Near miss reporting: the sounds of silence
by Matt Forck, CSP, JLW
October 8, 2009
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| “I say nothing…” |
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Five reasons lips are sealed
There is no doubt that near miss reporting is
important… very important. As safety professionals
and leaders, we know that a free lesson learned today is an injury avoided tomorrow.
And there are dollars associated with near misses — serious dollars.
If we ignore the tremendous “human” and emotional
impact of serious injuries and fatalities and
only compare their financial costs with the costs
of near miss injuries, it might be an eye-opening
exercise.
According to some estimates, near miss events
may cost twice as much as serious incidents
or fatalities. According to a Houston Business
Bureau, CII and Exxon Chemical report, a near
miss event is estimated to cost about $1,300
and they estimate about 1,000 near miss events
for every fatality. Using 2004 Bureau of Labor
Statistics data, 5,703 workplace fatalities were
reported across the United States. At an estimated
million dollars per fatality, near misses cost the
private sector more than a trillion dollars more, on
the monetary side of the equation, than fatality.
And, if estimated costs are shifted, near misses
can move this ledger amount to twice that of
fatalities.
As safety professionals, we already agree about
the importance of near miss reporting. Add to this
foundational understanding a cost basis rational,
then a question flows naturally — why don’t we
encourage reporting and thoroughly analyze near
miss events? After all, how many near misses have
you worked on this week, or this month? Chances
are, you can count them on one hand…one finger
probably. In truth, there are five key reasons why
these events are not reported and analyzed. Five
truths that no one wants to talk about, until now.
Unspoken Truth I — Reports come with a cost
Any article or training class dealing with near
miss reporting will frame a near miss event as a
“free lesson” or a “golden nugget” that must be analyzed
for learning. The truth, however, is that these
events are not free.
If you are still skeptical, then tell me how many near
miss reports have come across your desk in the last
week…I rest my case. In most organizations there is
a cost to near miss reporting. That cost can come in
many forms such as loss of credibility by the worker
reporting the near miss. The price might be in an
intimidating reporting system or unspoken signals from
line-management. The cost might be in the perceived
time and hassle to make the report. Our critical role is
to identify these costs and work to reduce them.
Questioning attitude: What are the hidden
costs to near miss reporting within your organization?
How can we put ourselves in the shoes of our workers
to truly understand these costs?
Unspoken Truth II — Reporting requires motivation
The next truth that no one talks about is this:
free isn’t enough. There must be an incentive or
motivator in order for our people to engage in a
near miss reporting process and work an incident
through the process.
Put yourself in the place of your workers. It’s
a typical afternoon, and things seem to be going
fine. All of the sudden, bam. The worker is almost
injured due to a part defect. She quickly replaces
the defective part and begins the task, as she does
this she realizes that she was lucky. Had she not
noticed the defect, there is a great chance she
would have been injured. At that moment, the
worker thinks… “I wonder if I should report it?”
The thought that comes next is key… will she be
motivated to do so or not? In most cases, “free”
isn’t enough, there must be a positive motivator
established so our workers will answer the “should
I report it” question with a strong positive.
Questioning attitude: Is there motivation
to report near miss events? At the moment a worker
realizes a near miss occurred, what can be the motivating
factor to allow him/her to report the event?
What is the “right” type of motivator for your organization?
Should I overcompensate with a motivator
in the short term to establish a long-term habit?
Unspoken Truth III — Reporting requires too much work
If we refer back to our college
days and reference the great H. W.
Heinrich’s accident triangle from his
book “Industrial Accident Prevention: A
Scientific Approach” we recall that for every
major injury there are 29 minor injuries and
300-near miss events. In looking at these ratios in
your organization, it is probably safe to say that if
reported, a line-manager could have at least one, if not
more, near miss events a week.
That being said, how busy are your line-mangers
right now? Chances are they are swamped. What are
they going to do with another one or two near miss
report events per week? Chances are they won’t do
anything with them…and that’s the fear.
In all honesty, what would your organization think
of a supervisor who managed over 100 near miss
events in a year? While safety professionals would
think its great, do you think managers would perceive
an issue with the supervisor’s performance?
Questioning attitude: What kind of near
miss reporting system can speed up the process, be
effective in eliminating future exposures and assist
line-managers at the same time? How can line-managers
be rewarded and motivated to follow near miss
events through the process? How can upper management
recognize a high number of near miss reports as
“effective supervision” instead of “poor performance”
by a line manager? Does an organization need a separate
position just to manage near miss events?
Unspoken Truth IV — A near miss is hard to define
One of the most effective football coaches of all
time, Vince Lombardi, used to say, “It’s hard to be
effective when you are confused!” The fact is that our
people have a hard time defining a near miss and have
a hard time translating a field event to a near miss
report. And when there is uncertainty, people will
withdraw into silence and status quo.
Questioning attitude: How can we design
a near miss definition that is both effective and easily
understood? How can we evaluate our employee’s current
understanding of near misses?
Unspoken Truth V — Hours of pointless questions
Think about it: something happens and the result
is that no one gets hurt, yet the employee or crew is
dragged
into a
room with
management
for an “investigation.”
After a couple
hours of seemingly
pointless questions that
meeting ends, few, if any,
changes are made…what’
doesn’t stink about that?
Questioning attitude:
How can technology be used to help
the process, how about a near miss
blog? How can the process be turned
from “stink” to roses? What if employees
ran the process with a fostering eye and consistent
support from management?
A sharing process that works
Having worked more than a decade and a half in the
utility industry, it is safe to say that the most dangerous
work for utilities workers is during storm restoration.
After a storm, weather conditions are generally poor
and electrical hazards extreme. To help mitigate these
hazards and maintain a high level of safety awareness,
crews will gather every morning to review hazards and
then meet again in the evening to review the day.
It’s in these evening sessions that line workers will
openly share near miss events. It’s a free exchange
motivated by a general intent to keep a “brother or
sister” from being injured by the same or similar
exposure.
The process is supported by line-management and
safety staff alike, it is free, workers are motivated by
a sense of genuine caring and a desire to help, it’s
not full of process or forms and it is done in a timely
manner. Yet, after a storm, most of this free sharing
is lost as crews revert back to “normal” hazards and
office politics.
Near miss reporting is one key to safety success,
yet it
is lost
in most
organizations.
In the
end, it’s up
to us as safety
leaders and professionals
to speak the
unspoken truths and
make a process where
experiences are shared and
supported for one common
goal: to eliminate that human
side of loss-before it happens.
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