Colorado Rural Electric Association

2009 Loss Control Conference

NEAR MISSES

REPORT/LEARN/USE

Presented By:

Eldon Humphers, CLCP-CUSA

July 14, 2009

NEAR MISSES

A near miss can be an effective tool for

management of safety, health and

environmental programs

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Each cooperative should have in place a

management structure for the application of

a near miss program

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Current Trends in the areas of

Economic Political Regulatory

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Current Trends Have Created The Necessity for

Development of Integrated EHS System

& Focus on Proactive Measures

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Near Misses are one of the best indicators of future problems involving the health and safety of employees.

Detecting Near Misses and Addressing Them Can Improve The Overall Safety Program of A Cooperative.

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Cooperative Safety Programs Are Being Recognized As An Important Reflection of the performance of the Cooperative.

RESAP Currently Using A Cooperative’s Injury Index As A Part of The Accreditation

Process

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Effective Management of EHS Programs

Improve Cooperative’s Operation

Reduce Operating Costs

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Outside influence Non-Governmental

•RESAP•Expectations •Transparency of Cooperative’s

Operation New Demands

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Outside Influence Regulatory Agencies

–OSHA–EPA

•Pro-Active Practices

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PROACTIVE PROTECTION Accident Pyramid Frank E. Byrd, JR Widely Used Widely Accepted

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Accident Investigation Adds New Data One Bad Accident Several Minor/Near Miss Incidents

•Little or No Significant Damage

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Accident Pyramid

Bottom of the Pyramid Information Gained On-Going Basis Identify Potential Exposures

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Address problems when they are identified

Reduce Probability Minimize the Damage

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Effective Management

Identify Weaknesses Reduce Accident Rate Provide Guidance For Improvement

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Proactive Prevention Utilize Minor Incident Information Based on Analytical Approach Systematic Procedure Develop Prognosis Opportunity To Improve Safety

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Near Miss Program

Analysis of Potential Problems Identification of Causes Find Solutions Implement Solutions

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NEAR MISSES ARE THE INCIDENTS AND

OBSERVATIONS AT THE BOTTOM OF THE

PYRAMID.

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Definition Vary From System to System Vary From Person to Person Some Are Narrow Some Are All Inclusive

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Definition

Broader Definitions Increase The Probability

Of Identifying Potential Problems At Their

Earliest Stages

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DEFINITION Example

A Near Miss Is An Opportunity To Improve

Safety, Health, Environmental and

Security of An Operation Based On A

Condition Of An Incident With Potential

For More Serious Consequence.

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Near Misses Always Reflect The Current Status Of A System.

Data Provided by Near Miss Program is Immediately Applicable

Near Miss Management Should Be a Key

Component of EHS Program

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Safety Programs Usually Only Address An Incident After It Happened.

Near Miss Programs Address Incidents and Observations With The Potential For Serious Consequences.

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Consequence

Injury To An Employee Property Damage Damage To The Environment Business Interruption

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LOSS CONTROL INSPECTIONS

•CREA LOSS CONTROL DEPARTMENT•INSURANCE COMPANY LOSS

CONTROL•OSHA•EPA

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INSPECTIONS

IDENTIFY POTENTIAL NEAR MISSES

REPORTS ARE PROVIDED DO YOU TAKE ACTION

OBSERVATION EXAMPLE

SUBSTATIONS

Electrical Tools

Guards should

be in place on

grinders.

Tool rest-1/8”

Tongue guard-1/4”

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THE CONDITIONS REPRESENTED BY THE PREVIOUS SLIDES ARE NEAR MISSES.

IT IS ONLY A MATTER OF TIME UNTIL AN EMPLOYEE SUFFERS AN INJURY.

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Feed Back Initial Cooperative Report Immediately After Investigation Discussions With Management Fine Tune Near Miss Program

Eight Steps of Effective Near Miss Process

•Identification•Disclosure•Priortization•Distribution•Identification of Causes•Solution Identification•Dissemination•Resolution

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IDENTIFICATION

First Step

Recognition

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DISCLOSURE Written Form Reporter Supervisor Procedure Increase Probability

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PRIORTIZATION

Critical Step Depth of Analysis Allocation of Resources Extent of Dissemination

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DISTRIBUTION Those Who Will Analyze Low Priority High Potential Often Occurring Pre-Determined

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IDENTIFICATION OF CAUSES Direct/Root Causes Reporter Committee Priority Determines Extent

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SOLUTION IDENTIFICATION

For Each Cause No Effective Solution Noted Address Each Cause

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DISSEMINATION Communicate Solution Stall The System Manager Permission Inform All Interested Parties Distribution List

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RESOLUTION (TRACKING) Changes

•Execution•Completion•Inform Reporter

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Management System Oversight Team Local Team Near Miss Process Electronic Management Check Effectiveness Training Programs

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Oversight Team Requirements

Define Objectives, Make-Up and Procedures

Guidance In Specific Issues Monitor Performance

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Oversight Team

First Step To Be Implemented

Composition•Managers•EHS Directors/Managers

NEAR MISSES NEAR MISS MANAGEMENT TEAM Responsibilities

•Identify Rules/Responsibilities•Define Details•Design Format•Set Up Criteria•Conflict Resolution•Monitor Performance

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Auditing Quality Control Critical Step Identify and Fix Problems All Levels of Employees

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Training Two Types

•Administrators–Those who will manage the

program

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Administrator Training

Guidelines Tracking Evaluation Improvement

NEAR MISSES Employee Training Subjects

What Are Near Misses Importance of Near Misses Role of Those Involved Near Miss Management System Team Members

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Employee Training Subjects

Near Miss Process Prioritization Help

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Near Miss Management

Powerful Tool Engages Employees Detect Problems

NEAR MISSES Management Support

Full Support Active Involvement Continuous Follow-Up Encourage Reporting Reward Participation Lead By Example

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Seamless Integration

Apply to All Sharing problems Sharing Solutions Enhance Value of Program

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Seamless Integration

Safety Culture Sensitized Employees Reduce Health & Safety Concerns Improve Efficiency

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Single Systems Two Types

•Single–Cumbersome –Detailed–Discourage Employees

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Parallel Systems Confusion Among Employees Which Incident to Report Hybrid System

•Eliminates Problems •Same Procedures

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CONCLUSIONS Best Indicators Resolved Properly Reduce Accidents Improve Quality Improve Productivity

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CONCLUSIONS All Encompassing

•Safety – Health – Environment – Security

•Production & Quality of Work•Timely Indicator•Proactive Program

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Proactive Protection Program Empowers Employees Enables Observation/Resolution Reflects Current Information Identifies Sources of Problems Provides Control of Health & Safety

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A NEAR MISS PROGRAM CAN BE

EXTENDED TO THE PUBLIC SECTOR

BE AWARE

BE SAFE

BE HAPPY

THANKS