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.

WHAT IS NOT A NEAR MISS ? KNOW UNSAFE ACT AND CONDITIONS.

WHAT IS NOT A NEAR MISS ?  KNOW UNSAFE ACT AND CONDITIONS.

What is NOT a Near Miss?

1. An important email composed on PC but forget to transmit- some people report it.
2. Spelling /verb mistake in display boards or document
3. Damaged road/walk ways.
4. Water leakage from tape or leaking fire hydrant. – Many people report it
5. A.C or tube light not working
6. Repair request of office furniture-Damaged furniture/lockers/doors /windows/broken glasses etc.
7. Water leakage from service water line.
8. Choked sewage / bath room drains
9. Complaints regarding grass growth  and tree/bushes causing hindrance
10. Complaints regarding scrap removal
11. Non-availability/ damaged safety shower, wind sock etc
12. Dog, snake, mosquito menace.
13. Empty drums removal requirement.
14. CCTV complaints
15. Requirement of warning signs
16. Damaged safety & other sign boards
17. Complaints on foul smell without identifying the source
18. Cleaning requirement of unit area
19. Seepage from roof or chajja.
20. Missing/damaged PG/loss of level in equipment/ Power failure/DCS black out etc.
21. Township related civil & Electrical complaints
22. Maintenance related regular work request
23. Plant related production /process QC lab issues

Examples of Unsafe acts & unsafe conditions:

Unsafe Acts:

•       Operating equipment or machinery without permission

•       Defeating safety devices/interlocks

•       Using defective equipment

•       Using the wrong tool for the job

•       Not using Personal Protective       Equipment

•       Incorrect lifting techniques

•       Working while intoxicated Hazardous atmospheres

•       Horseplay

•       Non-authorized personnel entering restricted areas.

•       Falling or flying objects that do not make contact with individuals nor cause any significant property damage.

•       Exceeding equipment operating conditions/parameters.

•       Deliberate/willful disobeyance of safety rules  (ex carrying of mobile phone inside battery area)

•       Operating Vehicles without license or authority

•       Bypassing safety interlocks without authorization

•       Not tagging field equipment when isolated from electrical Sub Station

•       Starting maint. job on machines/pump/motor without isolating power locally and from sub station

•       Opening of flanges on live equipment/line w/o permit

•       Discoordination between two working groups in same enclosure

•       Fueling running vehicles/cranes

•       Carrying a suspended load over personnel/standing under that.

•       Keeping files on floor in movement areas.

Unsafe Conditions

•       Lack of guarding on machinery

•       Crowding workers into one area

•       Using the wrong tool for the job

•       Inadequate alarm systems

•       Fires & explosions risk

•       Housekeeping

•       Excessive noise

•       Inadequate lighting

•       Faulty equipment

•       Waste going into the wrong waste stream.

•       Failure of any equipment or associated systems that are in place to protect health and safety.

•       Failure identified by statutory testing.

•       Working on perforated  roof or weak roof

•       Blocked exit/entry/stairs

•       Undressed cable /wire of computer /printer etc

•       Open manholes /Open trenches

•       Working in areas with oil spillage

•       Broken/missing wire net on revolving fan/machines.

•       Missing rung on ladder /missing stop, bar on monkey ladders

•       Hanging electrical fittings

•       Hanging  overhead load/material

•       Chemical spillage

•       Dusty atmosphere

•       Low illumination

•       High noise

•       Torn tires of vehicles/hydra etc.

•       Blind corner on roads with low visibility

Factors which can lead to unsafe acts or conditions:

Human Factors	System  Factors
Lack of knowledge or skills due to inadequate training	Substandard equipment  design
Physical limitations of the worker	Poor equipment maintenance
Distractions which interfere  with the worker’s ability to concentrate on task	Purchase of substandard equipment , material , tools & tackles
	Unusual increases in usages of equipment
	Non-existent or poorly  developed  work standards

WHAT IS A NEARMISS EVENT ?

WHAT IS A NEARMISS EVENT ? 

Understand - What is a Near Miss?

An incident which does not result in any injury or damage to property but has the potential to result in injury and / or property damage.

Definition from SEED Standard on incident reporting and investigation

NEAR MISS CASE (NMC):

An event that could have resulted in an incident is a near miss

Generally the following events are some examples of near miss when:

•          A person trips over an object and falls to the ground but did not get injured

•          A person has to dive or jump out of the way to avoid a collision with a motorized vehicle, or a suspended load that is swinging

•          A person has to jump from a falling ladder, but did not get injured

•          Any emergency equipment (fire extinguisher, Air Pack, Oxygen sensor, eye wash, etc) fails to operate properly when called on in an emergency.

HIGH-POTENTIAL (Hi-PO) NEAR MISS

•          Any Near Miss that has potential to convert into a major incident under slightly different circumstances shall be termed as Hi-Po Near Miss.

Below are some example of Near miss :

• Failure of a safety device without causing any damage to plant, equipment or injury to a person.
• Falling of a ceiling fan without hurting any person.
• Slipping on floor without getting hurt or injured.
• Failure of brake or controls on mobile equipment or vehicle.
• Collapse of excavated earth without causing damage Release of toxic or inflammable gas without causing fire or injury.
• Dropping of material from overhead without causing injury .
• A forklift tipped over while carrying a load that shifted on an uneven work surface. The driver escaped without a scratch by staying buckled inside the cage.
• A Railway Exchange Mechanic working under Rail Tank Wagon had just stepped away when the Rail wagon was struck by another wagon being positioned in TW gantry.
• A forklift ran over a welder’s foot which was protected by his steel toed boots when the driver backed up and did not see him walking behind his lift.
• Breaking of a hand tool, coming out of hammer from handle without injuring.
• Falling of load from height, without causing any damage or injury.
• Sudden failure of brake/locking device of EOT crane during lifting of load in compressor house in any unit.
• Snapping of wire rope of coke bucket of Kone crane in DCU without any damage or injury.
• Failure of magnetic lock or brake of elevator in FCCU or MSQU or opening of floor lift door without having lift at designated floor.
• Tripping over an unsecured cable or Electrical cord.
• If a person walking in a ware house and he felled due to cable in his way but he didn’t have any injury.
• A vehicle has been stuck with other but no major damage occurred.
• While working on height a spanner slipped from hand and fell down on a head of person, due helmet on head nothing happened to him.
• A lifted load felled down on the deck due to breaking of sling but nothing happened to anyone.
• While tightening a bolt your hand slips from spanner due to wet hand and spanner felt on floor very close to a person who is assisting you.
• While bending backward in an office chair, its wheels slipped and you fell down without hurting.

There are many examples of near miss added everyday……….

Unsafe Act And Unsafe Condition

 

Toolbox Talks – Unsafe Act And Unsafe Condition

Unsafe Act and Unsafe Condition

Accidents are caused either by an unsafe act or an unsafe condition or a combination of both. Accidents are rarely caused by a dramatic failure of equipment and are mainly caused due to human failure. Even an apparent failure of equipment may be due to common factor in failing to recognize signs of impending trouble. Analysis of accidents have shown that over 95% of accidents are caused by such human factors as failing to take proper precautions, ignoring safety regulations or carrying out jobs incorrectly.

Substandard Act or Unsafe Act:

It’s a human error or person mistake by which there is a chance of accident or property loss.

Substandard Condition or Unsafe Condition:

It is the condition by which there has a chance of getting accidents and property losses.

Examples of Unsafe Condition

·         Oxygen Deficiency

·         Presence of toxic gases

·         Presence of flammable gases

·         Poor Housekeeping

·         Presence of poisonous materials Slippery or damaged working floor

·         Unguarded Machinery

·         Improperly guarded machinery

·         Loose electrical connections

·         Unearthed electrical Appliances

·         Poor Housekeeping

·         Improper stacking of materials

·         Defective measuring instruments

·         damaged Tools

·         Defective materials

·         Inadequate illumination

Examples of Unsafe Act

·         Using Improper methods

·         Using improper tools / equipment

·         Failing to use proper PPE’s

·         Operating without authority

·         Over confidence

·         Impulsiveness

·         Laziness

·         Showing off

·         Horseplay Ill health

·         Supervisory failure i.e: poor training, lack of discipline, poor housekeeping.

·         Unsafe behavior

·         Unsafe attitude

·         Lack of knowledge

·         Unsafe personal dress and accessories