the wet hands
6 from the tool because of the wet hands
and the tool fell on the foot of the helper
and luckily no one got hurt.
and hurt him badly

The equipment is not properly strapped

The equipment is not properly strapped
to the surface of the truck, the equipment
to the surface of the truck, the equipment
falls into the middle of the traffic and
7 falls into the middle of the traffic and the
the car behind the truck collided with
car behind the truck braked in time and
the fallen body and created a multiple
the accident was avoided
collision

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 NEAR MISS REPORTING

NEAR MISS REPORTING. INVESTIGATION AND

ANALYSIS PROCEDURE

Reporting procedure:
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1. Any person who experience or witness the near miss incident shall fill in the no.
prescribed form and submit the same to safety section of HSE department by hard copy
or through soft copy.
2. The near miss incidents shall be reported within 24 hrs of the occurrence.

Investigation procedure:
1. On receipt of near miss incident report duty filled on the prescribed format by the safety
section will investigate with the assistance of the concerned section manager.
2. The management may also appoint a committee, if the near miss is of very serious nature.

Report Circulation:
1. The report shall be circulated by HSE Department to all concerned personnel.
2. The report shall be circulated within a week of reporting of near miss.
3. The section manager shall suitably communicate to all his employees.

Review:
1. The near miss report shall be circulated by HSE department to all concerned personnel.
2. The report shall be circulated within a week of reporting of near miss.
3. The section manager shall suitably communicate to all his employees.

Review:
1. The near miss report shall be reviewed in safety committee meeting.
2. Safety section shall monitor the progress of recommendation of implementation

Report maintenance:
Safety section shall keep the record of all near miss report.

Analysis of near miss:

Safety section shall make analysis of the near miss report once in six months.

Incentive for near miss reporting:

Suitable reward shall be given to person who reports minimum highest number of near misses
incidents for the year.

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 NEAR MISS REPORTING

NEAR MISS REPORTING AND INVESTIGATION FORMS

Part - A – Near Miss reporting form

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General Guidance & Instruction

1. Near Miss: - An undesired event that under slightly different circumstances could
have resulted in personnel harm, property damage or other loss such as environment
damage.
2. This form shall be filled by any person who had experienced or witnessed the Near
Miss, he may be employee or contractor or a visitor.
3. Filled form shall be submitted to safety section of HSE department either by a hard
copy or by a soft copy.

Name of the reporting Area or section /

Employee number
person department

Near Miss location Near Miss date Near Miss time

To be filled by employee

Incident brief description (Describe what happened)

Suggested measures to avoid recurrence (What actions are required to be taken to

prevent re – occurrence)

Suggested remedical measures

Signature of the reporting person : Date:

Follow up or review and close out report by safety section of HSE department (To be filled by
safety section of HSE department) :

HSE Officer with date :

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 NEAR MISS REPORTING

Part –B Near Miss reporting & Investigation from

LESSON LEARNED FROM NEAR MISS
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Section Report No: . . . . . . . . . . . . . . . . . . . .

Incident title

Description

Potential losses

Immediate cause

Contributing causes
To be filled by Safety Section

Basic cause

Lesson learned
(Recommendation)

Date Signature Designation

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 NEAR MISS REPORTING

Part – C Near Miss report form

(Recommendation compliance monitoring)
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Section Report No: . . . . . . . . . . . . . . . . . . . .

Action Closed out

S.No. Recommendation Target
Party date
To be filled by Safety Section

Review

Date: Date: Date:

Signature: Signature: Signature:

Name: Name: Name:

14 Salim Al Harthy