Near Misses/Close Calls What are they? Why are they important?
Near Misses • EX. Look at video & count them. Disregard sporting events like football, football basketball, basketball soccer, soccer tennis, tennis bowling,etc. bowling etc • 1) Man in parked car 2) lady crossing st. nearly hit by 2 vehicles 3) Guy in the road 4) Guys in PU truck 5) Guys vehicles. almost hit along the road 6) Train almost hits people on tracks. 7)) Robbers gget awayy despite p ppolice being g there. • 8) Driver gets thru intersection 9) Lady on balcony almost falls. 10) Parked car moves at last sec. misses falling tree. 11) Guy on cycle almost wipes out. • SEE Video #2 intersection
Near Misses • • • • •
What do they teach us? Something is right or wrong? ANSWER LACK OF TRAINING? LACK OF EXPERIENCE? Are most incidents caused by Unsafe acts/Unsafe conditions? Or both?
What % of incidents do you believe have f acts/conditions as their pprimaryy unsafe cause? Unsafe Acts
UNSAFE ACTS • EXAMPLES: • • • • •
NOT FOLLOWING PROCEDURES TAKING SHORTCUTS NOT WEARING PPE WHEN NEEDED TAKING DRUGS OR ALCOHOL NOT WAITING FOR HELP TO LIFT
UNSAFE CONDITIONS • EXAMPLES: • • • •
POOR HOUSEKEEPING OIL ON FLOOR NO GUARDS ON MACHINE WET, MUDDY JOBSITE OR MACHINE, SLIPPERY ROAD, ROAD ETC. ETC
The Incident Pyramid 1 FATALITY 30 SEVERE INJURIES 300 MINOR INJURIES 2000 NEAR MISSES 20,000
L.T. MED. ONLY
B h i Behavior
Fatality Severe Injury Minor Injury
At-Risk At Ri k Results
Incident Investigation In estigation
Incident Investigation Strategy • Gather information and establish the facts • Isolate the contributing factors to the cause • Determine corrective action(s) to prevent recurrence
Fact Finding g FAULT FINDING
Manyy incident investigations g wrongly gy pinpoint this as the cause:
Symptoms vs. Causes
Direct Cause of j y Injury
Cuts Un gu ar
B ro k en
Chem ic a
lay s ep r o H
te a Crea s
Defec tive PPE
Untr t ained w
ctt Fails to inspec
Fails to enforce
Lack of time work To much
Inadequate training No discipline procedures No orientation process I d Inadequate t training t i i plan l No accountability policy
a rd a haz e r o n Ig jury rt i n o p re s to Fail
Fails to tr
ack of vision N No mission stattement
Inadequate labeling Outdated hazcom program l plan iti No recognition N
No inspection policy
SYMPTOMS Unsafe acts and conditions which we can see
CAUSES • The underlying reasons for accidents which hi h we can’t ’t see. • • • •
Can only be identified through investigation and root cause analysis study
• WHO? WHAT? WHEN? WHERE? WHY? • WHO CAN MAKE IT BETTER? • HOW? BETTER INVESTIGATIONS AND REPORTING NEAR MISSES
– NOT WHOSE AT FAULT?
• WHO IS RESPONSIBLE for SAFETY? • The Employee? • His SUPERVISOR? • Are BOTH responsible? p
Hear no evil, See no evil, Speak no evil
• SUPERVISORS RESPONSIBILITES: 1) Conduct immediate initial accident investigations. investigations 2) Collect and preserve all evidence. 3) Conduct interviews of witnesses. 4) Take action to protect people and property at the accident scene. Get injured to doc.
• EMPLOYEE RESPONSIBILITES: 1) Immediately report all accidents & injuries to their supervisor. supervisor 2) Assist in all accident investigations. 3) Report all hazardous conditions and nearmisses to supervisors & complete form.
• Notice of “Near Near-Miss Miss” • •
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This form is to be used to document a “NEAR-MISS NEAR-MISS.” A Near Miss is defined as “an incident that may have resulted in personnel injury, equipment damage or a combination of the two, but did not.” ( p (Optional Name:____________________ Job Title:________________ Facility / Work Location:________________ Description Of “Near Miss:________________________________________ If you need more room, room use reverse side of form or additional paper paper.
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• Notice of “Near-Miss” Near-Miss • •
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What factors do y you feel may y have contributed to this “near miss”? ((For example: inattentiveness, improper PPE* or tools, inadequate procedure, lack of training, etc.) Please be specific. If you need more room, use reverse side or additional paper._____________________________________________ What do you feel would prevent this type of “near miss” in the future? (For example: better PPE or tools, revising a procedure, specialized training, etc.) Please be specific. If you need more room, use reverse side or additional paper.___________________________________________________________
Signature of Reporter:________________________(Optional) Reporter: (Optional) Date:__/__/2009
• Notice of “Near-Miss” Near-Miss •
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This “near miss” report will be distributed throughout the PARISH. You have the option of allowing parish management to use your name, or to remain anonymous when this report is distributed to all departments (your name will be removed). *PPE means personal protective equipment like safety goggles or gloves. YOU MAY USE MY NAME AS IT APPEARS ON THIS REPORT FOR PUBLICATION PURPOSES: (Circle/Check Appropriate Box) YES NO • • Please Send Completed p Form To Your SUPERVISOR. •
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Bottom-Line Results • Investigate incidents only – scratch the surface and lots of info. gets by the radar. • Investigate unsafe acts and conditions – we’re still not getting it all. • Investigate i Near Misses i andd all ll incidents i id much better data and chance to • PREVENT LOSSES.