Near Hit/Accident Reporting & Analysis Dr. Brian J. Finder, CIH University of Wisconsin-Stout Menomonie, Wisconsin

A Thought to Ponder ... “Prescription without diagnosis is malpractice, whether it be in medicine or management.” Karl Albrecht Organization Development

Survival of the Fittest ... ….. highly depends on an organization’s ability to: Maintain a pulse of operational errors which permit loss to occur People Process Materials Equipment Environment Expediently correct the true causes of such errors to prevent their recurrence

Near Hit/Accident Analysis A critical process which allows us to view a potential or actual loss-producing event with 20/20 vision Culminates with the development and implementation of corrective activities/ standards which help refine system-related processes

Objectives of Near Hit/Accident Analysis To determine the Who, What, Where, When, and How about an accident To identify the true causes of a near hit or actual loss To determine where operational errors occurred in the management system To prevent recurrence

What an Effective Near Hit/ Accident Analysis Should Do Describe what happened Determine the real causes Evaluate the risks Develop the controls Identify loss trends Provide future training-related information Demonstrate concern for employee welfare Promote team-building

Which Near Hits/ Accidents Get Analyzed? All near hits/accidents should be analyzed to determine the extent to which reasonable controls can be instituted to prevent recurrence Special attention should be given to those which possess high loss potential

ILCI Loss Causation Theory Inadequate MANAGEMENT control Basic causes: personal vs. job factors Immediate causes: substandard acts/ conditions Near hit/accident: contact with energy, substance, and/or people Loss: people, product, service, facility, and/or environment

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL Inadequate  Program  Program Standards Compliance to Standards BASIC CAUSES Personal Factors Job Factors IMMEDIATE CAUSES Substandard Acts & Conditions ACCIDENT/ NEAR HIT Contact With Energy, Substance or People LOSS People Property Product Environment    

Inadequate Management Control A lack of internal standards designed to reduce/eliminate risks to loss Hazard recognition and abatement Performance appraisal Employee/management communication Internal standards are in place, but they are outdated or inadequate Management and/or employees do not follow established internal standards

Basic Causes Job Factors Personal Factors Inadequate ... supervision engineering purchasing maintenance tools/equipment work standards Wear & tear Abuse or misuse Personal Factors Inadequate ... physical capacity mental capacity Excess ... physical stress mental stress Lack of ... knowledge skill Improper motivation

Immediate Causes: Substandard Acts Operating equipment without authorization Failure to warn Failure to secure Operating equipment at improper speed Removing safety devices Improper use of personal protective equipment Servicing equipment in operation Being under the influence of alcohol/drugs Horseplay

Immediate Causes: Substandard Conditions Inadequate guards/barriers Inadequate personal protective equipment Inadequate warning system Fire/explosion hazard Poor housekeeping Noise/radiation exposure Temperature extremes Inadequate illumination Inadequate ventilation

Near Hit/Accident Struck by or against Fall on same or to lower level Caught in, on, or between Contact with ….. Overstress, overexertion, or overload

The Loss People: A bruise to a fatality Product: A dented package to a destroyed shipment Service: A few minutes lost to a month delay Facility: A cracked window to a leveled building Environment: A brief air emission to contaminated groundwater

Why Supervisors Should Analyze Near Hits/Accidents They have a personal interest They know the people and conditions They know best how and where to get information They will ultimately start or take action anyway They benefit from the analysis The will use gained knowledge for future prevention tactics

Basic Elements of a Near Hit/ Accident Reporting System Develop agreed upon reporting standards Routinely remind supervisors and employees of the need to report near hits & accidents Maintain accurate records (computer-based) Use data to identify trends Routinely provide management and hourly employees with trend results

Equipment for Collecting Near Hit/Accident Evidence Flash camera w/extra film & batteries Disposable Polaroid-type Camcorder Tape measure Grid paper

Importance of Immediately Gathering Perishable Evidence The 4 P’s of Perishable Evidence People: tend to forget or misrepresent Positions: become altered Parts: get changed and/or discarded Paper: can become altered and/or lost

Initial Actions at Near Hit/Accident Scene Take control Ensure first aid and call emergency services Control potential secondary hazards Identify sources of evidence Preserve/gather evidence Notify appropriate line/staff management

The Near Hit/Accident Analysis Process Immediately collect the who, what, when, where, and how of the four P’s of evidence Determine the most likely immediate cause Perform an Ishikawa (e.g., cause-effect) analysis on the immediate cause Test for most probable uncontrolled risk factors Develop & implement control measures for at least 3 uncontrolled risk factors

Injury at the Convenience Store Employee sustains serious back, neck and head injuries Analysis of the situation indicates that she walked backwards into a floor opening Follow-up with the employees indicates that an unguarded floor opening was present behind the store counter

Injury at the Convenience Store (cont.) Supervisor must perform an Ishikawa diagram with store employees to analyze the following major risk factor areas: Equipment n Processes/practices Materials n Environment People

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL Inadequate  Program  Program Standards Compliance to Standards BASIC CAUSES Personal Factors Job Factors IMMEDIATE CAUSES Substandard Acts & Conditions ACCIDENT/ NEAR HIT Contact With Energy, Substance or People LOSS People Property Product Environment    

THE ILCI LOSS CAUSATION MODEL LACK OF CONTROL Inadequate  Program  Program Standards Compliance to Standards BASIC CAUSES Personal Factors Job Factors IMMEDIATE CAUSES Substandard Acts & Substandard Conditions ACCIDENT/ NEAR HIT Contact With Energy, Substance or People LOSS People Property Product Environment     THE ISHIKAWA (FISHBONE) DIAGRAM Exposed floor opening behind counter (Cause) (Effect)

ISHIKAWA (FISHBONE) DIAGRAM Exposedfloor opening behind People Equipment Procedures Exposedfloor opening behind counter Materials Environment