LEPC Conference - Near Miss Reporting Improving The Safety Culture

Near Miss
Reporting
Improving the
Safety Culture
Greg McKeeman, EHS Professional
Near Miss Reporting Improving the Safety

Culture
What is a near miss and what caused it to
happen? Why should near misses be reported
and how can they pave the way to a better
safety culture? If you dont know the answers
to these questions, plan to attend this
presentation!
Near Miss Reporting -
Improving the Safety Culture
Contents
Introduction
Near Miss Reporting
Definitions
Examples
Benefits
History and Theory
Implementing a Near Miss Program
Analyzing near misses (Eight Step Approach
to a successful near miss program)
Near Miss Reporting
Why isnt it called a near hit instead of a

near miss if it nearly missed, then didnt
it actually hit?
Definition of a 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 (Wikipedia).
An event, circumstance, condition or behavior which
has the potential to cause-injury, illness, accidental
release or property/productivity loss but did not
actualize due to chance, corrective action and/or
timely intervention.
Other familiar terms for these events is a

"close call", or in the case of moving objects, "near collision" or a
near hit.
Near Miss Definitions

OSHA provides the following definition of
a near miss in an Accident Investigation
Fact Sheet:
incidents where no property was
damaged and no personal injury
sustained, but where, given a slight shift in
time or position, damage and/or injury
easily could have occurred.
Examples of a Near Miss

Examples of a Near Miss

1. A forklift brushes the bottom of a storage rack
column. The operator drives off. The racking
doesnt fall and doesnt appear damaged.
2. A pedestrian walks in front of a forklift operator. The
forklift operator slams on the breaks. There is no
collision and no one is injured.
3. A forklift operator is stacking a high load, the load
shifts forward and crashes to the ground. No one is
injured, but the product on the pallet is damaged.
4. A pedestrian slips on some fluid that had leaked
from a forklift. The pedestrian falls to the floor, but is
not injured.
http://www.youtube.com/watch?v=WHWJYaGO4DE
Benefits of Reporting a Near

Miss
There are several benefits to having a near-
miss reporting culture in place, including
these:
Enables pro-active resolution of hazards
Engages the workforce
Increases safety ownership and reinforces
workers self-esteem.
Exposes valuable information that otherwise
might not be discussed.
Develops a positive attitude surrounding safety.
Others Benefiting from Near

Miss Reporting
Aviation - The Aviation Safety Reporting System
(ASRS) has been collecting confidential
voluntary reports of close calls from pilots, flight
attendants, air traffic controllers since 1976.
Fire-rescue services In 2005 the National Fire
Fighter Near Miss Reporting System was
established.
Healthcare A US based professional
organization of Registered Nurses developed
SafetyNet
S afe ty Ic e be rg
Near misses must be given the same priority as accidents
Upper management
Major event Reactive

w ork
day
Re
(acute)
t
Los Firs str
ict
t ai ed
d
Medical
Day-
Day-to-
to-day management
Investigate
s
Proactive ar mis A major
Ne event?
(chronic) Un
saf
ec
on d
itio
n
Trend s
ct az ard
f ea h
Un
sa
o rted
rep
Un Behavioral-
havioral-based
safety management

The culture of an organization can be

defined as the way we do things around
here.
As such, culture provides a context for
action which binds together the different
components of an organizational system in
the pursuit of corporate goals (Improving
Safety Culture, A Practical Guide. Dr.
Dominic Cooper, 2001).
Improving the Safety Culture:

A look back in History
During the 19th and early 20th centuries
many safety practitioners took the view that
safety was all about controlling physical
work conditions.
Heinrichs Domino Theory (1931). Accidents
were caused by either an unsafe act, an
unsafe condition, or both.

Incident Ratio Model
Heinrichs Theory
Serious Injury or Death

Most Accident 1
Investigations
Conducted
29 Biggest
Minor Injury percentage
of injury
Few Investigations causing
Conducted potential!
300
Near Miss
3,000
Unsafe Acts, Behaviors or Conditions

A look back
In 1976 E. Adams changed the emphasis of
the first three dominos to reflect
organizational rather than person features.

A look back
Although the above models have proved
useful in identifying the sequences of events
in the accident causation chain, they have
largely failed to specify how and under
what conditions each of the sequential
elements might interact to produce
accidents.
In 1988, Professor James Reason likened the
accident causation process to resident
pathogens in the human body.

A look back
Implementing a Near Miss

Program
A Near Miss Program can be defined as
an administrative tool to help reduce
accidents and injuries in the workplace.
Should address three disciplines in the

workplace.
1) Environmental
2) Safety
3) Health
Objectives of implementing a
Near Miss Program
Identifyrisks and prevent future accidents
Fix problems as they are identified
Make everyone an advocate of safety
Increase safety awareness
Options Of Implementation
There are several ways to ensure your near
miss program is executed and maintained.
Near
Miss Management Team
Comprised of a diverse team of employees,
managers, supervisors and workers.
Options, cont.
SafetyCommittee
Your safety committee can implement and
manage your near miss program.
Single
Person
You can designate a single person responsible to
manage the program
Training
There are two types of training associated
with a near miss program.
1) Administrative for administrators

2) Employee
Administrative Training
For the administrators, subjects should

include the guidelines at which the program
will function e.g., prioritizing, tracking and
responsibilities.
Employee Training should focus

on:
What are near misses
Why are near misses important and how they
can help
What is the role of each person in near miss
reporting
How will near misses be managed and by who
What is the near miss process (eight steps)
How do you report a near miss
How would you prioritize a near miss
Where to find near miss reporting forms
Employee Recriminations
Employees may be reluctant to report near
misses due to potential recriminations that
could result.
Such as:
Peer pressure
Disciplinary action
Unintended disciplinary action. For example, upon
incident investigation, additional job tasks or wearing
cumbersome PPE may be perceived as punishment for
reporting
Analyzing near misses: Eight Step

Approach to a successful near
miss program
Eight Steps
There are eight steps to an effective near
miss program.
Identification
Disclosure
Prioritization
Distribution
Root-cause analysis
Solution identification
Dissemination
Resolution
Step 1
Identification
The individual must recognize an incident

or condition as a near miss.
There must be a clear definition of what a
near miss is within your organization.
Step 2
Disclosure
Once a near miss is identified, it must be

disclosed, preferably in writing. Having a
simple procedure for reporting will encourage
this process. Having easy access to forms is
a key component to encouraging
participation.
Step 3
Prioritize
Once an incident has been reported it

must be prioritized. This very critical step
determines the path forward as to what
level of attention is needed. This should be
reviewed by management to help determine
the risk.
Step 4
Distribution
Distribute the near miss information to the

people that can help properly analyze the
cause of the incident. Ask for their
immediate feed back.
Step 5
Identification of Causes
Both direct and root-causes should be

determined. It could be a behavior based or
training based cause or other. Look at all
possible aspects of causes.
Step 6
Solution Identification
A solution for each identified cause should

be determined.
Step 7
Dissemination
Once solutions are identified, the information

should be communicated to the people who
will execute the solution.
Step 8
Resolution (Tracking)
Once solutions are identified and the

implementers are informed, it is important to
track all suggested changes to ensure that
they are properly executed.
Final Tips
A near miss in the workplace is a warning or
indication that something is wrong
Close calls or near misses on the job should be
corrected immediately
Constant safety awareness on everyones part is
the most important factor in accident prevention
Final Tips, cont.

Ifyou witness or are involved with a near miss
incident, stop and correct the problem or notify
the appropriate people immediately
Do not just shrug-off a near miss. Stop what you
are doing and report it.
Dont have the attitude that Thats the way we
have always done it.
Implementing a Near Miss

Program: OSHA regulations
In addition to making good business sense in terms of preventing
future accidents, there are OSHA requirements to investigate or take
action after certain near misses:
OSHAs Permit-Required Confined Spaces Standard, 29 CFR
1910.146, requires employers to review the entry program when
there is a near miss during entry.
OSHAs Powered Industrial Truck Standard, at 29 CFR 1910.178,
requires that refresher training in relevant topics be given to
operators involved in a near miss.
OSHAs Construction Fall Protection Standard, at 29 CFR 1926.502,
requires that employers investigate falls and near misses.
OSHAs non-mandatory Appendix A to the Process Safety
Management of Highly Hazardous Chemicals Standard, 29 CFR
1910.119, notes that OSHA expects employers to become aware of
and to investigate near misses that could have serious
consequences
J. J. Keller & Associates, Inc.,
THANKS
Greg McKeeman, EHS Professional

Corporation
1600 Perimeter Park Drive, Suite 400
Morrisville, NC 27560
Tel: 919.461.1210
Greg.McKeeman@urs.com

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Near Miss

Near Miss Reporting Improving the Safety

Near Miss Reporting

Why isnt it called a near hit instead of a

Definition of a Near Miss

Other familiar terms for these events is a

Near Miss Definitions

Examples of a Near Miss

Examples of a Near Miss

Benefits of Reporting a Near

Others Benefiting from Near

Major event Reactive

Near Miss Reporting -

The culture of an organization can be

Improving the Safety Culture:

Improving the Safety Culture

Serious Injury or Death

Improving the Safety Culture:

Improving the Safety Culture:

Improving the Safety Culture:

Implementing a Near Miss

Should address three disciplines in the

1) Administrative for administrators

For the administrators, subjects should

Employee Training should focus

Analyzing near misses: Eight Step

The individual must recognize an incident

Once a near miss is identified, it must be

Once an incident has been reported it

Distribute the near miss information to the

Both direct and root-causes should be

A solution for each identified cause should

Once solutions are identified, the information

Once solutions are identified and the

Final Tips, cont.

Implementing a Near Miss

Greg McKeeman, EHS Professional

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