Safety Management near Miss Identification, Recognition, and Investigation By Ron C. McKinnon, CSP Book

Safety Management near Miss Identification, Recognition, and Investigation By Ron C. McKinnon, CSP
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Contents

Preface……………………………………………………………………………………………………….xv
Acknowledgments……………………………………………………………………………………….xix
About the Author………………………………………………………………………………………..xxi
Chapter 1 Introduction……………………………………………………………………………….1
Clearing the Confusion……………………………………………………………….1
Minor Injury Is Not a Near Miss Incident……………………………………..1
Near Miss Incidents…………………………………………………………………….2
Defining a Near Miss Incident…………………………………………………2
Defining an Accident………………………………………………………………2
Conflicting Definitions……………………………………………………………4
Accidents versus Near Miss Incidents…………………………………………..4
Accidents, Near Miss Incidents, and Injuries…………………………………4
Defining an Injury………………………………………………………………….5
General Agencies……………………………………………………………….5
Occupational Hygiene Agencies…………………………………………..5
Definitions: Injuries and Diseases…………………………………………………5
Work Injury…………………………………………………………………………..5
Occupational Disease…………………………………………………………6
Injury Compared to Accident………………………………………………6
Facts Concerning Undesired Events and Near Miss Incidents
and Accidents………………………………………………………………………..6
Accident Sequence……………………………………………………………………..7
Failure to Assess the Risk……………………………………………………….7
Lack of Control………………………………………………………………………7
Basic Causes or Root Causes……………………………………………………8
Immediate Causes………………………………………………………………8
Contact and Exchange of Energy……………………………………………..9
Injury, Damage, or Loss……………………………………………………….. 10
Injury…………………………………………………………………………………. 10
Property Damage…………………………………………………………………. 10
Loss…………………………………………………………………………………… 12
Costs………………………………………………………………………………….. 12
A Measure of Safety…………………………………………………………………. 12
Treating the Symptoms…………………………………………………………. 12
NEMIRR (Near Miss Incident Recognition, Reporting, Risk
Ranking, Investigation, and Remedy)…………………………………….. 12
The Accident Ratio………………………………………………………………. 13
Extending the Accident Ratio………………………………………………… 14
Risk Assessment………………………………………………………………….. 14
Risk Ranking……………………………………………………………………….14
Risk Matrix………………………………………………………………………….15
No-Blame System…………………………………………………………………15
Aviation………………………………………………………………………………15
Firefighters…………………………………………………………………………..16
Healthcare……………………………………………………………………………16
The Railroad Industry…………………………………………………………..17
Conclusion……………………………………………………………………………….17
Chapter 2 The Safety Philosophy behind Near Miss Incidents………………………19
Introduction……………………………………………………………………………..19
Tracking Near Miss Incidents…………………………………………………….19
Near Miss—or Near Hit?…………………………………………………………..19
Benefits……………………………………………………………………………………19
Examples of Near Miss Incidents……………………………………………….20
Red Flags…………………………………………………………………………………21
A Gift……………………………………………………………………………………..21
Precursors to Accidents……………………………………………………………..21
Heed the Warnings……………………………………………………………………22
High Potential for Loss……………………………………………………………..22
Facts about Near Miss Incidents…………………………………………………23
Contact (Energy Exchange) Types………………………………………………23
Business Interruption………………………………………………………………..23
The Accident Ratios………………………………………………………………….24
Heinrich Accident Ratio………………………………………………………..24
Tye-Pearson Accident Ratio…………………………………………………..25
Frank E. Bird, Jr. and George Germain Accident Ratio…………….25
The Health and Safety Executive (HSE) Accident Ratio……………25
South African Ratio………………………………………………………………26
The Accident Ratio Conclusion…………………………………………………..26
Preventative Opportunities…………………………………………………………27
Injuries vis-à-vis Near Misses………………………………………………..27
Immediate Accident Causes……………………………………………………….28
Traditional Research…………………………………………………………………29
High Risk Acts…………………………………………………………………….29
High Risk Conditions……………………………………………………………29
Combination of High Risk Acts and Conditions……………………….29
Luck Factors 1, 2, 3, and Their Near Miss Incident Relationship…….30
Luck Factor 1……………………………………………………………………….30
Warnings……………………………………………………………………………..30
Real Life Example………………………………………………………………..31
Luck Factor 1…………………………………………………………………..31
Luck Factor 2…………………………………………………………………..32
Luck Factor 3…………………………………………………………………..32
Pattern…………………………………………………………………………………33
Exchange of Energy and Contact………………………………………………..33
Injury, Damage, or Loss…………………………………………………………….34
Injury………………………………………………………………………………….34
Measurement of Safety………………………………………………………….34
Costs…………………………………………………………………………………..34
Cost Statistics………………………………………………………………………34
Direct Costs…………………………………………………………………….35
Hidden Costs……………………………………………………………………35
Damage Costs………………………………………………………………….35
Fire…………………………………………………………………………………35
Production Losses…………………………………………………………….36
Conclusion……………………………………………………………………………….36
Chapter 3 Safety Management Functions That Relate to Near Miss Incidents…37
Introduction……………………………………………………………………………..37
Management Leadership……………………………………………………………37
Positive Behavior Reinforcement………………………………………………..38
What Is a Manager?………………………………………………………………….38
Basic Management Functions……………………………………………………..38
Safety Planning……………………………………………………………………39
The Functions of Safety Planning………………………………………39
Safety Organizing…………………………………………………………………41
Integrating Safety into the Organization……………………………..41
Safety Delegation……………………………………………………………..41
Creating Safety Relationships…………………………………………….41
Safety Responsibility………………………………………………………..41
Safety Authority………………………………………………………………42
Safety Accountability……………………………………………………….42
Safety Leading……………………………………………………………………..42
The Functions of Safety Directing (Leading)………………………43
Safety Controlling………………………………………………………………..45
1. Identification of the Risk and Safety Work to Be Done……..45
2. Set Standards of Performance Measurement……………………47
3. Set Standards of Accountability……………………………………..51
4. Measure against the Standard…………………………………………51
5. Evaluation of Conformance……………………………………………51
6. Corrective Action………………………………………………………….51
7. Commendation……………………………………………………………..52
Chapter 4 Safety Management Principles Relating to Near Miss Incidents……..53
Professional Safety Management Principles…………………………………53
Safety Management Principles……………………………………………………53
Principle of Management Results……………………………………………54
Principle of Setting Safety Objectives……………………………………..54
Principle of Resistance to Safety Change…………………………………54
Principle of Safety Communication………………………………………..54
Principle of Safety Participation…………………………………………….55
Principle of Safety Definition…………………………………………………55
Principle of Safety Authority…………………………………………………56
Principle of Interest in Safety…………………………………………………56
Principle of Safety Reporting…………………………………………………56
Principle of the Critical Few………………………………………………….56
Principle of Safety Recognition………………………………………………57
Past Safety Experience Predicts Future Experience Principle…….57
Principle of Safety Application………………………………………………57
Principle of Point of Control………………………………………………….58
Principle of Multiple Causes………………………………………………….58
Safety Success vis-à-vis Management Leadership…………………………59
Conclusion……………………………………………………………………………….60
Chapter 5 Near Miss Incidents, Myths and Safety Paradigms……………………….63
No Injury—No Accident (No Blood, No Foul)……………………………..63
Why Injuries Are Seen as “Safety”……………………………………………..64
Damage……………………………………………………………………………………64
Accident Ratios………………………………………………………………………..64
Risk Assessment……………………………………………………………………….65
Iceberg Effect…………………………………………………………………………..65
Near Miss Incidents Aren’t Important: A Paradigm………………………65
Injury-Free Culture…………………………………………………………………..66
Near Miss Incidents Not Reported………………………………………………66
Warnings in Advance………………………………………………………………..67
Luck Factors…………………………………………………………………………….67
Space Shuttle Columbia…………………………………………………………….68
Conclusion……………………………………………………………………………….68
Chapter 6 Safety and Health Policies………………………………………………………….69
Introduction……………………………………………………………………………..69
Safety and Health Policy……………………………………………………………69
Planning………………………………………………………………………………69
Advantages………………………………………………………………………….70
The Essentials………………………………………………………………………70
Safety Rule Book………………………………………………………………….70
Requirements of Policies……………………………………………………….70
Commitment………………………………………………………………………..71
Posted and Displayed…………………………………………………………….71
Examples and Extracts………………………………………………………….71
Example 1……………………………………………………………………….71
Example 2……………………………………………………………………….71
Example 3……………………………………………………………………….72
Conclusion……………………………………………………………………………….73
Chapter 7 Near Miss Incident Risk Management and Assessment…………………75
Introduction……………………………………………………………………………..75
The Risk Management Process…………………………………………………..75
Definitions of Risk Management…………………………………………….75
Goals of Risk Management……………………………………………………76
Definitions of Risk………………………………………………………………..76
Types of Risks……………………………………………………………………..76
Risk Management Components………………………………………………76
Physical Risk Management………………………………………………..77
Risk Assessment……………………………………………………………………….77
The Three Steps of Risk Assessment………………………………………77
Hazard Identification………………………………………………………..78
Risk Analysis…………………………………………………………………..81
Risk Evaluation………………………………………………………………..84
Risk Control…………………………………………………………………………….85
Dealing with Risk…………………………………………………………………85
Treat……………………………………………………………………………….86
Tolerate…………………………………………………………………………..86
Transfer…………………………………………………………………………..86
Terminate………………………………………………………………………..86
Safety Management Control……………………………………………………….87
Risk Ranking of Near Miss Incidents………………………………………….87
Conclusion……………………………………………………………………………….88
Chapter 8 Safety Auditing………………………………………………………………………..89
Introduction……………………………………………………………………………..89
Reasons for Audits……………………………………………………………………89
Benefits of Audits……………………………………………………………………..90
How Does an Audit Work?…………………………………………………………91
Who Should Conduct Audits?…………………………………………………….92
The Audit Program……………………………………………………………………92
How to Do an Audit Inspection…………………………………………………..94
Internationally Accepted Audit-Based Safety Systems…………………..94
Occupational Health and Safety Assessment Series (OHSAS)……95
National Occupational Safety Association (NOSA) and Safety Projects International (SPI)………………………………………….95
The International Safety Rating System (ISRS)……………………….95
Occupational Health and Safety Assessment Series System (BSI–OHSAS 18001)…………………………………………………………….96
Conclusion……………………………………………………………………………….96
Chapter 9 Near Miss Incident and Accident Recall………………………………………97
Introduction……………………………………………………………………………..97
Reporting…………………………………………………………………………………97
A Matter of Luck………………………………………………………………………98
Scenario 1……………………………………………………………………………98
Scenario 2……………………………………………………………………………98
Scenario 3……………………………………………………………………………98
Scenario 4……………………………………………………………………………99
Conclusion…………………………………………………………………………..99
Recalling the Near Miss Incident………………………………………………..99
Benefits of Near Miss Incident Recall……………………………………….100
Benefits of Accident Recall………………………………………………………100
Precontact and Postcontact Activities………………………………………..100
Discipline………………………………………………………………………………100
Methods of Recall…………………………………………………………………..101
Formal Recall…………………………………………………………………….101
Informal Recall………………………………………………………………….101
Major Loss Briefing…………………………………………………………………102
Safety Stand Down………………………………………………………………….102
Safety Stand Down Based on Near Miss Incidents………………….102
Accident Recall Aids……………………………………………………………….103
Safety DVDs………………………………………………………………………103
Newsletters………………………………………………………………………..103
Acting upon Near Miss Incident Recall……………………………………..104
Thanks………………………………………………………………………………104
Risk Assessment……………………………………………………………………..104
Remedies…………………………………………………………………………..104
Implementation…………………………………………………………………..104
Follow Up………………………………………………………………………….105
Near Miss Incident Recall Examples…………………………………….105
Near Miss Incident Recall Case Studies………………………………..107
Case Study 1………………………………………………………………….107
Case Study 2………………………………………………………………….107
Conclusion……………………………………………………………………………..109
Chapter 10 How to Motivate for Safety………………………………………………………111
Introduction……………………………………………………………………………111
Motivation……………………………………………………………………………..111
Create the Right Environment…………………………………………………..111
Involvement……………………………………………………………………….111
Inspire……………………………………………………………………………….112
Impel…………………………………………………………………………………112
The Hawthorne Effect……………………………………………………………..112
Foundation of Motivation…………………………………………………………113
The Ten Rules of Safety Motivation………………………………………113
Enthusiasm…………………………………………………………………….113
Avoid Arguments……………………………………………………………114
Never Tell Another Person They Are Wrong……………………..114
If You Are Wrong, Admit It…………………………………………….115
Always Begin in a Friendly Manner………………………………….115
Use Two-Way Communication…………………………………………115
Don’t Sell Safety, Let Them Buy………………………………………116
Have Confidence…………………………………………………………….116
Reward, Commend, and Compliment……………………………….117
Set the Example……………………………………………………………..117
Conclusion……………………………………………………………………………..118
Pushing the String…………………………………………………………………..118
Chapter 11 Implementing a Near Miss Incident System: Introduction……………119
How to Make It Happen…………………………………………………………..119
Observations…………………………………………………………………………..119
Recognizing Reported Safe Work……………………………………………..120
Safety Suggestions and Recommendations…………………………………120
Constraints…………………………………………………………………………….121
Understanding………………………………………………………………………..121
Benefits………………………………………………………………………………….121
Buy-In……………………………………………………………………………………122
Reporting……………………………………………………………………………….122
No Names………………………………………………………………………………123
Resistance to Change………………………………………………………………124
Barriers to Reporting………………………………………………………………124
Long-Time Employee………………………………………………………………125
Chapter 12 Implementing a Near Miss Incident Reporting System: Implementaion……………………………………………………………127
Setting the Standard………………………………………………………………..127
Policy………………………………………………………………………………..127
Standard…………………………………………………………………………….128
Objective……………………………………………………………………….128
References……………………………………………………………………..128
Definitions…………………………………………………………………….128
Standard………………………………………………………………………..128
Procedure and Responsibilities (Property Damage/Environmental/Vehicle Accidents/Near Miss)……………………129
Investigation and Reporting Requirements………………………..130
Amnesty……………………………………………………………………………131
Credibility………………………………………………………………………….132
What Are Critical Safety and Health System Elements?………………132
Examples…………………………………………………………………………..132
Principle of the Critical Few………………………………………………..133
Why These Elements?…………………………………………………………133
Benefit……………………………………………………………………………….133
Environmental and Behavior………………………………………………..133
Safety and Health Management System (Program)……………………..134
Definition…………………………………………………………………………..134
Examples of an SMS…………………………………………………………..135
Information………………………………………………………………………..135
The Form or Booklet…………………………………………………………..135
NEMIRR Training……………………………………………………………..135
Training Outline…………………………………………………………….137
Formal Reporting……………………………………………………………….138
Safety Reporting Hotline……………………………………………………..138
Informal Reporting……………………………………………………………..138
Risk Ranking……………………………………………………………………..138
Incentives…………………………………………………………………………..139
Collection System……………………………………………………………….139
Feedback on Reports…………………………………………………………..139
Chapter 13 Implementing a Near Miss Incident Reporting System: Follow Up.141
Introduction……………………………………………………………………………141
Reporting System Follow Up……………………………………………………141
Investigation………………………………………………………………………141
Remedy……………………………………………………………………………..142
Allocation of Responsibility…………………………………………………142
Central Record and Publication…………………………………………….142
A Good Example………………………………………………………………..142
Follow Up and Close Out…………………………………………………….142
Statistics…………………………………………………………………………….142
Evergreen…………………………………………………………………………..143
Main Requirements…………………………………………………………………144
The Magma Copper Case Study……………………………………………144
The Phoenix Water Services Department Case Study……………..145
Conclusion……………………………………………………………………………..147
Chapter 14 Investigating High Potential Near Miss Incidents……………………….149
No Difference…………………………………………………………………………149
Purpose………………………………………………………………………………….149
Accident/Near Miss Incident Investigation Facts………………………..149
Postcontact versus Precontact…………………………………………………..150
Potential Losses and Risk Ranking of Probabilities…………………….150
Misleading…………………………………………………………………………150
Potential…………………………………………………………………………….150
Potential Hazards………………………………………………………………..150
Loss Potential…………………………………………………………………….151
Ranking the Potential………………………………………………………….151
Safety Solution……………………………………………………………………151
Crystal Ball………………………………………………………………………..152
Successful Assessing and Analyzing…………………………………….152
Risk Matrix………………………………………………………………………..152
Benefits of Accident and Near Miss Incident Investigation…………..152
Personal Factors………………………………………………………………….153
Job Factors…………………………………………………………………………154
Principle of Multiple Causes…………………………………………………….154
Principle of Definition……………………………………………………………..154
The Golden Rule of Accident and Near Miss Incident Investigation…………………………………………………………………………..154
Who Should Investigate?………………………………………………………….155
Investigation Committees…………………………………………………….155
Investigation Form…………………………………………………………………..155
Near Miss Incident/Accident Investigation Procedure………………….156
Immediate Actions……………………………………………………………..157
Gathering the Facts……………………………………………………………..157
Determining the Causes………………………………………………………158
Taking Remedial Action………………………………………………………158
Following up………………………………………………………………………160
Lost Opportunities………………………………………………………………….160
Conclusion……………………………………………………………………………..160
Chapter 15 Summary……………………………………………………………………………….161
Safety in the Shadows……………………………………………………………..161
Summary of the Book……………………………………………………………..161
Identical Causes………………………………………………………………….161
Insufficient Energy……………………………………………………………..161
Losses……………………………………………………………………………….161
Accident Ratio……………………………………………………………………162
Multiple Causes………………………………………………………………….162
Immediate and Root Accident Causes……………………………….162
Reporting Near Miss Incidents……………………………………………..163
Risk Assessment…………………………………………………………………163
Near Miss Incident Investigation…………………………………………..163
Safety Management System…………………………………………………163
Auditing…………………………………………………………………………….164
Reducing Accident Probability……………………………………………..164
Friendly Warnings………………………………………………………….164
Guidelines………………………………………………………………………….165
Conclusion……………………………………………………………………………..165