Toolbox Talk- “Near Miss!!!”

NEAR MISS !!!!!! WHATS THIS??? !!!!!!!!! 

What’s a Near Miss / Near Hit? Usually a near miss or hit is defined as an accident that almost

happened.

For example, the situation where someone trips and almost falls down the stairs but manages to

grab the hand rail just in time, or when someone is almost hit by a reversing fork lift. In these two

examples no injury resulted but this was the result of good luck rather than good management.

When near misses occur they can be regarded as early warnings that something is wrong somewhere in

the system. We therefore need to develop a system which allows us to take action before an injury takes

place – and of course, this is nothing other than good management practice.

When a Hazard and Near Miss report is received by a supervisor, the supervisor should discuss it with the

person making the report, decide what corrective action should be taken and implement the change as

soon as possible if it is within the supervisor’s authority. If not, the matter should be referred to the

manager for correction. Near Miss reports and recommended corrective action should not be deferred

until the next committee meeting unless it requires further discussion. The idea is to take immediate

corrective action now.

Below is summary of a an actual near miss that is quite common:

Incident Date: 1/09/2009

Task Description: Working on elevated platforms using hand tools.

Summary: A hand tool fell through a small gap in the work area and dropped and deflected from other equipment

causing the hand tool to fall outside the exclusion zone identified for the process.

Incident consequences (potential or actual): Near Miss

Cause of incident: Moving, flying or falling object

Root cause: Lack of risk assessment

Activity Type: Maintenance

Specific Equipment: Hand Tools and the lack of securing devices to ensure they are unable to fall from aloft.

 Lesson Learned: It appears there was a deficiency in the risk assessment which had not identified a large enough exclusion zone

underneath the work area. It appears there was no ‘tool control’ for the safe and controlled use of working with tools at height.

It appears that gaps in the protective matting still existed; this had not been managed effectively.

Near-misses are often less obvious than accidents and are defined as having little if any immediate impact

on individuals or processes. Despite their limited impact, near-misses provide insight into potential

accidents that could happen. As numerous catastrophes illustrate, management failure to capture and

remedy near-misses may foreshadow disaster. Notable examples where near-miss precursors have been

observed but not effectively managed include:

1. The 1986 Space-Shuttle Challenger explosion. Engineers had identified and reported degraded O-ring seals on

previous missions dating back to 1982 with degradation increasing as ambient liftoff temperature decreased. The

night before the disaster, management had been warned of the potential for catastrophic failure when lifting off at

ambient temperatures of 53 °F or below (the liftoff temperature was 36 °F) (Vaughan, 1996).

2. The 1997 Hindustan refinery explosion in India. Sixty people died and over 10,000 metric tons of petroleum based

products were released to the atmosphere or burned. Written complaints of corroded and leaking transfer

lines where the explosion originated went unheeded (Khan and Abbasi, 1999).

3. The 1999 Paddington train crash catastrophe in which 31 people died. From 1993-1999 eight near-misses, or

‘signals passed at danger’ (SPADS), had occurred at the location (Signal 109) where the eventual collision and

explosion occurred. At the time of the crash, the signal was one of the 22 signals with the greatest number of

SPADS (Cullen, 2001).

4. The 1998 Morton explosion and fire resulting from a reactor temperature excursion. Nine people were

injured, two seriously. In an accident investigation, the Chemical Safety Board concluded, “Management did not

investigate evidence in numerous completed batch sheets and temperature charts of high temperature excursions

beyond the normal operating range.” A disproportionate number of excursions resulted after the process was

scaled-up (Chemical Safety Board, 2000).

Many accidents can be prevented by taking prompt action to prevent a hazardous situation from continuing or

developing into something worse. Therefore, use Near Miss reports as your early warning system – waiting for the

injury to happen before acting just doesn’t make sense!!!

“Discussion is an exchange of knowledge; argument is an exchange of ignorance.” Robert Quillen

Thanks TO