Why are they important?

Transcription

1 Near Misses/Close Calls What are they? Why are they important?

2 Near Misses EX. Look at video & count them. Disregard sporting events like football, basketball, soccer, tennis, bowling,etc. 1) Man in parked car 2) lady crossing st. nearly hit by 2 vehicles. 3) Guy in the road 4) Guys in PU truck 5) Guys almost hit along the road 6) Train almost hits people on tracks. 7) Robbers get away despite police being there. 8) Driver gets thru intersection 9) Lady on balcony almost falls. 10) Parked car moves at last sec. misses falling tree. 11) Guy on cycle almost wipes out. SEE Video #2 intersection

3 Near Misses What do they teach us? Something is right or wrong? ANSWER LACK OF TRAINING? LACK OF EXPERIENCE? Are most incidents caused by Unsafe acts/unsafe conditions? Or both?

4 What % of incidents do you believe have unsafe acts/conditions as their primary cause? Unsafe 90% Acts Unsafe Conditions 10%

5 UNSAFE ACTS EXAMPLES: NOT FOLLOWING PROCEDURES TAKING SHORTCUTS NOT WEARING PPE WHEN NEEDED TAKING DRUGS OR ALCOHOL NOT WAITING FOR HELP TO LIFT

6 UNSAFE CONDITIONS EXAMPLES: POOR HOUSEKEEPING OIL ON FLOOR NO GUARDS ON MACHINE WET, MUDDY JOBSITE OR MACHINE, SLIPPERY ROAD, ETC.

7 The Incident Pyramid 1 FATALITY 30 SEVERE INJURIES L.T. 300 MINOR INJURIES 2000 NEAR MISSES MED. ONLY FOCUS 20,000 UNSAFE ACTS Behavior

8 Fatality Severe Injury Minor Injury At-Risk Results Near Miss Unsafe Behavior Control Management System

9 Incident Investigation

10 Incident Investigation Strategy Gather information and establish the facts Isolate the contributing factors to the cause Determine corrective action(s) to prevent recurrence Fact Finding FAULT FINDING

11 Many incident investigations wrongly gy pinpoint this as the cause:

12 Symptoms vs. Causes

13 Strains Burns Cuts Direct Cause of Injury Horseplay Unguarded machine Create a hazard Ignore a hazard Broken tools Chemical spill Fails to report injury Defective PPE Fails to inspect Untrained worker Surface Causes Lack of time Fails to enforce Fails to train To much work No recognition No recognition plan ack of vision No mission statement Inadequate training No discipline procedures No orientation process Inadequate training i plan Inadequate labeling Outdated hazcom program No accountability policy No inspection policy Root

14 SYMPTOMS Unsafe acts and conditions which we can see

15 CAUSES The underlying reasons for accidents which h we can t see. Can only be identified through investigation and root cause analysis study

16 When an HAPPENS WHO? WHAT? WHEN? WHERE? WHY? WHO CAN MAKE IT BETTER? HOW? BETTER INVESTIGATIONS AND REPORTING NEAR MISSES NOT WHOSE AT FAULT?

17 WHO IS RESPONSIBLE for SAFETY? The Employee? His SUPERVISOR? Are BOTH responsible?

18 Hear no evil, See no evil, Speak no evil

19 SUPERVISORS RESPONSIBILITES: 1) Conduct immediate initial accident investigations. 2) Collect and preserve all evidence. 3) Conduct interviews of witnesses. 4) Take action to protect people and property at the accident scene. Get injured to doc.

20 EMPLOYEE RESPONSIBILITES: 1) Immediately report all accidents & injuries to their supervisor. 2) Assist in all accident investigations. 3) Report all hazardous conditions and near- misses to supervisors & complete form.

21 Notice of Near-Miss This form is to be used to document a NEAR-MISS NEAR-MISS. A Near Miss is defined as an incident that may have resulted in personnel injury, equipment damage or a combination of the two, but did not. (Optional Name: Job Title: Facility / Work Location: Description Of Near Miss: If you need more room, use reverse side of form or additional paper.

22 Notice of Near-Miss What factors do you feel may have contributed to this near miss? (For example: inattentiveness, improper PPE* or tools, inadequate procedure, lack of training, etc.) Please be specific. If you need more room, use reverse side or additional paper. What do you feel would prevent this type of near miss in the future? (For example: better PPE or tools, revising a procedure, specialized training, etc.) Please be specific. If you need more room, use reverse side or additional paper. Signature of Reporter: (Optional) Date: / /2009

23 Notice of Near-Miss This near miss report will be distributed throughout the PARISH. You have the option of allowing parish management to use your name, or to remain anonymous when this report is distributed to all departments (your name will be removed). *PPE means personal protective equipment like safety goggles or gloves. YOU MAY USE MY NAME AS IT APPEARS ON THIS REPORT FOR PUBLICATION PURPOSES: (Circle/Check Appropriate Box) YES NO Please Send Completed Form To Your SUPERVISOR.

24 Bottom-Line Results Investigate incidents only scratch the surface and lots of info. gets by the radar. Investigate unsafe acts and conditions we re still not getting it all. Investigate Near Misses and all llincidents id - much better data and chance to PREVENT LOSSES.