Promotion of

“Near-Miss” Reporting
January 2005
 Outline

• Background on Near Miss.

• Benefits of Near-Miss Reporting.
• Near-Miss and Accident Definitions.
• Accident Pyramid model.
• Reasons for not Reporting Near-Misses.
• Current Programs on Near Misses.
• Ways to Promote “Near-Miss” Reporting.
 Background

• Saudi Aramco Corporate Loss Prevention Manual

(LPM-120-044) addresses near-miss reporting.

• Near-Misses should be reported to supervisors or

designated persons.
• Currently, not enough near-miss reporting is being
done.
 Benefits Of Near-miss Reporting

• A person who recognizes and reports a near-miss

becomes more aware of unsafe situations.

• Investigation of a near-miss uncovers underlying

unsafe conditions and/or acts.

• Sharing near-misses with others helps them avoid

incidents of their own.

• Accumulated near-miss information allows us to

do realistic safety management based on facts.
 Near-Miss Definition

A “Near-miss” is an “incident” that could have

been an “accident” but, for some reason, was
not.

An “accident” is an “incident” that results in injury

and/or property damage, whereas a “near-miss”
is an “incident” that does not.

One or more additional “unsafe conditions”

and/or “unsafe acts” can turn a “near-miss” into
an “accident”.
Unsafe Act
Unsafe Condition
Near Miss
Accident
 Near-miss Or Accident ?

Near-Miss Near-Miss Accident

No Toe Board at A hammer left Area beneath the A worker walks

the elevated lying on the platform not by the scaffold
work Platform of platform is kicked- barricaded to while work
a scaffold off causing it to prevent entry into continues on the
fall down work area platform
Unsafe
Condition Unsafe Act Unsafe Condition Unsafe Act
 Unsafe Condition Examples

• Back Hoe is designed to

lift only that bucket-full of
earth.
• Using it to lift any other
type of load like shown in
the picture might result in
tipping it.
• Also it is stationed too
near the excavation edge,
which can collapse.
• Personnel working under
the load is in unsafe
position.
Unsafe Condition Examples (Continued)

• Dead man’s switch

provided?
• Breathing air quality
checked?
• Ear protection worn?
• Doing Grit-Blasting
without proper PPE is an
unsafe act and might
result in injury to exposed
parts of the body.
Unsafe Condition Examples (Continued)

• Rubber hoses are

placed too near.
• Pliers and other
equipment kept too
near and could get
too hot to handle and
cause burn injury.
• Sitting on unstable
support is an unsafe
act in the picture.
Unsafe Condition Examples (Continued)

• The “job” has not been

secured properly. This can
result in serious injury.
• The eye shield is left
hanging too near the
rotating drill assembly.
• Is any eye protection worn?
• Wearing proper gloves
might prevent possible
hand injury.
• Working in such unsafe
conditions is an unsafe act.
Unsafe Condition Examples (Continued)

• Damaged tools have a tendency of slipping or

breaking during work and resulting in injury.
Unsafe Condition Examples (Continued)

• Damaged
insulation
normally
results in
short
circuiting and
/ or
electrocution.
Unsafe Condition Examples (Continued)

• Splicing of wires
can be
dangerous.
• When it is not
done properly, it
can get
overheated,
cause short
circuit, or even
result in electrical
shock.
• It should be
replaced
promptly.
Unsafe Condition Examples (Continued)

• This sort of
connection
can cause
sparking,
over-
heating and
possible
fire.
• Use of such
unsafe
electrical
boards
should be
stopped.
Unsafe Condition Examples (Continued)

• Earthing is
required to
drain undesired
electricity and
prevent
electrocution.
• Cutting off the
“earth” pole of
the plug nullifies
the safety
feature.
Unsafe Condition Examples (Continued)

• This connection is
called “snap coupling”
because of the
snapping action when
joining.
• Deteriorated condition
of the tubing could
cause “snapping-off”
of this connection,
releasing high
pressure liquid,
resulting in injury.
Unsafe Condition Examples (Continued)

• The ladder
placed on
slope can slip
and cause
injury to
personnel.
• Working on
such unsafely
placed ladders
is an unsafe
act.
Unsafe Condition Examples (Continued)

• Corrosion can drastically reduce the sling strength.

• Slings should be inspected & SWL marked on them.
Unsafe Condition Examples (Continued)

Unsafe Shoring Safe Shoring

Unsafe Condition Examples (Continued)

Unsafe Traffic Control Safe Traffic Control

Unsafe Condition Examples (Continued)

• No machine guard can result in injury to personnel

working around it.
Unsafe Condition Examples (Continued)

Additional Examples of Unsafe Conditions

• A unit that runs outside the range of its design

parameters.
• Non-isolated or pressured piping while opening any
flange.
• Wrong gasket at a flanged connection of piping that
carries hazardous liquid.
• Unclassified electrical equipment installed in a
hazardous (classified) location.
• A lifting hook without a safety latch.
 Unsafe Act Examples

• The unsafe act is

obvious.
• Primarily lighting
cigarette with a gas
torch.
• Then smoking in
hazardous location like
near acetylene
cylinder.
 Unsafe Act Examples (Continued)

• Inadequate PPE.
• Unsafe position.
• Acid can splash
over him causing
injury.
 Unsafe Act Examples (Continued)

• Using anything else

other than the right
type of hammer for
hammering, not only
damages it but also
does not get the job
done properly.
• Mainly it may also
cause injury.
 Unsafe Act Examples (Continued)

• Pipe-
wrenches
should never
be hammered.
• Exceeding the
wrench torque
limit may
result in
equipment
damage and /
or injury.
 Unsafe Act Examples (Continued)

• Each
equipment is
designed for
particular type
of use.
• Using
excessive force
on equipment
can lead to
equipment
damage and /
or injury.
 Unsafe Act Examples (Continued)

• Use the equipment as

per their design.
• “A” frame ladder is
not meant to be
leaned in this fashion.
It will not be stable to
work from.
• It is supposed to be
opened properly and
placed on firm
horizontal plane
surface for stability.
 Unsafe Act Examples (Continued)

• Both your hands should be

free to take support, while
climbing on ladders.
• Use a sling instead of
carrying while climbing.
• There should be at least
three point contact while on
ladder –
- 2 hands & 1 foot,
- 1 hand & 2 feet, or
- 2 feet & a fall protection
harness.
 Unsafe Act Examples (Continued)

• Positioning plays an
important part in
avoiding injury.
• The jack hammer is
going to hit the
employee if the
supporting rope is
released.
• Also the debris will fall
on his feet.
 Near-miss Scenarios

Saudi Aramco employee driving from his home to his

work location encountered:
• face to face vehicle
• coming from the opposite direction,
• on the wrong side of the road and
• at a blind curve.
Since the employee was driving at a moderate speed
and ‘expecting the unexpected’, he reacted properly
and in time and narrowly escaped a head on collision.
This can be categorized as a near miss incident.
 Near-miss Scenarios (Continued)

In another incident, a fitter dropped a spanner while

working at elevated location. Fortunately the spanner
fell harmlessly to the ground. There was no injury or
property damage.
Again this was a near miss incident.
He recognized the near-miss and reported it to his
supervisor.
The response was
not to discipline him,
to provide boxes
pay more attention to barricade areas
 Near-miss Scenarios (Continued)

• While lifting/holding cranes

are supported on all the
Out-Riggers and the tires
are lifted off the ground.

• Near miss is when a crane

“tips” and some of the Out-
Riggers leave ground and
then the crane straightens
by itself, without causing
damage or injury.
• The picture shows an
accident.
 Near-miss Scenarios (Continued)

• Near miss is said to

have occurred when an
excavation wall caves in
without causing injury or
equipment damage.

• The picture shows a

heavy equipment fallen
into an excavation due
to cave in. This is an
accident.
 Near-miss Scenarios (Continued)

• There have been

many cases when
welder have been
affected by
conjunctivitis. This is
known as an accident.
• It would have been a
near miss if the welder
does his job without
proper eye protection
and does not get
affected.
 Near-miss Scenarios (Continued)

• Energizing equipment while work is being performed

and workers happen not to be in contact with the
energy source.

• A pressure relief valve whose discharge is not piped to

a safe location, relieves pressure on a work platform
when no one is around.
• A worker in a confined space felt dizzy due to oxygen
deficiency but was able to retract safely.
Unsafe Conditions & Acts
are
Precursors
of
Near Misses & Accidents
Unsafe Situations & Near-misses

Near-misses

Unsafe Acts & Conditions

Unsafe Situations & Accidents

1
Accident

600
Near-misses

Unsafe Acts & Conditions

 Visible Tip of the Iceberg.

But There Is More Than

What Meets The Eye
 What Is Wrong With This Picture?

Incident Model Reported

indicates that Accidents at
near-misses Saudi Aramco
occur more Facilities
frequently than
accidents
Reported Near-
misses at Saudi
Aramco Facilities
Clearly, Many Near-misses

Are Not Being Reported !

 Why Are “Near-misses”
Not Being Reported ?

Because of a “negative mindset” among employees that

makes them think -

• “it isn’t worth reporting!”

• “it is too much of a hassle to report and investigate!”
• “nothing happened, so what is the point ?”
• “the boss wouldn’t like me anymore if I told him about
it !”
 Why Are “Near-misses”
Not Being Reported ? (Continued)

The “negative mindset” among employees can also

make them think -
• “People would laugh at me !”
• “I am not going to be the one to blow the whistle on
my friend !”

• “Who cares !”
 Facts About Near Miss Reporting

Also perhaps there are some misconceptions about

“near-miss” reporting, which could be erased by
understanding the facts like -
• Names do not matter. If included, names are not
flagged or tracked
• Divisions or units are not penalized
• Near-misses do not adversely affect plant’s safety
record
• Near-miss reporting demonstrates commitment of the
division or unit to safety
 A Program To Promote
Near-miss Reporting And
Investigation Should Aim
To Change The
“Negative Mindset”
 Current Program On
Reporting Near Misses

• The department has an Instruction Manual for

‘Reporting of Near-Miss Incidents’.

• However, its implementation is not effective

 Instruction Manual On
Near- Miss Incidents

• The Instruction Manual provides a good basis for

reporting and investigating near-misses

• It is supplemented by a “near-miss incident report

sheet”
How To Improve Near-Miss Reporting ?
• Issue a “no-blame” policy statement
• Initiate an awareness campaign
• Modify current procedures to make it easy on the
person and his supervisor to do reporting and
investigation
• Reward those who report near-misses
• Add a “near-miss” bulletin board to the individual
department’s Web Page
• Organize seminars and talks for near-miss recognition,
reporting and investigation
 Report
And
Investigate
Near-misses
Before An Accident Stops You
Or Destroys Your Facility
Thank You