NO INJURY-NO INCIDENT?

“Near Misses”
OHT
 Accident Ratio Study

Serious Incident
Includes recordable and disabling Injuries
1
Minor Injuries
10 Any reported injury less than a recordable

Property Damage & Incidents

60 All Types, including environmental releases

Incidents with no visible

600 Injury or Damage
(Critical Incidents - Near Misses)

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 CHAIN OF ACCIDENT CAUSATION
Management Safety Policy & Decisions
Supervisory Performance
Basic Causes Personal Factors
Job Factors

Human Factor
Immediate Substandard Substandard
causes Practices Conditions
Near Miss - Warning
ACCIDENT
unplanned release of energy
Incident - Contact and/or
hazardous material

Focus on Near Misses

& Prevent Accidents
Personal injury
Accident Results
Property damage
Uninsured Costs

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 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
 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.

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 WHY THE RELUCTANCE TO REPORT?

It’s usually inconvenient to fill out the “accident

form”.

Near miss experiences are “private affairs”.

“Organizational Influences”- What’s to be gained? A

pleasant or unpleasant experience.

Slogans like “All injuries are preventable” don’t help.

Offering rewards for reporting near misses don’t help.

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 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”.
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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
 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
 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 1

 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.

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 Investigate????? Ye
 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.

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 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.

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 Extra Effort Needed
 We sometimes question near miss incidents, but
the causes of today’s near miss incident, if
not determined and corrected , may occur
again to produce tomorrow’s 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!

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 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 investigation’s Safety-O-Gram
form for the investigation and reporting document.
 Having the forms readily available to all employees.

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