Transcript Document 7711703

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Near Hit/Accident
Reporting & Analysis
Dr. Brian J. Finder, CIH
University of Wisconsin-Stout
Menomonie, Wisconsin
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A Thought to Ponder ...
“Prescription without diagnosis is
malpractice, whether it be in
medicine or management.”
Karl Albrecht
Organization Development
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Survival of the Fittest ...
….. highly depends on an organization’s ability to:
 Maintain
a pulse of operational errors which permit
loss to occur
People
Process
Materials
Equipment
Environment
 Expediently
correct the true causes of such errors
to prevent their recurrence
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Near Hit/Accident Analysis

A critical process which allows us to
view a potential or actual loss-producing
event with 20/20 vision

Culminates with the development and
implementation of corrective activities/
standards which help refine systemrelated processes
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Objectives of
Near Hit/Accident Analysis

To determine the Who, What, Where,
When, and How about an accident

To identify the true causes of a near hit
or actual loss

To determine where operational errors
occurred in the management system

To prevent recurrence
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What an Effective Near Hit/
Accident Analysis Should Do

Describe what happened

Determine the real causes

Evaluate the risks

Develop the controls

Identify loss trends

Provide future training-related information

Demonstrate concern for employee welfare

Promote team-building
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Which Near Hits/
Accidents Get Analyzed?

All near hits/accidents should be
analyzed to determine the extent to
which reasonable controls can be
instituted to prevent recurrence

Special attention should be given to
those which possess high loss potential
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ILCI Loss Causation Theory

Inadequate MANAGEMENT control

Basic causes: personal vs. job factors

Immediate causes: substandard acts/
conditions

Near hit/accident: contact with energy,
substance, and/or people

Loss: people, product, service, facility,
and/or environment
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THE ILCI LOSS CAUSATION MODEL
LACK OF
CONTROL
BASIC
CAUSES
IMMEDIATE
CAUSES
ACCIDENT/
NEAR HIT
LOSS
Inadequate
 Program

 Program
Standards

Compliance
to Standards

Personal
Factors
Job
Factors



Substandard
Acts &
Conditions



Contact
With Energy,
Substance
or
People



People
Property
Product
Environment
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Inadequate
Management Control

A lack of internal standards designed to
reduce/eliminate risks to loss
 Hazard
recognition and abatement
 Performance appraisal
 Employee/management communication

Internal standards are in place, but they are
outdated or inadequate

Management and/or employees do not
follow established internal standards
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Basic Causes
Job Factors
Inadequate ...
 supervision
 engineering
 purchasing
 maintenance
 tools/equipment
 work standards
Wear & tear
Abuse or misuse
Personal Factors
Inadequate ...
 physical capacity
 mental capacity
Excess ...
 physical stress
 mental stress
Lack of ...
 knowledge
 skill
Improper motivation
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Immediate Causes:
Substandard Acts

Operating equipment without authorization

Failure to warn

Failure to secure

Operating equipment at improper speed

Removing safety devices

Improper use of personal protective equipment

Servicing equipment in operation

Being under the influence of alcohol/drugs

Horseplay
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Immediate Causes:
Substandard Conditions

Inadequate guards/barriers

Inadequate personal protective equipment

Inadequate warning system

Fire/explosion hazard

Poor housekeeping

Noise/radiation exposure

Temperature extremes

Inadequate illumination

Inadequate ventilation
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Near Hit/Accident

Struck by or against

Fall on same or to lower level

Caught in, on, or between

Contact with …..

Overstress, overexertion, or overload
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The Loss
People: A bruise to a fatality
Product: A dented package to a destroyed
shipment
Service: A few minutes lost to a month delay
Facility: A cracked window to a leveled building
Environment: A brief air emission to
contaminated groundwater
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Why Supervisors Should Analyze
Near Hits/Accidents
They have a personal interest
 They know the people and conditions
 They know best how and where to get
information
 They will ultimately start or take action
anyway
 They benefit from the analysis
 The will use gained knowledge for future
prevention tactics

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Basic Elements of a Near Hit/
Accident Reporting System

Develop agreed upon reporting standards

Routinely remind supervisors and employees
of the need to report near hits & accidents

Maintain accurate records (computer-based)

Use data to identify trends

Routinely provide management and hourly
employees with trend results
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Equipment for Collecting
Near Hit/Accident Evidence

Flash camera w/extra film & batteries
 Disposable
 Polaroid-type

Camcorder

Tape measure

Grid paper
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Importance of Immediately
Gathering Perishable Evidence
The 4 P’s of Perishable Evidence
People: tend to forget or misrepresent
Positions: become altered
Parts: get changed and/or discarded
Paper: can become altered and/or lost
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Initial Actions at
Near Hit/Accident Scene

Take control

Ensure first aid and call emergency services

Control potential secondary hazards

Identify sources of evidence

Preserve/gather evidence

Notify appropriate line/staff management
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The Near Hit/Accident
Analysis Process

Immediately collect the who, what, when,
where, and how of the four P’s of evidence

Determine the most likely immediate cause

Perform an Ishikawa (e.g., cause-effect)
analysis on the immediate cause

Test for most probable uncontrolled risk factors

Develop & implement control measures for at
least 3 uncontrolled risk factors
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Injury at the Convenience Store
Employee sustains serious back, neck and
head injuries
 Analysis of the situation indicates that she
walked backwards into a floor opening
 Follow-up with the employees indicates that
an unguarded floor opening was present
behind the store counter

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Injury at the Convenience Store (cont.)

Supervisor must perform an Ishikawa
diagram with store employees to
analyze the following major risk factor
areas:
 Equipment
 Processes/practices
 Materials
 Environment
 People
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THE ILCI LOSS CAUSATION MODEL
LACK OF
CONTROL
BASIC
CAUSES
IMMEDIATE
CAUSES
ACCIDENT/
NEAR HIT
LOSS
Inadequate
 Program

 Program
Standards

Compliance
to Standards

Personal
Factors
Job
Factors



Substandard
Acts &
Conditions



Contact
With Energy,
Substance
or
People



People
Property
Product
Environment
THE ILCI LOSS CAUSATION MODEL
LACK OF
CONTROL
BASIC
CAUSES
IMMEDIATE
CAUSES
ACCIDENT/
NEAR HIT
LOSS
Inadequate
 Program

 Program
Standards

Compliance
to Standards

Personal
Factors
Job
Factors



Substandard
Acts &
Substandard
Conditions



Contact
With Energy,
Substance
or
People



People
Property
Product
Environment
THE ISHIKAWA (FISHBONE) DIAGRAM
Exposed floor
opening behind
counter
(Cause)
(Effect)
ISHIKAWA (FISHBONE) DIAGRAM
People
Equipment
Procedures
Exposed
floor
opening
behind
counter
Materials
Environment