SYSTEM FACTORS THAT HELPS IN REPORTING NEARMISS EVENT

SYSTEM FACTORS THAT HELPS IN REPORTING NEARMISS EVENT 

Examples of system factors (Often employee select inappropriate system factor while reporting Near Miss Online)

Slippery Floors

•       Water leaked on floor

•       Algae formed on floor

•       Oil spilled on the ground.

•       Muddy soil spread on the ground

•       Dust or sandy surface

Defective equipment

•       Any part of the grinding machine is damaged which is not being used.

•       Any part of the welding machine is damaged which is not being used.

•       Using an equipment or machine or tool having defective parts such as the electrical terminal box, broken bearing, damaged protective guard, broken oil cup, leaking pipes, leaking valves etc. and exposed to potential risk which could cause incident.

In adequate illumination 

•       Poor lighting in unit area.

•       Poor lighting in control rooms

•       Lights not working as per requirement i.e. some lights are not working

Poor Housekeeping

•       Scrap from maintenance jobs not removed from site.

•       Daily cleaning not done in plant.

•       Oil spillage near the oil loading point in the equipment.

•       Grass/vegetation not removed from tank farm area.

•       Material not stored properly at storage site.

•       Drums kept on road side in scattered manner.

•       Material brought for some job are not stored properly.

•       The tools and equipment used for a job at a work site are kept in scattered way.

Defective PPE

•       PPE (Helmet, Goggles etc.) in damaged condition.

•       Ropes/ belt of safety harness in damaged conditions.

•       Goggles glass became non visible

•       Helmet Chin strap missing or broken. Helmet is damaged having crack, brim damaged etc

Non Adherence of SOP

•       Flagman not provided for hydra /crane.

•       Moving of Hydra while carrying/hanging  load like motor, pipes etc. on its boom

•       Working on /adjusting a moving machine  like changing V belt, filling diesel in  a running engine, generator , etc.

•       Not following SOP for doing a job.

Use of Defective Equipment

•       If a person is found using the equipment which is faulty as mentioned in S. No.2 that comes under this heading.

Violation of Safety Norms

•       Mobile phone not allowed inside refinery

•       Match box not allowed inside refinery

•       Always drive the vehicle below 25kmph

•       Don’t park near fire hydrants etc.

•       Lifting and moving is not allowed for hydra /cranes.

•       Standing under suspended load is a safety violation

•       Non-compliance to work permit conditions

Un-authorized Activity

•       Operating a EOT crane without formal training

•       Operating a lifting equipment without authorization

•       Driving vehicle inside refinery without license.

•       Doing working at height job without green card.

Non-use of PPE

•       Not using PPE required for a particular job.

Lack of Knowledge (LOK):

•       Cable pulling job at height and walking haphazardly without providing side railing/guide Rope.

•       Lack of knowledge of making extra provision for temporary work at height etc.

•       Change Operating procedure not known/MoC communication not confirmed with Operating group after sharing

•       Leanings through SOP  not available for critical equipment

•       Lack of skill in using specialized PPE like BA set, trolley BA set.

•       Changes in process design, work methods, equipment, materials, etc. not understood properly /followed in actual job performance

•       Using water instead of DCP/CO2 fire extinguisher on electrical fire.

•       Lack of knowledge of plant /equipment by contract workers where they work in running plants.

•       Lack of knowledge of  surrounding work conditions/environment

Lack of knowledge of consequences of operating /playing wrongly with local push button switches for starting /stopping motor/compressors in units and resulting in shutdown of equipment.