K13720_cover.fhmx 1/24/K1123 37:2506_ PcoMv ePra.fghem 1x 1/24/12 3:56 PM Page 1 C M Y CM MY CY CMYCK M Y CM MY CY CMY K ENVIRONMENTAL & OCECNUVPIARTOIONNMAELN HTAEAL L&T HO C&C SUAPFAETTIOYNAL HEALTH & SAFETY M M c c K K in in no Sno afSeatyfety n n SafetyS Mafaentya gMemaneangtement Near Miss IdeNnetaifric Matiisosn ,I dReenctoifgicnaittiioonn,, aRnedc oIngvneitsitoing,a tainodn Investigation MaMnaagneamgeenmtent Close calls, narrowC leosscea pcaelsls, ,o nra nreroawr heistsc.a Hpeisst,o oryr hnaesa rs hhoitws.n H riesptoerayt ehdalys tshhaotwn repeatedly that these near miss incthideesnet sn eoaftre mn ipsrse cinecdidee lnotsss opfrteond upcrinegce edvee nlotsss, bpurto daurcei nlagr geevelynts, but are largely ignored or go unrepigonroterde db eocr aguos eu nnroetphoinrgte (dn ob eincjauurys,e d naomthaigneg o(nro lo isnsju)r hy,a dpapmenaegde. or loss) happened. Thus, many opportuTnhiutise,s mtoa npyr eovpepnotr tthuen iaticecsi dtoe nptrse tvheantt tthhee oarcgcaidneiznattsio tnh ahta tsh neo otrganization has not yet had are lost. Ryeect ohgandiz ianrge alonsdt .r eRpeocrotginngiz ninega ra nmdi srse pinocritdinegn tnse caarn m misask ein caidents can make a Near MNisesa Ird Menitsisfi cIdaetinotnif,ication, major difference tom thaejo rs adfieffteyr oefn cweo rtkoe trhse w siathfeint yo orgf awnoizraketirosn sw.ithin organizations. Supported by more Sthuapnp o3r0te yde bayr sm oof rien ttehranna t3io0n ayle saarsfe otyf einxtpeerrniaetniocen aal nsda freetsy eeaxrpcehr,ience and reseSarch, S RecognRiteiocno,g annitdi oInn,v easntdi gInavtieosntigation Safety ManagemenSta:f Neteya Mr Manisasg eIdmeennttif:i cNaetiaorn M, Risesc oIdgennittioifnic,a atniodn ,I nRveecsotgignaittiioonn, and Investigaation a discusses the safetyd pishciluosssoepsh yt hbee hsianfde tnye pahri lmosisosp hinyc bideehnintds anneda rc mleaisrsly indceimdeonntsst raantde sclearly demonstfrates f e e the accident sequethnec ea cschiodwenintg s tehqeu eTnhcree es hLouwckin gFa tchteo rTsh trheaet Lduectke rFmaicnteo rtsh ethat determine the t t outcome of the eveonutt.c oTmhee aouft hthoer ehvigehnltig. hTthse t haeu tfhoorrt uhitiyg holifg thhtes ethveen fto ratnudit yh oowf the event and how y y a simple risk assesas msimenptl ec arins kb ea susseesds mtoe nidte cnatinfy bteh eu sceadu steos i doef ntthifey ethveen ct aaunsdes of the event and rectify them. He alsroe cetxifpyl atihnesm th. eH me aalnsaog eexmpelanint sf utnhcet imonasn aogf esmafeentyt afunndc htioowns t hoef ysafety and howM they M relate to near missr einlactidee tnot sn.ear miss incidents. a a n n • Explains and reaf•firEmxsp lasianfse tayn pdh rileoasoffpirhmiess sfairfsett yp rpohpiloosseodp hmieosr efir tshta pnroposed more than a a 80 years ago 80 years ago g g • Applies the techn•iqAuep polife rsi stkh ea stseecshsnmiqueen to of nr isnke aars smeissssm inecnidt eonnt sn etoar miss incidents to e e identify high potentiidael nlotsifsy ehvigehn tpsotential loss events m m • Includes real-life e•xaInmclpuldeess o rf enael-alirfe m eixsasm inpcleidse onft sn etoa rs umpispso ritn cthideents to support the e e importance of neari mmpisosr traenccoeg onfit nioena ra nmdi sinsv eresctioggantiiotinon and investigation n n • Provides example•s Porf orveidpeosr teinxga mfoprmless ,o rf erpeoprotr ttrinagc kfoinrgms, report tracking t t and near missincidaenndt anweaarre mneissssi ntcriadiennintg a ownareness training on www.crcpress.comw/wprwo.dcruccpt/reissbsn.c/o9m7/8p1r4o3du9c8t7/9is4b6n/79781439879467 Near miss incidentsN aeraer tmruislys tihnec idfoeunntdsa atrioen t rouf lmy tahjoer f oinujunrdiaetsi,o nth oef bmuaildjoinr gin bjulorciekss, the building blocks of accidents, and owf aarcncinidge snitgsn, sa nthda tw alorsnsin igs simigmnsin tehnatt. lTohsesy isc aimn malisnoe nfot.r mThey can also form the impetus for prtohaec itmivep,e tpurse vfoern tpartoivaec taicveti,o npsr.e vTehnista tbioveo ka cetxipolnosr.e sT hhios wb otook explores how to implement a near immipslse minecnidte an tn iedaern tmifiicsast iionnc,id reencto igdneintitoifnic, aitnivoens, trigeactoiognn,i tiaonnd, investigation, and rectification prograrmec.tification program. K13720 K13720 Ron C. MRcoKnin Cn.o Mn,c CKSinPnon, CSP 6000 Broken Sound Parkway, N6W000 Broken Sound Parkway, NW Suite 300, Boca Raton, FL 3348S7uite 300, Boca Raton, FL 33487 711 Third Avenue 711 Third Avenue an informa business Neawn iYnofrokr, mNaY b1u0s0in1e7ss New York, NY 10017 www.crcpress.com 2 Pwarwk wSq.ucarrcep, Mreilstos.nc Poamrk 2 Pawrk Sqwuare,w Milt.onc Parrkc p rwe swsw. c.oc rmc p r e s s . c o m Abingdon, Oxon OX14 4RN, UKAbingdon, Oxon OX14 4RN, UK Composite Composite Safety Management Near Miss Identification, Recognition, and Investigation Safety Management Near Miss Identification, Recognition, and Investigation Ron C. McKinnon, CSP Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2012 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 2011908 International Standard Book Number-13: 978-1-4398-7947-4 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. 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Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com 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 v vi Contents 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 Contents vii 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 viii Contents 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