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Dear Subscriber,

ALMOST HISTORY

Last Saturday night. . . I had just put down a beer when the phone rings. "Hello, dad, can you come pick us up. Mike's car ran off the road."

"Are you OK? Is everyone alright?"

"Yeah. I might have a black eye but everyone's alright."

Off I go, figuring to find some kids next to a car stuck in the mud. As I get close to where they're supposed to be, a line of idling cars is backed up. Sirens wail and it looks like a couple of fire engines and police cars are up ahead, strobes flashing. Shadowy figures are setting down flares.

I pull into a driveway, hop out of the car, and jog down to ask a patrolman directing traffic where the kids are. He points down an embankment. Three or four teens are shivering in the snow, next to a smashed, totaled sedan flipped on the passenger side. I ask where Kate, my daughter, is. They point to the ambulance.

She's sitting inside, getting her "vitals" measured. "You sure you feel alright?" the EMT asks. Her face is pale. "If you get home and start feeling bad, call 911 or you can go to the hospital," says the EMT, smiling. As Saturday night calls go, this one is a relief. Close, but amazingly, no injuries.

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REAL POTENTIAL

Close calls have real potential to align us with safety in our organizations, says consultant David Sarkus, MS, CSP.

"Near misses are valuable diagnostic tools," writes another safety pro in a Web posting. "You can study a near miss for all the components of an accident yet without the loss of an accident."

Do close calls make a difference? I wonder. Will Kate be "aligned" more closely with safety. Or is the jolt of a near-miss (or near hit) like listening to a motivational speaker who jacks you up, only to have you forget the message the next day.

In this edition of ISHN's e-newsletter, we look at close calls, their value, and how to realize their potential to teach.

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CLOSE CALLS ARE COMMON

Everyone can tell you about a close call. They happen with frightening frequency. More than 60 years ago, H.W. Heinrich gave the safety world one of its core fundamentals when he estimated that for every one major injury, there are 29 minor injuries and 300 near-miss incidents.

Later, this "law" was tested empirically by Frank E. Bird, Jr., working for the Insurance Company of America. He analyzed 1,753,498 accidents reported by 297 companies. A new ratio resulted: For every 600 near-misses, there are 30 property damage incidents, 10 minor injuries, and one major injury.

In 2001, U.S. industry averaged about three (2.8) major injuries (lost workday cases) per 100 workers. Using Bird's ratio, for every 100 workers, there would be 1,800 close calls. Almost seven each working day - practically one an hour during an eight-hour shift. If you have 200 workers in your plant, that's about 14 near-misses every day, Monday through Friday.

That's a lot of twists of fate turning in our favor. A lot of opportunities to study where improvements in safety are needed, and to make corrections before it's too late.

There's one problem: People don't like to talk about near-misses, says psychologist Dr. E. Scott Geller.

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REPORTING RESISTANCE

Oh, they'll tell friends or family. "Dad, I thought I was going to die," said Kate. "Everything seemed to happen in slow motion. All I heard was breaking glass."

Or they'll tell it to a newspaper: A Modesto, Calif., man who was nearly clipped in a high-speed car chase complained to the Modesto Bee, "I could have been killed in that chase. Why can't a helicopter track these guys? I still shudder when I think of the experience."

Or a pollster: More than 40 percent of drivers in a survey by Farmers Insurance Group reported having close calls or near misses with a driver who was on the phone.

But reporting a near-miss is easier, safer, when it's the other guy's fault. "These people think that it is the other cell phone users who are the hazards, not themselves," said the president of the Insurance Institute for Highway Safety, in an article about cell phones and close calls.

But when it's you who gambled and took the risk, that's another story. A story that's hard to admit, except maybe if you're still in shock. "I think Mike saved my life," Kate said as we drove home that night. "He told me to put on my seat belt. I wasn't going to because it was a short drive. But he made me."

Still, if I hadn't seen the run-over mail box, the grazed telephone pole, the uprooted and hammered speed limit pole, and the severed wires that sent a transformer crashing to the ground, I don't think I would've appreciated how close her escape was. The kids told the story one way to the police ("The car pulled out in front of me, sir"), for the parents ("I'm sorry, I'm really sorry") and for each other ("It happened right by the high school. We knocked the lights out while the play was going on! I was never so scared in my life.")

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DON'T THINK ABOUT IT

"Guys will tell each other in the lunch room or the rest room about a close call, but they don't tell a supervisor," says Ron Hayes, a safety trainer.

Dr. Geller explained in an ISHN article why it's hard to turn near-miss experiences into valuable safety information:

1) It's inconvenient to fill out forms.

"Why did the police ask so many questions," asked Kate.

2) It's less stressful to just forget it every happened.

"Don't think about," a parent told me after hearing the story. "Those things happen. That's why you wear seat belts. That's about all you can say." She shrugged her shoulders and rolled her eyes.

3) Who wants to report an experience that reflects risk-taking, inattention, carelessness, and maybe an irresponsible attitude?

"I'm going to get a five-hour lecture tomorrow," said one of the boys in the car. "But you didn't do anything wrong." "That's just the way my parents are."

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BEARING IT ALL

It's easier on the psyche to describe an embarrassing close call if some humor comes with it. A meter reader in a San Bernardino Mountains neighborhood in California told this tale on his company's Web site:

"I saw what appeared to be a humongous pair of very hairy legs hanging out of a trash can. At first I thought it was a very large dog, but then realized it was a bear. I was only 20 feet from it. I was shell-shocked." The bear felt cornered and charged the man. "I was fortunate to have left my vehicle close by. The rest of the day I contemplated, 'What if?' What if the bear had been a little closer? What if I had not seen it in time? What if I stumbled?"

The meter man marked the account in his log book, "Beware of Bear", just in case somebody else drops by and "unexpectedly finds a rather large looking animal that wants to Bear It All," he said.

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NO BLAME, NO SHAME

The best way to encourage reporting is to avoid the shame game.

You need a blame-free culture to ensure people report every mistake and near-miss, said Dr. Jim Bagian of the Veteran Administration's National Center for Patient Safety in a report by WIS-TV, Columbia, S.C.

The center tracks medical errors and close calls. "I call fault the 'f-word' of medicine," he says. "Instead of saying 'Whose fault is it?' it's about saying, 'What happened, why did it happen, and what do we do to prevent it?'"

Here's one way of finding out: At Missouri Baptist Medical Center in St. Louis, a patient safety hotline was installed to report safety concerns or close calls right away. Then, a newsletter announces what actions have been taken. "We needed to change the whole culture of the organization," said one doctor.

To keep reports coming, you've got to fix the problems. No follow-up, no credibility. Says one safety pro: "A key component of improving safety is to proactively identify hazards that have the potential to result in harm. These reports are opportunities to fix the system before it breaks." Put the emphasis on "fix."

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DENIAL & SELF-DEFENSE

Make it easy for employees to report near-misses, anonymously perhaps. Discuss in safety meetings the value of reporting. Remove the stigma of stupidity. And follow through on fixing what's wrong. Do all these things and still your near-miss program will fight the force of human nature.

Carl Metzgar raised this point several years ago in an article in ISHN where he quoted from a study, "Patterns of alcohol consumption after liver transplantation."

The patients surveyed were unlikely to have lived for more than a year without a new liver. All had stopped drinking alcohol for six months prior to their transplant. But nearly half (47 percent) of these people, faced with a life-threatening condition and given a second chance, resumed drinking to some degree after their brush with death. "They started to feel better and no doubt in their minds the death threat receded," wrote Metzgar.

Kate and her girlfriend said they'd never get in a car again unless their mom or dad was driving. That was right after the crash. A day later, feeling better, she protested new rules about when and where she could drive with friends. Controls, more rules, a negative consequence - this is what her close call got her. Even when you try to do the right thing, you can drive honesty underground.

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ANOTHER HURDLE

What do we take from close calls? Everyone reacts with their own philosophy. All we can do is try to nurture the right response.

"What did you learn from it?" I asked Kate. "What do you mean?" "What would you do different the next time?" "Oh. I don't know. I mean nobody did anything wrong." "What about wearing seat belts?" "Duh, well of course."

Concessions and lessons often come hard. We drove back to the crash scene the next day and I deliberately slowed to the speed limit - 35 mph. "Oh, we were definitely going faster than this. A lot faster," she said.

Of course a line of cars was stacked up behind me. No one goes the speed limit on this stretch of road. When we got out to look at the damage from the night before, cars whizzed by going 50, 60 mph. "Look, everyone's speeding," Kate said.

Take a close look at close calls, goes a safety slogan. Yeah, but what if everyone does it. . .

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YOUR TURN

Everyone reading this newsletter has had a fortunate twist of fate or close escape somewhere along the way, at home or at work. Did it have a lasting impact on you? On anyone close to you? Share your experience with us and we'll put the lessons learned (or not learned) in our next newsletter.

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Dave Johnson is the ISHN E-News editor. He can be reached at djsafe@bellatlantic.net, (610) 666-0261; fax (610) 666-1906.

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Direct mail

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WE NEED YOU!

Shakespeare need not apply, but ISHN is looking for authors to publish short articles (1,000 words) in our monthly issues.

Topics include: safety success stories, close calls and personal experiences, training tips, use of software, engineering controls (machine guards, lockout-tagout), gas detection and air monitoring, confined space safety, personal protective equipment, and OSHA compliance issues.

If any of these topics interest you - or if you have other ideas - e-mail editor Dave Johnson at djsafe@bellatlantic.net

We will also consider articles you've already written but not submitted to any safety magazine.

Thanks.