NEAR MISS REPORTING Chemical compnan.ppt

Nearmiss

1. REPORTING A
NEAR MISS
AN OPPORTUNITY TO
AVOID MAJOR ACCIDENT

2. WHAT IS NEAR MISS ?
AN EVENT HAVING THE POTENTIAL
TO CAUSE EITHER PERSONAL
INJURY OR PROPERTY DAMAGE IS
CALLED NEARMISS.
IT MAY BE NOTED THAT ACCIDENT HAS NOT
HAPPENED, BUT IT COULD HAVE HAPPENED .

3. PROPERTY
DAMAGE
NEAR MISS
( FREE FALL)
INJURY

4. THERE IS A LESSON IN EVERY
NEAR MISS, REPORT IT !

5. EXAMPLES
•Free fall of object from height
•Non working of online trip system
•Bursting or accidental disconnection of
pressure hoses without any injury
•Non-functioning of online safety valve,
which failed
•Narrow escape from a collision of a
vehicle with another

6. •VALUE OF LIFE OF PERSON
•HOSPITAL PAYMENTS
•PROPERTY DAMAGE COSTS FOR PLANTS
& SURROUNDINGS AREA
•BUSINESS INTERRUPTION COSTS,
MAINLY LOSS OF PRODUCTION
•ENVIRONMENT DAMAGE COSTS
COST OF ACCIDENTS
ICEBERG
•LOSS OF EXPERTISE
•LOSS OF EXPERIENCE
•LOSS OF EMPLOYEES MORAL AND CONFIDENCE
•LOSS OF REPUTATION
•PRODUCTION DELAY
•MANAGEMENT TIME
•CLERICAL TIME
•PRODUCT AND MATERIAL DAMAGE
•LEGAL COST
•EMERGENCY SUPPLY
•CLEANING SITE
•OVERTIME EXPENSES
Direct losses ,
which are visible
Indirect Losses,
which are not visible
but felt at later stage

7. WHY TO REPORT NEARMISS ?
600
Near misses
30
Property Damage
10
Minor Accidents
1
Major
Accident

8. WHY TO REPORT NEARMISS ?
600
Near misses
30
property damage
10
minor accidents
1
major
Accident
Near misses are free learning
opportunity
“Near-miss” signals a system
weakness that if not remedied
could lead to significant
consequences in the future.
Near-miss is also an
opportunity to improve system
structure and stability, and an
opportunity to reduce risk
exposure to potential
catastrophe.

9. So, whenever you come across a
Near miss , report it. Let’s try to
find out What went wrong ?

10. HOW TO REPORT NEARMISS ?
RECOGNISE A NEARMISS INCIDENT AND ADDRESS THE POTENTIAL
DANGER
ENTER INFORMATION IN NEARMISS FORM
PERFORM ANY CORRECTIVE ACTION
OFFER INFORMATION TO CO-WORKERS
REINFORCE THE REPORTING BY GIVING FEEDBACK TO
EMPLOYEES AND TAKING FURTHER LONG-TERM CORRECTIVE
ACTION WHEN NEEDED
TRACK REPORTS TO UNCOVER AREAS THAT NEED ATTENTION
AND TO MEASURE SUCCESS

11. CASE STUDY
1. IN A BARRICADED AREA, A CHAIN PULLEY BLOCK FELL DOWN
NOBODY INJURED, NO MAJOR PROPERTY DAMAGE
2. IN UNBARRICADED AREA NUT BOLT FELL DOWN
THE OPERATOR WORKING BELOW GOT INJURED

12. NEARMISS - IN COOLING WATER TOWER
•During Turn around, one of the Operations Supervisors issued
permit for servicing of the fans of a cooling water tower.
•Electrical crew providing isolation at the switch room , serviced
the fans. After completion of the job, electrical crew went to the
switch room to charge the fans and check the performance.
•Mean time other Operations Supervisor without the knowing that
permit had been issued for servicing of the fans, issued separate
permit to Civil group for plastering job inside the Cooler.
•By the time Civil group reached the site, Electrical group had
already left the area. 3 workers of Civil group started the
plastering job inside close to the fan area.
•Electrical group started the fans from the switch room and fans
started moving.
•The civil workers were about to get trapped inside and luckily
people were little away from the fan blade area and could be
saved.

13. NEARMISS -IN COOLING WATER TOWER
Contd.
The major cause of the accident was analyzed as there was no
coordination between two operations supervisors working for
shutdown. There was no procedure available for electrical lock
out.
LESSON LEARNT
•Implementation multi lock system could have prevented this
type of incident.
•There should be proper coordination between operation
supervisors and different groups working at one place especially
during shut downs when quantum of job is very high.
•Description of the permits issued in a particular day must be
entered in a register for proper follow up and to avoid this type of
mistake.

14. CRANE TILTED AND RESTED ON PIPE LINE
A crane was engaged to remove the cut pieces of 6 “
unused Natural Gas line , which was not in use and was
made into pieces upto 12 feet length. The crane operator
parked the crane to a side of the road for keeping the road
wide open. He did not check the stability of the soil . As the
load was not heavy , he did not use outriggers for lifting.
While lifting the load, due to loose soil, the crane tilted to one
side. The crane instead of giving support to the pipe line , it
took support on another 12” pipeline on the over head pipe
rack. Luckily there was no damage to pipeline and its
support.
Lesson learnt
Before using the crane always check the stability of the ground.
During lifting operations always use Outrigger.

15. NEAR MISSES ARE
EYE OPENERS