TPM Safety Pillar

Concept of Near Misses

Tomasz Kuś | 20 September 2011 HEINEKEN Supply Chain BV

Accident Causes

♦Unsafe Behavior - 88%

■An action of the injured person or
another person (or both) which
caused the accident;

♦Unsafe Condition - 12%

■Some environmental or hazardous
situation which caused the accident
independent of the employee(s)
Safety pyramid (basic)

Research has shown that each

1 accident causing an injury is
preceded by more similar
Accident
events which didn’t cause
injuries.

29 On 330 events of the same type

and suffered by the same
Incidents
person, 300 don’t cause
injuries (Near Misses), 29 cause
injuries (Incidents) and 1 causes
300 absence from work (Accident)

Near Misses
Safety pyramid – Extended version in Heineken
Definition of the 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.
(Only a fortunate break in the chain of events prevented
an injury, fatality or damage)

in other words:

♦ Near Misses these are events which are an unexpected

occurrence that just missed being an employee or
equipment accident (incident) or an environmental
release.
 HMESC Safety procedures – Definitions (HMESC: 01.40.01.503)

♦ Accident
■ An instantaneous, unplanned and undesired work-related event which results in
death or personal injuries involving loss of working time (ILO definition) (lost
day case)
■ Serious Accident
● An accident which results in death or permanent disability or which requires
hospitalization for more than 24 hours or resulting in more than 3 lost days
■ Minor Accident
● Any accident not falling into the serious accident category but leading to lost days
♦ Incident
■ an instantaneous, unplanned and undesired work-related event which causes
personal harm or other damage and requires only medical treatment (no lost
day)
♦ Near miss
■ an instantaneous, unplanned and undesired work-related event that, under
slightly different circumstances, could have caused an accident or incident
Why are Near Misses not recorded? (1)

♦ Fear of:
 Supervisor/Manager Disapproval
 Getting a Bad Reputation

 Being terminated or disciplined

♦ Not Wanting to:

 Lose time from the job
 Be perceived by others as a “whiner”

 Be the subject of or involved in an investigation

♦ Notknowing why minor incidents should be reported or what

near misses are.

♦ Fear of having a poor or blemished safety record.

Why are Near Misses not recorded? (2)

It’sthe
Why
 usually inconvenient
reluctance to fill
to report? out the “Near Miss form”.

 Near Miss experiences are considered as “private issues”.

 Organizational Consequence- What’s to be gained? A

positive or negative experience.

 Offering rewards for reporting near misses not always helps.

Why Focus on Near Misses?

♦ Establish Causes

♦ Prevent
Recurrences before they
become Accidents (Incidents)

♦ Establish corrective actions

♦ Learn from the events

♦ Improve our company safety culture

Why should we investigate Near Misses

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

must be investigated

♦ They
are forewarnings of what can and
might happen.

♦ An accident (incident) is almost always sure

to follow when such forewarnings are
ignored.
Extra Effort Needed

♦ We sometimes question near misses, but the causes of

today’s near misses are not determined and corrected
they may occur again to produce tomorrow’s employee
or equipment accident (incident) or environmental
release.

♦ Near miss investigations must be directed not only at

what did occur but also the potential of what could
have occurred.

♦ INVESTIGATE ALL NEAR MISS INCIDENTS! Nothing is

learned from unreported Near Misses and the causes
are left uncorrected!
Some examples of Near Misses
Near Miss – example (1)

The school bus stopped

to give the way the red
car which pass the road
cross on the red lights.

No injury or damage,
however it was very
close to an accident.
Near Miss – example (2)

Aircraft cruising height of

those two airplanes are
too small.

Under certain conditions

it could lead to an
accident (crash)
Near Miss – example (3)

Protruding bolt could

injury the second worker
Near Miss examples (from Elblag Brewery)

See comment on next page!

Near Miss examples

♦ 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 unsafe

condition cannot be removed and the personnel has been trained
to 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.
Near Miss examples (from Elblag Brewery)
Do not mix Near Misses with Unsafe Conditions

Do not wait with recording

unsafe conditions (and
improving conditions) until
Near Miss or Accident
(Incident) happens

Be sure what is a Near Miss or

an Unsafe Condition

Until nothing happened it is

not a Near Miss
Some examples not being Near Misses

The oil on the floor is not a Near

Miss. It is just unsafe conditions, Similar situation is with
however it can lead to an hoses on the floor. It is not a
accident. near miss.
Encourage Reporting of Near Misses by…

♦ Ensuring all employees are told to report near

misses.

♦ Positively reinforcing each other when reporting near

miss.

♦ Reminding ourselves of its importance.

♦ Sharingsuccesses--improved work environment

across the entire company.

♦ Having the forms readily available to all employees.

Example of the information flow

The Safety pillar should analyze

The involved person should
the near-miss report and plan
fill the near-miss report form
appropriate actions

Near
miss

Communication of the event to

the management and to all the
personnel when the event could Actions
have caused major problems
How to establish Near Miss recording system?

 Provide the communication about Near Misses to everyone

in the plant including good understanding of definition.
 ( Campaigns, posters, movie in the canteen, discussions)

 Prepare Near Miss form. Easy to fill and available

everywhere
 ( 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 positive

atmosphere and link this discussion with improvement of
their workplaces
 ( Give a feedback from the analysis to all people who were or could be affected
by the Near Miss. Show them improvements.)
 TPM Safety Pillar

Concept of Near Misses

End of presentation

Tomasz Kuś | 20 September 2011 HEINEKEN Supply Chain BV