HSE-Near Miss

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Hazard Identification and

Near-Miss Reporting

A training guide for CEBC


researchers
Rev. 2-19-2010

Preventing Accidents

Accidents are prevented by:


Identifying and communicating hazards and
potential causes of accidents
Developing a plan to minimize the risk of an
accident, and reduce the consequences if the
accident does occur
Following the plan
Reporting and learning from near-misses

Near-Miss reporting standard in industry


The Center for Environmentally Beneficial Catalysis

Safety Pyramid*

* Risk Analysis 2003 23:3 445-459


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What is a Near-Miss
An opportunity to improve environmental,
health, and safety practice, based on a
condition or an incident with potential for
more serious consequence.

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Types of Near-Misses

Unsafe conditions or behaviors


Minor accidents and injuries that had potential to

be more serious
Events where injury could have occurred, but did
not
Events where property damage results
Events where a safety barrier (fume hood, safety
glasses, temperature alarm, etc.) prevented an
injury or accident
Events where potential environmental damage
could result
The Center for Environmentally Beneficial Catalysis

Identifying Near-Misses

Researchers awareness must raised to identify

hazards and near-miss events


Does not have to be an incident, can simply be
an unidentified hazard
The litmus test of whether a near-miss should
be reported:
Could someone (now or in the future) benefit
by learning from the event/situation?
Researchers should err on the side of reporting;
Safety Committee will prioritize Near-Miss
Reports
The Center for Environmentally Beneficial Catalysis

Reporting Near-Misses

Reporting a near-miss is an opportunity to


teach others
Provided the researcher was not acting
recklessly, no disciplinary action will be
taken for reporting a near-miss
Peer-pressure should encourage, not
discourage, reporting near-misses
Your near-miss report will be taken
seriously by CEBC leadership
The Center for Environmentally Beneficial Catalysis

Lots of Near-Misses?!?

Are high rates of near-miss reports a good


sign or bad?

Near-misses will happen to ALL researchers


from time to time. New experiments are being
conducted. All experiments have some risk.
Near-miss reports mean that researchers are
attuned to hazardous conditions and potential
accidentsmuch better than being oblivious!!

Remember, the goal is preventing injury or


death, and your report may prevent a
future accident!
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What to Report?

Reporting should be quick and simple


Form on CEBC web site under Lab Safety
Name, date and location
Brief description of the near-miss and the
cause(s)
Identify both direct causes and any root causes
Safety Committee may request additional info if
clarification is necessary

Suggested changes/improvements or lessons


learned
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What Happens Next?

Lab Safety Committee will review each report in

a timely fashion (high-priority reports reviewed


as soon as possible)
If necessary, additional information will be
sought from researcher
Committee will prepare response, including
suggested changes to procedures if appropriate
Anonymous Near-Miss Reports and Safety
Lessons/ Reminders will be distributed to CEBC
research community, added to searchable
archive
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How to Use the Near-Miss Reports

Read the notices/reports promptly when


distributed by the Safety Committee,
assess whether the lessons learned could
improve your experimental procedures
Search the near-miss archive when
developing new experiments/procedures,
and incorporate lessons learned when
developing your Standard Operating
Procedures
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11

Reference

Some information in this presentation


taken from:

Phimister, J. R.; Oktem, U.; Kleindorfer, P. R.;


Kunreuther, H. Near-Miss Incident
Management in the Chemical Process
Industry, Risk Analysis 2003 23:3 445-459.

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