NO INJURY-NO INCIDENT?

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NO INJURY-NO INCIDENT?

• Near Misses

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Accident Ratio Study
Serious Incident Includes recordable and
disabling Injuries
1
Minor Injuries Any reported injury less than a
recordable
10
Property Damage Incidents All Types, including
environmental releases
60
Incidents with no visible Injury or Damage
(Critical Incidents - Near Misses)
600
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CHAIN OF ACCIDENT CAUSATION
Management Safety Policy Decisions Supervisory
Performance Personal Factors Job Factors
Basic Causes
Human Factor
Substandard Practices
Substandard Conditions
Immediate causes
Near Miss - Warning
ACCIDENT unplanned release of energy and/or hazard
ous material
Incident - Contact
Focus on Near Misses Prevent Accidents
Accident Results
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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)

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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?
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.
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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. Property Damage is a physical trace of
an incident.
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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

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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.

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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?
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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?????

• 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 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!

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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 investigations Safety-O-Gram
  form for the investigation and reporting
  document.
• Having the forms readily available to all
  employees.