1. HOW to INCREASENEAR MISS REPORTING STEVE WISE DECEMBER 2010

2. Have you ever been involved in an Accident Investigation – where the contributing factors of the Accident happened before but weren’t reported? ______________________________ Do you find that your People are reluctant to report Near Misses? HOW to INCREASE NEAR MISS REPORTING

3. Near Misses – Are Everywhere Shock over workplace close calls Posted Tue Sep 14, 2010 3:27 pm AEST Authorities are urging employers to ensure their workplaces are safe. (ABC News: Giulio Saggin). Tasmania's workplace safety authority is investigating a series of electrical explosions involving young workers. Workplace Standards is urging employers to ensure their workplaces are safe. All of the recent incidents involved unsafe work practices. In three of them, young tradesman were working on live switchboards. The explosions caused extensive damage and one forced the closure of a Hobart primary school for a day. Workplace Standards' general manager Roy Ormerod says the workers were lucky to escape serious injury. Near Misses can be very much a part of the Normal Work Day "They were very, very lucky indeed. There was a similar incident on the mainland where a person received severe burns to his face working on a live switchboard and that person has been in hospital for months and months and will probably never work again," he said. "That's how serious it could be.” http://www.abc.net.au/news/stories/2010/09/14/3011531.htm

4. How to Increase Near Miss Reporting This Safety Training Presentation – is directed to Safety Leaders of their Organization – whose mission is to Protect their People. The Information that is contained herein – Is taken from the Safety Experience that I have accumulated along my way. Along with various and worthwhile sources on Near Miss Reporting from the Internet – which are so noted. The Goal of this Presentation – is to give all Safety Leaders ideas on how to increase Near Miss Reporting – in order to Help Keep our People Safe.

5. How to Increase Near Miss Reporting What is a Near Miss? Reasons Why Our People are Reluctant to Report Benefits of Reporting Near Misses How to Improve Near Miss Reporting Actions Needed to Address Near Miss Reporting’s Keeping the Process Flowing

6. If You were asked to define what a Near Miss is – What would You Say? WHAT IS A NEAR MISS?

7. What Is a Near Miss? A Near Miss – Simply put – is a Close Call Where the Individual(s) involved – were not Injured But may have resulted in Damage to T&E And if not attended to and corrected timely – More than likely will result in one or more of your Employees being Injured possibly severely or acquiring an Illness from its cause.

8. What is a Near Miss? Examples of Near Misses that I have been exposed to – Forklift tipped over while carrying a load that shifted on an uneven work surface – Driver escaped without a scratch by staying buckled inside the Cage. Mechanic working under Railcar had just stepped away when the Car was struck by another Railcar being positioned on an active Work Track. Forklift ran over Welder’s Foot which was protected by his Steel Toed Boots – when the Driver backed up and did not see him walking behind his Lift.

9. Examples of Escapes from Near MissesJICOSH - Japan International Center for Occupational Safety and Health In the work of replacing the bucket securing pin, a mechanic hit the pinhead with a sledgehammer forcibly. The pin was driven out of the hole in a high speed and came near to hitting a fellow mechanic on the opposite side. http://www.jniosh.go.jp/icpro/jicosh-old/english/cases/sacl/saigai03e/saigai03e_19.htm

11. The tool operator, while attempting to anchor a plywood form in preparation for pouring a concrete wall, fired the gun causing the nail to pass through the hollow wall.

12. The nail travelled some twenty-seven feet before striking the victim.

13. The tool operator had never received training in the proper use of the tool, and none of the employees in the area were wearing personal protective equipment.A NEAR MISS – is often only an Inch or two away from a Tragedy. http://www.osha.gov/OshDoc/data_FatalFacts/f-facts02.html

14. What % of Near Misses do You think are actually reported? REASONS WHY OUR PEOPLE ARE RELUCTANT TO REPORT NEAR MISSES

15. Reasons Why Our People are Reluctant to Report NEAR MISSES I would venture to say that Near Miss Incidents in any Organization – outnumber Actual Injuries between 2:1 to 4:1 I would also venture to say that Less than 20% of Near Miss Incidents are actually Reported What would You say?

16. Reasons Why Our People are Reluctant to Report NEAR MISSES There is No System for Near Miss Reporting. Workers believe that their Supervisors will hold such Near Miss Reporting against them. Generates Additional Work – i.e., paperwork, subsequent Investigation, etc. Supervisors and/or Workers have Not Been Instructed How to Report Near Misses. Once reported – Nothing is Done to Address or Correct what Caused the Near Miss.

17. Reasons Why Our People are Reluctant to Report NEAR MISSES Upon reporting – there is No Follow-up Communicated to the Individual(s) who so reported the Near Miss. Loss of Credibility for those that report such – may be viewed as a “Squealer.” There is No Motivation for Organizational Employees to report Near Miss Incidents – nothing is gain Individually or Organizationally.1 Near Misses are so Frequent that they become common place and part of the everyday work life.

18. Reasons Why Our People are Reluctant to Report NEAR MISSES Employees may Fear a Possible Job Loss or be Penalized – if they are found to be a contributing factor of the Near Miss Incident. Form(s) Used may be too Complicated for Near Miss Reporting.2 There is No One Assigned to handle / direct the actions needed to correct what caused the Near Miss. Workers have the Mindset that being Safe in the Workplace also includes Being Lucky.

19. We MUST find Ways to Hear and Learn from our Near Misses BENEFITS of REPORTING NEAR MISSES

20. OSHA – Weekly Fatality / Catastrophe Report(Federal and State data tabulated week ending November 6, 2010) Wouldn’t You have wanted to make a Difference here? http://www.osha.gov/dep/fatcat/fatcat_weekly_rpt_11062010.html

21. Benefits of Reporting Near Misses As a Safety Leader – It is hard to argue with the fact that a Near Miss Safety Incident –is a “Do Over” without a Cost or Penalty or Injury. It is also hard to argue that Near Misses must not only be attended to and corrected timely – but that they must be Used as a Learning Experience.

22. Benefits of Reporting Near Misses A Real Life Example – At one of our Facilities – a Mechanic was operating a Machine with a Rotary Mechanism. When the Machine got clogged – the Mechanic reached inside to clear it without turning off and Locking Out – catching his Arm Sleeve on the rotating mechanism. His initial reaction was to fall away from the Machine – resulting in his Arm Sleeve ripping from his Shirt. The Mechanic received No Injury – and was very lucky that his Hand / Arm was not pulled into the Machine.

23. Benefits of Reporting Near Misses A Real Life Example (con’t) – This Near Miss Incident was reported – and an Incident Investigation and Report were completed. Corrective Actions included reviewing the Incident with all Personnel that use such a Machine – and the need to Lock Out any such Machinery before servicing. A Safety Bulletin was issued that included a Picture of an Individual that suffered Fatal Injuries from such an Incident that was pulled into a Machine. To see such – Google Image – “Machine Accidents”

24. Benefits of Reporting Near Misses Reporting of a Near Miss and the subsequent Investigation of – will more than likely reveal – acts, conditions, etc. that will need to be corrected.

25. Benefits of Reporting Near Misses EXISTING CONDITIONS – Do not be surprised when investigating Near Misses – to find Unsafe Conditions that have been present for some time. NO STANDARD WORK PRACTICE – Near Miss Incidents are often caused by having no such standard practice or procedure in place – which results in having various and most likely unsafe ways to accomplish a task or responsibility. LACK OF TRAINING – Another condition that leads to Safety Incidents –is the lack of Training of the Workers involved – i.e., How to Safely use a Come-Along.

26. Benefits of Reporting Near Misses USING IMPROPER or UNSAFE TOOLS – Can a Near Miss Incident ever be caused by Management? How about when a Tool is given to an Employee that is either improper or unsafe to use for the Job that that they are asked to perform. CUTTING CORNERS – Common place in the Work Place – will be Employees that “Cut Corners” – i.e., not following the steps that need to be performed in order. Such may be due to Complacency and the belief that they will not get hurt – or it may include simply trying to speed up their work process.

27. Benefits of Reporting Near Misses LACK of SAFETY AWARENESS – A leading cause within my Organization – is the lack of Safety Awareness by our People involved in Near Misses and Accidents. Such has included –not seeing Co-Workers in their immediate Work Area – to placing their Body Parts between Pinch Points – to not checking their work area prior to setting up or beginning their work. OUTDATED PROCEDURES – Organizations must ensure that when their Processes change – that they update their Procedures to reflect such changes.

28. It is essential for Safety Leaders – to hear and know about Near Misses HOW to IMPROVE NEAR MISS REPORTING

29. How to Improve Near Miss Reporting Safety Leaders must create an environment – where Near Misses are reported timely – so that events such as this are stopped before they occur. Rig worker dies in workplace accident near Fort McMurray Occupational Health and Safety investigating By Journal Staff, edmontonjournal.com November 10, 2010 EDMONTON — A man is dead after a workplace accident in the Fort McMurray area on Tuesday. A rig worker for Encore Coring and Drilling was killed during the assembly of an oil rig at a remote Devon Energy work site near Kirby Lake, about 350 kilometers northeast of Edmonton. Occupational Health and Safety is investigating. "A piece of equipment fell and hit a worker in the head," said Occupational Health and Safety spokesman Chris Chodan. The man was an experienced rig worker, said Rob Wilman, vice-president of health and safety for the parent company, Ensign Energy Services. © Copyright (c) The Edmonton Journal http://www.edmontonjournal.com/health/worker+dies+workplace+accident+near+Fort+McMurray/3800911/story.html

30. How to Improve Near Miss Reporting There are three (3) important factors that must be present to ensure that Near Misses are reported – There must be a Near Miss Reporting System in placethat tracks the status of. The Near Miss System must be understood by All Employees. All Near Misses should be investigated and corrective actions takenif necessary to prevent their reoccurrence and/or more serious Injury.

31. How to Improve Near Miss Reporting In addition to these Factors – there are other important elements that should also be in place – NO PENALTY – There should be No Penalty what-so-ever to any Employee that reports a Near Miss. As soon as such is experienced – all Near Misses will go underground. DRIVER OF THE SYSTEM – At each of your Locations–you need to have someone assigned to be the “Handler” of all Near Misses. Such duties will include Recording, leading the Near Miss Investigation, and helping to determine and complete Corrective Actions to prevent any reoccurrence.

32. How to Improve Near Miss Reporting In addition to these Factors (con’t) – PUBLICIZE YOUR EFFORTS – In order to make Near Miss Reporting successful – you must Publicize Your Efforts. You need to find a way to report how corrective actions taken as a result of Near Misses – have helped the Organization and your People – by making their Workplace Safer. You will have People reluctant to report Near Misses – until they see that they have something to gain from so reporting. SHARE WITH OTHERS – Near Misses can and should be a Learning Tool for all applicable Organizational Employees. Make sure that you take time to not only share the Near Miss Incident – but also how it occurred and what actions were taken to prevent its reoccurrence.

33. How to Improve Near Miss Reporting In addition to these Factors (con’t) – COMMUNICATE ACTIONS TAKEN – It is very important that you communicate any findings and actions taken to those involved with the Near Miss. This includes both the Individual(s) that reported the Near Miss – as well as any Individual(s) that were actually involved in the Near Miss. In addition, it would be beneficial to advise any Work Group Members that are involved in similar work actions. USE AS A LEADING INDICATOR – Take time to track and record your Near Miss Incidents. Such can be used as an indicator of your Safety Performance to come. Various factors can be interpreted from Near Misses including – are they major vs. minor in nature, is their primary cause from either lack of awareness or lack of training, etc. Near Misses can point to what Safety Efforts are needed in the Workplace – to address what is causing them – and any negative trends in Performance

34. How to Improve Near Miss Reporting In addition to these Factors (con’t) – SENIOR MANAGEMENT SUPPORT – Sr. Management must support Near Miss Reporting in three aspects – First – it must support the Process of Near Miss Reporting and expect it to be an integral part of the Company’s Safety Efforts. Second – it must understand Near Miss Reporting and not react negatively to a spike in Near Misses reported for a particular area. Third – they must know and accept that there is a Cost to Near Miss Reporting – such as the time needed to track and correct, incident investigation, etc.3 Sr. Management must let the necessary actions play out that should address any need that may be creating Near Misses.

35. Once Near Misses are reported – what will You Do with them? ACTIONS NEEDED TO ADDRESS NEAR MISS REPORTING’s

36. Actions Needed to Address NMReporting’s The Actions that we take in response to Near Miss Reporting’s – will determine how successful this Process will be.

37. Actions Needed to Address NM Reporting’s

38. Actions Needed to Address NM Reporting’s

39. Actions Needed to Address NM Reporting’s

40. Actions Needed to Address NM Reporting’s Suggested Flow Chart of Near Miss Actions Needed

41. Example of a Near Miss ReportWorkforce Safety & Insurance – www.WorkforceSafety.com NEAR MISS REPORT A near miss is a potential hazard or incident that has not resulted in any personal injury . Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and /or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations. Department/Location ________________________ Date: ________________ Time __________ am / pm Please check all appropriate conditions: ____ Unsafe Act ____ Unsafe Condition ____ Unsafe equipment ____ Unsafe use of equipment Description of incident or potential hazard: ____________________________________________________ __________________________________________________________________________________ Employee Signature _____________________________ (optional) Date ___________________ NEAR MISS INVESTIGATION - Description of the near-miss event / condition: ___________________________________________________________________________ ___________________________________________________________________________ Causes (primary & contributing) ___________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Corrective action(s) taken (i.e., Remove the hazard, replace, repair, or retrain in the proper procedures for the task) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Signed _________________________________________ Date Completed __________________ Not completed for the following reason: _____________________________________________________ Management ________________________________________ Date ___________________________ http://www.workforcesafety.com/safety/sops/NearMissReport.pdf

42. Actions taken in Response to Near Misses – will often dictate the type of Accidents Your Organization Incurs KEEP THE PROCESS FLOWING

43. Keep the Process Flowing The following Suggestions are offered to help ensure the Success of your Near Miss Reporting Program – Near Miss Reporting, Investigation, and Corrective Action – should be considered an INTEGRAL PARTof your Organization’s Safety Program. Be CONSISTENT with your response to and actions taken regarding Near Miss Incidents. Near Miss Incidents that are severe in nature – should receive as much ATTENTION and CORRECTIVE ACTION as an actual Accident / Injury.

44. Keep the Process Flowing The following Suggestions are offered (con’t) – Put out the Message to all of your People –that Near Miss NON-REPORTING is UNACCEPTABLE. COMMUNICATION of both Near Miss Events and the Corrective Actions taken – will be the key to its success. The Reporting of Near Misses – should NEVER BE INCENTIVEIZED. Let the Program prove its merit. Employees should NEVER BE PENALIZED for reporting Near Miss Incidents.

45. Keep the Process Flowing The following Suggestions are offered (con’t) – LEARN – LEARN – LEARN – from your Near Miss Incidents and be Safer because of them. Any and all Near Miss Incidents should be SHARED WITH OTHERS. Let others Learn too. As with any Safety Effort – REVITALIZE from time to time to ensure such matches current Processes. Engage your ENTIRE ORGANIZATION in your Near Miss Reporting. Senior / Local Management should know about Near Misses as well.

46. How to Increase Near Miss Reporting As Safety Leaders – we must work with our People to see events, conditions, etc. – BEFORE they turn into Accidents & Injuries. This Safety Training Presentation – was offered to give You Ideas on How to Increase Near Miss Reporting.

47. How to Increase Near Miss ReportingReferences – Those Not Noted 1 - Forck, Matthew (2010). The S.T.O.R.M Model for Near-Miss Reporting. TDWorld.com. Retrieved December 26, 2010 from http://tdworld.com/overhead_distribution/storm-model-near-miss-reporting-20100201/ 2 – Professional Safety (Nov 2010). Safety Management – Webinar Encourages Near-Miss Reporting. American Society of Safety Engineers.Retrieved December 10, 2010 from http://findarticles.com/p/articles/mi_hb5618/is_200911/ai_n42857768/ 3 – Forck, Matt (Oct 2009). Near Miss Reporting – The Sounds of Silence. ISHN. Retrieved December 29, 2010 from http://www.ishn.com/Articles/Feature_Article/BNP_GUID_9-5-2006_A_10000000000000678682

48. How to Increase Near Miss Reporting SAFETY LEADERS – Must be there for Our People – including those that Do and Don’t know better.

49. HOW TO INCREASE NEAR MISS REPORTING Steve Wise steve.wise@ttx.com I welcome your Comments.