This is a terrific discussion, and I appreciate Dr. Casadone sharing TTU’s near miss reporting form. The University of Minnesota’s description and form is behind
a secure page via http://www.jst.umn.edu/incident.html –could someone see if they will share it? I also found UC Santa Barbara’s description and form on the web at:
http://www.chem.ucsb.edu/about/safety/near-miss
My favorite resource, Wikipedia, has a nice discussion about near miss reporting, as well as good references about near miss definitions and reporting from the
aviation industry, healthcare and railroads. See
https://en.wikipedia.org/wiki/Near_miss_(safety) . Wikipedia led me to two great reports on near miss reporting benefits and investigations from the Process Improvement Institute, via
http://www.piii.com/resources/ No reason to reinvent the wheel.
Google found me this: “OSHA defines a near miss as an incident in which no property was damaged and no personal injury was sustained, but where, given a slight
shift in time or position, damage or injury easily could have occurred.”
As for Yale, we added near miss reporting to our first report of injury form. I do not recommend this because these systems tend not to be intuitive, anonymous
or easy to complete. Only a handful of people have used it. Our Chemistry Department’s Chemistry Joint Safety Team is developing their own form..
As for how Yale uses near miss reports—significant near miss reports (learned via a form or by other means) are reviewed by our Chemical Safety Committee. You can’t
beat real human beings—engaged in safety—for thoughtful evaluation of near misses and other concerns to determine what the root causes are and if policies, procedures or practices should be altered to reduce risks. Reports of near misses are invaluable for
improving safety.
We don’t have enough near miss data to do anything statistically with them. After all, minor real accidents and injuries are very under reported.
Pete Reinhardt, Yale EHS
Peter.reinhardt**At_Symbol_Here**yale.edu
p.s., Thanks to everyone who commented on EPA’s Generator Improvements proposed rule!!
From: DCHAS-L Discussion List [mailto:dchas-l**At_Symbol_Here**MED.CORNELL.EDU]
On Behalf Of Casadonte, Dominick
Sent: Wednesday, January 13, 2016 8:38 AM
To: DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU
Subject: Re: [DCHAS-L] near-miss reporting form
Believing a near-miss is not an "incident" is the fundamental reason effective corrective actions aren't developed to prevent a future loss.
The "event" where things deviated from planned protocol is the "incident."
Once an incident occurs, you have little or no control over the consequences, which is why identifying the actual "incident" is so critical.
Variation in outcomes can range from no injury or property damage, to minor or major of each, lawsuits, regulatory action, bad PR, etc.
Once you recognize each event is an incident, then you will start to evaluate & correct them effectively.
Think about a forklift moving a pallet with a drum of hazardous chemical on it. The driver turns while moving a bit too fast & it falls off the pallet. That
is the incident. Regardless of consequences.
If the drum does not rupture or leak, then the consequence is no loss unless the driver is injured putting it back on the pallet. However, if the drum leaked &
entered a creek near the facility, major consequences would occur. The event that occurred & the cause in both cases is identical, only the consequences were different. The corrective action should be the same for both outcomes, but seldom are, because one
will be called a near-miss (if reported) & the other an incident.
As for using the data, there is a system to objectively quantify corrective action effectiveness, and you can actually cause incident reporting & effective cause resolution using it. And it is relatively simple.
Regards,
**At_Symbol_Here**apexhse (Twitter)
I totally agree with Ralph, a good discussion ( for later) is needed on " what to do with the data and how to share?"
The difference with an incident is that there is no loss or ($=0)
Charles
> Date: Tue, 12 Jan 2016 20:23:03 +0000
> From: Ralph.Stuart**At_Symbol_Here**KEENE.EDU
> Subject: Re: [DCHAS-L] near-miss reporting form
> To: DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU
>
> > >How about discussing how to define a Near Miss?
> >
> The other question is what do you do with the information? I can see lots of potential uses, but it's unlikely that you'll gather statistically useful information with a random data collection system. People will have to see it being used usefully in order
to be motivated to provide the information you're after. To me, this suggests that sharing the stories in a community honored way (i.e. prizes) is one possible use.
>
> - Ralph
>
> Ralph Stuart, CIH, CCHO
> Chemical Hygiene Officer
> Keene State College
>
> ralph.stuart**At_Symbol_Here**keene.edu
