Concept of Near Misses-Jan2012

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Revision No 02, Jan 2012

Revision No: 02 Document Type: Knowledge Item Issued By: L. Giordano, T.KusDate: Jan 2012 Filename: Safety Pillar, Concept of Near Misses

Concept of Near Misses




♦

■

♦ ■




1

Accident

29Incidents

300

Near Misses

Research has shown that eachaccident causing an injury ispreceded by more similarevents which didn’t causeinjuries.

On 330 events of the same typeand suffered by the sameperson, 300 don’t causeinjuries (Near Misses), 29 causeinjuries (Incidents) and 1 causesabsence from work (Accident)




♦ A is an unplanned event that did notresult in injury, illness, or damage – but had thepotential to do so.(Only a fortunate break in the chain of events preventedan injury, fatality or damage)

in other words:

♦ these are events which are an unexpectedoccurrence that just missed being an employee orequipment accident (incident) or an environmentalrelease.




♦

■ An instantaneous, unplanned and undesired work-related event which results indeath or personal injuries involving loss of working time (ILO definition) (lostday case)

■

● An accident which results in death or permanent disability or which requireshospitalization for more than 24 hours or resulting in more than 3 lost days

■

● Any accident not falling into the serious accident category but leading to lost days

♦

■ an instantaneous, unplanned and undesired work-related event which causespersonal harm or other damage and requires only medical treatment (no lostday)

♦

■ an instantaneous, unplanned and undesired work-related event that, underslightly different circumstances, could have caused an accident or incident




♦ Fear of:Supervisor/Manager DisapprovalGetting a Bad ReputationBeing terminated or disciplined

♦ Not Wanting to:Lose time from the jobBe perceived by others as a “whiner” Be the subject of or involved in an investigation

♦ Not knowing why minor incidents should be reported or whatnear misses are.

♦ Fear of having a poor or blemished safety record.




It’s usually inconvenient to fill out the “Near Miss form”.

Near Miss experiences are considered as “private issues”.

Organizational Consequence- What’s to be gained? Apositive or negative experience.

Offering rewards for reporting near misses not always helps.




♦ Establish Causes

♦ Prevent Recurrences before theybecome Accidents (Incidents)

♦ Establish corrective actions

♦ Learn from the events

♦ Improve our company safety culture




♦ Near- Misses, such as “no - injury” events,must be investigated

♦ They are forewarnings of what can andmight happen.

♦ An accident (incident) is almost always sureto follow when such forewarnings areignored.




♦ We sometimes question near misses, but the causes of today’s near misses are not determined and correctedthey may occur again to produce tomorrow’s employeeor equipment accident (incident) or environmentalrelease.

♦ Near miss investigations must be directed not only atwhat did occur but also the potential of what couldhave occurred.

♦ INVESTIGATE ALL NEAR MISS INCIDENTS! Nothing islearned from unreported Near Misses and the causesare left uncorrected!




Aircraft cruising height ofthose two airplanes are

too small.

Under certain conditionsit could lead to anaccident (crash)




Protruding bolt couldinjury the second worker




from Elblag Brewery)

See comment on next page!




♦ In the example of the previous slide the slippery floor is an

unsafe condition.■ The person walking there should know not to step into it (when he

does it, it is an unsafe act).■ When slippery floors cannot be avoided, personnel should be trained

how to walk there: slowly, hand to a handrail, etc.■ When despite the training the person falls, it is a near miss.

♦ So a near miss is an occurrence in a situation where the unsafecondition cannot be removed and the personnel has been trainedto handle the unsafe condition.

♦ Why this distinction:■ Unsafe conditions shall be removed immediately !■ Not to wait for forms to be filled out, meetings to discuss etc.




(from Elblag Brewery)




Do not wait with recordingunsafe conditions (and

improving conditions) until

Near Miss or Accident(Incident) happens

Be sure what is a Near Miss oran Unsafe Condition

Until nothing happened it isnot a Near Miss




The oil on the floor is not a Near

Miss. It is just unsafe conditions,however it can lead to an

accident.

Similar situation is withhoses on the floor. It is not a

near miss.




♦ Ensuring all employees are told to report near

misses.

♦ Positively reinforcing each other when reporting nearmiss.

♦Reminding ourselves of its importance.

♦ Sharing successes--improved work environmentacross the entire company.

♦ Having the forms readily available to all employees.




The involved person should

fill the near-miss report form

The Safety pillar should analyzethe near-miss report and plan

appropriate actions

Communication of the event tothe management and to all the

personnel when the event couldhave caused major problems




Provide the communication about Near Misses to everyonein the plant including good understanding of definition.

( Campaigns, posters, movie in the canteen, discussions)

Prepare Near Miss form. Easy to fill and availableeverywhere

( The form should be available in every workplaces. Collecting boxes should be

found on the area only –

e.g. line)Engage the Management Team to record Near Misses.Publish Near Misses recorded by the management team

( The Management Team should give an example)

Discuss with people their Near Misses in the positiveatmosphere and link this discussion with improvement of their workplaces

( Give a feedback from the analysis to all people who were or could be affectedby the Near Miss. Show them improvements.)



Revision No 02, Jan 2012Revision No: 02 Document Type: Knowledge Item Issued By: L. Giordano, T.KusDate: Jan 2012 Filename: Safety Pillar Concept of Near Misses

Concept of Near Misses

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Concept of Near Misses-Jan2012

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