Safety Management: Near Miss Identification, Recognition, and Investigation

193 Pages·2012·3.84 MB·English

by  Ron C McKinnon

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• 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
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and near missincidaenndt anweaarre mneissssi ntcriadiennintg a ownareness training on
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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)
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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
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