jurnal nearmiss incident management

8/16/2019 jurnal Nearmiss Incident Management

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Risk Analysis, Vol. 23, No. 3, 2003

Near-Miss Incident Management in the Chemical

Process Industry

James R. Phimister,1 Ulku Oktem,

1∗ Paul R. leindor!er,

1 and "o#ard unreuther

1

This article provides a systematic framework for the analysis and improvement of near-miss

programs in the chemical process industries. Near-miss programs improve corporate environ-

mental, health, and safety (EHS performance through the identification and management of near

misses. !ased on more than "## interviews at $# chemical and pharmaceutical facil-ities, a seven-stage framework has %een developed and is presented herein. The framework ena%les sites to

analy&e their own near-miss programs, identify weak management links, and implement

systemwide improvements.

$% &OR'() Near-miss management' precursors' process industries' safety

1. IN*RO'UC*ION

n review of adverse incidents in the process in-dustries, it is o%served, and has %ecome accepted, that for every serious accident, a larger num%er of inci-dents result

in limited impact and an even larger num-%er of incidentsresult in no loss or damage. This o%ser-vation is captured in

the well-known Safety )yramid shown in *ig. ".("

ncidents at the pyramid pinnacle, referred to in this

article as accidents,$ may result in in+ury and loss,

environmental impact, and significant disruption anddowntime of production processes. These incidents areoften o%vious, are %rought to the attention of man-agement,and are reviewed according to site protocols. Near missescomprise the lower portion of the pyra-mid. Theseincidents have the potential to, %ut do not,

1 isk anagement and ecision )rocesses /enter, 0perations

and nformation anagement, The 1harton School of anage-

ment, 2niversity of )ennsylvania.1∗ 3ddress correspondence to 2lku 0ktem, irector of the Near-iss )ro+ect, isk anagement and ecision )rocesses /en-ter, "4$4Stein%erg Hall-ietrich Hall, 45$# 6ocust 1alk,

)hiladelphia, )3 "7"#8-5455' 0ktem9wharton.upenn.edu.2 The term :accident; is used to imply solely an incident that in-volves some form of loss to an individual, environment, property, and

1. The "7?5

Space Shuttle/hallenger e=plosion.Engineers hadidentified andreported de-

graded 0-ringseals on previousmissions dat-ing

%ack to "7?$with degradationincreasing asam%ient lift-off temperaturedecreased. Thenight %efore thedisaster,management had

%een warned of the potential for catastrophicfailure whenlifting off atam%ient tempera-

tures of @4◦

* or

%elow (the lift-off temperature was

45◦

*.($

2. The "77AHindustanrefinerye=plosion in n-dia. Si=ty peopledied and morethan "#,###metric tons of

petroleum-%ased


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products were released to the atmosphere or %urned. 1ritten complaints of corroded andleaking transfer lines where the e=plosion

originatedwent un-

heeded.(4

++ #$A$-844$


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++ Phimister et al.

1

serious

injury

Accidents

10 minor injuries

60 incidents with

property damage

Near

Misses 600 incidents without damage or loss

? unsafe/hazardous

conditions

ig. 1. Safety pyramid (the lowest strata, unsafe conditions, is not shown %y !ird and Cermain("

.

3. The "777 )addington train crash catastrophe in

which 4" people died. *rom "774D"777, eight near misses, or :signals passed at dan-ger; (S)3S,had occurred at the location where the eventualcollision and e=plosion oc-curred (Signal "#7. 3tthe time of the crash, the signal was one of $$

signals with the great-est num%er of S)3S.(8

4. The "77? orton e=plosion and fire result-ing

from a reactor temperature e=cursion. Nine peoplewere in+ured, two seriously. n an accidentinvestigation, the /hemical Safety !oardconcluded> :anagement did not in-vestigateevidence in numerous completed %atch sheets andtemperature charts of high temperature e=cursions

%eyond the normal operating range.; 3

disproportionate num%er of e=cursions resulted

after the process was scaled-up.(@

3s these e=amples illustrate, failure to %enefit from near misses to identify and remedy systemic flaws can producecatastrophic results. To reduce the likelihood of futurecatastrophe and further improve employee safety, processrelia%ility, and environment integrity, management systemsthat recogni&e operational weaknesses need to %e

developed to seek and utili&e near-miss incidents.(5

These

programs operate under the um%rella of :near-missmanagement systems.;

Near-miss management systems have %een devel-oped

and are implemented across a range of indus-tries,

including the chemical and process, airline, rail, nuclear,

and medical disciplines. 3 compilation of pa-pers with a

cross-industry perspective

is provided in Near-Miss Reporting as a

Safety Tool .(A

The %ookil-

lustrates how management

strategy and program im-

plementation vary

according to application

area.

1ithin the chemicaland process industries,anal-ysis of near-missmanagement has %eenlimited. The most detailed

study of near-missmanagement in thechemical industry knownto us is the thesis of T. 1.

an der Schaaf.(?

The

work presents a discussionof the human factorsinvolved in reporting, andempha-si&es that toencourage reporting, sitemanagement should not e=press or infer the viewthat near-miss re-port rates

are a desira%le metric todecrease over time. Theauthors of this articlefound evidence to supportthis same

recommendation.(7

The an der Schaafthesis provides asystem for

(" near-miss

classification, ($ the

analysis of a group of


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near-miss reports, and (4 the implementation of safety

improvements %ased on near-miss events. n the an der

Schaaf approach, the causes of near misses are identified

and classified and are used to analy&e hu-man

performance. an der Schaaf applies this frame-work to a

near-miss program at an E==on /hemical facility in

Holland. He argues that the integration of the program was

successful in achieving higher levels of near-miss reporting

(an increase of 4##F was o%-served. The site had a highsafety standard prior to implementation of the program'

hence an der Schaaf was

una%le to assess to what

degree the program may

have actually improved

safety performance.

Gones et al.("#

provide an account of

near-miss managementsystems successfullyapplied in the European

chemical industries. Twoe=amples of near-miss

programs applied at Norsk Hydros offshore andonshore facilities arestudied. n %oth cases, theresults suggest that anincrease in near-miss

reports can yield improvedsafety performance. noff-shore drilling,


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Near-Miss Incident Management/Chemical Process Industry ++0

over seven years a "#-fold increase in near-miss re-portingcorresponded with a 5#F reduction in lost time in+uries. non-shore activities, over a "4-year span, an increase inreporting rates from &ero, to one report per two employees

per year corresponded with a A@F reduction in lost timein+uries.

4 Gones et al . note the recent inclusion of near

misses in the ma-+or accident reporting system(""

(3S

as a favor-a%le step in encouraging sites to implement near-miss programs.

There has %een nota%le work in the codifying andevaluation of precursor data through utili&ation of !ayesian

analysis.("$−"8

)recursors are seIuences or events in

accident chains' on some occasions a pre-cursor event can %e considered synonymous with a near miss. This approachhas received considera%le attention within the nuclear

industry where modeling approaches are used to identifyand assess potential precursors to reactor core meltdown.("@,"5

n the ap-proach taken in the nuclear industry, a prior

distri%u-tion is formed as a product of a precursor distri%ution and a distri%ution representing a final %arrier failing, hence leading to core meltdown. 1hen newo%serva-tions of precursors, accidents, or lack thereof occur over time, an updated posterior distri%ution is gener-ated from the prior. The !ayesian procedure can helpidentify sources for improvement to reduce the likeli-hoodof %oth precursors and accidents. 2pon updatingdistri%utions, shifts in the posterior distri%ution curves

provide insight into increased and decreased accident

likelihood resulting from the failure modes associated withspecific precursors.

n this article a seven-stage framework for the

management of near misses is presented, with the em-

phasis on o%taining operational and strategic value from

such incidents. The key finding of this article is that near-

miss management can %e systemati&ed and provide an

important reinforcing element of accident prevention and

preparedness at ha&ardous facilities. To do so, however,

reIuires a well-designed infras-tructure for recogni&ing,

reporting, analy&ing, iden-tifying, and implementing

solutions to prevent future near misses and accidents. This

articles intended con-tri%ution is to synthesi&e %est practices for such an infrastructure from the companies in

our interview sample and from other near-miss systems

reported in the literature. 3lthough the sample in our study

was *ortune @## companies, the sites visited ranged in si&e

from @# to several thousand full-time employ-ees' hence

we %elieve that the general framework pro-posed is widely

applica%le even though it should %e

4 Estimated from graphs in citation.

customi&ed to fit

particular organi&ational

and %usi-ness needs.

The article proceeds

as follows. n the ne=t sec-

tion, we descri%e the

structure of near-miss

manage-ment systems and

identify key stages in the

process-ing of a near miss,

from identification to

resolution. 1e also point

out similarities,

differences, and inter-

actions with accident-

management systems. n

Sec-tion 4, an overview of

the data sample and

interview framework is provided. n Section 8 we

analy&e each of the near-

miss stages in our

proposed framework in

more detail and present

data from our interviews

on %est practices for each

stage. 1e conclude with

o%ser-vations on the

implementation of near-

miss manage-ment

systems, and with a

discussion of future

research activities.

. R2M$&OR

1e propose a

framework that relates the

effec-tiveness of a

companys near-miss

management sys-tem to

the operational and

strategic value that can %ederived from a systematic

analysis of such inci-

dents. 0ur field research

and surveys of e=isting

near-miss management

systems delineate seven

consecu-tive stages

underlying the

identification and manage-

ment of near misses.


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These stages, shown in *ig. $, are>

1. Identification> 3n incident is recogni&ed to have

occurred.

2. Reporting > 3n individual or group reports the

incident.

3. rioriti!ation and "istri#$tion> The incident is

appraised and information pertaining to the incident

is transferred to those who will assess follow-up

action.

4. %a$sal Analysis> !ased on the near miss, the causal

and underlying factors that could have ena%led an

accident are identified.

5. Sol$tion Identification> Solutions to mitigate

accident likelihood or limit impact of the po-tential

accident are identified and corrective actions are

determined.

6. "isse&ination> *ollow-up corrective actions are

relayed to relevant parties. nformation is %roadcast

to a wider audience to increase awareness.

7. Resol$tion> /orrective actions are imple-mented

and evaluated, and other necessary follow-up

action is completed.

The seven stages have a :con+unctive; effect on each

other. Near misses that are not identified


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++3 Phimister et al.

Identi!y Re4ort Prioriti5eCausal (olution

'issemination Resol6e2nalysis Identi!ication

ig. . ncident processing stages.

cannot %e used to reduce risk e=posure. *urther, near

misses that are identified %ut not reported, or identified and

reported %ut not acted on further, will, at %est, have a

modest impact on reducing site-risk e=posure. mplicit in

the framework is that only through the successful e=ecution

of every stage is the ma=imum risk reduction achieved for

a given near miss.

t is perhaps not surprising that sites often achieve

significant risk reduction through forensic evalua-tion of

accidents, although they may gain little %en-efit in the

identification and management of near misses. n anaccident, %oth identification and re-porting are all %ut

guaranteed. n such instances, the in+ury of an individual,

an environmental impact, large-scale property damage,

and


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2. Key elements for successful stage perfor-mance are

identified.

3. /ommon o%stacles that impede successful stage

performance are

outlined.

4. Ceneral

o%servations of

practice to

overcome these

o%stacles are

presented.


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Near-Miss Incident Management/Chemical Process Industry ++:

+.1. Identi!ication inor accidents and in+uries that had potential

To harvest value from a near miss it must %e iden-to %e more serious.

Events where in+ury could have occurred %uttified. To successfully identify a near miss, individuals

did not.must recogni&e an incident or a condition with po-

Events where property damage results.tential for serious conseIuence. To aid in near-miss

Events where a safety %arrier is challenged.identification, individuals reIuire an understandingEvents where potential environmental dam-

of what is a near miss. n our study, 8# (5?F of theage could result.

hourly employees e=pressed confusion as to what con-

stitutes a near miss, %elieved that near misses must The definition proposed captures the ephemeral

have resulted in a threat to safety (though not the en- Iuality of a near miss without dwelling on how an

vironment, or potential for significant process upset, event should %e classified. Near misses are opportu-

or e=pressed the sentiment of :you know it when you nities. f the underlying ha&ard is Iuickly identified

see it.; and remedied, the likelihood of the event recurring

To have an effective near-miss management sys- is greatly reduced or eliminated. f not identified, dis-

tem there is an overwhelming need for sites to have closed, and properly managed, the incident may %e

an encompassing and helpful near-miss definition that forgotten and the latent potential for damage remains.

can %e easily understood %y all employees. 1e %elieve, Through utili&ation of a %road near-miss defini-

in providing a site- or corporate-wide definition, the tion, identification is encouraged, whereas restrictiveissue should not %e whether an occurrence is an event definitions, and failure to recogni&e near misses as op-

with potential for more serious conseIuences, an ac- portunities to improve EHS practice, present the pos-

cident, or simply the identification of an unsafe condi- si%ility that many near misses may not %e recogni&ed.

tion or unsafe %ehavior. ather, the definition should Two restrictions to near-miss definitions that were o%-

focus on identifying a situation from which site EHS served in the field are (" near misses must entail an

performance may %e improved. n search for a new :event,; or ($ near misses must involve a last %arrier

definition, the tree shown in *ig. 4, which includes %eing challenged. The rational for these restrictions

desira%le definition features, is generated. may %e the perception that when an event occurs or a

The following new definition, %ased on the ele- last %arrier is challenged, an operation is closer to an

ments depicted in *ig. 4, is> accident threshold. /onsider *ig. 8, which illustrates

a process in operation, and how it responds after an

Near-miss> An opport$nity to i&pro'e en'i- event E. n the case of event E, two %arriers, 3 and !,ron&ental, (ealt( and safety practice #ased are in place to prevent an accident coming to fruition,

on a condition, or an incident )it( potential and an accident occurs only if 3 and ! fail. efining

for &ore serio$s conse*$ence. + as the pro%a%ility event E occurs over a given

time frame, and +A as the pro%a%ility %arrier 3

!y this definition a wide variety of incidents and con- fails if challenged given incident E, +/A is the

ditions are defined as near misses. These include> pro%a%ility ! fails if challenged given incident E, and3 failing.

2nsafe conditions. t will %e noted that at point L, the pro%a%ility of

2nsafe %ehavior. an accident occurring is ++A +/A, at M

the accident pro%a%ility is +A +/A, and at

'$INI*ION Normal Event E !arrier 3 !arrier !

0peration /hallenged /hallengedEncouraging Easily

definition !road understanda%le 3ccident

definition ; *ails

unsafe minor environmental unsafe< % *ails Success

conditions accidents potential %ehavior ecovery

potential potential last %arrier Success property damage product loss challenged ecovery

ig. =. efinition tree. ig. +. Event tree with two

%arriers.


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+>

it is +/A. *urthermore, provided %arriers 3 and

! are in place>

)L(accident ( / / A

the operation is closer to an accident threshold at lo-

cation L, where an event has not %een e=pressed nor a

%arrier challenged, than if the %arriers A and / are

functioning and the last %arrier is challenged. Civen the pro=imity of the operation to the accident thresh-old, the

operation should %e considered a near miss even though

no event has occurred.

To illustrate the %enefit of encompassing near-miss

definitions, an incident discussed %y a plant me-chanic

is presented. The mechanics responsi%ilities involved

the maintenance of a distillate stream at the top of a $#-

meter-high column. The mechanic, who was positioned

on a platform at the top of the col-umn, was short in

stature and reIuired a step-ladder to reach the pipework.

)rior to clim%ing the ladder, the mechanic noted that to

reach the pipework his positioning would %e precarious,

and would result in his leaning over a guardrail. Hereported the un-safe condition through the site near-miss

program, a short investigation proceeded, and

su%seIuently the guardrail was raised.

1hen the a%ove incident was discussed with in-

terviewees, some indicated that they did not consider the

incident a near miss and hence would not report it.

However, they countered, had the individual clim%ed

the ladder, slipped, and not %een in+ured, then it was a

near miss. f management conveys that near misses must

%e :event-driven; or the result of a last %arrier %eing

challenged, many similar opportunities may go

unreported.

+.. Re4orting

3 recogni&ed near miss has only limited value, even

to the person who recogni&ed it, unless it is re-ported

and properly analy&ed with appropriate mea-sures taken

to prevent its recurrence. However, when a near miss is

recogni&ed, there is no assurance that

Phimister et al.

it will %e reported. The o%+ective therefore in the e-

porting stage is to ensure that all identified near misses

are reported.

!ridges("A

focuses on %arriers that inhi%it report-ing. To increase report rates, !ridges advocates that nine

%arriers %e overcome. n this article we group these %arriers as>

1. )otential recriminations for reporting (fear of

disciplinary action, fear of peer teasing, and

investigation involvement concern.

2. otivational issues (lack of incentive and

management discouraging near-miss reports.

3. 6ack of management commitment (sporadic

emphasis, and management fear of lia%ility.

4. ndividual confusion (confusion as to what

constitutes a near miss and how it should %e

reported.

!ased on our interviews, we provide correspond-

ing solutions to help overcome these four groups. n

developing near-miss programs, site and EHS man-

agers should identify the %arriers at their sites that in-

hi%it reporting. The a%ove %arriers and corresponding

solutions to address each one of them are presented

%elow.

1.2.. Reporting Recri&inations

Employees may %e reluctant to report near misses

due to potential recriminations that could result. )o-tential recriminations are>

1. eer ress$re> Employees may feel pressure

from colleagues not to report.

2. In'estigation Style> 6engthy investigations that

reIuire employee participation may dis-courage

reporting.

3. "irect "isciplinary Action> /oncern a%out re-

ceiving a ver%al warning, the potential addi-tion

of the incident to the employees record, up to

and including +o% dismissal, will discour-age

reporting.4. nintended "isciplinary Action> *or e=am-ple,

upon incident investigation, additional +o% tasks

or wearing cum%ersome ))E may %e perceived

as punishment for reporting.

To overcome peer pressure, it is recommended

management consider>

1. 1ide dissemination of su%mitted near-miss

reports.


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Near-Miss Incident Management/Chemical Process Industry +1

2. The formation of employee teams to evaluate and

prioriti&e near-miss reports.

3. )u%lici&ing of improvements that result from

reported near misses.

4. eIuiring a specified num%er of near misses %e

reported per person per year (e.g., one per person

per year.

!road dissemination of near-miss reports may %e con-

sidered counterintuitive to alleviating peer pressure if one

thinks an individual would %e reluctant to report if he or

she %elieved it was to %e widely pu%lici&ed. However, we

found that if near misses are widely dis-seminated,

individuals are e=posed to many incidents and an

additional report does not draw attention to the reporter,

thus alleviating peer pressure.

*or the chemical process industries, the authors do notfavor schemes where employees remain anony-mous upon

su%mitting a report. 0ur field work strongly underscores

the view that anonymous report-ing is pro%lematic %ecause

(" it is often necessary to follow-up with the reporter to

ascertain incident causes, and ($ anonymity does not infer

that near misses are desira%le learning opportunities. Three

sites visited offered anonymous reporting, though at these

sites anonymity systems were run in con+unction with

incentive schemes that encouraged identity dis-closure, and

hence anonymous reporting was rarely utili&ed.

0ur assessment of e=isting near-miss systems also

suggests that reporting should %e Iuick and simple ascompletion of long forms discourages reporting. Though

follow-up action may necessitate a thorough investigation,

a short summary of the near miss and time and location of

the incident or o%servation nor-mally suffices. ncluding a

%rief appraisal of causes and potential solutions at the time

of reporting is de-sira%le %ut should not %e a reporting

reIuirement. Note that even if completion of the report

form is a Iuick process, if retrieving near-miss forms is

difficult, or involves trolling through we%sites, reporting

rates will %e adversely affected.

To remove fear of disciplinary action, sites may wish

to develop a nondisciplinary policy. Such a policy could %e %ased around the following statement.

ro'ided a cardinal r$le (as not #een #roken

and no da&age done, disciplinary action )ill not

#e taken.

f implemented, this policy must %e rigidly adhered to'

damage that results from management failure to adhere to

their policies can take years to undo. ore-

over, safeguards to help

catch instances when man-

agement fails to a%ide %y

this policy should %e con-

sidered.

*inally, on

determining solutions,

management must

scrutini&e whether

corrective actions that

result from near-miss

investigations might %e

perceived as punishment.

n such cases, alternate

solutions should %e

sought.

1.2.2. 4ack of Incenti'e

nterviewees at "8

sites e=pressed a lack of

in-centive to report near

misses. )erhaps the largest

en-ticement to su%mit a

near-miss report is the

knowl-edge the report will

%e handled seriously and

ap-propriately, with

appropriate remedial

action when necessary.

anagement can also

provide additional

encouragement through

implementation of

incentive programs. Two

types of incentive

programs o%served during

site visits are>

1. Tc(otc(kes

5i'ea)ays> 3

near-miss report

en-titles the

reporter to a T-shirt, mug, or

some-thing

similar.

2. 4ottery Syste&s>

Each near miss

constitutes a

lottery ticket, with

drawings held

Iuarterly, %i-

annually, or

annually. 6ottery

pri&es o%served at

sites included cash

pri&es, dinner at a

local restaurant,

event tickets, and

a day off.

0f the sites visited, lottery

programs showed higher

participation levels than

giveaway programs,

although most sites did

not adopt either. The four

sites that had :tchotchkes;

giveaways had an average

near-miss reporting rate of

#.7 per person per year,

whereas the two sites that

had lottery systems had

reporting rates that

averaged 4.# reports per

person per year.

Senior and sitemanagement should notcreate disincentives toreport near misses. an

der Schaaf (A

reports of a

site where senior management conveyed to

personnel that high near-

miss reporting correlateddirectly with poor safety

performance. t wasspecu-lated that althoughthis site was su%seIuentlysuccess-ful in reducing thenum%er of near missesreported, the actualnum%er of near missese=perienced likelyremained constant andhence, due to inaction, thesites risk e=posure

actually increased./onfusion of whether high near-miss reportingrates are positive or negative indicators of safety performanceremains. Eleven sites inour study viewed thenum%er of near-missreports as a metric thatwas desira%le to increase


12/23

or keep constant over time. These sites e=pressed the viewthat near-miss reports were a gauge of employee+

EHS awareness and involvement. The remaining nine

sites either did not maintain a view on this issue, or

viewed su%mitted near-miss reports as a metric that is

desira%le to decrease over time.

1.2.3. Indi'id$al %onf$sion

Since near misses can %e su%+ective, there can %e

confusion as to what constitutes a near miss. 3s dis-

cussed in the dentification section, an encompassing

near-miss definition can facilitate understanding, and

there%y encourage reporting. 0ne site in our study

referred to near misses as :safety event communica-

tions,; which were shared over the site intranet. The

:litmus test; for sharing a safety event communica-tion

was>

%o$ld so&eone #enefit #y learning fro& t(ee'ent6

t was %elieved that this simple test encouraged

reporting.

3nother site in our study included a similar defi-

nition on the %ack of the near-miss report form. nter-

viewees, when Iuestioned for their near-miss defini-

tion, referred the interviewer to the %ack of the form.

n addition to understanding what constitutes a near

miss, individuals must know to whom and how to report

near misses. ultiple mechanisms (e.g., %oth paper-

%ased and intranet-%ased can aid reporting, as can

management emphasis and training.

1.2.1. 4ack of Manage&ent %o&&it&ent

*ailure of management to remain committed to

near-miss programs can decrease employee reporting

and result in employee accusations that near-miss pro-

grams are :a flavor of the month.; /ommitment fail-ure

can %e %oth passive, where management stops em-

phasi&ing program participation due to inattention, or

active, where management actively seeks to reduce

program participation.

)assive failures can %e avoided %y>

1. egular report generations and postings that

highlight program participation, resulting im-

provements, and other %enefits of the near-miss

program.

2. ntegrating near-miss program components with

other site-management mechanisms, such as

work-order entry, action-item track-ing, and

accident-investigation systems. This approach

utili&es employee familiarity with

Phimister et al.

current procedures that would otherwise have to

%e instilled if new systems are implemented.

3. 6inking process with outcome. Specifically,

sites may wish to attempt to show that near-miss

program participation correlates favor-a%ly withEHS performance.

3ctive measures %y site management to reduce

near-miss reporting can stem from ina%ility of site

management to process a high level of participation, and

management concern a%out %eing lia%le due to inaction

on reported near misses. 3ddressing each of these items>

1. ntegration of management systems, distri%ut-

ing management responsi%ilities, and imple-

menting a two or higher tier-investigationclassification system can greatly reduce the re-

source %urden of a near-miss program with high

levels of participation.

2. Ensuring that every identified cause has an

accompanying solution, or solutions, and that

systems are in place to track solutions until im-

plemented can alleviate lia%ility concerns.("?

4.3. Prioriti5ation and 'istri?ution

This stage incorporates two tasks> near-miss pri-oriti&ation and distri%ution. These two activities are

performed in unison to allocate the appropriate time,

e=pertise, and resources to follow-up on an incident.

)rioriti&ation is very important for a near-miss

program with a high num%er of near-miss reports. *or

these systems, most near misses will %e investigated %y

the reporter and

1. E=pertise %eyond the reporters


13/23

Near-Miss Incident Management/Chemical Process Industry +=

/orrespondingly, high priority reports may have sep-arate

distri%ution channels to ensure that the incident is

trafficked to the appropriate parties.

/ommon o%stacles that limit )rioriti&ation and

istri%ution performance include>

6ack of understanding of the characteristics of high

priority near misses.

6ack of guidelines or tools to distinguish low and

high priority near misses.

6ack of protocols for low and

1. erge incident distri%ution with reporting. This

can %e performed relatively easily in automated

systems, where decisionmakers, whether

supervisors, EHS managers, engi-neers, or others,

are copied upon initial reporting.

2. Specify time frames on information transfer. Thishas %een o%served in paper-%ased sys-tems where

protocols specify that reported near misses must %e

reviewed %y EHS man-agers within a certain time

frame.

3. 3utomate systems to ensure cross-checking. These

systems reIuire management review to confirm

accurate prioriti&ation.

4. Ena%le reporters and supervisors to perform most

investigations. Such systems that engage reporters

and supervisors to

perform inves-

tigations involve

employees,

Iuicken investi-

gations, and

decrease

investigator and

EHS workload.

+.+. Causal 2nalysis

0nce a near miss is

reported and transferred to

appropriate parties, it is

necessary to carry out

steps to ensure that the

near miss does not recur.

The o%+ective in /ausal

3nalysis is to determine

what are the direct andunderlying factors that

ena%le an incident or

unsafe condition. Short-

term solutions resolve

direct causes, farther-

reaching and more per-

manent solutions rectify

root causes. 3lthough in

structuring near-miss

programs it is important to

rec-ogni&e the interaction

%etween /ausal 3nalysis

and Solution

dentification, it is eIually

important to rec-ogni&e

that these are two distinct

activities.

There are a num%er of

o%stacles that limit /ausal

3nalysis performance.

*actors that deteriorate

stage performance

include>

1. 6ack of tools or frameworks to

analy&e near

misses.

2. nsufficient

e=pertise toanaly&e near misses.

3. ilution of

relevant

information due to


14/23

infor-mation transfer or lapsed time prior to inci-

dent investigation.

The presence of the feed%ack loop %etween /ausal

3nalysis and eporting must %e recogni&ed in structuring

stage activities. There can %e a trade-off %etween high

reporting rates and comprehensive investigations in that if

all reported near misses are thoroughly investigated, near-

miss reporting may %e adversely affected due to concernover lengthy pro-ceedings. 3s a conseIuence, many sites

may wish to forego a lengthy investigation for most

reported near misses. 3t the same time, and as indicated

during our interviews, reporters must have some involve-

ment in the investigation, for failure to consider what the

reporter views as causes

may discourage future

reporting.

n sites visited, root-

cause analysis tools were

gen-erally not used to

analy&e near misses'

rather, sites appeared to

%ase corrective actions on

incident de-scriptions.

There are a num%er of

techniIues to aid in

/ausal 3nalysis that are

widely used in accident

investigations. These

include>

1. 'ent and %a$sal

7actor "iagra&s>

The detailing of

events leading up

to, during, andfollowing an

incident, followed

%y the


15/23

+,+ Phimister et al.

deconstruction of each su%event into ena%lingPerson injured 6

causal factors linked through 3N

Reporter

In'ol'e&ent > The

reporter is often

intrinsic in

understanding

what caused a near

miss and how it

may %e avoided in

the future. Hence,

where possi%le, the


16/23

reporter must %e involved in determining causal

factors.

4isted %a$ses> nvestigation forms should have

entries for multiple direct and root causes. n

addition, if solutions are linked in an ad+oining

column, the structure provides a framework to help

ensure each cause has a corresponding solution or

solutions.

Integrated Syste&s> 3lthough the ma+ority (5#F of near-miss programs analy&ed in our study are run

independently of accident-investigation programs,

some integrated

ac-cident and near-

miss systems to

streamline

investigation

systems, eliminate

system dupli-

cation, and

improve employeeunderstand-ing

that near misses

are intrinsically

related to accidents

that result in loss.

System in-

tegration may

improve near-miss

root-cause analysis

with tools

developed for accident


17/23

Near-Miss Incident Management/Chemical Process Industry +

investigations %eing similarly applied to near-miss

investigations.

+.. (olution Identi!ication

The o%+ective in the Solution dentification stage is to

determine corrective actions that will remedy causes of the

potential accident.

The process is achieved through three su%stages.

1. Ceneration of potential corrective actions.

2. /omparative evaluation of corrective actions.

3. Selection of corrective actions to implement.

None of the sites in our survey had a widely ap-plied

procedure for generating corrective actions to prevent

future near misses. ather, appropriate cor-rective actions

were generally thought to %e identifi-a%le %y the reporter

and 3ssuming the near miss de-

scri%ed in 6everage )oint " occurs, a :%arrier; is

constructed to make it less likely that the event can

%e +oined with the nonocc$rring key event.

4e'erage oint 3> !ased on the description of the

other key event, corrective actions are de-termined

to make the occurrence of this non-event less likely.

4e'erage oint 1> 3ssuming the nonoccurring event

descri%ed in 6everage )oint 4 occurs, a :%arrier; is

constructed to make it less likely that the event can

%e +oined with the near miss.

*a?le I. )otential /orrective

3ctions for

!ul%-!reaking

ncident !ased

on ncident

6everage )oints

"3> 3lways wait for

%ul%s to cool prior to

replacement. "!> 1ear

gloves while replacing

%ul%s.

$3> )ut drop %lanket %elow areaof %ul% replacement.

43> nstall warning signs

or cones on floors

%elow signaling

overhead work.

83> ather than grating each

floor, put covers on

each floor to prevent

o%+ects falling

through.@3> 2se shatter-proof %ul%s.

@!>

/ontinue to

ensure hard-

hat

compliance.

53> )ut first

aid stations

closer to

platforms.

5!> Train

personnel in

removing

glass shards.

4e'erage oint ;>

3ssuming %oth the

near miss and the

other nonoccurring

event occur and

that any %arriers

constructed at

6everage )oints 4

and 8 fail, a %arrier

is determined tomake the accident

less likely.

4e'erage oint

3ssuming that the

accident occurs,

contingency plans

to lessen the

severity of the

accident are

determined.

Ta%le shows

potential corrective

actions for the %ul%-

%reaking e=ample

depicted in *ig. 5, at each

leverage point.

1ith a set of potential

solutions identified, the

solution set must %e

reduced to determine

which cor-rective action

or actions to implement.

Cauging how well

identified solutions

successfully reduce risk

e=po-sure is not a simple

endeavor since generally

metrics are not easily

applied. Nonetheless, proposed safety

improvements can %e

loosely rated from most to

least %eneficial %y the

following ranking.

1. The corrective

action eliminatesthe ha&ard.

2. The corrective

action reduces theha&ard level.

3. The corrective

action manages

incident recur-

rence.

4. The corrective

action alerts

people of ha&ard

(e.g., through

alarms or signs.

5. Standard operating

procedures (S0)s

are changed to

account for ha&ard.

6. Employee

awareness isincreased.

n addition to the

proposed solutions

reducing the likelihood or

impact of the e=posed

ha&ard, the solution must


18/23

also not infer new risks. Hence, cor-rective actions must %e

carefully screened to ensure that new and une=pected risks

are not inferred upon implementing new solutions. Here it

is stressed that the

remedying of one pro%lem

can result in other

unforeseen ha&ards,

particularly when changes

are

+

su%tle. owell and Hendershot($8

provide e=amples of changes intended to improve safety or process relia%ility

resulting in operations with une=pected risks (thewidespread implementation of air%ags and theune=pected risks these infer on children is cited as onee=ample. They recommend implementation of management of change programs where all pro-cesschanges are considered. *ailure ode and Ef-fect3nalysis in the location of the instituted processchanges is one method that can %e applied to assess

whether changes infer new risks.("7

f new risks areunaccepta%le, alternative solutions must %e identified.

/orrective actions should %e evaluated across

nonrisk dimensions to assess the :practicality; of the

solution. t is noted that selecting corrective actions

%ased solely on risk reduction may not %e practical. f solutions are unfavora%le to either management or

employees, future reporting and participation in a site

near-miss program may %e adversely affected. 3mong

other dimensions, solutions should %e assessed ac-

cording to>

1. Solution cost.

2. )otential increased revenue on solution im-

plementation.

3. )otential improved process eport form struc-ture

can help ensure that remedying solutions help

resolve identified causes. /lear mappings where

a solution or solutions are linked to causes

reduce the likelihood of spurious so-


19/23

Phimister et al.

ost )ractical

1ear gloves

6et %ul%s coolEnsure hard-hat compliance

rop %lanket 2se shatter-proof %ul%s

6east1arning cones

ostEffective *loor covers Effective

ore training

ore first aid stations

6east )ractical

ig. 0. )reference diagram for %ul%-%reaking incident.

lutions %eing applied. EHS incident reviews

should evaluate whether corrective actions areresolving identified causes.

9ork-=rder Integration> 1ork orders that stem

from an investigation should, where pos-si%le,

%e seamlessly integrated with the inves-tigation

file such that on reviewing a file, it is clear

which work orders remain outstanding and on

reviewing a work order it is evident whether the

work order resulted from an inci-dent

investigation and if so, what the investi-gation

findings were.

/ommon o%stacles that limit Solution dentifica-

tion success are>

1. *ailure to generate more than one corrective

action for a near miss.2. 6ack of procedures to reduce the num%er of

identified corrective actions to +ust a few for

implementation.

3. *ailure to address management of change is-

sues, whereupon solutions give rise to unrec-

ogni&ed new risks.

4. dentified corrective actions fail to achieve their

intended purpose. Specifically, the solu-tion

does not remedy the identified cause.

3dhering to a%ove practices during Solution dentifi-

cation should help to eliminate these o%stacles.

+.. 'issemination

2pon suita%le corrective actions %eing deter-mined,

they are disseminated to implementers. 3lso, at this

point, having completed the near-miss analy-sis and

determined the remedying actions it %ecomes


20/23

Near-Miss Incident Management/Chemical Process Industry +0

prudent to inform a %roader audience of the informa-tion

collected and decisions made.

Hence, there are two o%+ectives in the issemi-nation

stage.

1. Transfer corrective actions that stem from a near-

miss investigation to implementers.

2. nform a %roader audience of the incident so as to

increase awareness.

n addition, if EHS has not %een involved in the inves-

tigation to this stage, it may %e desira%le for EHS to review

the incident to determine if further investiga-tion is

warranted. 3 more detailed evaluation of the incident may

%e necessary if, on review, it is evident that the near miss is

a repeat incident, thus indicat-ing that previous near misses

were not suita%ly ad-dressed, or if it is %elieved thatadditional root causes could %e uncovered, or farther-

reaching solutions found.

The two o%+ectives have corresponding chal-lenges.

0ne of the most significant pro%lems that de-teriorate stage

performance when transferring action-item information is

when intended corrective actions are not possi%le (e.g., due

to lack of resources. n such instances it is critical that

EHS or similar incident overseers intervene to determine

suita%le alterna-tive solutions that satisfy the same intended

purpose. /ommon o%stacles that limit the sharing of

lessons learned include %oth underdissemination, where allwho could %enefit from learning of the near miss do not

receive the near-miss report, and overdissemina-tion,

where reports are not read or a%sor%ed due to the high

num%er of reports disseminated.

ecommendations provided in the )rioriti&ation and

istri%ution stage apply eIually to issemina-tion.

)articularly, intranet systems can %e e=cellent vehicles for

transferring information, initiating action tracking, and

informing a %road audience of the re-port. /orrective-

action monitoring to ensure that in-dividuals or

departments are not overwhelmed with assignments that

stem from investigations have %een o%served and applied

successfully.

+.0. Resolution

esolution is the final stageOall investigation

corrective actions are completed and all remaining ac-

tivities prior to closing an incident report are fulfilled.

emaining activities prior to closing an incident file

include>

1. 2pdating the near-

miss report if

deviations from

the intended action

item were imple-

mented.

2. eviewing


21/23

and outstanding corrective actions.

3 typical :action-traction; algorithm to ensure

corrective actions are completed is shown in *ig. ?. To

account for the o%stacles that can impede stage per-

formance, o%served variations to the action-traction

algorithm include>

1. nclusion to allow for updates in the case of

changes to intended design.

2. 3udits to evaluate action-item effectiveness in

satisfying the intended item purpose.

3. )rocedures to return the action item to the initiator

if implementation of the proposal is not possi%le.

4. )riority levels that affect when alerts are sent to

implementers for

outstanding action

items.

6astly, prior to

closing the incident file it

may %e %eneficial to

disseminate incident

descriptions, find-ings,and actions taken offsite if

the learning value is of

significant %enefit.

. CONC8U(ION( 2N'

U*UR$ (*U'I$(

This article proposes

a near-miss management

framework that adds

operational and strategic

value to corporate

environmental, health, and

safety prac-tice. Since our field visits show that to

improve near-miss

management systems one

must focus on the de-tails

of the process %y which

near misses are identified,

+3

Action entered

ACTION TRACTION of single entry (mulitple entries are done in parallel)

Definition: Owner—the person responsible to complete action.

Definition: Steward—the person who overseas that the item is

completed (e.g., EHS or Owner's direct supervisor).

Action item consists of description of required activities,

expected completion date, owner, and steward.

Has the action yesSTOP

been completed?

no

Check no Has completionTomorrow date expired?

yes

Remind OwnerAlert EHS,manager and

that completion isothers if delay

requiredmounts

no

Check noHave 2 weeks

yesHas the action

passed since last beenTomorrow

reminder? completed?

yes

STOP

ig. 3. 3ction-traction algorithm.

reported, analy&ed, and, where appropriate, correc-tive

actions implemented, we identify a seven-stage

framework that helps sites accomplish this o%+ective.

Each one of these stages is critical for the effectiveness

of the overall system, with incidents recommended to %e

processed as follows> Identification of a near miss, Reporting and rioriti!ation and "istri#$tion of

relevant information, %a$sal Analysis, Identifica-tion of

Sol$tions to prevent recurrence, "isse&ination of

remedial action, and Resol$tion through tracking. To

achieve %est results, all seven stages must %e per-formed

in seIuential fashion.

Since each stage can take place only if the pre-

vious stages have already %een completed success-fully,

earlier stages in the near-miss management sys-


22/23

Phimister et al.

tem have :con+unctive; effects on later stages. 3l-

though it is important to have a near-miss system where

all stages perform successfully, development of such a

system is contingent upon thorough un-derstanding of

fundamental issues. *or e=ample, it is important to

avoid cum%ersome reporting forms, lengthy analysis for every near miss, corrective ac-tions that discourage

future reporting, and so forth. 3ny of these defects could

cause near-miss manage-ment to do more harm then

good to the overall safety process.

*uture studies on near-miss management sys-tems

will include adaptation of various statistical tools for

each one of the seven stages to improve their efficiency,

effectiveness, and Iuality control. Two crit-ical and

highly desired research areas that can con-tri%ute

significantly to corporate management opera-tions are>

evelopment of tools for the identification of

resource levels to %e dedicated to each near miss

%ased on the potential impact of the in-cident

(there%y differentiating %etween near misses that

illuminate potential for ma+or ac-cidents from

ones whose impact is more toler-a%le.

dentification of tools for the leveraging of

knowledge that is collected and stored in near-

miss data%ases.

2CNO&8$'9M$N*(

)reparation of this document was partially sup- ported through a /ooperative 3greement %etween the

2.S. E)3


23/23

Near-Miss Incident Management/Chemical Process Industry +:

any or all of the content herein, and hence no legal

responsi%ility is assumed. The views e=pressed in this

article are those of the authors and do not necessarily

represent views of companies that participated in the study.

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