From: Ray Cook <raycook**At_Symbol_Here**APEXHSE.COM>
Subject: Re: [DCHAS-L] near-miss reporting form
Date: Thu, 14 Jan 2016 08:49:45 -0600
Reply-To: DCHAS-L <DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU>
Message-ID: FE52FA1C-D697-4784-8130-F801D5E0F30B**At_Symbol_Here**apexhse.com
In-Reply-To <4689A115A3AC51469C216AA140861060EA70BA1C**At_Symbol_Here**CMS-P03.uottawa.o.univ>


Interestingly enough, every unsafe condition can be traced back to an "act of people." So in reality, whether it is an unsafe act or condition, a change in business process is required to eliminate it. This might include protocols, procedures, training, etc.., but the bottom line is the real corrective action will be a change in what people do.  Prevention enters a new dimension when viewed through this lens. When you widen the traditional view, all of these things can be analyzed as incidents or potential incidents & resolved accordingly. Traditional views limit us to traditional solutions.

Regards,

Ray Cook, CIH, CSP
ApexHSE.com
832-477-4454
**At_Symbol_Here**apexhse (Twitter)
I Cor 1:18
Sent from my iPhone


On Jan 13, 2016, at 10:03 AM, Andrew Zlotorzynski <azloto**At_Symbol_Here**UOTTAWA.CA> wrote:

 

I belive that instead of near misses we should concentrate on unsafe conditions or unsafe acts and we should encurage everybody to report them. In my classes I am using picture you can find at https://www.flickr.com/photos/10596319**At_Symbol_Here**N03/23728961613/ to give people reason to report. A picture some time is worth a thousand words.  Some institution I have worked for, mandate that everyone must put minimum number of reports in the system per year and some make monthly  drawing for small prices among all reports. When people see that their reports are causing some actions they will report unsafe conditions. This is part of safety culture and it takes some time to be a norm but we should encurage everybody to do reporting. Texas Tech form is a very good example how we can collect this information but to have the system working we should have also follow up procedures for all reports.

 

Regards,

 

Andrew Zlotorzynski

University of Ottawa

Faculty of Science

MCD 317

Ext. 6020

 

 

 

From: DCHAS-L Discussion List [mailto:dchas-l**At_Symbol_Here**med.cornell.edu] On Behalf Of Casadonte, Dominick
Sent: January-13-16 8:38 AM
To: DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU
Subject: Re: [DCHAS-L] near-miss reporting form

 

We have an incident reporting portion of our EH&S website that we worked for a while to be reasonably happy with. The URL is http://www.dept.ehs.ttu.edu/ehs/ehshome/home/IncidentReporting

 

Dom Casadonte

 

From: DCHAS-L Discussion List <dchas-l**At_Symbol_Here**med.cornell.edu> on behalf of Ray Cook <raycook**At_Symbol_Here**APEXHSE.COM>
Reply-To: DCHAS-L <DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU>
Date: Wednesday, January 13, 2016 at 6:53 AM
To: "DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU" <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.

 

Here is an example:

 

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,

 

Ray Cook, CIH, CSP

832-477-4454

**At_Symbol_Here**apexhse (Twitter)

I Cor 1:18

Sent from my iPhone

 


On Jan 12, 2016, at 2:33 PM, Charles Corey <charles.corey**At_Symbol_Here**BELL.NET> wrote:

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

Previous post   |  Top of Page   |   Next post



The content of this page reflects the personal opinion(s) of the author(s) only, not the American Chemical Society, ILPI, Safety Emporium, or any other party. Use of any information on this page is at the reader's own risk. Unauthorized reproduction of these materials is prohibited. Send questions/comments about the archive to secretary@dchas.org.
The maintenance and hosting of the DCHAS-L archive is provided through the generous support of Safety Emporium.