Dc. N.: HS-082ENG Date f Issue: 16/05/17 Issue N.: 001 Page 1 f 5 Tpic Sheet N. 2 Near misses: Learning frm failure A tpic sheet prepared by IRATA Internatinal (2017) SAFETY AND HEALTH TOPIC SHEET NO. 2: NEAR MISSES: LEARNING FROM FAILURE A safety and health tpic sheet aimed at raising awareness f hazards in the rpe access industry. The series may be f use as a tlbx talk. 1 INTRODUCTION 1.1 Human failure is as imprtant as a rigging r mechanical failure. There are numerus causes f falls frm a height which result frm human failure. These include: pr cmmunicatin, cmplacency, ver cnfidence and lack f knwledge. 1.2 Within the rpe access industry, many have had mments f stupidity ; unwitnessed near misses that might have resulted in a cnsequence greater than an increased heartrate and a sudden realisatin f yur wn mrtality. 1.3 It might have been a frgtten leg-lp, a karabiner clipped back t a cwstail rather than an anchr pint, descenders threaded up-side-dwn, a karabiner miscnnectin, etc. All these ccurrences are cnsidered t be near misses. 1.4 It is imprtant t reprt them t yur cmpany! Withut this, they dn t becme a learning experience fr thers. LEARN LESSONS FROM OTHERS. HOWEVER, YOU CAN ONLY DO THIS IF THEY REPORT THEM! 2 WHAT CAN GO WRONG 2.1 An unreprted near miss, e.g. a small fall frm height, may at sme pint result in an injury r fatality elsewhere. 2.2 One thery 1 tells us that fr a large number f N damage, Near miss events there will be a smaller number f damage accidents and ultimately a serius r disabling event, e.g. a fatality. 1 Frank E. Bird, Jr (1921 2007)
Dc. N.: HS-082ENG Date f Issue: 16/05/17 Issue N.: 001 Page 2 f 5 Tpic Sheet N. 2 Near misses: Learning frm failure 2.3 Accrdingly, ne way t help prevent the mre serius incidents is t reprt the near misses. It might then be pssible t identify a pattern in the types f incidences, which culd lead t a way t prevent them. 2.4 Nbdy wants t reprt a flish mistake; nr ught they take a cnscius risk withut cnsequence t save time r effrt. Hwever, near miss infrmatin can be used t make changes, prevent accidents and save lives. Case study Descriptin Technicians carrying ut windw cleaning did nt have enugh rpe t reach the grund n a lng drp. They asked ther technicians t re-rig the rpes t reach the flr whilst they waited in a psitin f safety. Using mbile phnes t cmmunicate, they waited until the rigging technicians had finished mving the rpes and gave the all clear t cntinue. Causes Unsuitable rigging as the rpes culd have been rigged t reach the flr, remving the necessity t re-rig during peratins. There was a lapse in judgment in nt checking that the rpes reached the flr befre starting wrk. 3 WHY THINGS CAN GO WRONG 3.1 Things can g wrng fr many reasns: There may be a lapse f judgment. Smene may decide t cut a crner. A near miss may nt be reprted. There may be pr supervisin. A technician may lack experience r knwledge. Smene may be vercnfident. Cmmunicatin may be pr. There may be a false sense f safety. Prcedures may be ineffective r inefficient. There may be a blame culture. 4 WHAT YOU CAN DO AND HOW YOU CAN DO IT 4.1 Yu shuld always: Take time t assess what is ging n. Yu re less likely t have a lapse in judgement when tasks are thught thrugh prperly. Allw adequate time t cmplete tasks. Dn t encurage rushing. Encurage near miss reprting (If necessary, reprting can be annymus). Yu can learn frm failure
Dc. N.: HS-082ENG Date f Issue: 16/05/17 Issue N.: 001 Page 3 f 5 Tpic Sheet N. 2 Near misses: Learning frm failure Ensure gd standards f supervisin. There shuld be sufficient number f manager(s) and/r supervisr(s). Use the crrect peple fr the task. Prtect and teach thse wh are inexperienced. Make sure that technicians are aware f the risks and the ptential severity f an incident. Training and infrmatin is vital. Ensure that cmmunicatin is suitable and sufficient. Assess each task separately and ask yurself, What s different tday? Ensure that prcedures are kept under review. Wrk methds evlve and imprve; make use f the mst efficient and effective methds available. Encurage a n blame culture. Where pssible, ensure that technicians learn frm their mistakes (rather than being punished fr them). 5 ADDITIONAL CONSIDERATIONS 5.1 Encurage technicians t reprt and discuss near misses and experiences that they have encuntered r heard abut. 5.2 Utilise tlbx talks r task assessment briefings. Vary the tpics and encurage participatin frm all thse invlved. 5.3 In many cases, discussing these tpic sheets will be a gd aide memire in helping t prevent incidents. 6 ACTION 6.1 Review yur management system s prcedures fr near misses. 7 REFERENCES 7.1 Further infrmatin can be fund in: (a) IRATA Internatinal cde f practice fr industrial rpe access (Third Editin, September 2016) 2 : Part 1, 1.4.2.2, Training and cmpetence Part 1, 1.4.2.3, Management and supervisin Part 2, 2.2.6, Prcedures and persnnel t be in place befre wrk begins Part 2, 2.2.6.2, Persnnel Part 2, 2.3, Selectin f rpe access technicians Part 2, 2.3.2, Experience, attitude and aptitude Part 2, 2.4, Cmpetence 7.2 Fr a list f current (and past) safety cmmunicatins by IRATA, see www.irata.rg 2 https://irata.rg/safety-bulletins
Dc. N.: HS-082ENG Date f Issue: 16/05/17 Issue N.: 001 Page 4 f 5 Tpic Sheet N. 2 Near misses: Learning frm failure 8 RECORD FORM 8.1 An example Safety and Health Tpic Sheet: Recrd Frm is appended. 8.2 Members may have their wn prcedure(s) fr recrding briefings t technicians and thers. 9 FURTHER READING 9.1 Reducing errr and influencing behaviur, HSG48 (HSE) 3 9.2 Near miss reprting (HSE) 4 9.3 Human factrs: Behaviural safety appraches an intrductin (HSE) 5 3 4 5 www.hse.gv.uk/pubns/priced/hsg48.pdf www.hse.gv.uk/slips/step/general/advanced/8e7f777b-3b84-49fe-a3d6- D0324E25A801/HSLCurseTemplate/28531/slidetype2_174026.htm www.hse.gv.uk/humanfactrs/tpics/behaviuralintr.htm
Dc. N.: HS-082ENG Date f Issue: 16/05/17 Issue N.: 001 Page 5 f 5 Tpic Sheet N. 2 Near misses: Learning frm failure IRATA SAFETY AND HEALTH TOPIC SHEET RECORD FORM Site: Date: Tpic(s) fr discussin: Tpic Sheet N. 2: Near misses: Learning frm failure Reasn fr talk: Start time: Finish time: Attended by Please sign t verify understanding f briefing Print name: Signature: Cntinue verleaf (where necessary) Matters raised by emplyees: Actin taken as a result: Cntinue verleaf (where necessary) Briefing leader I cnfirm I have delivered this briefing and have questined thse attending n the tpic discussed. Print name: Signature: Date: Cmments: