Using Industrial Hydraulics |
Applications of Computer-Aided Manufacturing
Definitions: The definitions of the terms used throughout this guide will be repeated in a number of sections. The reason for this seeming duplication is to clearly explain the concepts so that a clear understanding is given as to what an accident, near miss incident, or other concept is and how it’s defined.
CLEARING THE CONFUSION
Experience gained in many organizations internationally has shown that confusion exists within organizations, as well as within the safety and health profession, as to what a near miss incident is and how to identify it in relation to an accident, incident, and unsafe (high risk) behaviors and conditions. This uncertainty has led to near miss incidents being incorrectly labeled and, consequently, almost forgotten.
Some also teach that all near miss incidents must be investigated--an almost impossible and impracticable task. If there is confusion within the minds of safety professionals, that confusion is passed on to employees and management and the end result is that near misses are not recognized, reported, or acted upon. This confusion is possibly the reason for near miss incident reporting systems not existing, or the failed attempts at near miss incident reporting in organizations.
Once understanding is reached as to what exactly a near miss incident is, near miss recognition is much easier. The approach taken in this publication is to keep the concepts simple so that all can understand the difference between the various concepts.
MINOR INJURY IS NOT A NEAR MISS INCIDENT
One event that is often referred to as a near miss incident is an accident that results in minor injury, which could have been a lot worse. This is not a near miss incident; if there is an injury, it’s an accident. An accident is the event and the injury is a consequence.
As an example, an operator was splashed with acid from a degreasing process and, because he was wearing the correct personal protective clothing, only received minor acid burns to one arm. Under slightly different circumstances, the injuries could have been more severe if, for instance, his face shield had been out of place or he was not wearing gloves, etc.
The fact that the injury was minor in relation to the potential for serious injury does not rate this event as a near miss incident. It was an accident that resulted in minor injury (loss) and should be termed as such. The fact that there was high potential for serious injury that didn't occur does not qualify this event as a near miss incident. In some instances, an accident scenario could involve injuries, damage, and near miss incidents all in one event.
NEAR MISS INCIDENTS
Near miss incidents are near miss events that come close to causing some form of loss, as there was an actual flow of, or exchange of, energy below the threshold level. In some instances, the flow of energy may have dissipated without making any contact, thus causing no loss. In most cases, the energy does not contact anything, thus causing no harm. In some cases, the exchange of energy was insufficient to cause loss or injury, but the fact that there was an exchange of energy is reason enough to heed the warning. Remember, it's not what happened--but what could have happened. Near miss incidents are accidents waiting in the shadows.
Defining a Near Miss Incident
Near miss incidents are also known as: near miss, or incident, close shaves, or warnings.
Other familiar terms for these events are: close calls, or, in the case of moving objects, near collisions. Near miss incidents also sometimes have been termed near hits by some writers.
A near miss incident is:
• An undesired event that, under slightly different circumstances, could have resulted in harm to people, or property damage, or business disruption, or a combination.
• An accident with no injury or loss.
• An event that narrowly missed causing injury or damage.
• An incident where, given a slight shift in time or distance, injury, ill health, or damage easily could have occurred, but didn't this time around.
Merriam-Webster defines a near miss incident as: "A result that is nearly, but not quite, successful." What does this mean to industry? It simply means that a serious accident (loss) almost occurred. Someone trips over a pallet, but doesn't fall. Two forklifts almost collide at a corner. A tool is dropped, but toes are missed … this time.
Wikipedia, the free online encyclopedia, defines a near miss incident as: "An unplanned event that did not result in injury, illness, or damage, but had the potential to do so." Only a fortunate break in the chain of events prevented an injury, fatality, or damage. Although human error is commonly an initiating event, a faulty process or system invariably permits or compounds the harm and is the focus for improvement.
From here on this guide will refer to a near miss incident as: An undesired event, which, under slightly different circumstances, could have resulted in harm to people, or property damage, or business disruption, or a combination of the three. (No substantial loss is experienced.)
Defining an Accident
There is confusion in the safety and health field concerning the words accident, incident, and near miss incident. Many years ago, the term incident was used to describe near misses, but since the modern approach is to term accidents (loss producing undesired events) as incidents, confusion between accident and incident still exists.
The American Society of Safety Engineers (ASSE) defines "a near miss accident" as an incident and further defines it as "an undesired event that, under slightly different circumstances, could have resulted in personal harm or property damage; any undesired loss of resources." This definition seems to be a combination of the definitions of an accident and a near miss incident and is confusing.
Often the word accident is replaced by the term incident, which leads to confusion; therefore, this publication will refer to near misses/close calls/near hits as near miss incidents to clearly and definitely remove any confusion concerning terminology.
Here are some definitions of an accident to indicate that there is general consensus that an event termed an accident results in some form of loss, either to an individual, property, organization, or all of these. These definitions will explain the terminology used throughout this publication.
• An accident is an undesired event often caused by unsafe acts or unsafe conditions and results in physical harm to persons, damage to property, or business interruption.
• An accident is an unplanned, uncontrolled event caused by unsafe acts or unsafe conditions and that results in harm to people or damage to property and equipment.
• An accident is the culmination of a series of activities, conditions, and situations and which ends in injury, damage, or interruption.
• An accident is the occurrence of a sequence of events that usually produces unintended injury or illness, death, or property damage.
• An accident is an undesired event or sequence of events causing injury, ill health, or property damage.
• An accident is an undesired event that results in harm to people, damage to property, or loss to process.
The contact phase in the accident sequence is traditionally often referred to as the accident segment of the sequence, which is incorrect as the accident is the total sequence of events and the loss (injury and damage) is the last phase of the event.
The National Safety Council (USA) defines an accident as: "that occurrence in a sequence of events that usually produces unintended injury or illness, or death and/or property damage." This definition, too, refers to the contact and exchange of energy where the harm is done as the accident phase of the sequence of events. The entire sequence of events, the loss causation sequence, is the accident. The unintended injury referred to is caused by the exchange of energy.
Frank E. Bird, Jr. and George L. Germain, in Practical Loss Control Leadership (1996), define an accident as "an undesired event that results in harm to people, damage to property, or loss to process." In analyzing these definitions, it’s clear that the factors leading up to a contact are undesired and the resultant effects, after the contact, are also undesired. A simple yet effective way to distinguish between an accident and a near miss incident is that the accident results in a loss and the near miss incident doesn't.
From here on, this guide will describe an accident as "An accident is an undesired event, which results in harm to people, damage to property or loss to process." (Loss is experienced.)
What causes the most confusion concerning the recognition of a near miss incident are definitions that describe an incident as some event that may or may not have caused injury. That could be anything. The American National Standards Institute, Inc. (ANSI), Standard: ANSI/AIHA Z10-2005, Occupational Health and Safety Management Systems, is one of the many definitions that cause this confusion and applying its definition of a near miss will confuse the issue more. The institute defines a near miss as an incident:
An event in which a work-related injury or illness (regardless of severity) or fatality occurred or could have occurred (commonly referred to as a "close call" or "near miss").
This is totally confusing. No wonder safety personnel are inclined to call all events "incidents." Many refer to accidents/incidents to make sure all events are covered, which is also misleading. Was the event an accident or a near miss incident? This guide endeavors to separate accident and near miss incident by clear definitions and descriptions of the two similar, yet very different, events.
ACCIDENTS VERSUS NEAR MISS INCIDENTS
In some accidents, there also can be near miss incidents involved. In a boilermaker workshop, a pressure vessel explodes due to a faulty relief valve. Shrapnel from the exploding boiler (damage) flies across the work area (energy) injuring two employees (accident) and narrowly missing (near miss incident) a group of workers who are working on a nearby milling machine. The shrapnel flying over their heads misses them, constituting a near miss incident. The event injured two employees and damaged property and, therefore, is an accident.
ACCIDENTS, NEAR MISS INCIDENTS, AND INJURIES
For the purpose of the following sections, it’s important to understand the following:
• An accident is an undesired event that actually results in injury, damage, business interruption, or combination thereof.
• A near miss incident does not result in any injury, damage, or business interruption, but has the potential to do so under slightly different circumstances.
• An injury is the resultant physical harm to a person's body (including occupational illness and disease).
-Defining an Injury-
An injury is also defined as "the bodily hurt sustained as a result of an accidental contact. This includes any illness or disease arising out of normal employment." The contact with a source of energy could cause injury to people. The word injury includes occupational illness and disease. The injury is a direct result of contact with a substance or source of energy greater than the resistance of the body. The item that inflicts the injury is the agency that could be an occupational hygiene agency, or a general agency. Injuries caused by accidents are normally immediate (acute). Industrial diseases are mostly long-term (chronic) as they manifest over a period of time. The exchange of energy in diseases is normally referred to as exposures and occurs over a time period. There is an exchange of energy as in an injury accident, except it’s phased over a longer time.
General agencies include:
• Sharp edges
• Power/hand tools
-Occupational Hygiene Agencies-
Occupational hygiene agencies are those items that cause the illness or disease. They include:
• Ergonomic defects
• Insufficient lighting
• Chemicals, etc.
DEFINITIONS: INJURIES AND DISEASES
"A work injury is any injury suffered by a person, and which arises out of, and during the course of, his normal employment." The definition of work injury includes occupational disease, work related disability, and occupational illness.
"An occupational disease is a disease caused by environmental factors, the exposure to which is peculiar to a particular process, trade or occupation, and to which an employee is not normally subjected, or exposed to, outside of, or away from, his normal place of employment."
Injury Compared to Accident
Most people confuse accident and injury. Not all accidents result in injury, and there is a definite distinction between the term accident and injury. An accident is the event and an injury is a consequence or end result of the event. The end result may have multiple consequences, such as property or equipment damage, process interruption, etc. The severity of the injury caused by an accidental event is difficult to predetermine, or define. The "luck factors" referred to later explain how the severity is sometimes determined by absolute fortune, either good or bad.
Trying to reduce the severity of the injury is a post-contact safety control. Quick evacuation, prompt medical treatment, adequate medical facilities, and trained personnel all contribute to the reduction of the severity of the injury. The recuperation time after an injury depends on numerous factors. It also determines the number of shifts lost as a result of the accident. These losses, in turn, determine the total costs of the accidents.
Facts Concerning Undesired Events and Near Miss Incidents and Accidents
• The majority of undesired events (high risk acts, high risk conditions, and near miss incidents) don’t end up in injury. Less than 1 percent of all undesired events result in serious injury (injury-producing accidents), approximately 2 percent result in minor injury, and about 5 percent cause damage to property, material, and the environment. Based on the Bird-Germain (1992) 1:10:30:600 ratio, the majority are ranked as near miss incidents.
• Accidents and near miss incidents are not planned or budgeted for.
• All accidents result in some form of loss, which can be tied to a cost.
• Near miss incidents don’t result in a loss.
• Accidents and near miss incidents occur as the result of a sequence of events.
• There is normally more than one cause for an accident and/or near miss incident.
• Fortune, chance, or luck plays a major role in determining the outcome of high-risk acts and high-risk conditions.
• The severity of an injury is also fortuitous.
• The majority of accidents and near miss incidents can be prevented.
• A small percentage of accidents are beyond control due to natural factors.
• Accidents indicate poor management control as a result of a failure to assess the risk.
• Accidents are often described as "a series of small blunders."
• An accident that results in serious injury has possibly occurred previously, but did not culminate in injury.
• Failure to assess the risk and take necessary action is the main cause of preventable accidents.
At this stage, it’s pertinent to examine the loss causation model, or accident sequence, and understand the sequence of events that lead to a near miss incident, accident, and subsequent loss.
Accidents are caused by a sequence of events, a combination of circumstances and activities that culminate in loss, similar to a snowball or domino effect. The loss may be an injury, damage, or business interruption. Due to some unexplained circumstance, sometimes called fortuity or luck, the event does not end in loss and this is usually termed a near miss incident. The factors leading up to an accident are there, but the event is interrupted as there is no exchange of energy and, therefore, no injury, property damage, or loss.
Failure to Assess the Risk
The first factor in the loss causation sequence is the failure to assess and mitigate the risk. As Dr. Dan Petersen (1997) said:
A firm can dictate, in advance, what actions it should take to prevent accidents, and then it can measure how well these predetermined actions are executed (37).
Risk assessment is a method that is predictive and can indicate potential for loss. With this knowledge, an organization is then able to set up the necessary management controls to prevent these risks resulting in losses, such as injuries, property damage, business interruptions, and environmental pollution. This method of accident prevention entails examining near miss incidents, risk assessing, and ranking their potential and investigating and rectifying the root causes of the high-risk, near miss incidents.
Many safety programs focus on the consequence of loss and not the control. Effective risk assessment is proactive, predictive safety in the finest form. In risk assessment, the keywords are: "It's not what happened, but what could have happened."
Lack of Control
The second link in the accident sequence is lack of control. This lack of safety management control could be no safety program, no safety program standards, or noncompliance to the standards or lack of a structured safety management system. This triggers the basic causes of accidents. If no formal, near miss event reporting and investigation system is in place, this would be classified as an inadequate control system.
-Basic Causes or Root Causes-
The basic (root) causes of accidents are categorized as personal and job factors. They are the underlying reasons why high risk acts are committed and why high risk conditions exist. A personal factor could be a lack of skill, physical or mental incapability to carry out the work, poor attitude, or lack of motivation. Job factors could include inadequate purchasing, poor maintenance, incorrect tools, or inadequate equipment.
These basic causes then trigger the immediate causes that are unsafe work conditions and unsafe work practices (high risk conditions and high risk acts).
High risk conditions are physical work conditions that are below accepted standards. This results in a high risk situation or an unsafe work environment.
High risk work conditions include:
• Unguarded machines
• Cluttered walkways
• Poor housekeeping
• Inadequate lighting
• Poor ventilation Near miss incident control will highlight high risk practices and conditions before they result in an accident.
High Risk Acts
High risk acts are the behaviors of people that put them, and possibly others, at risk (at-risk behaviors). This means that people are behaving contrary to the accepted safe practices and, thus, creating a hazardous situation that could result in a loss.
High risk acts include:
• Working without authority
• Failure to warn somebody
• Not following procedures
• Rendering safety devices inoperative
• Clowning and fooling around in the workplace Accidents and near miss incidents are always a result of multiple causes, normally a combination of high risk conditions and practices, and seldom, if ever, is an accident or a near miss incident attributable to a single cause.
Natural factors account for a small percentage of accidents. Tornadoes, thunderstorms, volcano eruptions, earthquakes, and floods are examples of natural or environmental factors that can lead to major losses. These can neither be attributed to high risk behavior nor an unsafe work environment. Taking up an unsafe position or tempting the elements would contribute to, or aggravate the severity of, a loss in a natural event, but does not cause the event itself.
Contact and Exchange of Energy
The high risk conditions or acts give rise to an exchange of energy and a contact that is the stage in the accident sequence where a person's body or a piece of equipment is subject to an external force greater than it can withstand, which results in injury or damage.
A luck factor exists here because the high risk act or condition may only result in a near miss incident with no loss. There is no contact with the energy or the energy is insufficient to cause harm. For example:
• In scenario one, a person is driving a motor vehicle and fails to stop at a stop sign at an intersection. This is a high risk act. The action had potential for loss.
• The same person is driving down the road in scenario two and the vehicle fails to stop at the stop sign. This is the high risk act and the car speeds through the intersection. However, another vehicle, which has the right of way, also passes by at the same time, narrowly missing the vehicle that failed to stop. Here we have a flow of energy as the two cars narrowly missed each other, but no contact or exchange of energy took place and there was neither damage nor injury. This is a near miss incident.
• The same event occurs in scenario three, but this time an oncoming car is speeding down the road and there is a collision. The losses are injury to the drivers and damage to the vehicles.
What determined the difference between scenario one and two? The difference was good fortune or luck. This is sometimes attributed to timing or positioning at a certain moment. Some believe it was being at the wrong place at the right time. The driver was lucky that there was not an approaching car and he got away with committing the high risk act of not yielding. In scenario three, the luck factor has proved unfortunate and the perpetrator was unlucky; there was a contact, exchange of energy, an accident took place, and there were losses.
A near miss incident must have an energy phase or there is no near miss scenario. A high risk act or condition does not constitute a near miss incident if there is not a flow of energy that could have contacted. They should be reported and acted upon, anyway.
The energy phase must consist of a flow of energy and not merely potential energy. A suspended load has potential energy, but a worker walking under the load is not involved in a near miss incident. He is committing a high risk act and the suspended load is a high risk condition (no matter how secure the load is).
If the load falls, we have a flow of energy, and if it narrowly misses the employee when it falls, we have a near miss incident. This is if the load was recovered before it fell to the ground completely causing damage.
There could be a flow of energy and an exchange of energy that is also classified as a near miss incident, but only if the exchange of energy was below the threshold limit of the body or structure. The load fell and just scraped past the employee's sleeve causing no injury.
If there was no perceivable damage or injury the event would remain as a near miss incident. Agreed, that there was a loss of time due to the event and the subsequent investigation, etc.
If the falling load damaged the goods being hoisted, or the surface onto which the load fell, we would have an accident scenario rather than a near miss incident scenario because of the substantial loss. Remember that if the goods fell causing damage and narrowly misses the employee, then there is a property damage accident and a near miss incident combined.
Many events result in injury as well as damage and also involve near miss incidents, all outcomes of one event.
Injury, Damage, or Loss
After the contact and exchange of energy, luck again plays a role in determining the outcome of the contact. The outcome could be injury to people, damage to property, harm to the environment, or process interruption, or a combination. We have no control over the outcome of the contact. Once the process is in motion, no control activity whatsoever can determine the outcome, which could be minor injury, serious injury, negligible, or severe damage to property or even death.
If the contact results in an injury, we are again dependent on luck. The injury may be minor, disabling, or fatal. The outcome of the exchange of energy and subsequent injury is fortuitous and depends on luck. The end result of a contact cannot be predicted or controlled. Contact safety controls (at the time of the energy exchange), such as personal protective equipment, safety belts, and vehicle air bags, contribute to help reduce the severity of injuries that are hard to predict.
One of the three major outcomes of a contact is property damage. Accidental property damage is damage caused by an accident, which does not result in injury or business disruption. Many safety programs don’t call for the reporting or investigation of these damage accidents, which in most cases also have potential to cause injury to employees under different circumstances.
The damage is usually a result of a contact and exchange of energy greater than the resistance of the object. Property damage can include damage to buildings, floors, equipment, machinery, and material.
In referring to the accident ratios, the property damage accident occurs more often than any other type of accident. Property damage accidents, therefore, are opportunities to identify the basic cause, and take steps to eliminate a similar accident
occurring. It will be appreciated that should a similar accident occur, because of hazards that have not been rectified, the outcome may be different, The next time the accident may result in injury, damage, business interruption, or a combination of all three.
Property damage accidents are the most important in the accident ratio. They also are warnings that a failure exists in the management system. This causes root causes to exist, which in turn, give rise to immediate causes and the contact, which then causes a loss in the form of damage to equipment, machinery, etc.
Property damage accidents are often a result of motorized vehicles colliding with the building, the cladding, the raw product, or the finished goods. Most manufacturing concerns are intent on the throughput of the plant and cannot afford the final product to be damaged by accidents. All property damage accidents should be reported and investigated. They should receive the same attention as an accident that causes serious injury.
Most property damage accidents have the potential to injure people, therefore, they should not be ignored. All significant property damage accidents should be thoroughly investigated and a costing done to indicate the actual losses incurred. Costs of repairs to equipment and vehicles should be listed and tabled as well at the various safety committee meetings. These statistics form a vital part of loss statistics.
The environment also can be damaged as a result of fire or pollution. Extensive losses can occur even though no injuries take place. Most property damage does result in business interruption and financial loss.
Fires are devastating. Every year, millions of dollars worth of property and products are destroyed. Fires are undesired events and occur as a result of high risk acts, high risk conditions. Property damage caused by fires is overwhelming. Instances can occur where the fire causes no injuries, in which case, the only consequence is damage to property, machinery, and products.
A contact need not necessarily cause injury or damage, but may well end up in some form of interruption of the business at hand.
The interruption may either be major or minor depending on the severity of the contact. Invariably, a contact causes some form of loss. If substantial time is lost restarting a machine or rectifying a continuous process that has been interrupted as a result of an accidental contact, it’s a loss. The losses caused by business interruption may not be as severe as losses incurred by injuries or property and equipment damage accidents. The exchange of energy in a business interruption is sometimes not as severe, but is sufficient to disrupt the work.
The work output would be affected because of the delay. Extra effort is needed to rectify this delay. Time to clean up, readjust, to realign, are all losses as a result of the business disruption. In certain instances, a critical part may be affected by the contact and, if not damaged, may be malfunctioning or temporarily displaced. All business work, process, and flow interruptions also cost money.
Each accident results in some form of loss and all losses cost money. Time may be lost, forms need to be filled out, and the business is interrupted to a degree. Many of the costs of an accident are hidden and, therefore, go unnoticed. Direct costs or insured costs are normally the only costs associated with an accident and are the lesser of the two amounts.
The final phase of the accident sequence and the last link in the chain reaction are costs. All contacts and exchange of energy result in some form of loss. Losses could include both direct and indirect costs of the accident. In mining and industry, property damage costs could be up to 50 times greater than the direct costs of accidents. A third cost is the totally hidden costs that are seldom identified or tallied. The totally hidden costs of the accident are also losses that are hard to determine, but that exists nevertheless.
Part of the management control function would be costing out the accidental losses and showing these as part of the losses of the business. Well-known management consultants have stated that maximizing profits is not the only aspect of business, as minimizing losses is just as important.
A MEASURE OF SAFETY
Because an injury is minor does not mean that the event that caused the injury was. The event should be investigated and the potential and probability of recurrence evaluated. The next similar event may have more serious consequences as a result of luck factors (under slightly different circumstances).
Most safety programs count the serious injuries as a measure of "safety." This measurement method, while still accepted, is, in fact, a measurement of failure. Assessing and controlling the risks of the business and the activities that make up the control measures should be audited and the result will be a more positive measurement of management work being done to combat loss (safety).
Treating the Symptoms
In the accident ratio proposed by many safety professionals, the serious or fatal injury represents the tip of the triangle or iceberg. One cannot focus on the tip of the iceberg, as the tip is the result of the base of the iceberg, or the underlying cause of the loss. In the accident/near miss incident ratio, the high risk conditions or behaviors, or a combination thereof lead to the accidental exchange of energy that causes loss.
NEMIRR(Near Miss Incident Recognition, Reporting, Risk Ranking, Investigation, and Remedy)
Focusing on the tip of the iceberg, or the serious injuries, is treating the symptoms of the problem and not the cause. Near miss incident recognition, reporting, investigation, and remedial action (NEMIRR) offers management an opportunity to react to accident warnings and to eradicate the problems before they result in loss to people, property, plant, or the environment.
As one safety practitioner put it:
I believe that there is huge opportunity to reduce actual workplace accidents by ramping up the focus on near misses to the same level as actual accidents.
The Accident Ratio
Most people involved with workplace safety are aware of the iceberg theory, the safety triangle, or its correct terminology, the accident ratio. For every recorded injury or loss sitting above the surface, there are many unrecorded near miss incidents submerged below the surface. This was first proposed by H. W. Heinrich in 1931 when he published his 1:29:300 ratios.
Statistics tell us that there could be as many as 600 near misses for each one serious injury. According to the Bureau of Labor Statistics (BLS), 3.3 million injuries occurred during 2009. If we multiply each injury by 600, the result is 1.9 billion near miss incidents, or opportunities to prevent accidents, for 2009 alone.
According to the National Safety Council's Injury Facts in 2008 some 26 million accidental injuries were experienced during that year. This all inclusive figure includes work-related, recreational, and home injuries. Using the Bird ratio, this converts to at least 7 billion near miss incidents or warnings that may have preceded these actual injuries.
The accident ratio depicted in Model 1.1 shows that for every serious injury as a result of an accident there are some minor injuries, more property damage events, and plenty of near miss incidents. The only way to reduce the injuries that make up the peak of the triangle is to identify, investigate, and rectify the near miss events before they result in injuries or other losses.
As the late safety entrepreneur Frank E. Bird, Jr. explained to me:
If you look after the near miss incidents, the accidents will look after themselves. You see, you can't be accident free until you are near miss incident free.
One Some Serious or Disabling Injury Minor Injuries Property Damage Accidents Near Miss Incidents More Plenty
MODEL 1.1 The accident ratio conclusion.
This ratio which has been developed and researched for a number of years is perhaps one of the most important axioms in safety philosophy. The introduction of thorough near miss incident recognition, reporting, and rectification programs in industry have proved without a doubt that if one reduces the number of near miss incidents the consequent number of injury-producing accidents is reduced considerably.
Extending the Accident Ratio
While the near miss incidents that form the base of the accident ratio are truly the foundation of a major injury, numerous high risk acts and conditions lie below on the next level (Model 1.2). Research has indicated that this lower level of unsafe situations could equate to as many as a thousand high risk situations for every serious injury experienced. While the actual numbers are debatable, the fact remains that there must be numerous high risk acts and conditions for the plenty of near miss incidents experienced.
Not all near miss incidents should be investigated. Many organizations think that this is the correct thing to do and find their near miss incident program failing because employees and safety staff are bogged down in investigating every near miss incident reported. While this is humbling and has good intent, it’s not the correct approach.
Each near miss incident should be risk ranked as to its loss severity potential and probability of recurrence. Only those with high potential should be investigated initially. Once an organization has control over the high potential near miss events, it can then direct its efforts to investigating the lower potential events.
MODEL 1.2 The lower level of the accident ratio.
One Some Serious or Disabling Injury Minor Injuries Property Damage Accidents Near Miss Incidents High Risk Acts and Conditions More Numerous Plenty
MODEL 1.3 A simple risk matrix.
Based on the safety management principle of the critical few, the top 20 percent of near misses could hold the potential for 80 percent of the potential accidental losses.
An invaluable safety tool is the risk matrix (Model 1.3). Remember, it's not what happened, it's what could have happened. The risk matrix is a crystal ball to predict the future or possible outcomes of near miss incidents. It can be used to forecast the probability and severity of the next loss.
High potential events, such as near miss incidents that did not result in loss, should be investigated as rigorously as serious injury-producing accidents, if the assessment of the risk shows in the black (high-high) on the matrix. Risks that rank (high, medium-high) or (medium-high, medium-high) also should be subject to an investigation. All injuries and loss-producing events (in excess of $1,000) should be investigated irrespectively.
Reporting all undesired events, such as near miss incidents, is perhaps the most important aspect of any safety program. A no-blame system should be introduced to encourage reporting without consequence. Most near miss incident programs fail as a result of disciplinary steps being taken once an event has been reported. The more warnings that are turned in, the more the opportunity to investigate, identify, and rectify the root cause before a serious loss occurs.
In the U.S. aviation industry, the Aviation Safety Reporting System (ASRS) has been collecting confidential, voluntary reports of close calls (near miss incidents) from pilots, flight attendants, and air traffic controllers since 1976. The system was established after TWA Flight 514 crashed on approach to Dulles International Airport near Washington, D.C., killing all 85 passengers and 7 crew in 1974.
The investigation that followed found that the pilot misunderstood an ambiguous response from the Dulles air traffic controllers, and that earlier another airline had told its pilots, but not other airline pilots, about a similar near miss incident. Some familiar safety rules, such as turning off electronic devices that can interfere with navigation equipment, are a result of this system. Due to near miss incident observations and other technological improvements, the rate of fatal accidents has dropped about 65 percent, from 1 in nearly 2 million departures in 1997 to 1 fatal accident in about 4.5 million departures in 2007, according to The New York Times.
In the United Kingdom, an aviation near miss incident report is known as an "Airprox" by the Civil Aviation Authority. Since reporting has begun, aircraft near miss incidents continue to decline according to the same source.
The rate of firefighter fatalities and injuries in the United States is unchanged for the past 15 years despite improvements in personal protective equipment, apparatus, and a decrease in structure fires. In 2005, the National Firefighter Near Miss Reporting System was established, funded by grants from the U.S. Fire Administration and Fireman's Fund Insurance Company, and endorsed by the International Association of Fire Chiefs and Firefighters. Any member of the fire service community is encouraged to submit a report when he/she is involved in, witnesses, or is told of a near miss event. The report may be anonymous, and is not forwarded to any regulatory agency.
In healthcare, the Association of peri-Operative Registered Nurses (AORN), a U.S.-based professional nurses organization, has put in effect a voluntary near miss incident reporting system covering medication or transfusion reactions, communication or consent issues, wrong patient or procedures, communication breakdown, or technology malfunctions. An analysis of incidents allows safety alerts to be issued to AORN members.
The Patient Safety Reporting System (PSRS) is a program modeled on the Aviation Safety Reporting System and developed by the U.S. Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) to monitor patient safety through voluntary, confidential reports.
The near miss incident registry is a risk free, anonymous reporting tool for near miss incidents in internal medicine. It’s sponsored by the New York State Department of Health and administered by the New York section of the American College of Physicians. This tool collects information about both near miss incident medical errors and the barriers that kept these errors from reaching patients.
The Railroad Industry
CIRAS (Confidential Incident Reporting and Analysis System) is a confidential reporting system modeled on ASRS and originally developed by the University of Strathclyde for use in the Scottish rail industry.
Near miss recognition, reporting, risk ranking, and remedy offers organizations opportunities to rectify potential loss-producing accidents before they happen.