Good Catch – Now What?

Contributor: Chris McGlynn, Director of Safety/VPP Coordinator, Roco Rescue

Your company has a strong safety culture with outstanding employee participation. Everyone is committed to safety and goes out of their way to do things in the safest way possible. As a safety professional, everything is great in your world until suddenly, a “near-miss” report lands on your desk. Supervisors, managers, and company executives are now concerned, worried, or even stressed out about the fact that something unsafe just happened at their company! Many would-be quick to speculate that a near miss is a bad thing; however, as a safety professional, you know that this is not necessarily the case. The reality is, a near-miss or “good catch” report can be one of the most valuable tools for improving your company’s safety program.

What is a Near Miss?

According to OSHA, a near miss is an unplanned event that did not result in an injury, illness, or damage – but under different circumstances, could have. Your company may have another term for a near miss such as “close call,” “good catch,” “narrow escape,” “near hit,” “cliffhangers,” or a number of other terms. However, at the end of the day, these are all near misses. Near misses are caused by the same things as accidents: unsafe conditions and/or unsafe behaviors. Near misses are often precursors to accidents and should not be ignored. In fact, according to the National Safety Council (NSC), 75% of all accidents are preceded by one or more near misses.

Heinrich’s Law and Bird’s Safety Triangle

In 1931, Herbert Heinrich published Industrial Accident Prevention: A Scientific Approach where he proposed a concept that would eventually become known as “Heinrich’s Law.” Heinrich’s law states that for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injury (i.e., near misses).

Years later, Frank Bird analyzed nearly 2 million incident reports from over 300 companies and used his findings to amend and expand upon Heinrich’s theory. Bird developed the “Safety Triangle” (depicted below) which states that for every fatality, there will be 10 serious accidents, 30 minor accidents, 600 near misses, and an unknown, but significant number of unsafe acts. The important thing to take away from this is that near-miss reports should be taken seriously, investigated, and used to prevent future incidents.

Near Miss Reported – Now What?

A near miss report is submitted. You’re thankful that it wasn’t an injury report, but you also realize that this could have easily been one under different circumstances. You also realize that this is a potential precursor to something worse, so now what? The answer – Root Cause Analysis.

There’s almost always a deeper root cause to why a near-miss occurred. While there may be an obvious reason on the surface level, by digging a little deeper into the situation, you may find that there’s more than meets the eye. Correcting the immediate cause may help to resolve the symptom of the problem, but not the problem itself.

For example, a worker at your facility slips in a puddle of water on the floor and falls. The worker is not injured and as a result, a near-miss report was submitted. The investigation should not conclude with “employee slipped in puddle and fell – instructed employee to be more aware of their surroundings.” An effective root cause analysis would instead look for deeper issues, such as:

  • Why was the puddle there in the first place?
  • Where there changes in the environment, weather, conditions, or a process?
  • What was the source of the water?
  • What tasks were being performed when the water was spilled?
  • Why was the water not cleaned up?
  • How long was the water there?
  • Was the spill reported?

By performing a root cause analysis, you may learn that it was raining on the day of the near-miss and that the roof in your warehouse has developed a leak, causing a puddle of water to form, creating the unsafe condition that led to the incident. Simply instructing the employee to be more aware of the surroundings may prevent them from slipping again; however, it will not prevent the unsafe condition from reoccurring. The true root cause needs to be addressed; the roof must be repaired.

OSHA provides a great resource for Root Cause Analysis here.

Improving Your Company’s Near Miss Program

You’ve received a near miss, conducted an investigation, identified a true root cause, and took corrective action to eliminate it; now you see the tremendous benefit of near-miss reporting. Then ask what can you do to improve your company’s near-miss program?

  1. Keep the reporting process simple.
    Consider implementing google forms, phone applications, or even a universal near-miss email address. The key is to make the process to submit a near-miss as easy, quick, and painless as possible. For example, we chose to create a QR code that could be scanned that takes personnel right to the form to complete and submit.
  2. Train employees on the importance of near-miss reporting.
    If employees don’t recognize the importance of near-miss reporting, they will have no interest in doing so. Ensure that employees know the benefits of near-miss reporting.
  3. Keep near-miss reports non-punitive.
    No one wants to willingly broadcast their mistakes, especially if they will be punished for doing so. Punishing an employee who submits a near-miss report is a sure-fire way to send a message that safety may not rank as high on the priority list as you claim. This is also a guaranteed way to discourage employees from participating in the program. On the other hand, when near-miss reporting is rewarded, it can change their mindset.
  4. Incentivize the program.
    Even if employees know the benefits of a near-miss program and know that it will be non-punitive, they may still need a little encouragement to do so. Consider implementing a periodic drawing for all who submit near-miss reports. Alternatively, consider highlighting the best near-miss submitted for the month to promote quality participation.
  5. Celebrate and communicate your success.
    Perhaps the most important part of a successful near-miss program is communicating your findings and celebrating your success. Communication should be transparent but does not have to be so transparent that it includes every detail of the situation. Include highlights of the near-miss and the corrective actions that will be taken to prevent them in the future. Communicating your findings could help prevent other incidents as well.

Summary

When your employees know they can openly report an incident or mishap without being reprimanded, it can encourage more open communications and improved safety awareness. Most certainly, it gives you the opportunity to take corrective action and prevent a more serious injury, or worse. Actively promoting employee involvement via near-miss reporting will provide a boost to your overall safety program and result in a safer worksite for everyone. A “good catch” is a good catch for all concerned.

For more information about near miss reporting, other safety topics, or safety and rescue training or services, call Roco at (800) 647-7626 or submit a contact request at RocoRescue.com/contact.

Author’s Bio:

Chris McGlynn is the Director of Safety/VPP Coordinator for Roco Rescue. He is a Certified Safety Professional (CSP) through the Board of Certified Safety Professionals as well as a Certified Confined Space and Rope Rescue Technician, and a Nationally Registered Paramedic. As Director of Safety, Chris oversees all corporate safety initiatives, ensuring that employees at Roco have the tools and training that they need to do their work safely and effectively. He is also responsible for managing Roco’s Safety Services Division, which provides trained safety professionals for turnarounds and other special projects. Finally, Chris serves as the VPP Coordinator for Roco, continuing Roco’s long-standing commitment to excellence in safety and health. Roco has been an OSHA VPP Star Worksite since 2013.

Jacqueline "Jackie" Annis is an industrial hygienist with the Office of Partnerships and Recognition, Directorate of Cooperative and State Programs in OSHA’s National Office.  Jackie’s primary responsibilities include developing and overseeing internal policies and procedures for the VPP, reviewing VPP on-site evaluation reports for process safety management information, serving as the National Office liaison for two of OSHA’s ten Regions, and facilitating the management of OSHA’s National Strategic Partnership Program.  She is an integral part of OSHA’s National Office team. 

She has served with the Agency for 36 years, including five years as a senior industrial hygienist in OSHA’s Office of Health Enforcement, Directorate of Enforcement Programs in the National Office and 17 years as a compliance safety and health officer in the Denver, CO Area Office.  Prior to her tenure at OSHA, Jackie worked as an industrial hygienist for the Department of the Navy in Alameda, California.  Jackie obtained a Bachelor of Science degree from Old Dominion University in Norfolk, VA in 1983.

Wayne Howard earned a B.S. in Chemical Engineering from UC Davis and has spent 12 years with Shell (at Martinez) refinery, 3 years with the consulting firm Process Safety, 15 years with Valero (at Benicia), and the last 10 years in the Corporate Process Safety Department. He is the Valero representative to AFPM's Advancing Process Safety Initiative.

Nathan Obaugh, PE is a senior engineer in the Safety and Operational Excellence Group at NuStar Energy. Nathan has over 10 years of PSM and process design experience in the petrochemical, refining and midstream industries. At NuStar, Nathan oversees all elements of the corporate PSM program and works directly on hazard analysis, process safety studies, PSM/RMP audits and provides process engineering support to the operations and capital projects groups.

Jared Teter, PhD is a senior staff scientist with a background in physics and hazards analysis. He has extensive experience in subscale testing of energetic materials and has served as program manager for several large testing and risk management projects. He has applied engineering and risk management protocols while evaluating the risk associated with propellant and explosives manufacturing, combustible dust, and other hazardous material related processes.

Tim Belitz has a degree in Environmental Health/Industrial Hygiene from Old Dominion University and a Master’s from Duke University. He has over 25 years of Industrial Health Safety and Environmental Experience and is a Certified Safety Professional. He has many years focused on Contractor Management and Process Safety programs.

Rob Walker graduated from Virginia Tech in Microbiology and Chemical Engineering. Rob has almost 35 years of experience working in the chemical plant and refining industry. His passion for Process Safety and Mechanical Integrity began very early in his career. Rob began with his current company, Honeywell, back in 2011.

Prasad Joshi has B.S. and M.S. Degrees in Chemical Engineering from two universities in India. Prasad has over 30 years’ experience in the business. He began with Honeywell in May 2022 as Principal Maintenance Engineer. He has worked internationally in Asia and Europe.