NO INJURY-NO INCIDENT?

Near Misses
OHT 1

Accident Ratio Study

Serious Incident

1
10
60
600

Includes recordable and disabling Injurie

Minor Injuries

Any reported injury less than a recordab

Property Damage & Incidents

All Types, including environmental relea

Incidents with no visible

Injury or Damage
(Critical Incidents - Near Misses)
OHT 2

CHAIN OF ACCIDENT CAUSATION

Basic Causes

Immediate Substandard
causes
Practices

Management Safety Policy & Decisions

Supervisory Performance
Personal Factors
Job Factors

Human Factor

Substandard
Conditions

Near Miss - Warning

ACCIDENT

Incident - Contact

unplanned release of energy

and/or
hazardous material

Focus on Near Misses

& Prevent Accidents
Accident Results

Personal injury
Property damage
Uninsured Costs
OHT 3

Accident Causes

Unsafe Act - 88%

an act by the injured person or

another person (or both) which
caused the accident; and/or

Unsafe Condition - 12%

some environmental or hazardous

situation which caused the accident
independent of the employee(s)
OHT 4

Why Minor Incidents Go

Unreported

Fear of:
Supervisor/Manager Disapproval
Getting a Bad Reputation
Being terminated or disciplined
Not Wanting To:
Lose time from the job
Risk Embarrassment, Peer Pressure
Rat on other employees or being perceived by others as a whiner
Have a incident on their work record
Be the subject of or involved in an investigation
Not knowing why minor incidents should be reported or what near misses are.
Lack of Management follow-through in the past.
Fear of having a poor or blemished safety record.

OHT 5

WHY THE RELUCTANCE TO REPORT?

Its usually inconvenient to fill out the accident

form.
Near miss experiences are private affairs.
Organizational Influences- Whats to be gained? A
pleasant or unpleasant experience.
Slogans like All injuries are preventable dont help.
Offering rewards for reporting near misses dont help.
OHT 6

A DIFFERENT FOCUS!
Environmental Assessments
Particularly Property Damage
We need to investigate property damage where
there
is no injury.
If damaged equipment or physical structures are not
repaired, injuries will eventually follow. Yet little
value is given to investigating property damage.
Litter Begets Litter. Psychologically speaking,
Property Damage begets Property Damage.
OHT 7

Why Focus on Near

Misses?

Establish Causes
Prevent Recurrences
before they become
Recordable or Serious
Establish corrective actions
Learn from the incident
Improve our companies
safety culture
Statistical safety data base

OHT 8

What is a Near Miss

Accident ?

Near miss these are events which are a unexpected

occurrence that just missed being an employee or
equipment incident or an environmental release.
One step away from a employee or equipment incident
or an environmental release
Any deviation beyond the safe operating limits of
process parameters or procedures.
Challenge the last line of defense.
Failure of any one or multiple safeguards.

OHT 9

Near Miss Examples

Operating heavy equipment too close to each other almost colliding

due to operating activities are close in proximity.
Equipment not tied down properly on the truck bed, equipment is
loose or it falls off without striking anything or anyone.
Waterblast operators blasting too close to each other without
striking each other, but could potentially have.
Backing up in a forklift without looking back and another employee
passes behind without the operator aware.
Not cleaning up a spill and someone else finding it and cleaning it up.
A truck arrives to be unloaded, during travel the load has shifted,
when the door is opened a drum falls out just missing a employee.
Kicking a brace and almost falling.
Climbing out of Bob Cat and foot slipped on step.
Slightly damaged van, pulling trailer out of dock.

Can You Think of Others?

OHT 10

MORE Examples.

Sprayed with solvent after opening 55 gallon drum.

Pallet broke, spilling chemicals, weather deterioration to pallet.
Sprayed with etch after pressure build-up in line.
Pressure in a tank caused material to shoot out probe inlet.
Stepped into open sump when unloading oil tanker.
Chemical splash, after pressure build-up at filter basket.
Guard rail broke when employee was climbing down. While excavating a area, a gas line
was struck and broken, releasing natural gas. The owner assured us prior to work that
all lines were blocked and/or locked.
An employee reached into a piece of moving equipment without shutting it down to
dislodge a jam, no injury or equipment damage occurred.This time. (Shut down
equipment and lockout/tagout)
A major release of flammable gas that forms a vapor cloud but does not explode.
A major release of a hazardous material into a storm sewer that is successfully
impounded before the material enters a waterway.

OHT 11

Investigate?????

Yes!

Near-Miss incidents, like no-injury

accidents, must be investigated whenever
reported or observed.
They are forewarnings of what can and
might happen.
An accident is almost always sure to follow
when such forewarnings
are ignored.

OHT 12

Need to Complete a Whole

Incident Investigation?

Have a separate, simple Near Miss Report Form.

For most, the Near Miss Report is all that will
be needed. The events from the Near Miss
Report will be used to show trends in safety
performance along with the Risk Ranking.
When the trend or risk ranking change,
increasing the likelihood, a full incident
investigations may be needed to determine the
cause of the change for a particular incident
cause or risk.
OHT 13

Extra
Effort
Needed
We sometimes question near miss incidents, but

the causes of todays

near miss incident, if
not determined
and corrected , may occur
again to
produce tomorrows employee or
equipment incident or an environmental release.
Accident 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 incidents
and the causes are left uncorrected!

OHT 14

Encourage Reporting of Near

Miss Incidents by

Ensuring all employees are told to report near miss

incidents.
Positively reinforcing each other when reporting
near miss incidents.
Reminding ourselves of its importance.
Sharing successes--improved work
environment
across the entire company.
Using the incident investigations Safety-O-Gram
form for the investigation and reporting document.
Having the forms readily available to all employees.

OHT 15