'Everybody gets to go home in one piece'

While running up a flight of stairs on an icy morning, merging from one lane to another during rush hour or sliding centimeters past an open file cabinet at the office, every day we narrowly avoid incidents that could result in a serious injury. When these incidents take place on the job, it can serve as a warning that a serious incident is waiting to happen.   

Near misses and resulting inspections may help prevent an injury or even a fatality, but an investigation cannot take place if the near miss is not reported accurately. Therefore, setting up a successful safety management program to ensure near misses are reported and investigated is an important step in reducing occurrences of serious incidents.

Recognizing near misses

OSHA defines a near miss as an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near misses also may be referred to as close calls, near accidents, accident precursors, injury-free events and, in the case of moving objects, near collisions.

With so many different names, establishing an agreed-upon term and a concise meaning is the first of several steps toward creating a successful near-miss program, said Dr. Ulku Oktem, adjunct professor at the Operations and Information Management Department of the Wharton School of the University of Pennsylvania and a senior fellow at the Risk Management and Decision Process Center.

Through interviews conducted with individuals who manage near-miss programs in the environmental, health and safety departments at five Fortune 500 companies, Oktem and her colleagues created the following steps for setting up a successful near-miss program:

• Create a clear definition of a near miss.
• Make a written disclosure and report the identified near miss.
• Prioritize reports and classify information for future actions.
• Distribute information to the people involved in the near miss.
• Analyze the causes of the problem.
• Identify solutions to the problem.
• Disseminate the solutions to the people impacted.
• Resolve all actions and check any changes.

Among these steps, Oktem stressed the issue of prioritizing. “You need to prioritize, and each company will be different than another company. Prioritizing, I think, is an extremely important part of the process,” Oktem said. “If you do not prioritize, you really do not take care of things in the right order.”

Companies must remember a thorough near-miss investigation can save time and money by improving system reliability and minimizing the risk of an incident waiting to happen, Oktem said.

“People just cannot afford not to do it,” Oktem said. “By identifying near misses and taking care of them, you can improve profits and you can prevent any potential hazards that can happen to the people or the equipment.”

Involving employees

For Duane Smith, an electrician at New York-based aluminum producer Alcoa Inc., the main reason for having an accurate system for reporting and investigating near misses is “everybody gets to go home in one piece.” According to Smith, who works at a company plant in Davenport, IA, Alcoa instituted several changes to its near-miss reporting system a few years ago that opened the dialogue between employees and the safety management team.

“As far as the formal reports, you have to report it to your supervisor,” he said. “That’s what we do. That’s very important. People need to know who to turn to.”

Currently, five to 10 near-miss reports are discussed each day in regularly scheduled meetings with employees from each shift, said Bob Bartholomew, a mill operator who serves as co-chair of the joint safety, environment and health league at Alcoa. “We try to make sure that we document all the near misses if it happens. It’s probably not the first time, and it’s probably not going to be the last time it’s going to happen,” Bartholomew said. “And the next time it happens, it may be much worse than a near miss.”

Bartholomew said a recent near miss at his facility involved using a crane to lift a sheet of scrap metal nearly 30 feet off the ground and move it from one side of the plant to the other.

After receiving several near-miss reports, Bartholomew worked with the crane operator to change the lift and only raise the sheet 10 feet off the ground, increasing visibility and decreasing the risk of a piece of metal falling on someone, he said. Bartholomew added that because management involved the employees as the changes were being made, the changes worked.

“One of the big things is even just talking about what happens,” Bartholomew said. “If you don’t involve the individual, they think it’s lost. You have to have that trust, where people know that you’re following up on it and that something is getting done. It’s the basis for the whole process.”

Avoiding the blame game

Another part of the near-miss system is learning how to encourage employees to report a near miss without feeling that they will get into trouble.

“The key to that problem is not to look at it as, ‘Who is to blame?’ Ask what system flaws exists,” said Phil La Duke, an associate at Rockford Green International, a Michigan-based consulting company. “Get rid of the concept of blame. You really have to have a blame-free environment. Very few people are going to report a near miss if there is going to be a negative consequence to them.”

According to La Duke, people should not be punished for reporting near-miss incidents; instead, supervisors need to encourage their employees to feel comfortable coming forward to achieve a workforce that anticipates and identifies hazards before anyone gets hurt.

“When we make a mistake, we feel very vulnerable,” La Duke said. “We do feel foolish when we screw up, and it takes a special person to admit their mistakes, and that’s what we’re asking them to do. So we have to try to counterbalance that.”

Research exists that supports the claim that the safety climate of a workplace has a direct impact on the reporting of near misses. Researcher Sunil Lakhiani of the University of Wisconsin-Madison presented findings from a study on near-miss reporting systems to the American Institute of Chemical Engineers at the 7th Global Congress on Process Safety in Chicago in March 2011.

Researchers surveyed 108 employees at three chemical plants in the United States, examining the relationships among employees’ perceptions of various factors that are part of the safety climate of the plants and their near-miss reporting behavior.

“Results showed that subjects who perceived a more positive management culture towards safety were more willing to report near misses,” Lakhiani wrote in the report. “The results of this study show a correlation between employees’ willingness to report and their perception of organizational factors, such as their perception of top management commitment, support of peers and their comfort in reporting issues to their supervisors.”

Making it easy

Having several outlets to report a near miss will make the process less painful for employees, said Tim Neubauer, safety consultant for the National Safety Council.

“Give them as many options to report as possible to make it convenient for them,” Neubauer said. “They need to make this a really easy process of reporting to the department or management. If they don’t want to see you [to report the near miss], you’re not going to get any feedback.”

Neubauer added that near-miss reports are critical because, most of the time, companies are looking at trailing indicators. “The beauty of a near-miss report is that you had an incident and nothing was damaged and no one was hurt,” Neubauer said. “It’s telling you the health of your company now.”

Maintaining the health of your company will take some hard work, said Shawn M. Galloway, president of ProAct Safety, a consulting company in The Woodlands, TX.

“One of the reasons why employees suggest the [near-miss reporting] system fails is mostly because of the massive amounts of data,” Galloway said. “The same thing that people can run into in establishing a near-miss program is, ‘How do we respond to copious amounts of data?’”

According to Galloway, people may become bogged down by the research and hundreds of near-miss reports received once a program begins, and he cautions against becoming overwhelmed.

“The reality of the world is more organizations are becoming leaner and leaner, so we get [bombarded] with all this data and that, unfortunately, becomes a demotivater,” Galloway said. “If we are going to get to a level of excellence in safety, we have to measure what we don’t want to occur.”