What is near miss

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Permalink Reply by Darren F. Billesbach on February 17, 2009 at 5:44pm

Several years ago I initiated a "Near Miss" program with my Generation System at LADWP. It soon became a Labor-Management Topic and became a department-wide program. We defined a Near miss as follows:

A Near Miss is “an event that may have resulted in personnel injury, equipment damage or a reduction in system integrity but did not”, and is reported by the individual that experienced the near miss (“self-reported”)

In the beginning, we had several employees try to use the "amnesty" of the Near-Miss Report to avoid disciplinary action, even when the incident was prevented by another employee or Supervisor stopping the job because of an unsafe action. We ammended the program to read as follows:

The intent of the “Near Miss” Program (Program), is to encourage employees to discuss near misses that normally they would not discuss for fear of discipline or other reprisal. It is not intended to be a blanket “amnesty clause” for any incident that falls in the definition of a near miss, when a supervisor, manager, or other employee must take action to stop the process that caused the near miss to occur. Such an incident, although it fits in the near miss definition, would be noted as an infraction of a safety rule, policy or procedure, and therefore not covered under this program.

In the years up until my retirement, I witnessed a lot of legitimate Near Miss Reports. We handled every report as a possible incident by performing a root-cause analysis of the incident, using committees to determine the root causes of the Near Miss / Incident, and possible solutions to prevent it from recurring in the workplace. I think it is a very worthwhile program if used properly.

Darren

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Permalink Reply by John Pfleger on February 18, 2009 at 8:31am

Approximately how many employees did your near miss program cover and around how many reports of near misses did you receive per quarter?

I have always requested personnel report near misses but have yet to receive any reports of near misses.

We do however report and record any incident causing lost time, injury, or damage regardless of severity. Thorough investigations into minor incidents has proved fruitful.

Many in our industry may only record what they consider "recordable" incidents. Do safety professionals here agree with recording everything or only "recordable" incidents? Pros and cons?

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Permalink Reply by Craig Banning on February 19, 2009 at 12:55pm

We have been working on improving our near miss reporting and at a corporate level we target 1.5 near miss reports per employee per year. So each site is challenged with 1.5 per employee. Care should be taken to not include items such as bad house keeping as a near miss unless an incident occurred, some people will get carried away trying to reach a goal.
I would say that a good near miss reporting program is essential to long-term safety success.

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Permalink Reply by Darren F. Billesbach on February 18, 2009 at 9:00am

Initially, the program only covered about 2000 employees, but was later expanded to over 5000. We received a very low number of reports in the beginning, but once the employees understood the purpose for the Near Miss Program, and gained trust that legitimate reports would not receive disciplinary action, we began receiving regular reports of near misses. I would say that within two years of the program inception (when i retired), we were receiving between 3-5 per quarter. I would need to get in touch with my contacts there and see how the program has progressed.

It must be understood that near misses are NOT recordable incidents under OSHA rules, because they did not result in any actual injury or equipment damage. I have heard arguments from Safety Professionals and Lawyers, that anything we "record" is accessible to OSHA and that they can use that against us in a serious injury investigation. I would agree with this, if all we did was "record" near misses. The intent of the program MUST be to reduce or eliminate these Near Misses, thus reducing and eliminating actual injuries. If you record ten near misses for similar issues (slips, trips and falls for example), and have several injuries from the same issue, then the program has not done it's job. Every Near Miss needs to be evaluated/investigated, and steps taken to reduce or eliminate the possibility of injuries occurring from this issue.

Remember I worked in a Civil Service workplace with a very strong Union. It becomes very important that Management and the Union BOTH buy into the program and support it completely. You have to take the time to perform proper investigations (utilizing management and workers) to determine root causes for incidents, and near misses alike, find solutions to eliminate the hazards and/or unsafe behavior, and implement those solutions. All near misses need to be discussed with employees, as you would a "real" incident, as a valuable training tool.

Hope this helps...

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Permalink Reply by John Pfleger on February 18, 2009 at 9:28am

Thanks for describing the scope of your near miss program. It definitely seems as something worth while if you are able to gain trust of employees and cooperation of top management down.

If you find out if the program grew in cooperation and strength let me know.

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Permalink Reply by Dave Tortorich on February 18, 2009 at 10:01pm

Was planning to suggest my clients start a Near Misses Program, but after reviewing your remarks it may not work. You see I work with parish or county entities throughout the state, primarily Road Departments or Public Works and in order for this program to be effective you need employee trust and managements committment to not fire or suspend someone through this program. Do you have any suggestions on how I might get started with a "Near Misses" Program?

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Permalink Reply by Darren F. Billesbach on February 19, 2009 at 2:25pm

Hey Dave.. it HAS to be a concerted effort between management and the union/labor. For the program to work, management must buy in 100% to follow the definition of a near miss and not discipline for "self-reported" near misses. Labor and the union must buy in to the fact that there WILL be those that try to use the program to gain amnesty from a "HIT" or from a situation where a supervisor or coworker stopped the job to prevent an incident or injury. In those cases, the program does not provide amnesty from dicipline. With L.A. Water and Power and IBEW Local 18, we had a very good understanding and buy in from both sides. They adopted a "mutual-gains" attitude and approach to problem solving many years ago, and because it has developed and become successful gaining trust on both sides, it made implementing programs like the Near Miss Program a lot easier to do. Good Luck.

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Permalink Reply by Dave Tortorich on February 20, 2009 at 11:33am

Thanks Dareen, The parishes may on occasion try and stop a job, but I think the real challenge will be to get management to enforce their rules and other programs. It's always a tough situation with political entities. Most employees with the parishes do have a fear of discipline by their supervisors and that's another obstacle that I will face. It seems like they will object to doing more formal investigations of incidents. Supervisors may argue that they don't have time to do a near miss program and employees may also not report them for fear of embarressment over what they did or failed to do. Any suggestions about these problems?

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Permalink Reply by Darren F. Billesbach on February 22, 2009 at 2:30am

Hey Dave, Does Lousiana have it's own OSHA or do you fall under Fed OSHA? I ask because I can see management being more lax from enforcing their rules and programs if they are dealing with FedOSHA. In Califorinia, CalOSHA is very active in worksite safety. If we do not follow (and enforce) our own rules and safety programs, we can get fined $7k for first offenses, and much larger amounts for willful or negligent disregard for safety, up to and including criminal prosecution.

I'm not sure I understand what you mean by "political entities". As far as fear of discipline, objecting to formal investigations, and fear of embarassment.... well that is another issue altogether. It seems that all too often the only people that talk about incidents, accidents and near misses are the safety guys. In fact, I have heard the statement.. "to become a safety guy, you need to have experienced all the unsafe stuff..." I have always told the employees under my care... "Safety Coordinators don't have any more accidents or near misses than any other employee. The only difference is... that they are willing to talk about them so that hopefully someone else can benefit from their misfortunate experiences".

We had no choice in accident investigations. OSHA requires investigations into accidents. I always made it a point to include management, union and workers in the investigation committee. I stressed that the investigation was to find "root causes" for the incident and to find solutions to prevent recurrence in the future. It is NOT to point fingers, place blame, or recommend discipline at all. If the root causes show that a step was missed, or overlooked by the employee, we don't stop at that.. we ask "Why did he miss it or overlook it". There was never a guarantee that management would not use our findings for some sort of discipline, but I used to tell them, that if they were a part of the solution, cooperated with the investigation and helped find ways to prevent someone else from getting injured, that I would make a statement to management that the discipline should be weighed against the cooperation. At the same time, employees must understand that discipline IS part of the safety program. If we let people walk around without hard hats, and just slap their hand each time, we are doing nothing to prevent that major head injury that will certainly affect their life (and that of their family), a lot more than any discipline that management could hand down. "I'd rather be fired for a major safety infraction, than to be a severly disabled person because I was allowed to continue having unsafe habits".

I don't know if any of this helps your situation. Feel free to message me privately and send me your phone number and maybe we could discuss it better. A good safety program will never happen if management and labor doesn't work together. Management has to respect the opinions of it's labor; has to enforce it's safety programs, laws and rules; and develop ways to gain the trust of labor. Labor has to provide 'positive' input about the safety program, realize that management has their best interests in mind, and take responsibility for their actions on the job.

Darren

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Permalink Reply by Darren F. Billesbach on February 23, 2009 at 6:08pm

I want to share the conversation that Dave Tortorich and I had on Near Misses. He asked if we had given any incentives to employees for participating in the program: below is my response:


Hi Dave,

Yes I do have a form and I'd be happy to send it to you. Send me your email address, as I don't think I can attach it on here.

As to using "incentives"... I'd stay away from any type of "incentive program" that includes material rewards. After having run a "monetary / gift based" program for many years, we finally got away from that type of award. It took us 3 years with the union's help, to remove the "gift" aspect as a reward for being safe. Money and gifts become an "entitlement" rather than an award, and especially with group awards, the peer pressure causes workers to NOT report accidents, so as to not mess up the group award. I saw a person lose all possibility of getting Worker's Compensation Benefits, because he failed to report an accident for just that reason. He had claimed that the injury occurred at home. When the injury was determined as chronic, he tried to file a claim stating that he only said it happened at home because he didn't want to screw up the group incentive award. His claim was denied.

The incentive should be .... fewer injuries to themselves and their coworkers. Safety is part of their Job Responsibility!! They don't need rewards for being safe, or cooperating with a program that will clearly save themselves and others from pain and suffering down the road.

Darren

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