Safety Management--Philosophy behind Near Miss Incidents

INTRODUCTION

According to the National Safety Council (USA), and other safety researchers and pioneers, a large percentage of all accidents are preceded by one or more near miss incidents. In other words, close calls should be wake-up calls for employers and employees to realize that something is wrong in the system and needs to be corrected.

TRACKING NEAR MISS INCIDENTS

Writing for Occupational Hazards, S. L. Smith (1994) said:

Near-miss investigations war with the tradition of using an accident to trigger a thorough look at safety conditions and training. Williams, project manager for safety at Raytheon services in Nevada, suggested that if the purpose of safety programs is to prevent accidents, then tracking near-misses offers organizations a better opportunity to lever their preventive efforts. Near-misses can help employers pinpoint trouble areas and focus their safety efforts and training.

Most organizations don’t encourage employees to report near miss incidents. Because there has been no injury, little importance is placed on the seemingly trivial event. Most near miss incidents have some form of potential for injury and loss, no matter how trivial they may seem. Although there may not have been a serious outcome, these near miss incidents could result in future accidents.

NEAR MISS-OR NEAR HIT?

Many argue that the event should be called a near hit as this will get management's attention quicker than near miss. Both descriptions are true as: "If it didn't miss, it would have hit." The American Society of Safety Engineers (ASSE) refers to near miss in their dictionary of technical terms, so this will be the preferred term in this guide.

BENEFITS

The main benefit of a near miss recognition, reporting, investigation, and remedy (NEMIRR) system is the fact that by recognizing near miss incidents and taking action to correct the underlying problems, an organization won’t only reduce the number of near miss incidents, but, more importantly, will reduce the number of actual accidents in the future. Reducing the number of near miss incidents will fix the problems before they can cause accidents. Another major benefit of near miss reporting is that it’s easier to get to the root causes of the event because nobody has been injured or killed, which means there is no pressing need for a cover-up.

Near miss incidents also can be defined as: "close calls that have the potential for injury or property loss." Most accidents can be predicted by close calls. These are accidents that almost happened or possibly did happen, but simply didn't result in an injury this time around. In fact, all the stages of the accident were present in the correct sequence except for the exchange of the energy segment that would have caused the injury, damage, loss, or a combination thereof.

EXAMPLES OF NEAR MISS INCIDENTS

Below are some true-to-life examples of actual near miss incident reports. The reports have been edited to make for easier reading, but the contents have not been changed.

• An employee tripped over an extension cord that lay across the floor, but avoided a fall by grabbing the corner of a desk.

• An outward-opening door nearly hit a worker who jumped back just in time to avoid a collision with the door.

• Instead of using a ladder, an employee put a box on top of a drum, lost balance, and stumbled to the ground. Although the employee was shaken, there was no injury.

• A pry bar that was left on the bottom of a mill under repair flew through the air like a missile when a loosened liner fell onto it while the mill was being rotated. The heavy bar missed workers in the immediate vicinity and neither injury nor damage was sustained.

• An employee tested the brakes at the beginning of the shift and they checked out okay. As he approached another vehicle, he hit the brakes and they did not work and he narrowly missed the other vehicle.

• While walking from his car to the stairs, an employee was almost struck by a fast-moving pickup.

• A miner was pulling out hoses to set up the jack leg and the hoses hung up making the miner mad. He pulled really hard and lost his balance and fell down.

• After changing the engine oil on a vehicle, the employee left the discharge gun in the fill tube of the tank and the air purged in the line and spat oil out the tube nearly striking him in the eyes.

• Two welders received minor shocks when they touched a welding machine. On inspection, a loose wire was discovered in the plug of an extension lead that was connected to the welding machine.

• While the employee was in the process of lowering a side plate of a bulkhead, the safety catch on the hook opened and the grab that held the plate almost unhooked.

• An employee was walking toward his job on the demarcated walkway inside the big workshop. The forklift driver rode toward the workshop. At the corner, the forklift driver nearly knocked the employee over because he was unaware that the forklift was approaching.

RED FLAGS

When near miss incidents like these happen, most workers are simply relieved they were not injured and then forget about what happened moments later. However, when employees narrowly avoid injury like this, they may have just been lucky (the three "luck factors"). Because there was no injury, the event is not reported, therefore, the accident causes won’t be identified or rectified.

Another person is very likely to be injured by that very same hazard or practice in the future. In fact, the difference between a near miss incident and a serious injury (contact or no contact with a source of energy) is often a fraction of an inch or a split second of time. This can be defined as being lucky. These are red flags waving at employees to let them know something is unsafe and requires immediate attention.

A GIFT

As one safety practitioner put it:

Near miss incident reports are a gift. They allow an organization to analyze potential accidents, such as fatal accidents, collisions, fires, and explosions, enabling them to take corrective action to improve and rectify processes and procedures before loss-producing accidents happen.

Safety is traditionally taken seriously, but only for a short period of time after an accident. Proactive safety is when serious attempts are made to predict when the next accident may happen by identifying and reducing risks and fixing things before the event may occur. Near miss incidents offer such an opportunity and will involve a change in safety culture.

PRECURSORS TO ACCIDENTS

Near miss incidents are the precursors to accidents that lead to an exchange of energy and subsequent loss. Literally, fractions of an inch or a split second may be the difference between a serious loss-producing accident and a near miss incident. For example, an individual may be on a ladder and the ladder starts slipping sideways, but fortunately catches on a protruding nail or bolt. This should be reported and investigated so that ladder safety could be addressed throughout the organization and the need for tying off ladders emphasized.

The term accident precursors is defined as:

Near miss and its analogs, near hit and close call, are other terms that are likely to arise frequently during workshop discussions. Although near misses are clearly related to precursors, we have tried to distinguish them from precursors, and we encourage you not to use them interchangeably. One way to define a near miss (or, equivalently, a near hit or close call) is as an almost complete progression of events-a progression that, if one other event had occurred, would have resulted in an accident. A near miss might consist of one or more precursors that did occur, and one that did not. A near miss can be considered a particularly severe precursor (p. 198).

HEED THE WARNINGS

Six operators at an aluminum casting wheel were waiting for a crucible of molten aluminum to be lowered to the pouring table when the heat from the pot melted the grease on the crane cable causing the break to slip and the full crucible slammed down onto the platform splashing 80 pounds of molten metal all over the area normally occupied by the operators. However, this time the operators were standing on the opposite side of the wheel and none were injured by the flying molten metal. Although this was a property loss accident, the six workers were involved in a near miss incident with high potential. When interviewed, not one of the operators could explain why, on that particular day, they took up a different position. Normally, they would have been standing in the path of the metal splash.

In another instance eight workers were 30 feet off the floor on a scaffold erected in an aluminum smelter pot line. A crane operator proceeded to move the overhead crane from one side of the building to the other. This particular gantry had two cranes mounted on it with different lifting capacities, which shared the common overhead gantry. As he was moving the crane, his focus was on the main 50-ton hook as it traversed the length of the building. Meanwhile, the smaller hook on the 10-ton crane was dangling halfway down at the end of the gantry and unnoticed by the operator. This hook snagged the edge of the 30-foot scaffold and slowly but surely started to lift it off of the ground, tilting it alarmingly. Fortunately, the workers screamed and shouted at the operator who managed to stop the crane movement before the scaffold was completely overturned.

HIGH POTENTIAL FOR LOSS

The next near miss incident not only indicates the luck factor, but also the high potential for loss. An underground miner related this event:

We were trying to open the man-way doors to go to the surface. We could not open the door because the door to the shaft and the door to the station were open causing a temporary vacuum. We finally got the door open and the pressure of the air pulled me in toward the shaft. I almost ended up falling down the mine shaft had it not been for the retainer wire.

Boylston (1990) refers to near miss incidents as potential problems. He also quotes the luck factors by saying that failure by an organization to recognize, evaluate, and implement controls for early warnings of potential problems usually results in a system of reactive approaches.

Consequently, there is little if any way to control the magnitude of the problem. Such organizations are "lucky" or "unlucky," depending on the situation. This is no way to manage an organization.

FACTS ABOUT NEAR MISS INCIDENTS

• Many near miss incidents have the potential to cause injury to people.

• Near miss incidents are largely ignored because they don’t result in any loss.

• Most near miss incidents aren't investigated because a loss did not occur.

• They have often been called near hits, near misses, or near accidents, as they are warnings of potential accidents.

• All high potential, near miss incidents should be reported and investigated to determine and rectify root causes.

• Luck plays a major factor in determining whether the events become accidents (contact) or near miss incidents (no contact).

• Near miss incidents are caused by system failures and can be prevented.

• Reporting, investigating, and eliminating near miss incidents will lead to a reduction in property damage and injury causing accidents.

• Multiple causes are also evident in near miss incidents.

Near miss incidents are warnings and, if an organization eliminates the near miss incidents, the accidents causing damage and injury will look after themselves.

CONTACT (ENERGY EXCHANGE) TYPES

In an accident, there is some form of contact or energy exchange that is above the threshold limit of the body or structure and that causes the damage or injury. In near miss incidents, there is no exchange of energy. There is a flow of energy that misses. If there is a contact, the amount of energy exchanged is below the threshold limit and no loss is incurred.

BUSINESS INTERRUPTION

A contact and exchange of some form of energy need not necessarily cause injury or damage, but may well end up in some form of interruption of the business at hand. The interruption may either be major or minor depending on the severity of the contact. Invariably, a contact causes some form of loss and, if substantial time is lost restarting a machine or rectifying a continuous process that has been interrupted as a result of accidental contact, it’s a loss.

The losses caused by business interruption may not be as severe as losses incurred by property and equipment damage accidents or injuries. The exchange of energy in a business interruption is sometimes not as severe as that which caused damage to the equipment, machinery, and environment, but nevertheless is sufficient to disrupt the work.

The work output would be affected because of the delay. Extra effort is needed to rectify this delay. Time to clean up, time to readjust, or time to realign are all losses as a result of the business disruption. In certain instances, a critical part may be affected by the contact and if not damaged may be malfunctioning, or temporarily displaced. All business work, process, and flow interruptions also cost money.

THE ACCIDENT RATIOS

Over the years, researchers around the world have investigated the near miss theory and have compiled numerous accident ratios. They have researched the ratio between the near miss incidents, accidents causing damage, minor injuries, and serious injuries. Most of the research has indicated that there are more near miss incidents that have no visible sign of loss than injury- or damage-producing accidents.

Heinrich Accident Ratio

One of the first researchers was H. W. Heinrich (1931) whose accident ratio showed that for every 330 accidents (undesired events) there were 300 accidents that caused no injury, 29 that caused minor injury, and only 1 that caused a serious or major injury. The conclusion was that for every injury-causing accident there were numerous other undesired events (near miss incidents) that had the potential to cause injury (Model 2.1).

When this research was done in the 1930s, the term near miss incidents was not yet used and these were referred to as accidents (with no injury). These 300 non-injury accidents could be termed near miss incidents if no damage or interruption occurred. This led industrialists to think about the non-injury accidents and give attention to them.

MODEL 2.1 The Heinrich accident ratio. Fatal or Serious Injury Property Damage Near-Miss Minor Injuries First Aid

MODEL 2.2 The Pearson accident ratio. (From the British Safety Council. 1974/1975 Tye-Pearson theory.)

Tye-Pearson Accident Ratio

In 1974-1975, the Tye-Pearson theory was conducted on behalf of the British Safety Council and was based on a study of almost 1 million accidents in Britain (Model 2.2). The ratio showed that for every 1 serious injury experienced, 3 minor injuries occurred, 50 first aid injuries took place, 80 accidents caused damage, and there were in excess of 400 near miss incidents. The study was concluded by stating that:

There are a great many more near miss incidents than injury-or damage-producing ones, but little is generally known about these.

Frank E. Bird, Jr. and George Germain Accident Ratio

In 1966, Frank E. Bird, Jr., and George Germain compiled an accident ratio. This accident ratio study changed the concept by proposing that for every 641 events, there were 600 near miss incidents with no visible loss, 30 property damage events, 10 events resulted in minor injury, and 1 serious or major injury was experienced. This analysis was made of nearly 2 million accidents reported by approximately 300 participating companies employing 1.7 million employees. The Bird and Germain report involved 4,000 hours of confidential interviews by trained supervisors. Their report and subsequent ratio highlighted the occurrence of near miss incidents that under slightly different circumstances could have resulted in injury or property damage.

In referring to the 1:10:30:600 ratio, it should be remembered that this represents accidents and near miss incidents reported and not the total number of accidents or incidents that actually occurred.

The Health and Safety Executive (HSE) Accident Ratio

This accident ratio, which was derived from a study by the Health and Safety Executive of Great Britain in 1993 (Model 2.3), showed that for every serious or disabling injury, 11 minor injuries were experienced and 441 accidents occurred that damaged property.

MODEL 2.3 The HSE accident ratio. (From Health and Safety Executive, U.K. 2006. Online at: www. hse.gov.uk/statistics/causinj/index.htm) Fatal or Serious Injury Minor Injuries Accidents.

South African Ratio:

The author (Ron McKinnon), in Safety Management magazine (September 1992), elaborated:

A ratio such as this is truly invaluable, since it makes prediction possible. As soon as too many near miss incidents are reported in a specific area, it’s a clear sign to the management and safety staff that a more serious accident is about to occur and they can take preventive action.

South Africa's National Occupational Safety Association (NOSA) decided that statistics, which will enable it to construct a ratio, would be of great value to industry:

We want to determine whether there is a unique ratio in this country ( South Africa) or whether Bird's Ratio of 1:10:30:600 was accurate.

Often the only difference between a near miss incident and a serious accident is generally just a matter of luck. Take, for example, a brick falling off a platform and narrowly missing the head of a passerby. The accident sequence occurred the minute the brick started to fall. The fact that it missed the passerby was not due to any safety intervention, but was purely fortuitous. While this is recorded as a near miss incident, the implications are very serious.

THE ACCIDENT RATIO CONCLUSION

The accident ratio conclusion is a generalization based on the work of safety research and studies conducted in some seven different countries. No figures are used, but the ratio concludes that there are plenty of near miss incidents where nothing happens, but where something might have happened, if circumstances had been slightly different.

In summary, the accident ratio conclusion shows that for every serious or disabling injury an organization has, it could be experiencing some minor injuries, more property damage accidents, and plenty of near miss incidents.

One Some More Plenty Serious or Disabling Injury Minor Injuries Property Damage Accidents Near Miss Incidents

MODEL 2.4 Accident ratio conclusion.

All of these studies clearly show the futility of investigating only the few serious or disabling injuries when there are hundreds of near miss incidents which, if investigated and their causes corrected, would have prevented the occurrence of the more serious injury-causing accidents.

In conclusion:

• There are more undesired events with no consequence than those with consequences.

• Plenty of near miss incidents occur where nothing happens, but where something might have happened, if circumstances had been slightly different.

• This is where safety management control should be concentrated (Model 2.4).

Krause (1997) refers to the accident ratio and explains:

An at-risk behavior whose outcome lies off of the triangle is a near miss incident. An identical behavior whose result lies on the triangle is an accident. Behavior based safety investigators are not confused by the difference in chance outcomes.

PREVENTATIVE OPPORTUNITIES

By taking action to reduce the base of the accident ratio triangle, you are aiming to prevent the serious injury accidents at the peak of the ratio triangle from occurring. Hence, the near miss incidents at the base of the ratio are often referred to as "preventative opportunities." This ratio between near misses and accidents often becomes obvious during accident investigations. While interviewing witnesses to an accident, it becomes apparent that similar events have frequently happened before. Only, in the past, fortune has smiled upon the participant and prevented a serious injury from occurring.

Injuries vis-à-vis Near Misses

MODEL 2.5 Reduction in reported injuries.

By constantly eroding the base of the iceberg or accident ratio triangle, successes will eventually start to impact the top of the triangle, i.e., the minor and serious injuries. An interesting example of this was a study carried out in 1998. A near miss incident reporting system was encouraged and from a mere 50 near miss incidents reported in a month, this figure jumped to 231 in the month of March. In superimposing the reduction of injuries (all classifications) on the number of near misses reported, it was found that as the near miss incidents reported increased, the number of injuries fell. The injuries reduced from four in February to one injury in the month of April (Model 2.5). As the number of near miss incidents reported fell, the injury rate once again continued to climb. When only 114 were reported, 8 injuries were experienced.

As is stated in NOSA's MBO Five Star Safety and Health Management System Introduction Booklet (1991):

The work of any good manager should be to reduce the "plenty" of near-miss accidents.

IMMEDIATE ACCIDENT CAUSES

The immediate causes of the contact stage of the accident are the high risk acts and high risk conditions. These are often referred to as the unsafe acts or unsafe conditions.

• A high risk/unsafe act is the behavior or activity of a person who deviates from normal safe procedure.

• A high risk/unsafe condition is a hazard or an unsafe mechanical or physical environment.

Many years ago, research of some 75,000 accidents indicated that the majority of accidents were caused by the high risk acts of people and the minority by the high risk physical, mechanical, or environmental conditions. However, looking back at the investigation techniques used, it’s clear that the most obvious cause, human failure, was selected more often because of the "fault-finding" approach to accident investigation. This approach still features prominently today with many thinking that 100 percent of all accidents are the result of unsafe human behavior.

TRADITIONAL RESEARCH

Traditional research proposed by W. H. Heinrich showed that ±88 percent (the majority of all accidents) could be caused by the unsafe or high risk behavior of people. The high risk mechanical, physical, or environmental conditions could cause ±10 percent of all accidents (minority of all accidents) and there is a small percentage (±2 percent) of all accidents that are beyond our normal control and that can be contributed to natural causes, acts of providence, or other phenomena that we can neither predict nor control.

Years of experience and international accident investigations clearly show that all accidents have multiple causes and cannot simply be explained away as worker failure.

High Risk Acts

High risk acts include:

• Operating without authority, failure to secure, or warn

• Operating or working at an unsafe speed

• Making safety devices inoperative

• Using unsafe equipment or equipment unsafely

• Unsafe loading, placing, mixing, combining, etc.

• Taking unsafe position or posture

• Working on moving or dangerous equipment

• Distracting, teasing, abusing, and startling (horseplay)

• Failure to wear safe attire or personal protective devices

High Risk Conditions

There are numerous high risk work conditions that have a higher level of risk than other work conditions. These vary from workplace to workplace.

Combination of High Risk Acts and Conditions

Numerous accidents are a result of a combination of high risk acts and high risk conditions (National Safety Council, 2010). Very seldom does one isolated act or condition ever result in an accident. Multiple causes are nearly always present in the accident sequence.

High risk physical, mechanical, or environmental conditions. However, looking back at the investigation techniques used, it’s clear that the most obvious cause, human failure, was selected more often because of the "fault-finding" approach to accident investigation. This approach still features prominently today with many thinking that 100 percent of all accidents are the result of unsafe human behavior.

TRADITIONAL RESEARCH

Traditional research proposed by W. H. Heinrich showed that ±88 percent (the majority of all accidents) could be caused by the unsafe or high risk behavior of people. The high risk mechanical, physical, or environmental conditions could cause ±10 percent of all accidents (minority of all accidents) and there is a small percentage (±2 percent) of all accidents that are beyond our normal control and that can be contributed to natural causes, acts of providence, or other phenomena that we can neither predict nor control.

Years of experience and international accident investigations clearly show that all accidents have multiple causes and cannot simply be explained away as worker failure.

High Risk Acts

High risk acts include:

• Operating without authority, failure to secure, or warn

• Operating or working at an unsafe speed

• Making safety devices inoperative

• Using unsafe equipment or equipment unsafely

• Unsafe loading, placing, mixing, combining, etc.

• Taking unsafe position or posture

• Working on moving or dangerous equipment

• Distracting, teasing, abusing, and startling (horseplay)

• Failure to wear safe attire or personal protective devices

High Risk Conditions

There are numerous high risk work conditions that have a higher level of risk than other work conditions. These vary from workplace to workplace.

Combination of High Risk Acts and Conditions

Numerous accidents are a result of a combination of high risk acts and high risk conditions (National Safety Council, 2010). Very seldom does one isolated act or condition ever result in an accident. Multiple causes are nearly always present in the accident sequence.

In the United States, machinery is one of the top four sources of compensable work injuries and accounts for nearly 10 percent of all injuries. The other sources are manual handling accidents, which cause 23 percent of all injuries; falls, 20 percent; and struck by falling or moving objects, 14 percent.

Although the high risk acts or conditions may be the most prominent factor that cause the accident, the identification and remedy must not stop there. A thorough investigation must be done to determine why the high risk act took place or why the high risk condition exists. This query will inevitably identify the root causes that must be eradicated.

For example, A worker was walking on the factory floor when he stepped in and slipped on a puddle of oil. Upon investigation, it was obvious that the accident and consequent injury was caused by the oil on the walkway, which rendered the floor slippery and unsafe.

Wiping up the oil is a good way of preventing a recurrence of the same type of accident, but won’t solve the problem. After wiping up the oil, one may discover another patch of oil farther down the walkway. Cleaning that up will also only be rectifying immediate causes and not the basic reason for the high risk condition.

An investigation will possibly reveal that a fork truck has a leaking engine oil seal and each time it stands with the engine idling a puddle of oil is left on the floor. An in-depth investigation may discover that the wrong oil seal was fitted. By replacing the oil seal, the root cause of oil on the floor is determined. Immediate causes can be misleading and investigations must take place to determine the root cause of the accident.

LUCK FACTORS 1, 2, 3, AND THEIR NEAR MISS INCIDENT RELATIONSHIP

Luck Factor 1

Once a high risk act has been committed, the outcome (or result) of this act depends largely on chance, good or bad fortune, or luck. This is termed Luck Factor 1. A high risk condition is a hazard and can result in a number of outcomes depending on Luck Factor 1.

Warnings

S. L. Smith (1994) says that:

If enough near-misses occur, the question is not, will an actual accident ever happen, but when will it happen.

Many call the near miss incidents warnings and quite rightly so. Safety management is perhaps the only management science where numerous warnings are given before an accidental contact and loss occurs. The only reason that a contact occurs, or does not occur, is because of the luck factor. The warnings should be heeded nevertheless. Many accidents occur because of missed warning signals.

Real Life Example

In investigating an accident in which a worker climbed a non-compacted, poorly supported electric utility pole and was killed when both he and the pole fell to the ground, it seemed a clear-cut case that the man had committed a high risk act. Thorough investigation and some five days of gathering further evidence showed that a fellow worker had been doing exactly the same as the victim except on a different pole. This pole was on the same line and was half a mile distant from the fatality site. Investigation showed that this pole was also not completely compacted or supported. The worker had ascended the pole on numerous occasions and had completed the running of the conductors through the isolators. When trying to analyze why the one pole fell, killing its climber, and the other pole did not, one can only conclude that the electrician on the distant pole was lucky. The practice of working on unsupported poles was commonplace and a condoned practice.

Luck Factor 1

Failure to Assess Risks Poor Control Personal & Job Factors Substandard Acts/Conditions Luck Factor 1SlightlyDifferentCircumstancesCould Have...Basic Causes Immediate Causes Chance

MODEL 2.6 The first luck factor.

Luck Factor 1 (Model 2.6) determines whether the high risk act or condition results in a near miss incident or accident. A near miss incident is an undesired event that under slightly different circumstances could have resulted in injury, damage, or process loss. The slightly different circumstances are largely at the discretion of Luck Factor 1. The difference between a contact "accident" and the near miss incident, "no contact" is a matter of chance. The high risk act or high risk condition, the undesired event, and the slightly different circumstances are reliant on the Luck Factor 1.

Most near miss incidents have the potential to either injure people, damage property and equipment, or interrupt the business process.

Numerous high risk acts are committed daily, but don’t result in a contact of any sort. These are not near miss incidents as there has been no flow of energy that, in a contact situation, would have caused injury, damage, or other loss. Many confuse the high risk act and the high risk condition with near miss incidents. To fall into the latter category, there must be a flow of energy.

High risk conditions may exist for years, but because of circumstances (luck), never result in a contact or any form of loss. Should something happen, a near miss incident, no loss or an accident with loss could occur. The difference is determined largely by chance or by luck. Thus, it can be deduced that the outcome of a hazardous situation is largely fortuitous. A high risk act may result in a contact with resultant loss or may remain an incident that had the potential, but did not cause any loss.

Luck Factor 2

Once an inadvertent and unplanned exchange of energy takes place, the outcome is unpredictable and could result in either injury to persons, damage to property and equipment, or some form of business disruption. Pollution and other forms of loss also may occur as a result of this energy transfer. The results of a contact are unpredictable and the outcomes are normally as a result of chance or Luck Factor 2.

For example, imagine a person walking on a construction site below an unguarded scaffold when a brick is accidentally bumped off and it falls to the ground. In the first instance, the brick falls to the ground and causes neither damage nor injury, but minor process interruption, as the brick has to be picked up and returned to its original position.

In the second case, the same undesired event occurs and the brick falls, this time breaking and creating a loss in the form of damage to material.

In case three, the exact same undesired event takes place, the brick falls from the scaffold and this time hits a worker who happens to be passing by below. The exchange of energy causes minor injury.

In all the three examples given above, there was an exchange of energy, yet the three outcomes or losses were totally different. This is as a result of Luck Factor 2.

It’s extremely difficult, and in some cases impossible, to determine the outcome of an undesired exchange of energy. One factor that is inevitable is that the exchange of energy will result in some form of loss, the degree of which is largely determined by chance.

Luck Factor 3

Heinrich, Petersen, and Roos (1969) compiled 10 axioms of industrial safety, the most pertinent one to this section being axiom number 4, which states:

The severity of an injury is largely fortuitous-the occurrence of the accident that results in injury is largely preventable.

This fourth axiom is perhaps the most significant statement in the safety management profession. What Heinrich, Petersen, and Roos are explaining is that the degree of injury depends on luck, but that the accident can be prevented. What they further indicate by this axiom is that while the accident can be prevented, the severity is something over which we have little or no control.

In examining the Cause, Effect, and Control of Accidental Loss (CECAL) sequence, once an injury occurs as a result of an exchange of energy, the degree of injury is largely dependent on Luck Factor 3. Most safety activities are focused around the severity of an injury or illness. Consequently, the focus is on an end result, which is determined by fortune, chance, or luck.

Even in the fourth edition of Industrial Accident Prevention (1959) H. W. Heinrich and E. R. Granniss further explain Luck Factor 3 by stating:

There are certain types of accidents, of course, where the probability of serious injury may vary in accordance with circumstances (p. 28).

In other words, the circumstances that determine the probability of a serious injury are really those of either good or bad fortune.

Pattern

All loss-causation events follow the CECAL pattern, but their progress through the loss-causation sequence is channeled either by Luck Factor 1, Luck Factor 2, or Luck Factor 3. The difference between a fatality, permanent or disabling injury, temporary disabling injury, lost-time injury, and a first aid case is largely a matter of luck.

In examining hundreds of cases where the degree of injury could have been far greater than it was, it’s difficult to explain the resultant injury other than by conceding it was luck, as depicted by Luck Factor 3.

Dan Petersen (1997) says:

Quit looking at accident-based measurements to assess systems effectiveness (p. 40).

What Petersen is referring to is that, because of Luck Factor 3, any measurement of safety performance based on degree of consequence is based on degree of luck. Admittedly, the number of serious injuries and fatalities is important, as is the number of first aid and dressing cases. So much emphasis is placed on lost time, disabling injuries, and reportable injuries that this degree of harm to the body has become the focus of most safety programs, safety practitioners, unions, and regulatory bodies.

EXCHANGE OF ENERGY AND CONTACT

The high risk conditions and acts give rise to a contact that is the segment of the undesired event where a person's body or a piece of equipment is subject to an external force greater than it can withstand, resulting in injury or damage. This is the portion of the accident sequence that is missing in a near miss incident.

A luck factor exists here because the high risk act may only result in a near miss incident with no loss. For example, a motorist fails to stop at a stop sign. This is a high risk act, but there was no loss. The action only had potential for loss. The same action is committed, but this time another car, which has the right of way, narrowly misses the vehicle that failed to stop. There was a flow of energy, but no contact or collision, therefore, no loss. This is an example of a high potential near miss incident.

The same event occurs, but this time an oncoming car is speeding down the road and there is a collision. The losses are injury to the drivers and damage to the vehicles.

In this case, the luck factor has proved unfortunate and the perpetrator was unlucky; there was a contact and an accident and subsequent loss took place.

MODEL 2.7 The iceberg effect. Direct Costs (visible) Totally Hidden Costs $50 $100 $200

INJURY, DAMAGE, OR LOSS

After the contact, luck again plays a role in determining the outcome of the contact. The outcome could be injury to people, damage to property, or process interruption. We have no control over the outcome of the contact. Once the accident sequence is set in motion, no control activity whatsoever can determine the outcome.

Injury

If the contact results in an injury, the severity is dependent on luck. The injury may be minor, disabling, or fatal. The outcome of the injury is fortuitous and depends on luck. The end result of a contact cannot be predicted or controlled.

Measurement of Safety

The HSE of the United Kingdom conducted an extensive study, which is summarized as follows:

Any simple measurement of performance in terms of accident (injury) frequency rates or accident/incident rate is not seen as a reliable guide to the safety performance of an undertaking. The report finds there is no clear correlation between such measurements and the work conditions, in injury potential, or the severity of injuries that have occurred. A need exists for more accurate measurements so that a better assessment can be made of efforts to control foreseeable losses.

Costs

The final phase of the accident sequence and the last link in the chain reaction is costs. All contacts result in some form of loss. Losses could include both direct and indirect costs of the accident. Model 2.7 shows the iceberg effect where the property damage costs could be 60 to 100 times greater than the direct costs. The totally hidden costs of the accident also are losses that are hard to determine, but which exists nevertheless.

Cost Statistics

Once all the loss-producing statistics have been compiled, the costs should be tabulated and presented. The cost of accidental losses is seldom tallied by organizations that consider them as cost of doing business. Cost can be reduced by effective safety management systems that help reduce expensive property damage and injury accidents.

The costs of medical attention, compensation, and rehabilitation for injuries and occupational diseases should be tabulated monthly and on a 12-month progressive basis. In some instances, it may be necessary to go back in history and record the costs of these injuries and illnesses over a period of years in an effort to determine a trend.

These costs will include the cost of first aid rendered on the premises and also should include the direct and indirect costs.

Direct Costs

The direct costs of any injury-producing accident are normally the hospitalization, the rehabilitation costs, and compensation costs, where applicable.

Hidden Costs

As with all downgrading incidents, the hidden costs are often not visible and add up to more than the direct costs.

Damage Costs

The accident ratio has proved beyond a doubt that there are always more accidents that end up in property damage than end up in injury.

The number of damage accidents should be recorded and tabulated monthly and on a 12-month progressive basis. The damage costing statistic has two aspects and these, like the injury accident, are the direct and indirect costs.

Fire

Fire losses also should be tabulated and reported, both monthly and progressively. Fire losses should include the following components:

• The direct costs of the fire

• The costs of extinguishing the fire

• Indirect costs due to lost orders, delays in production, etc.

If an external fire service was used, the cost of the call-out should be included in the cost of the fires as well.

Production Losses

All the production losses as a result of delays and wastages caused by accidents should be calculated. Although difficult to cost out accurately, an indication or estimated cost will be sufficient to draw attention to the fact that accidents are hampering the production and that there is a loss.

CONCLUSION

Research by many safety authors has clearly shown that the difference in the outcome of an undesired event cannot be predetermined and that in many instances people have been lucky to escape serious injury. The fact that no one was injured is often a cause to ignore what happened and, thus, the potential loss-causing problem does not get fixed. The same event can happen on another occasion, perhaps with different results.

Examining the CECAL accident sequence, it’s clear that the three luck factors often determine the difference between a near miss incident and an accident.

Proactive safety involves recognizing, reporting, and eliminating both the immediate and root causes of the event to ensure that we don’t rely on luck to prevent injury-producing accidents. A full-fledged NEMIRR system can contribute more to a safety program than most activities based on reactive post-accident actions.

Prev. | Next


Home   Related articles   top of page