NO INJURY-NO INCIDENT?

1. NO INJURY-NO INCIDENT? “Near Misses”

2. Accident Ratio Study Serious Incident Includes recordable and disabling Injuries 1 Minor Injuries Any reported injury less than a recordable 10 Property Damage & Incidents All Types, including environmental releases 60 Incidents with no visible Injury or Damage (Critical Incidents - Near Misses) 600

3. Personal injury Property damage Uninsured Costs CHAIN OF ACCIDENT CAUSATION Management Safety Policy & Decisions Supervisory Performance Personal Factors Job Factors Basic Causes Human Factor Immediate causes Substandard Practices Substandard Conditions Near Miss - Warning ACCIDENT unplanned release of energy and/or hazardous material Incident - Contact Focus on Near Misses & Prevent Accidents Accident Results

4. Accident Causes • Unsafe Act - 88% • an act by the injured person or another person (or both) which caused the accident; and/or • Unsafe Condition - 12% • some environmental or hazardous situation which caused the accident independent of the employee(s)

5. Why Minor Incidents Go Unreported • Fear of: • Supervisor/Manager Disapproval • Getting a Bad Reputation • Being terminated or disciplined • Not Wanting To: • Lose time from the job • Risk Embarrassment, Peer Pressure • “Rat” on other employees or being perceived by others as a “whiner” • Have a incident on their work record • Be the subject of or involved in an investigation • Not knowing why minor incidents should be reported or what near misses are. • Lack of Management follow-through in the past. • Fear of having a poor or blemished safety record.

6. WHY THE RELUCTANCE TO REPORT? It’s usually inconvenient to fill out the “accident form”. Near miss experiences are “private affairs”. “Organizational Influences”- What’s to be gained? A pleasant or unpleasant experience. Slogans like “All injuries are preventable” don’t help. Offering rewards for reporting near misses don’t help.

7. A DIFFERENT FOCUS! Environmental Assessments Particularly Property Damage We need to investigate property damage where there is no injury. If damaged equipment or physical structures are not repaired, injuries will eventually follow. Yet little value is given to investigating property damage. “Litter Begets Litter”. Psychologically speaking, “Property Damage begets Property Damage”. Property Damage is a physical trace of an incident.

8. Why Focus on Near Misses? • Establish Causes • Prevent Recurrences before they become Recordable or Serious • Establish corrective actions • Learn from the incident • Improve our companies safety culture • Statistical safety data base

9. What is a Near Miss Accident ? • “Near miss” these are events which are a unexpected occurrence that just missed being an employee or equipment incident or an environmental release. • One step away from a employee or equipment incident or an environmental release • Any deviation beyond the safe operating limits of process parameters or procedures. • Challenge the last line of defense. • Failure of any one or multiple safeguards.

10. Near Miss Examples • Operating heavy equipment too close to each other almost colliding due to operating activities are close in proximity. • Equipment not tied down properly on the truck bed, equipment is loose or it falls off without striking anything or anyone. • Waterblast operators blasting too close to each other without striking each other, but could potentially have. • Backing up in a forklift without looking back and another employee passes behind without the operator aware. • Not cleaning up a spill and someone else finding it and cleaning it up. • A truck arrives to be unloaded, during travel the load has shifted, when the door is opened a drum falls out just missing a employee. • Kicking a brace and almost falling. • Climbing out of Bob Cat and foot slipped on step. • Slightly damaged van, pulling trailer out of dock. Can You Think of Others?

11. MORE Examples…. • Sprayed with solvent after opening 55 gallon drum. • Pallet broke, spilling chemicals, weather deterioration to pallet. • Sprayed with etch after pressure build-up in line. • Pressure in a tank caused material to shoot out probe inlet. • Stepped into open sump when unloading oil tanker. • Chemical splash, after pressure build-up at filter basket. • Guard rail broke when employee was climbing down. While excavating a area, a gas line was struck and broken, releasing natural gas. The owner assured us prior to work that all lines were blocked and/or locked. • An employee reached into a piece of moving equipment without shutting it down to dislodge a jam, no injury or equipment damage occurred….This time. (Shut down equipment and lockout/tagout) • A major release of flammable gas that forms a vapor cloud but does not explode. • A major release of a hazardous material into a storm sewer that is successfully impounded before the material enters a waterway.

12. Yes! Investigate????? • Near-Miss incidents, like no-injury accidents, must be investigated whenever reported or observed. • They are forewarnings of what can and might happen. • An accident is almost always sure to follow when such forewarnings are ignored.

13. Need to Complete a Whole Incident Investigation? • Have a separate, simple Near Miss Report Form. • For most, the Near Miss Report is all that will be needed. The events from the Near Miss Report will be used to show trends in safety performance along with the Risk Ranking. • When the trend or risk ranking change, increasing the likelihood, a full incident investigations may be needed to determine the cause of the change for a particular incident cause or risk.

14. Extra Effort Needed • We sometimes question near miss incidents, but the causes of today’s near miss incident, if not determined and corrected , may occur again to produce tomorrow’s employee or equipment incident or an environmental release. • Accident investigations must be directed not only at what did occur but also the potential of what could have occurred. • INVESTIGATE ALL NEAR MISS INCIDENTS! Nothing is learned from unreported incidents and the causes are left uncorrected!

15. Encourage Reporting of Near Miss Incidents by… • Ensuring all employees are told to report near miss incidents. • Positively reinforcing each other when reporting near miss incidents. • Reminding ourselves of its importance. • Sharing successes--improved work environment across the entire company. • Using the incident investigation’s Safety-O-Gram form for the investigation and reporting document. • Having the forms readily available to all employees.