2. OHT 2
1
10
60
600
Serious Incident
Includes recordable and disabling Injuries
Minor Injuries
Any reported injury less than a recordable
Property Damage & Incidents
All Types, including environmental releases
Incidents with no visible
Injury or Damage
(Critical Incidents - Near Misses)
Accident Ratio Study
3. OHT 3
Management Safety Policy & Decisions
Supervisory Performance
Personal Factors
Job Factors
Human Factor
Substandard
Practices
Substandard
Conditions
ACCIDENT
unplanned release of energy
and/or
hazardous material
Personal injury
Property damage
Uninsured Costs
Basic Causes
Immediate
causes
Incident - Contact
Accident Results
CHAIN OF ACCIDENT CAUSATION
Near Miss - Warning
Focus on Near Misses
& Prevent Accidents
4. OHT 4
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)
5. OHT 5
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.
6. OHT 6
It’s usually inconvenient to fill out the “accident
form”.
Near miss experiences are “private affairs”.
“Organizational Influences”- What’s to be gained? A
pleasant or unpleasant experience.
Slogans like “All injuries are preventable” don’t help.
Offering rewards for reporting near misses don’t help.
WHY THE RELUCTANCE TO REPORT?
7. OHT 7
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.
8. OHT 8
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
9. OHT 9
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.
10. OHT 10
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?
11. OHT 11
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.
12. OHT 12
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.
Yes!
13. OHT 13
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.
14. OHT 14
Extra Effort Needed
We sometimes question near miss
incidents, but the causes of today’s
near miss incident, if not determined
and corrected , may occur again to
produce tomorrow’s 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!
15. OHT 15
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 investigation’s Safety-O-Gram
form for the investigation and reporting
document.
Having the forms readily available to all
employees.
