This presentation is brought to you by …

Daniel (Dan) W. KruszeDKSafety

Anchorage, Alaska

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DISCLAIMERThis information and training content are meant to provide ageneral overview and discussion relating to variousregulatory standards. It does not alter, determine, or reduceyour organization’s compliance responsibilities with regardto state or federal OSHA standards, FMCSA/CSA, AK-DOT, and/or any local regulatory compliance standards. Further, it does not create abinding legal responsibility on the part of the trainer(s) orhis/her organization for your organization’s required state ofcompliance under any afore-mentioned jurisdiction.Because interpretations and enforcement policy maychange over time, you should consult any current administrative interpretations and decisions by the various agenciesto which you are subject and/or the Courts for any additional guidance on your individual compliance requirements.

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At the present time,most regulatory

agencies

DO NOT require near-miss

reporting !

So why are NEAR-MISSES

important ?

“The Safety Pyramid”

Focusing on minor incidents, including near-misses, provides the where-with-all to reduce the probability of serious incidents and/or injuries. As indicated by the Safety Pyramid, near-misses occur far more often than the other categories of incidents.

Working from the top down, serious incidents

and/or injuries can often be traced back to

a number of minor incidents that

happened earlier. By addressing the causes

of these “precursor events”, one can often

prevent a serious incident and/or injury

from ever taking place!

Example: Several rows of shelves collapse in a storeroom. No injuries to personnel occur and there is only minor property damage. A subsequent investigation reveals that the shelves collapsed because they were severely overloaded.Once this fact became known, the instructions for stocking the shelves were revised and better load rating limit signs were posted to deter an incident of this type from happening in the future.

(Information cited from a recent research project byThe Wharton School of Business, University of

Pennsylvania)

STEP # 1: NEAR MISSES SHOULD BE BROADLY DEFINEDThe first thing researchers noticed is that within the

companies that manage effectively, the term “near-miss” warranting safety program attention is defined broadly to include not just events, but things like unsafe conditions and/or behaviors. Other such event triggers include:

•Minor incidents/injuries that had the potential to be more serious;•Events where a physical injury could have occurred, but did not;•Events where property damage was or could have been the result;•Events where a safety barrier, such as a machine guard, was altered/ignored whether or not an injury and/or incident took place; and, lastly,•Events where potential environmental damage could have resulted.

One sound definition of how to maximize the effectiveness of your own near-miss management program could be:

“A near-miss is an opportunity to improve health and safety in a workplace based on a condition and/or incident with the potential for more serious consequences.“

STEP # 2: USE CLEAR AND SIMPLE REPORTING PROCEDURES

You cannot manage or learn from the occurrence of near-misses unless you are aware they’re taking place! When a qualifying event occurs, it should be reported, with documentation in writing, by the personnel affected/involved, as well as the immediate supervisor of that person.

Research suggests that having a clear and simple procedure for the reporting/recording of near-misses will encourage a successful process.

For the most part, today’s existing occupational health/safety regulations DO NOT require the reporting of near-miss events. There is also a general reluctance on the part of some personnel to report these incidents for fear of a negative response and/or disciplinary action from management.

How can this negativity be overcome?

In order to overcome your personnel’s possible reluctance to the reporting of near-misses, strive to train them as to the value and importance of this statistical information. It is also an excellent opportunity to stress your worker’s role in contributing to the quality and effectiveness of your company’s safety program.

The necessary training to support your system should include:

•What is the procedure to identify a near-miss?;•What is the value in identifying such an event?;•What are the roles of the affected/involved personnel?;•How do we document the incident for management?; and•What can be done in the way of corrective action?

Other key elements to making your program work would include making sure the reporting is timely, confirming that this will result in corrective action on the part of management, and that our personnel’s efforts and contributions to safety truly matter!

DO encourage personnel to be active and

involved in the investigation and reporting process from start to end. Consider adopting an incentive system to promote their participation.

DON’T allow any anonymous

reporting in these cases as there will likely be the need for follow-up interviews to support the investigation and/or root-cause identification processes.

The next slide is an example of one company’s method of documenting their safety program’s near-miss incidents/events.

STEP # 3: MAKE SURE NEAR-MISS INCIDENTS ARE PRIORITIZED

Once your near-miss events are properly investigated and documented, you’ll need to assign a priority value to each of them in order to determine the following:

•What steps should we take next?;•How much attention should we devote to the incident?;•How much effort do we assign to a root-cause analysis?;•What resources are available to provide corrective actions?;•Do we need to obtain third-party help and/or consultation?;•How do we incorporate information and lessons-learned from this event/incident into our company’s safety culture?; and•Is our management invested in any solutions/corrective actions?

STEP # 4: ALL RELEVANT INFORMATION IS DISTRIBUTED

Companies that manage their near-miss events effectively also do a good job of distributing and discussing the appropriate type of information regarding the incidents throughout the structure of their entire organization.

This process should include a quick and secure transfer of the information regarding the event, the proper routing of such information to the correct departments/staff, and the assurance that the information is being delivered in a useful and understandable format.

A company’s chosen method of communicating their internal near-miss incidents/events to their management and personnel is absolutely fundamental to making this process a success!

STEP # 5: ALL CONTRIBUTORY CAUSES ARE DETERMINED

Effective near-miss management requires proper identification of the direct and root-cause of all events/incidents. This process is somewhat different from a root-cause analysis associated with an actual injury and/or high-value property damage incident.

Companies that best manage these events when they occur do not hesitate to form investigative teams selected from within their ranks. This type of diverse and systematic fact-finding approach can be quite effective when the causes of the incident(s) in question are not readily apparent to a single investigator.

STEP # 6: VIABLE SOLUTIONS ARE DETERMINED

The next hallmark of an effective near-miss management program is possessing both the means, and the will, to put in place one or more solutions to the causes/hazards that were discovered during the investigative stage. Hazard elimination is always the preferred goal, but management/control should be implemented where such total elimination is not feasible.

The desired hierarchy for this is as follows:

•Elimination of the identified cause/hazard;•Manageable reduction of the hazard/risk/exposure;•Installation of engineering solutions and/or safety devices;•Warning signs/devices to alert personnel to the hazard;•New work-safe practices to account for the hazard; and•Any means necessary to increase your personnel’s awareness of the condition/hazard, such as additional safety/training.

STEP # 7: NECESSARY SOLUTIONS ARE IMPLEMENTED

Once effective solutions are identified, the company’s management should implement them as soon as possible.

At that time, all supervisors and affected/involved personnel should be made aware of the changes through appropriate methods, such as training sessions and/or safety meetings.

STEP # 8: SOLUTIONS ARE AGGRESSIVELY MONITORED

The last step in this process is the need for constant monitoring of the adopted solutions to make sure they are providing the desired outcomes. Sometimes, changes meant to resolve one hazard/issue can contribute to the creation of a new, unforeseen risk. To have a truly viable near-miss management program, you must always be on the look-out for this possibility to develop!

The bottom line is that near-misses are a largely untapped source of useful information that, when recognized, can contribute greatly to the creation of a safer workplace for everyone. The adoption and use of a functional system for tracking this information can be a challenge at first, but certainly will pay tremendous dividends in terms of enhanced safety and well-being for those willing to face up to the tasks!

REMEMBER: “A near-miss is an opportunity to improve health and safety in a workplace based on a condition and/or incident with the potential for more serious consequences.“

THANKS FOR

ATTENDING !

ANY QUESTIONS?