POSITIVE SAFETY CULTURES: Your golden opportunity: the - near miss'

June 1, 2008
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The near miss is an incredibly powerful learning tool, and one that is largely wasted. It carries all the information regarding a potential accident without someone actually getting hurt. Why would the culture of a plant discourage taking advantage of this golden resource?

“Confessing” a near miss suggests that I’ve done something stupid, taken a dangerous chance or even knowingly cut a corner and violated a safety procedure. I will have to explain the situation to my boss and the safety committee, and in the process, might set myself up for disciplinary action or even termination.

A hypothetical case

Let’s take the case of James, a senior mechanic. He’s doing a routine equipment repair. Engineering has made modifications to the equipment, and James is aware of this. He removes the control-box cover, and, as he has always done, reaches in for the control switch to deactivate the machine before locking it out. The switch has been relocated, and he unexpectedly finds his hand in a pinch point just as he is trying to shut down the machine. He withdraws his hand, barely avoiding getting caught in the gears as they mesh.

James steps back, waits until the adrenaline rush passes, and looks around. He’s glad no one saw his error; at least he won’t have to explain himself to anyone. Very carefully, he looks in the control box, goes to the relocated switch, shuts the equipment off, locks out the controls, and proceeds to make the simple repair.

The same thing happens several nights later to TJ, one of the night shift mechanics. He missed the briefing where the engineering modifications were announced. But he too is lucky. And he too keeps quiet about it.

Workplaces can be full of “near misses” waiting to happen.

Safety smart — after the fact

A few weeks after James’s “near miss,” the same equipment is down again for a minor repair. The line has accumulated too much downtime this month, and Carlos, the second-shift mechanic, is under pressure to get it up and running quickly. He removes the lock, jumps the machine, and puts his hand in to deactivate the equipment. His buddy Jack says something to him, and Carlos glances at Jack just as the relocated gears mesh. He suffers a severe hand injury, is out of work for weeks and returns to light duty for two months with permanent limited mobility in his hand.

The ensuing investigation indicates the engineering upgrades were not sufficiently communicated to production or maintenance, a pinch-point hazard was created, and proper lockout procedures were not completely followed. New signage is posted at the controls, engineering makes some safety improvements, and an internal guard is installed to prevent a hand from being inserted into the new pinch point. Everyone is now alert to the hazard, and this accident does not occur again.

But why does it take an injury to make us wise up? The critical question is how to turn things around and capture these golden learning opportunities. Here are a few suggestions:

  1. Set up an anonymous “near-miss box,” similar to the venerable suggestion box, as a useful starting point. Reported events can then be discussed in safety meetings and appropriate steps taken to alert everyone to risks, as well trigger appropriate training and signage and encourage folks to watch out for each other in high-risk situations.
  2. Non-work examples can set the tone for discussion of work-related near-misses. Traffic stories are typically not work-related, and most of us have tales to tell. The same is true for at-home examples; most of us have had a near miss with ladders, lawn mowers, Weed Eaters, or kitchen stoves. Work your way up from non-work to work examples gradually until employees realize they are free to share this type of information about situations they face in the plant.
  3. “Protect” your employees when they talk about a near miss of their own, or one that they observed in a co-worker. Initially, employees may be uncomfortable and tentative about speaking up. Make sure that when they do, they are reinforced for their courage and willingness to take a chance to help others. The way the first few examples are managed will determine whether others will take the chance and talk about what they have experienced.

One of the single strongest markers of a healthy and positive safety culture is the way an organization deals with near misses. The question is not whether we have them — of course we do — but how we deal with them. What does your organization do with these golden opportunities?

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