INTRODUCTION
It has been established by studies that before an accident occurs, it gives sufficient systems in terms of near miss incidents. Studies in several industries indicate that there are between 50 to 100 near misses for every accident.
Traditionally in mostly industries scope of accident / incident investigation is limited to physical injury and property damage. So as a pro- active approach, managements should encourage the employees to report Near Miss reported and investigated to avoid accidents at workplace.
Definitions
- Accident: An undesired event that results in harms to people, damage to property, loss to process or harm to the environment.
- Incident: An incident is an unplanned event and chain of events that had or could have, resulted in injury or illness or damage too assets, the environment or company’s image reputation.
- Near Miss: An undesired event or situation that could have resulted in personnel harm, property damage or other loss such as environment damage, but did not do so due to chance, corrective action and / or timely intervention.
- High potential Near Miss Incident or dangerous occurrence: An undesired event, which under slightly different circumstances could have resulted in major injury, major property damage, major environment damage, major reputation damage. E.g. Crane failing and no one get hurt.
- First Aid Injury: Any one time treatment and subsequent observation of minor scratches, cuts, burns, splinters, etc. which do not ordinarily require medical care by a physician. Such treatment and observation are considered first aid even if provided by a physician or registered professional personnel.
- Medical treatment case: A medical treatment case is any reportable injury that involves neither lost workdays nor restricted workdays but which requires treatment by, or under the specific order of, a physician or could be considered as being in the province of a physician. Medical treatment does not include first aid even if this is provided by a physician or registered professional personnel.
- Lost time injury: Lost time injuries are the sum of fatalities, permanent total disabilities, permanent partial disabilities, and lost workday cases, but excluding restricted work cases and medical treatment cases. Note. If, in a single incident give people receive injuries, which are falls in LTI, then it shall be counted as 5 LTI.
- Lost workday case: A lost workday case is any reportable injury other than a permanent partial disability which renders the injured person temporarily unable to perform any regular job or restricted work on any day after the day on which the injury was received. Medical coordinator reports shall be used to decide whether particular incident falls under lost time work case or not, regardless of next working days falls as rest day, weekend day, scheduled holiday, public holiday or subsequent day after ceasing employment or person proceed on leave or business trip.
- Restricted work case (RWC): A restricted work case is any work injury which results in a work assignment after the day the incident occurred that does not include all the normal duties of the person’s regular job. The restricted work assignment must be meaningful and pre- established or a substantial part of a regular job.
- Lost work days: The number of lost work days is the total number of calendar days on which the injured or ill person was temporarily unable to work as a result of a lost workday case, illness or a permanent Partial disability.
- Serious Injury: An accident shall be deemed serious according to the following criteria:
- Every accident which leads to the death of worker or causes him 50% or more disability.
- Fire accident, collapse or explosion which results in the loss of machines.
- Fire accident, collapse or explosion which results in the loss of machines.
- Immediate causes: The substandard acts / practices or condition which directly contributes to the occurrences of accident / incident. This is frequently referred as unsafe act or condition.
- Basic Causes: The job and personnel factors, such as inadequate engineering, lack of knowledge or skill etc., from which the substandard acts / condition originate. Basic causes may be referred as underlying, root or real cause, system defects or contributing causes. Basic causes are most frequently the result of an inadequate safety system, in adequate system standards and / or inadequate compliance with standard.
LOSS CAUSATION MODEL
Let us understand the process of near miss occurrence through loss causation model.
BENEFITS OF NEAR MISS REPORTING
It has been experienced that the industries where near miss incidents are reported, investigated & recommendation are implemented the rates of accidents are very low compare to industries they don’t report on near misses’ incidents.
We must learn from accidents and near miss to prevent recurrence. The first step in the learning process is investigation of to determine the causes and underlying reasons and
why accident and near miss occurs. A thorough investigation to root cause will identify the management weakness. Learning which management system weaknesses are leading to near miss and accident is one of the highest value activities in which company can invest. And learning from near misses is much cheaper than learning from accident.
ANALYSIS OF NEAR MISS INCIDENTS
The analysis is done by applying the principle of multiple causes: “problems and loss producing” events are seldom, if ever the result of a single cause. Analyze for:-
- Unsafe / substandard acts
- Unsafe / substandard conditions
- Personal facts
- Job factors.
- System deficiencies
Avoid the satisfaction of each syndrome, i.e. don’t stop the analysis when you first find some evidence to support your favorite hypothesis. Explore alternatives.
Process should include all contributing factor. Apply principle of critical few. The investigation team decides which, critical few immediate & basic causes contributed to the accident or near miss.
BARRIERS TO REPORT ACCIDENT / INCIDENTS
Experience research & experience indicate that due of following reasons employees generally, not report the accident / incidents.
- Fear of disciplinary action
- Concerned about the record.
- Concerned about reputation
- Fear of medical treatment
- Desire to avoid work interruption.
- Desire to keep personnel record clear.
- Avoidance of paper work.
- Poor understanding of importance.
TYPICAL EXAMPLES OF NEAR MISS
An incident / accident having the potential for either personal / property damage of environmental impact or both are termed as a near miss. Examples are:
- Non – relieving of a relief value at set pressure.
- Relieving of relief value before set pressure.
- Non – working of emergency appliances.
- Non – working shutdown / trip systems.
- Violation of safety regulation (e.g. Working without valid work permit)
- Free failing of objects from height
- Bursting / disconnection of pressure hoses
DIFFERENCE BETWEEN NEAR MISS INCIDENT & INCIDENT
Before reporting near miss you must understand between near miss incident & incident, as it is matter of interpretation of individual. However, following example incidents have been provided for better understanding of concept.
NEAR MISS REPORTING. INVESTIGATION AND ANALYSIS PROCEDURE
Reporting procedure:
- Any person who experience or witness the near miss incident shall fill in the no. prescribed form and submit the same to safety section of HSE department by hard copy or through soft copy.
- The near miss incidents shall be reported within 24 hrs of the occurrence.
Investigation procedure:
- On receipt of near miss incident report duty filled on the prescribed format by the safety section will investigate with the assistance of the concerned section manager.
- The management may also appoint a committee, if the near miss is of very serious nature.
Report Circulation:
- The report shall be circulated by HSE Department to all concerned personnel.
- The report shall be circulated within a week of reporting of near miss.
- The section manager shall suitably communicate to all his employees.
Review:
- The near miss report shall be reviewed in safety committee meeting.
- Safety section shall monitor the progress of recommendation of implementation
Report maintenance:
- Safety section shall keep the record of all near miss report.
Analysis of near miss:
- Safety section shall make analysis of the near miss report once in six months.
Incentive for near miss reporting:
- Suitable reward shall be given to person who reports minimum highest number of near misses incidents for the year.