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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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    

11. 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Internal standards are in place, but they are outdated or inadequate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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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    

26. 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)

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