1. Colorado Rural Electric Association 2009 Loss Control Conference NEAR MISSES REPORT/LEARN/USE Presented By: Eldon Humphers, CLCP-CUSA July 14, 2009

2. NEAR MISSES A near miss can be an effective tool for management of safety, health and environmental programs

3. NEAR MISSES Each cooperative should have in place a management structure for the application of a near miss program

4. NEAR MISSES Current Trends in the areas of  Economic  Political  Regulatory

5. NEAR MISSES Current Trends Have Created The Necessity for  Development of Integrated EHS System &  Focus on Proactive Measures

6. NEAR MISSES Near Misses are one of the best indicators of future problems involving the health and safety of employees. Detecting Near Misses and Addressing Them Can Improve The Overall Safety Program of A Cooperative.

7. NEAR MISSES Cooperative Safety Programs Are Being Recognized As An Important Reflection of the performance of the Cooperative. RESAP Currently Using A Cooperative’s Injury Index As A Part of The Accreditation Process

8. NEAR MISSES Effective Management of EHS Programs  Improve Cooperative’s Operation  Reduce Operating Costs

9. NEAR MISSES Outside influence  Non-Governmental RESAP Expectations Transparency of Cooperative’s Operation  New Demands

10. NEAR MISSES Outside Influence  Regulatory Agencies –OSHA –EPA Pro-Active Practices

11. NEAR MISSES PROACTIVE PROTECTION  Accident Pyramid  Frank E. Byrd, JR  Widely Used  Widely Accepted

12. NEAR MISSES Accident Investigation  Adds New Data  One Bad Accident  Several Minor/Near Miss Incidents Little or No Significant Damage

13. NEAR MISSES Accident Pyramid  Bottom of the Pyramid  Information Gained  On-Going Basis  Identify Potential Exposures

14. NEAR MISSES  Address problems when they are identified  Reduce Probability  Minimize the Damage

15. NEAR MISSES Effective Management  Identify Weaknesses  Reduce Accident Rate  Provide Guidance For Improvement

16. NEAR MISSES Proactive Prevention  Utilize Minor Incident Information  Based on Analytical Approach  Systematic Procedure  Develop Prognosis  Opportunity To Improve Safety

17. NEAR MISS Near Miss Program  Analysis of Potential Problems  Identification of Causes  Find Solutions  Implement Solutions

18. NEAR MISSES NEAR MISSES ARE THE INCIDENTS AND OBSERVATIONS AT THE BOTTOM OF THE PYRAMID.

19. NEAR MISSES Definition  Vary From System to System  Vary From Person to Person  Some Are Narrow  Some Are All Inclusive

20. NEAR MISSES Definition Broader Definitions Increase The Probability Of Identifying Potential Problems At Their Earliest Stages

21. NEAR MISSES DEFINITION  Example A Near Miss Is An Opportunity To Improve Safety, Health, Environmental and Security of An Operation Based On A Condition Of An Incident With Potential For More Serious Consequence.

22. NEAR MISSES Near Misses Always Reflect The Current Status Of A System. Data Provided by Near Miss Program is Immediately Applicable Near Miss Management Should Be a Key Component of EHS Program

23. NEAR MISSES Safety Programs Usually Only Address An Incident After It Happened. Near Miss Programs Address Incidents and Observations With The Potential For Serious Consequences.

24. NEAR MISSES Consequence  Injury To An Employee  Property Damage  Damage To The Environment  Business Interruption

25. NEAR MISSES LOSS CONTROL INSPECTIONS CREA LOSS CONTROL DEPARTMENT INSURANCE COMPANY LOSS CONTROL OSHA EPA

26. NEAR MISSES INSPECTIONS  IDENTIFY POTENTIAL NEAR MISSES  REPORTS ARE PROVIDED  DO YOU TAKE ACTION

27. OBSERVATION EXAMPLE

28. SUBSTATIONS

31. Electrical Tools Guards should be in place on grinders. Tool rest-1/8” Tongue guard-1/4”

32. NEAR MISSES THE CONDITIONS REPRESENTED BY THE PREVIOUS SLIDES ARE NEAR MISSES. IT IS ONLY A MATTER OF TIME UNTIL AN EMPLOYEE SUFFERS AN INJURY.

33. NEAR MISSES Feed Back  Initial Cooperative Report  Immediately After Investigation  Discussions With Management  Fine Tune Near Miss Program

34. Eight Steps of Effective Near Miss Process Identification Disclosure Priortization Distribution Identification of Causes Solution Identification Dissemination Resolution

35. NEAR MISSES IDENTIFICATION  First Step  Recognition

36. NEAR MISSES DISCLOSURE  Written Form  Reporter  Supervisor  Procedure  Increase Probability

37. NEAR MISSES PRIORTIZATION  Critical Step  Depth of Analysis  Allocation of Resources  Extent of Dissemination

38. NEAR MISSES DISTRIBUTION  Those Who Will Analyze  Low Priority  High Potential  Often Occurring  Pre-Determined

39. NEAR MISSES IDENTIFICATION OF CAUSES Direct/Root Causes Reporter Committee Priority Determines Extent

40. NEAR MISSES SOLUTION IDENTIFICATION  For Each Cause  No Effective Solution  Noted  Address Each Cause

41. NEAR MISSES DISSEMINATION  Communicate Solution  Stall The System  Manager Permission  Inform All Interested Parties  Distribution List

42. NEAR MISSES RESOLUTION (TRACKING)  Changes Execution Completion Inform Reporter

43. NEAR MISSES Management System  Oversight Team  Local Team  Near Miss Process  Electronic Management  Check Effectiveness  Training Programs

44. NEAR MISSES Oversight Team Requirements  Define Objectives, Make-Up and Procedures  Guidance In Specific Issues  Monitor Performance

45. NEAR MISSES Oversight Team  First Step To Be Implemented  Composition Managers EHS Directors/Managers

46. NEAR MISSES NEAR MISS MANAGEMENT TEAM  Responsibilities Identify Rules/Responsibilities Define Details Design Format Set Up Criteria Conflict Resolution Monitor Performance

47. NEAR MISS Auditing  Quality Control  Critical Step  Identify and Fix Problems  All Levels of Employees

48. NEAR MISSES Training  Two Types Administrators –Those who will manage the program

49. NEAR MISSES Administrator Training  Guidelines  Tracking  Evaluation  Improvement

50. NEAR MISSES Employee Training Subjects  What Are Near Misses  Importance of Near Misses  Role of Those Involved  Near Miss Management System  Team Members

51. NEAR MISSES Employee Training Subjects  Near Miss Process  Prioritization  Help

52. NEAR MISSES Near Miss Management  Powerful Tool  Engages Employees  Detect Problems

53. NEAR MISSES Management Support  Full Support  Active Involvement  Continuous Follow-Up  Encourage Reporting  Reward Participation  Lead By Example

54. NEAR MISSES Seamless Integration  Apply to All  Sharing problems  Sharing Solutions  Enhance Value of Program

55. NEAR MISSES Seamless Integration  Safety Culture  Sensitized Employees  Reduce Health & Safety Concerns  Improve Efficiency

56. NEAR MISSES Single Systems  Two Types Single –Cumbersome –Detailed –Discourage Employees

57. NEAR MISSES Parallel Systems  Confusion Among Employees  Which Incident to Report  Hybrid System Eliminates Problems Same Procedures

58. NEAR MISSES CONCLUSIONS  Best Indicators  Resolved Properly  Reduce Accidents  Improve Quality  Improve Productivity

59. NEAR MISSES CONCLUSIONS  All Encompassing Safety – Health – Environment – Security Production & Quality of Work Timely Indicator Proactive Program

60. NEAR MISSES Proactive Protection Program  Empowers Employees  Enables Observation/Resolution  Reflects Current Information  Identifies Sources of Problems  Provides Control of Health & Safety

61. NEAR MISSES A NEAR MISS PROGRAM CAN BE EXTENDED TO THE PUBLIC SECTOR

62. BE AWARE BE SAFE BE HAPPY THANKS