Near-miss investigations

Division A revised its near-miss investigation procedure after last January s incident. 

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. 

In practice, especially with near-miss investigations, sometimes initial investigation efforts are started without the full team to meet the federal mandate of standard. There can be scheduling problems. With today s mobile work force, technical specialists that could be out of town, or key operating personnel on revolving shifts could result in a shortage of the necessary expertise within the first 48 hours. 

An important advantage is that near miss investigation provides a. pre-... 

Percentage of incicients and near misses investigated by the facility that had root causes related to contractor activities X ... 

All activities required for process safety management, such as process hazard analysis, mechanical integrity, incident and near-miss investigations, and management of change... 

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. 

Set the expectation for timely and interdisciplinary error and near miss investigations with an emphasis on patient/family impacted by the error the broader institutional implications of and learning from the error and the support of staff at the sharp end (closest to care). 

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. 

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 ... 

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. 

When an incident or near-miss investigation has identified an SIS deficiency... 

Were Incident, Near Miss, investigation Reports completed submitted to the Safety Dept, within 72 hours Yes or No. if not, why ... 

Zero injury goals are enforced with safety training and accident/near-miss investigations coupled with a lucrative injury incentive program [3]. 

Managanent at all levels is then held accountable to rectify the problems identified by the near miss investigations and to ensure that the high risk acts or conditions highlighted by the system are rectified and do not recur. 

Commence the accident/near miss investigation process and head the investigation meeting. 

Publish the Near Miss/Accident Initial Report before the end of the shift. Commence the accident/near miss investigation process and head the investigation meeting. 

For the system to succeed, it is important to note that all the events reported cannot, and should not, be subject to a full near miss investigation process. This will bog the investigators down and prove too time consuming. 

Near miss investigation is more proactive as it takes place before a loss has occurred and is a precontact control activity. The flow of energy has not caused damage or injury, but the accident symptoms are the same. It is easier to investigate a near miss incident because, since there has been no injury, there is less likely to be a cover up. Because there has been no loss, there is generally less of a postaccident fear factor. 

With so much information and work that has culminated in this book, numerous people need to be thanked. I would like to thank the industrialists and miners that I have dealt with over the past 38 years. I learned industrial safety from them and a great deal about near miss incidents from their near miss investigation systems and from their experiences in dealing with the aspect of safety in the shadows. ... 

Program Elements 1. Written policy, purpose, scope Statement of objectives Standards compliance Responsibility/accountability assigned Implementation activities A. Training/certification Written procedures Hazardous operations Hazardous materials Hazardous operations permits Personal protective program Mishap/near-miss investigations Mishap/near-miss records and reports Fire/explosion safety Emergency preparedness Procurement and subcontract safety Safety representatives on-site Implementation of supplemental requirements... 

Incident and near miss investigation is a key element, whereby the history of incidents can be learned from to eliminate patterns that may lead to similar hazards. 

All loss-producing incidents and near misses investigated root-cause analyses conducted as required. 

Do employees understand and accept the results of accident and near-miss investigations ... 

Review human error potential by observation (see Chapter 10 for more detail), and examination of relevant risk assessments and aceident/near miss investigations. 

Employee recognition and disciplinary action programs Immediate reporting of occupational injuries and illnesses Injury/illness/near miss investigation procedure Procedures for timely corrective action... 

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