Near Miss Reporting and Medical Treatment Boy, we dodged a bullet on that one. Someone could have gotten really hurt there! Man, that was close!

Near Miss Reporting Why is near miss reporting important What is a near miss Examples of high potential near misses What do we report and how Expectations and rules Questions September 18, 2018

Near Misses Who believes that unsafe acts, inadvertent mistakes and errors can happen without an injury being the final result? If we agree that unsafe acts, inadvertent mistakes and errors are still occurring, then unless we capture and record those types of events, learning opportunities are being missed. Opportunities that, given a slightly different sequence of events, produce real injuries and other significant losses. How would you feel if a fellow employee got hurt performing a task that you had nearly gotten hurt while performing and you told no one? These opportunities are also commonly referred to as “near misses” or, in the case of moving objects, “near collisions.” It’s these near miss or near collision events that we’ve chosen to focus on going forward. September 18, 2018

Why is near miss reporting important? Pre-incident problem solving. Practically a zero cost learning tool. Near miss events are typically more numerous. Some studies show a rate of 10 Near Misses to 1 Recordable incident. Near Misses are usually smaller in scale, simpler to analyze and easier to resolve. Determining the “root cause” of near miss events allows us to fix the gaps in the systems or programs before they produce an actual incident resulting in an injury or property loss. Near miss reporting allows you to get involved without having to suffer the pain of an injury. Being more involved: delivers a sharper awareness of events that cause injuries and other significant losses; drives reduction/elimination of unsafe acts and, allows employees to take even more ownership of the safety program September 18, 2018

Near Misses role in the Safety Triangle Then we can eliminate some of these outcomes If we can eliminate the factors here that led to a near miss… September 18, 2018

What is a near miss? An unplanned event that did not result in an injury, illness or damage, but had the potential to do so. It didn’t do so only because of a fortunate break in the chain of events that would have otherwise led to an actual injury, illness or some other type of damage. Some people would say, I’m not sure how to define it, but I’ll know it when I see it. Key question: “Could someone benefit from learning more about this event?” September 18, 2018

Safety Alert Letter Sulfuric Acid Near Miss 9/18/2018 Safety Alert Letter Sulfuric Acid Near Miss What happened? A 16,500 gallon sulfuric acid tank was being replaced. A formal risk assessment was conducted prior to the event. This assessment reviewed the risks of sulfuric acid exposure and controls to minimize/eliminate that exposure. Among those controls were blowing out and locking out the pipes leading to the tank, and the wearing of the proper PPE for this task. Although the piping had been cleaned prior to cutting into the line, it had not been locked out. When the non-supervised contractor was cutting the inlet pipe, the pipe began to leak residual sulfuric acid. The contractor was not wearing the required PPE and although the acid did not come in contact with him the opportunity for a major accident was possible. What contributed? Risk assessment was conducted in department but not at job site. Although lock-out was identified during the risk assessment, the procedure to lock out and tag out was not properly executed to confirm control of the system prior to beginning the work. PPE requirement should have been maintained based on the system hazard involved (sulfuric acid) even though the line was believed to be clean. Contractor representative was at risk assessment but it should have been the person who would actually perform the task. Inlet pipe that had residual sulfuric acid September 18, 2018

Safety Alert Letter Recordable – Ankle Sprain 9/18/2018 Safety Alert Letter Recordable – Ankle Sprain What happened? Employee stepped across a puddle onto an awkward surface and rolled his ankle. What contributed? A grating was removed from the bottom surface, leaving no dry space to step on. The stairs were moved which increased the gap to step over. Employee used poor judgment. What was done? Stairs permanently mounted at proper distance. Stairs modified to include grating at the bottom. Employees trained on walking and working surfaces. What is to be done? Evaluate all similar cross-over bridges and stairs. Modify as needed. Complete walking and working surfaces survey for entire site. Do you believe that this was the first employee to have ever walked over this? September 18, 2018

Near Miss Example: Description of Near Miss Event: Employee working on top of tank without guard rails or a fall protection harness Drum falls off of mezzanine to floor level striking no one. Hose inadvertently decouples from bulk mix tank while being filled by a tanker, but not a drop is spilled. The addition of a chemical to another chemical/group of chemicals results in an unwanted chemical reaction An employee slips on a patch of ice in the parking lot Potential ? September 18, 2018

What do we report? Potential unsafe condition Potential unsafe behavior (personal or colleague) Events where an injury could have occurred but did not Events where there was a potential for environmental harm; e.g. spill, near collision of pedestrian and forklift, dropped container, loose banding/shrink wrapping on floor, puddle in aisle. September 18, 2018

Key “Take Aways” Near miss events are our next level of learning opportunities. Do I or don’t I report? Don’t over think it. If you think someone would benefit from learning more about an event, report it. Full and open disclosure drives the investigation in the right direction and allows for identification of the correct root causes. Always tell the truth, it’s easier to remember. It’s always better to be the source of bad news, instead of being victim of it. Near miss learning opportunities will help to deliver zero (0) injuries. September 18, 2018

Questions September 18, 2018