Near misses.Accident investigation

Previously, the facility had several mullimillion dollar accidents, and near misses. After each accident, investigations were made and corrective actions taken. However the large fire precipitated a risk evaluation of the entire mining complex to find latent accidents. 

M. he investigation of accidents and near misses (that is, close calls) provides opportunities to learn how to prevent similar events in the future. Accident investigations, including detailed descriptions and recommendations, are commonly shared within the chemical industry. Many professionals believe that this sharing of information about accidents has been a major contributor to the steady improvement in safety performance. 

An important principle in safety states that the causes of accidents are visible the day before the accident. These causes are visible to professionals who see deficiencies. This vision (knowledge or awareness) is developed by the study and development of accident and near-miss investigations. 

Wright L.B., Schaaf van der T.W., 2003. Accident versus near miss causation a critical review of the literature, an empirical test in the UK railway domain, and their implications for other Sections, ESReDA Seminar on Safety Investigation of Accidents, Petten. 

An apparently high level of effort is required to report and investigate near misses. The costs of this effort are quantifiable. The benefits of these investigations are not as easy to tabulate. The actual number of accidents that have been prevented by improved near miss reporting may never be known. However, organizations that have seen dramatic increases in near miss reporting have also seen dramatic reductions in losses. The root causes of near misses of safety consequences may be the same management system weaknesses that adversely affect operability, quality, and profitability. 

Investigation and follow-through of accidents and near misses shows the intent by the company to discover and correct problems in the system. However, investigations without follow-up may be perceived as a demonstration of neglect by company management. 

Minor incidents—Infrequent occurrence of these accidents or near misses have acceptable consequences but recurring occurrences of this magnitude may warrant an investigation. 

Trend analysis can be confused or invalidated by a sample that is too small. If the charting or analysis is limited only to major incidents, there will often be too few within a period to arrive at meaningful conclusions. For example, a facility with one thousand employees may experience only one or two serious incidents per year, and several years worth of data would be needed to make any meaningful statistical analysis. Minor incidents and near misses can be as useful in trend analysis and preventive prediction as major incidents. All process incidents should be reported, classified, and investigated as appropriate. The severity of an incident is frequently more a function of chance than actual fundamental system differences among accidents and near misses. 

Poorly defined feedback can lead to a decrease in safety. As an incentive to reduce the number of accidents in the California construction industry, for example, workers with the best safety records—as measured by fewest reported incidents— were rewarded [126]. The reward created an incentive to withhold information about small accidents and near misses, and they could not therefore be investigated and the causes eliminated. Under-reporting of incidents created the illusion that the system was becoming safer, when instead risk had merely been muted. The inaccurate risk perception by management led to not taking the necessary control actions to reduce risk. Instead, the reporting of accidents should have been rewarded. 

Words and phrases such as incident, accident, and near miss tend to be used quite loosely in general conversation. They also tend to have different connotations in English, American, and Canadian usage. However, in the context of formal incident investigation and analysis such words need to be tightly defined. The definitions used for these terms in this chapter are provided below. 

As stated by the principle of definition, if the real causes of accidents and near-miss incidents are not found, how can real solutions be proposed If all the contributing factors are not investigated, how can the causes of the events be identified and rectified ... 

Report of company-wide injuries, damage accidents, and near-miss incidents Report of site injuries, damage accidents, and near-miss incidents Outstanding actions from accident investigations Safety suggestions submitted... 

Investigate accidents and near-miss incidents and take corrective action... 

Participate in accident and near-miss incident investigations... 

Health and safety representatives who have received specific accident investigation training could be used to assist in accident and near-miss incident investigations. Since they will be conducting both formal and informal inspections, a training session in auditing techniques will help them to audit safety standards in their own areas. 

Accident and near-miss incident reporting and investigation Fire prevention and protection... 

Part of my role as safety advisor was to train the safety teams in all aspects of the system so that they were competent to implement and coordinate it in their own areas of responsibility. I also assisted in developing the newly redesigned safety team and taught them accident and near-miss investigation techniques, risk management, and other safety system-related courses. 

Employers should have trained inhouse teams for investigation of unusual incidents. These include accidents and near misses that could have had harmful consequences. The objective of an incident investigation is to learn from experience, and this requires publication and dissemination of a clear report of the findings. Multidisciplinary teams are better able to gather and analyze the facts of an event. The knowledge of employees who work in the area where an incident occurred is a substantial asset. They should be consulted, interviewed, or made part of the investigating team. 

Worksite analysis involves examining the workplace for existing and potential hazards. Comprehensive baseline and periodic safety and health surveys should be conducted. Job hazard analysis, accident, and near-miss investigations should also be held. Workers should be able to report unsafe conditions without fear of reprisal. Trends of illness and injury should be studied over time to identify patterns and prevent problems from recurring. 

All accidents and near-miss incidents should be investigated to determine causes, and means for their prevention identified. Analysis of injury and illness trends over time should be undertaken so that patterns with common causes can be identified and prevented. 

Do accident investigation reports show a thorough analysis of causes, rather than a tendency to automatically blame the injured employee Are near-misses (property damage or close calls) investigated using the same techniques as accident investigations Are hazards identified as contributing to accidents or near-misses tracked to correction ... 

Do employees understand and accept the results of accident and near-miss investigations Do employees mention a tendency on management s part to blame the injured employee Do employees believe that all hazards contributing to accidents are corrected or controlled ... 

Worksite analysis is the process of identifying hazards related to a project, process, or activities at the worksite. Identify hazards before determining how to protect employees. In performing worksite analyses, consider not only hazards that currently exist, but also hazards that could occur because of changes in operations or procedures or because of other factors, such as concurrent work activities. First, perform hazard analyses of all activities and projects prior to the start of woik, determine the hazards involved with each phase of the project, and perform regular safety and health site inspections. Second, require supervisors and employees to inspect their work areas prior to the start of each shift or new activity, investigate accidents and near-misses, and analyze trends in accident and injury data. 

Accident investigation is an effective part of a program that provides for investigation of accidents and near-miss incidents, so that their causes, and the means for their prevention, are identified. All loss-producing accidents and near-misses are investigated for root causes by teams or individuals that include trained safety personnel and employees. 

Investigation of Accidents and Near-Misses The site must investigate all accidents and near-misses and must maintain written reports of the investigations. 

Trend Analysis The process must include analysis of information such as injury/illness history, hazards identified during inspections, employee reports of hazards, and accident and near-miss investigations for the purpose of detecting trends. The results of trend analysis must be shared with employees and management and utilized to direct resources prioritize hazard controls and determine or modify goals, objectives, and training to address the trends. 

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