Tony Mazzocchi

Near-Miss Prevention

Written and produced by the Tony Mazzocchi Center for Health, Safety and Environment Education, a project of the United Steelworkers - USW, the Communications Workers of America and the Labor Institute

October 2013

Edition 5.0

© 2013 Tony Mazzocchi Center

This book is written and produced in cooperation with the United Steelworkers - USW (Five Gateway Center, Pittsburgh, PA 15222), the Communications Workers of America (501 3rd Street NW, Washington, DC 20001) and The Labor Institute, a non-profit organization (817 Broadway, 6th Floor, New York, NY 10003). The project is supported by grant number EPA 2 U45 ES06175 from the National Institute of Environmental Health Sciences (NIEHS), NIH. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIEHS, NIH.

i

John Grobsmith On January 15, 2009, USW Brother, John “Grubby” Grobsmith, age 58, a longtime USW member and a 35 ½ year employee of Crucible Specialty Metals in suburban Syracuse, New York, was working as a Roller when he was fatally injured while attempting to connect a water hose to its related piping. He lost his balance and was pulled through two opposing rotating shafts of a rolling stand. The rotating shafts are powered by a 900 horse-powered motor. The rotating shafts are approximately 6 ½ inches apart. He was born in Syracuse and lived in Elbridge for 28 years. He enjoyed hunting, fishing, camping and photography. He was an avid lacrosse and football fan. Grubby loved his family. He left behind Susan, his wife of 38 years; three daughters, three grandchildren, a brother, two sisters and his mother. The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) later cited Crucible Specialty Metals for 71 alleged serious and repeat violations of safety and health standards following John Grobsmith’s death. OSHA’s inspection found that the machine’s moving parts were not guarded against contact. The inspection also identified a wide range of additional safety and health hazards throughout the plant. “This accident shows how even one instance of an unguarded machine can cost a worker’s life,” said Christopher Adams, OSHA’s area director in Syracuse. “Safeguarding workers against death, injury or illness on the job requires that all applicable safety and health requirements be met at all times.”

Sources: Syracuse Post Standard, January 15, 2009, Department of Labor, Occupational Safety and Health Administration (OSHA) website: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=16065.

ii Near-Miss Prevention

Tony Mazzocchi (1926-2002)

Tony Mazzocchi is credited by many with founding the modern health and safety movement. As Vice-President and Secretary-Treasurer of the Oil, Chemical and Atomic Workers, he also helped to create OSHA and was the first to link worker safety and health to the environmental movement. The following passage from his biography, The Man Who Hated Work and Loved Labor, by Les Leopold, conveys some of his vision and passion for the labor movement:

“Tony Mazzocchi conjured up a labor movement that didn’t really exist, but just might. This movement would be militant and green. It wouldn’t just fight to protect the workforce from toxics — it would eliminate toxics. It would lead the struggle to prevent global warming. It would give workers real control over the quality and pace of work and over corporate investment decisions. It would champion the fight against militarism and for justice and equality. It would demand life-enhancing social programs like free higher education and free health care for all. In short, it would make good on its potential to transform American capitalism into something more humane.”

iii Table of Contents

Factsheet Reading Method v Activity 1: Near-miss Programs and Their Flaws 1 Activity 2: A Functional Near-miss Program — Your Right; Not an Option 7 Activity 3: Identifying Near-misses 17 Activity 4: The Early Days of an Incident 31 Activity 5: Near-miss or No Near-miss 37 Activity 6: How’s the Program Going to Work? 43 Activity 7: Making Program Decisions 61 Activity 8: Building a Plan 89 Final Assessment 99

Appendices: A-1 USW Policy on Sexual Harassment A-2 Tony Mazzocchi Center Worker-Trainers and Worker-Centered Training A-3 Tony Mazzocchi Green Policy Statement A-4 Attendance Form A-5 Sign-in Sheet A-7 Cards for Activity 3, Task 1 A-9 Sample Forms A-29

iv Near-Miss Prevention

Example of the Factsheet Reading Method for a Task Containing Seven Factsheets

The Small Group Activity Method places workers at the center of the learning experience. It is designed to draw on two bodies of knowledge: The knowledge and experiences workers bring into the room and the factsheets contained in your workbooks. Each of you will be assigned a small number of factsheets to read. You will then share this new information with your table. The idea is for each of you to describe your assigned factsheets to the others in your group. Your trainer will assign your individual factsheets in the following way: First, select a scribe for this task. Starting with the scribe and moving to his/her left, count out loud from 1 to 7. Keep going around the table until all numbers (factsheets) are distributed. For example, if there are four people at your table, the scribe will have self-assigned Factsheets 1 and 5; the person to their left will be responsible for Factsheets 2 and 6, etc. The numbers that you have assigned yourselves correspond to Factsheets 1 through 7 on the following pages. Once everyone has read their assigned factsheets individually, your scribe will go around the table and ask each of you to explain to the rest of your group what you have learned. No notes need to be taken during this discussion. The factsheets should be explained in the order they were assigned (1 through 7), as many times factsheets build on previous factsheets. Once this process is complete, your trainer will read the scenario and the task. In this way we all start at the same place and with the same information.

Scribe 1 2 The method described above is used several Table 2 times in this book. A note appears each 4 time the method is 3 to be used.

v

vi Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment

Near-Miss Prevention

Complete this page BEFORE you begin your training.

Workbook Title: Near-Miss Prevention

Workbook Version: Edition 5.0, October 2013

Today’s date: _ _ / _ _ / _ _ _ _ MM DD YYYY

As you complete the assessments at the end of each activity, please only mark one answer choice per question. Make your marks dark and clear when selecting your choice. See the following example:

O  No Yes

vii

viii Near-Miss Prevention

Activity 1

Near-miss Programs and Their Flaws

Purpose To explore why many near-miss programs don’t work. This Activity has one task.

Activity 1: Near-miss Programs and Their Flaws 1

Task

Scenario: We’ve all had experiences with near-miss programs. Although near-miss programs have great potential in theory, the reality is that many near-miss programs fail. A study of near-miss programs conducted by the Wharton Risk Management Center at the University of Pennsylvania concluded that “Near-misses remain a recognized, yet largely untapped, safety improvement resource.” So, let’s explore why these potentially valuable programs do not function as they are designed. Using your experience, please make a list of why many near-miss programs don’t work.

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

2 Near-Miss Prevention

Notes

Activity 1: Near-miss Programs and Their Flaws 3

Summary: Near-miss Programs and Their Flaws 1. Workers fear being disciplined when involved in near-miss reporting. 2. Hazardous conditions don’t always get fixed. 3. The reporting system can be difficult and complicated. 4. Someone else will turn it in — complacency. 5. Near-misses are not reported because they are not seen as hazards or they are accepted as normal.

4 Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment Activity 1: Near-miss Programs and Their Flaws

Learning Objectives:

1. To explore why many near-miss programs don’t work. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

2. Workers fear being disciplined when involved in near-miss reporting. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

3. Hazardous conditions don’t always get fixed. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

4. The reporting system can be difficult and complicated. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

5. Someone else will turn it in — complacency. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

6. Near-misses are not reported because they are not seen as hazards or they are accepted as normal. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

Activity 1: Near-miss Programs and Their Flaws 5

6 Near-Miss Prevention

Activity 2

A Functional Near-miss Program — Your Right; Not an Option

Purposes To explore how near-miss programs have the potential to really protect workers. To understand how workers’ buy-in and involvement are the keys to making a near- miss program work. This Activity has one task.

Use the Factsheet Reading Method for the Task, Factsheets 1 through 5.

The Factsheet Reading Method is described on page v.

Activity 2: A Functional Near-miss Program — Your Right; Not an Option 7

Factsheet 1: Near-miss Programs Can Provide High Levels of Protection Think about an incident where there was injury and/or loss of life. Let’s consider three ways to approach this. What if: A. Good — There is an investigation and all the reasons for the incident are determined and problems are fixed; B. Even Better — In near-miss incidents in which there was no injury or where damages were reported, the incident was investigated and root causes were identified and fixed; or C. Best — The hazards which caused the reasons for the near-miss action were identified and fixed before the near-miss action ever happened. There can be no higher level of protection than one which keeps the incident or accident from happening. A worker-designed, functional near-miss program can do this!

C. Prevention in Near-miss Prevents B B. Prevents A A. the Future Prevention Near-miss Incident Project Reporting Investigation (Identifying Program Program Hazards)

Reported Not reported Not reported because until they until damage they exist. happen. is done. Someone was Inherent Flaw: almost hurt. Inherent Flaw: None. Some action Someone was happened; hurt and/or and it just damage was missed being done. an incident.

Inherent Flaw: It could have been a hit instead of a miss.

Source: USW Near-miss Project Curriculum Team, November 30, 2006.

8 Near-Miss Prevention

Factsheet 2: Near-miss Programs Can Be Valuable to Workers Near-miss programs can be valuable to workers to help them to identify near-misses. Learning why near-misses are important and how they can help workers is an important part of a near-miss program:  A near-miss program involves workers who are intimately familiar with daily system operations; and who are therefore able to easily and quickly detect potential problems.  Near-miss programs keep workers from getting hurt.  A near-miss program can empower workers.  Workers have an increased awareness of hazards in their work area.  Workers should own their near-miss program.  Near-miss programs should find resolutions to problems in a timely manner.

Source: Oktem, Ulku G., Wharton School of Management, Near-Miss: A Tool for Integrated Safety, Health, Environmental and Security Management, Copyright, 2002.

Activity 2: A Functional Near-miss Program — Your Right; Not an Option 9

Factsheet 3: Don’t Settle for Less Workers must never settle for being hurt or killed on the job by incidents that could have been prevented! A near-miss is an unplanned sequence of events that could have caused harm if conditions were different or allowed to progress. This is typically blamed on human error. Studies suggest that nearly 87 percent of all near-miss programs are mismanaged. It’s not surprising, therefore, that near-miss programs face adversity.

Source: Oktem, Ulku G., Wharton School of Management, Near-Miss: A Tool for Integrated Safety, Health, Environmental and Security Management, Copyright, 2002.

10 Near-Miss Prevention

Factsheet 4: A Near-miss Program Designed for Workers The USW Near-miss Program includes the following elements designed for workers:  Making hazard identification available and a tool for all workers.  Reporting 100 percent of the hazards that are identified.  Assuring that timely fixes of all hazards are made.  Making sure solutions are reached by thorough tracking.  Reporting only the hazards to be fixed and not individuals involved.

Source: Oktem, Ulku G., Wharton School of Management, Near-Miss: A Tool for Integrated Safety, Health, Environmental and Security Management, Copyright, 2002.

Activity 2: A Functional Near-miss Program — Your Right; Not an Option 11

Factsheet 5: Workers Deserve a Functional Program — Demand It! As we begin this important task of building a Near-miss Program that can make our workplace safer, a question comes to mind. Will they let us use it? A better question might be: Do we have the right to demand it? Let’s consider some things that could help us answer that question:  We are the ones who do the work and are in harm’s way;  We are the ones who can uncover the problems which can lead to incidents; and  Our families are the ones who will suffer from the incidents and accidents which could have been averted.

Source: USW Near-miss Project Curriculum Team, November 30, 2006.

12 Near-Miss Prevention

Task

Statement: Many times near-miss programs fail. We have discussed many of the reasons for these failures. Other near-miss programs continue but are not effective for workers in making their workplace safer. Is it possible to have a near-miss program that is functional for workers? The USW believes that it is possible and that you are the key. Task: Let’s begin to shape a program that works for you. Answer the questions which follow: 1. Do you believe that a functional near-miss program is a worker’s right? If so, give your reasons.

2. List below three things about a near-miss program that would make it valuable for you.

Activity 2: A Functional Near-miss Program — Your Right; Not an Option 13

Summary: A Functional Near-miss Program — Your Right; Not an Option 1. Properly functioning near-miss programs offer the highest level of protection. 2. Workers must demand a functional near-miss program as a right.

14 Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment Activity 2: A Functional Near-Miss Program — Your Right; Not an Option

Learning Objectives:

7. To explore how near-miss programs have the potential to really protect workers. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

8. To understand how workers’ buy-in and involvement are the keys to making a near-miss program work. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

9. Properly functioning near-miss programs offer the highest level of protection. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

10. Workers must demand a functional near-miss program as a right. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

Activity 2: A Functional Near-miss Program — Your Right; Not an Option 15

16 Near-Miss Prevention

Activity 3

Identifying Near-misses

Purpose To recognize hazards as near-misses. This Activity has three tasks.

Activity 3: Identifying Near-misses 17

Task 1

A worker severely injured her back on the job. Events leading to the worker’s injured back: 1. Two workers had slipped and fallen from handrails while trying to open valves. (There were no injuries.) 2. Valves throughout the facility are stuck and are difficult to open. 3. Cheater bars are needed to turn valves. 4. Cheater bars had slipped in several instances while operators were attempting to turn valves. (There were no injuries.) 5. There is no preventive maintenance program for lubricating valves. 6. Valves throughout the facility are located in awkward positions. 7. There is poor lighting throughout the facility. 8. Man-lifts and/or ladders are not readily available in this area. In your groups, decide in which order the cards should be placed leading up to the injury and write them into the boxes in the diagram on the next page. Once your table agrees on the positions of the events in the workbook, each table will be asked to post their sequence from hazard-to-action-to-incident on the wall. Be prepared to discuss with the large group.

Note: One person at your table should remove the nine cards from

Appendix E (pages A-11 through A-28) in the back of the book. These cards list the events that led to the injury.

18 Near-Miss Prevention

Use the Factsheet Reading Method for Task 2, Factsheets 1 through 4.

Activity 3: Identifying Near-misses 19

Factsheet 1: All Hazards Are Near-misses Waiting to Happen Any hazard at our workplaces is just an accident or an incident waiting to happen. This makes perfect sense to most everyone who has ever thought about things like safety and health. Most people, when they think about a close call or they have missed being hurt because of good luck, consider an event like that a near-miss. The physical “near-miss” or a toxic “near-miss” is the same thing. A workplace hazard! Hazards are the real near-misses at any workplace. Not thinking about hazards as near-misses misses the point. And, most importantly, misses real opportunities for the best prevention of workplace incidents, accidents, injuries and toxic exposures. If in the perfect workplace all hazards were identified and controlled or eliminated, there would be no incidents or accidents. Seeking out workplace hazards and controlling or eliminating them is central to a functioning near-miss program.

20 Near-Miss Prevention

Factsheet 2: Two-headed Hazards Workplace hazards come in two different categories: Physical hazards and exposure hazards. These hazards are just like their names make them sound. Physical hazard Something that affects a worker’s body like a slip, trip or fall, being struck by an object, being caught in a machine, etc. Exposure or toxic workplace hazard One that exposes workers to toxins by inhalation, skin absorption and ingestion (swallowing). Exposure hazards may be more dangerous because we can be exposed to many toxic hazards without even knowing it. Many times toxic exposures do not hurt, burn or make us feel ill; but they can be deadly in a minute, an hour, a day, a month or 25 years later. Workplace hazards need to be controlled or eliminated; they should not be merely avoided or, even worse, considered normal.

Activity 3: Identifying Near-misses 21

Factsheet 3: Getting Past Normal What is “normal?” Some might say:  What I accept;  What no longer concerns me;  What I can do nothing about; and/or  What I think someone else will take care of. What if we asked someone who worked in our industry 20 or 30 years ago what they accepted as “normal” back then? Some might say:  To remove asbestos from piping with a hammer, with no respirator and no protection for anyone in the area.  To work in elevated areas with no fall protection.  To clean skin with solvents or gasoline.  Loud noise had only a temporary effect on our hearing.  Radiation is not a concern; you get more from enamel baked on dinnerware. So what are we accepting as “normal” today?

Source: USW Near-miss Project Curriculum Team, November 30, 2006.

22 Near-Miss Prevention

Factsheet 4: A Direct Line to an Accident Workplace hazards are the cause of accidents. In the line of events or continuum that causes illness, injury and death at work, hazards are always the start or the root cause. Any workplace hazard that has not caused an illness, injury or death is a near-miss; a near-miss waiting to spring into action and eventually be a workplace illness, injury, death or some kind of terrible event. A hazard leads to an action that results in an event. A hazard is a near-miss! A near-miss is an undetected and uncontrolled hazard.

Activity 3: Identifying Near-misses 23

Notes

24 Near-Miss Prevention

Task 2

Now that you have constructed the line of events that led to the worker’s back injury and discussed the factsheets, in your small groups answer the following questions. 1. List the near-misses you see.

2. At what point in the line of events should you report to get the best prevention?

3. What hazards need to be reported?

Use the numbers on the cards to identify the hazards which should be reported to get the best prevention.

Activity 3: Identifying Near-misses 25

Task 3

Near-miss programs fail for many reasons. In Activity 1 we examined many of the causes of their failures. Program Failures: 1. Workers do not report near-miss incidents because they do not want to be disciplined or to have their coworkers disciplined. 2. Workers report near-misses but nothing gets fixed. 3. Because the reporting system is so difficult, workers don’t participate. 4. Near-misses are often seen as a normal and accepted as part of work. A worker-developed and led near-miss program sees hazards as the “real” near- misses in a workplace and quickly works to control or eliminate them. Task: Complete the chart on the next page to identify how a workers’ near-miss program can eliminate the failures of many programs. The four failures listed above are represented by the numbers 1–4 in the chart on the next page. In the space next to each number, give ways a functioning worker-developed and led program can eliminate the program failures.

26 Near-Miss Prevention

Number of How Can a Worker-designed Near-miss the Program Program Eliminate this Failure? Failure

1

2

3

4

Activity 3: Identifying Near-misses 27

Summary: Identifying Near-misses 1. A hazard is a near-miss because it exists. 2. There are two kinds of hazards: Physical and exposure. 3. Hazards that are accepted as normal are most dangerous. 4. No hazard should be considered acceptable. 5. Near-misses run in a connected sequence from hazard to action to incident. 6. Reporting only hazards (and not near-miss actions) can be a core element of a worker-designed program.

28 Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment Activity 3: Identifying Near-misses

Learning Objectives:

11. To recognize hazards as near-misses. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

12. There are two kinds of hazards: Physical and exposure. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

13. Hazards that are accepted as normal are most dangerous. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

14. No hazard should be considered acceptable. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

15. Near-misses run in a connected sequence from hazard to action to incident. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

16. Reporting only hazards (and not near-miss actions) can be a core element of a worker-designed program. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

Activity 3: Identifying Near-misses 29

30 Near-Miss Prevention

Activity 4

The Early Days of an Incident

Purpose To understand the value of preventing an incident by controlling or eliminating its cause before it becomes an incident or near-miss.

This Activity has one task.

Activity 4: The Early Days of an Incident 31

Task

Scenario: Bill, an operator, was sprayed with acid and burned as he walked under a flange. The flange was in an acid line and was located directly above the walkway. “The pressure goes sky-high in that line every time the elbow plugs, which happens about three or four times a month,” said Frank. “I sure hope Bill is OK.” “We’ve been trying to get some high-pressure gasket material for those flanges; but they told us to use the regular stuff until the other comes in,” said Tom, a maintenance guy. “The flange on Acid Line B leaked some the other day, but no one was even close to it,” said Patty. “I think all the acid lines in Building 3 on the other side of the plant have pressure relief valves,” said Frank. “But they have a safe, enclosed place for a drain and we don’t,” said Tom. “If there had been a high-pressure alarm, we could have at least shut the pump down and kept everyone away,” said Patty. “This was a needless incident that didn’t have to happen,” said Tom. “Aren’t they all?” said Patty.

32 Near-Miss Prevention

Task: As all too often is the case, we are entering the path of this event far too late. Let’s begin to look back to the early days in the path of the incident. Answer the questions below. 1. What near-miss action should have foretold this incident and provided the last chance to stop it?

2. Now, let’s get to the heart and soul of a functioning near-miss program for workers. What hazards should have been reported and fixed which would have stopped even the near-miss action?

3. What fixes would you recommend to eliminate the possibility of this incident occurring?

Activity 4: The Early Days of an Incident 33

Summary: The Early Days of an Incident 1. A functioning near-miss program is all about reporting and fixing hazards. 2. If we do nothing but wait for near-miss actions to happen — they may not miss!

34 Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment Activity 4: The Early Days of an Incident

Learning Objectives:

17. To understand the value of preventing an incident by controlling or eliminating its cause before it becomes an incident or near-miss. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

18. A functioning near-miss program is all about reporting and fixing hazards. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace.

O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

19. If we do nothing but wait for near-miss actions to happen — they may not miss! How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

Activity 4: The Early Days of an Incident 35

36 Near-Miss Prevention

Activity 5

Near-miss or No Near-miss

Purpose To work together to identify near-misses.

This Activity has one task.

Activity 5: Near-miss or No Near-miss 37

Task

Scenario: In William G. Bridges’ paper, Get Near-misses Reported, he concludes that: The definitions of near-misses are not always the easiest thing to determine. In training 2,000 near-miss incident investigators, he reported that the definition of near-misses was vague in his words; and that when quizzed, 30 percent of these incident investigators at the facilities believed that the lifting of a relief valve on demand was a “non-incident” or not a near-miss, while the rest of the class considered it an “incident” or a near-miss. The ones who believed it was a non-incident cited that it “worked as designed.” The rest of the investigators believed that the relief valve opening was a near-miss because if it hadn’t opened, there could have been a catastro­ phic loss of containment.

Source: Bridges, William G., “Get Near-misses Reported,” EQE International, Inc., Knoxville Office, an ABS Group.

38 Near-Miss Prevention

Task: The chart below lists events that may be categorized as either a near-miss (it will be reported, investigated and fixed) or not a near-miss (no report/no action.) In your groups, discuss each event then indicate if the event should be classified as a near-miss or not a near-miss. Be prepared to report back to the class and explain your decisions. . Not a Near-miss Incident Near-miss Incident Incident

Excessive pressure in line opens safety valve on demand.

Pressure reaches relief valve set pressure but relief valve does not open.

High-pressure trip/shutdown occurs (one layer of defense against overpressure of the system).

Toxic gas detector in the area tripped/alarms.

Walking under suspended crane load.

Suspended crane load slips.

Safety relief device found to be outside of tolerances during routine inspection.

Unusual pressure excursion occurs but remains within process safety limits.

High pressure alarm rings (possible quality impact).

Toxic gas detector found to be defective during routine inspection/testing.

Pulley belt is not guarded.

Crane wire found to be defective during pre-lift check.

Activity 5: Near-miss or No Near-miss 39

Summary: Near-miss or No Near-miss 1. A clear, agreed-on definition of a near-miss is necessary for a functioning near- miss program. 2. Correcting the reasons that safety devices are set into action is an important element of a functioning preventive near-miss program.

40 Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment Activity 5: Near-miss or No Near-miss

Learning Objectives:

20. To work together to identify near-misses. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

21. A clear, agreed on definition of a near-miss is necessary for a functioning near- miss program. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

22. Correcting the reasons that safety devices are set into action is an important element of a functioning preventive near-miss program. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

Activity 5: Near-miss or No Near-miss 41

42 Near-Miss Prevention

Activity 6

How’s the Program Going to Work?

Purpose To examine how a union worker’s near-miss program could function most effectively.

This Activity has two tasks.

Activity 6: How’s the Program Going to Work? 43

Task 1

Let’s take a look at an incident which was used earlier in this training; but this time we change it to a near-miss. To make it more interesting, we’ll change the name from Bill to “you.” Yes, for training purposes, this near-miss happened to you. Scenario: “What are you guys talking about?” asked Elaine, a Global Paper operator, as she entered the bleaching area. “I almost got sprayed with acid,” you replied. “A flange gasket on the addition line leaked just as I walked under it. It just barely missed me.” “The problem is that you weren’t wearing your splash gear and now you’re trying to decide whether or not to report it. Am I right or wrong?” asked Elaine as she sits in front of you. “You’re right; and after Sarah got sprayed last year, they made PPE a requirement whenever you go into the area,” you replied. “It’s not leaking now, so maybe we just let the pressure get too high on the line,” said Phil another coworker. “Phil’s probably right. I’ve never seen that flange leak before. Maybe we should just forget it,” you said. “They have been telling us to report near-misses but I’m not even sure that this would qualify as one,” said Phil. “Now that I think about it, maybe it wasn’t really that close and I bet it never leaks again,” you said. “Others are not going to know about this unless it’s reported. It’s your decision,” said Elaine.

44 Near-Miss Prevention

Task: Answer the following questions: 1. List some reasons you might not report the near-miss.

2. List some reasons other workers might not report the near-miss.

3. If you chose not to report the near-miss, what effect could this failure to report have on you and your coworkers in the future?

Use the Factsheet Reading Method for Task 2, Factsheets 1 through 7.

Activity 6: How’s the Program Going to Work? 45

Factsheet 1: A Near-miss Reporting Program Many incidents do not result in injuries or other catastrophic events but easily could have been disasters. Dangerous trends and special problems can be identified by analyzing the root cause of these incidents. Near-miss as an Opportunity: Near-misses provide a stark warning of the possibility of a harmful incident occurring. If the near-miss is investigated and appropriate fixes are made, potential future incidents can be prevented. If the lessons learned are shared and fixes are made in other similar locations, even more potential future incidents can be prevented.

46 Near-Miss Prevention

Factsheet 2: Discipline: A Roadblock to Near-miss Reporting Incidents or near-miss actions cannot be investigated if they are not reported. Many people are reluctant to report incidents and near-misses because they expect to be blamed or punished. In addition witnesses will hesitate to be cooperate if they believe they or their friends may receive discipline or blame. Under the USW/TMC Program, we believe it is important for us to learn from our mistakes or close calls.

Activity 6: How’s the Program Going to Work? 47

Factsheet 3: Systems vs. Symptoms When an incident happens, the best way to prevent its recurrence is to find its root causes and correct them. Yet most of the time, industry efforts are directed toward treating the symptoms of the incident rather than its root causes. The Environmental Protection Agency also emphasizes the importance of finding root causes: . . . an operator’s mistake may be the result of poor training, inappropriate standard operating procedures (SOPs) or poor design of control systems; equipment failure may result from improper maintenance, misuse of equip­ ment (for example, operating at too high a temperature) or use of incompatible materials. Without a thorough investigation, facilities may miss the opportunity to identify and solve the root problems.

Sources: Center for Chemical Process Safety, “Guidelines for Investigating Chemical Process Incidents,” New York: American Institute of Chemical Engineers, 1992; and American Institute of Chemical Engineers, “Guidelines for Auditing Process Safety Management Systems,” Environmental Protection Agency Proposed Rule, Risk Management Programs for Chemical Accidental Release Prevention.

48 Near-Miss Prevention

Factsheet 4: It’s All About the Hazards Hazards are most always the reasons for near-miss actions. If hazards are eliminated, then it follows that most near-miss actions would never happen. Therefore, the focus of a successful near-miss program must be on the hazards. How do we design a program to do this? The Near-miss Program only reports hazards to be fixed and not the individuals involved.

Activity 6: How’s the Program Going to Work? 49

Factsheet 5: How to Report Hazards The best ways to report near-miss actions and hazards vary between workplaces, but some suggestions are:  Have several locations for workers to pick up a reporting card or form;  Personally hand the form to members of the union leadership team;  Mail the form or card to local union leadership;  E-mail the report to a member of union team; and  Provide a secure drop-off point.

50 Near-Miss Prevention

Factsheet 6: Near-miss Hazard Tracking Recording: Near-misses are important opportunities to investigate and correct problems before a serious injury or disaster happens. For your program to be effective, it must include a tracking system. Investigation of Near-misses: In some cases, active near-miss incidents should be investigated in order to determine the hazards which need to be fixed.

Activity 6: How’s the Program Going to Work? 51

Factsheet 7: Workers Need Feedback Workers must know:  The hazard or near-miss action report was received;  That it was understood;  That an investigation was done (if necessary);  The results of the investigation;  The recommendations that were made to fix the hazards; and  If and when the recommendations are completed.

52 Near-Miss Prevention

Task 2

Scenario: An investigation team was assigned. After inspection of the area and interviews with workers, they produced the following set of facts to be used in determining hazards to be eliminated:  Acid sprayed onto the walkway;  Flange gasket failed;  Acid was in the addition line;  Pipe flange located directly above walkway;  Gasket material was not rated for high pressure;  The pressure reached a high level;  The acid line was plugged at an elbow;  Operator was not aware of high pressure;  There was no pressure relief for the line;  There was no high pressure alarm; and  Operator was not wearing PPE.

continued

Activity 6: How’s the Program Going to Work? 53

Task 2 (continued)

The investigation team then used the logic tree investigation tool to identify the hazards (root causes) which needed to be eliminated. The completed logic tree is shown on page 56. Notice that:  Acid sprayed onto walkway is the near-miss action investigated;  Five root causes (hazards) were identified; and  The hazards are failed safety systems. Trainer’s Note: Read aloud the near-miss investigated, the five root causes (hazards) and the failed safety systems. The recommendations listed below were made using the input that you had on your reporting form and also the training and experience of the Union Worker’s Leadership Team. These recommendations were the total report to the company from this incident.  Redesign the line to eliminate the flange.  Relocate the flange to an area where there is no worker traffic.  Use gasket material rated for high pressure.  Use relief vent and pipe to safe return.  Install high pressure alarm.  Determine cause of plugging and try to eliminate.

54 Near-Miss Prevention

Task: Answer the questions below. 1. Consider a program like the one described in the scenario and in the fact- sheets you just reviewed and like the one which did the investigation in the example. If the local union at your workplace ran such a union-worker program, would you report your near-miss action (almost sprayed with acid) to your union worker’s program?

If yes — give your reasons.

For workers who might not report — list below other aspects of the program which would have to be added in order for you to report the near-miss action to the union worker’s leadership of the program.

2. List other recommendations to help design a Union Worker Near-miss Prevention Program.

continued

Activity 6: How’s the Program Going to Work? 55

Task 2 (continued)

Acid Sprayed in Walkway

Acid sprayed onto walkway

Flange located directly above Acid was not in walkway the addition line (Root Cause)

Flange gasket S.O.S. Failure failed No S.O.S. Design and Failure Engineering

Gasket material Pressure not rated for reached high pressure high level (Root Cause)

Acid line was Operator not No pressure S.O.S. Failure plugged at an relief on acid Design aware of rising elbow pressure line (Root Cause) (Root Cause)

No high- Need More S.O.S. Failure pressure alarm Information Mitigation (Root Cause)

S.O.S. Failure Warning Devices

56 Near-Miss Prevention

Notes

Activity 6: How’s the Program Going to Work? 57

Summary: How’s the Program Going to Work? 1. Near-miss actions and hazards should be viewed as opportunities to fix the hazard before someone really gets hurt. 2. Discipline can destroy a near-miss program by putting fear between workers and reporting. 3. The results of near-miss investigations can be used to eliminate hazards before they can cause damage. 4. Workers must know that reports are received, acted on, what recommendations have been made and if and when the hazards have been eliminated. 5. An effective program must be run by the union and the focus must be on the hazards and not on the person who fell victim to the hazard.

58 Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment Activity 6: How’s the Program Going to Work?

Learning Objectives:

23. To examine how a union worker’s near-miss program could function most effectively. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

24. Near-miss actions and hazards should be viewed as opportunities to fix the hazard before someone really gets hurt. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

25. Discipline can destroy a near-miss program by putting fear between workers and reporting. How much do you agree or disagree with the following statement? Under­ standing and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

26. The results of near-miss investigations can be used to eliminate hazards before they can cause damage. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

Activity 6: How’s the Program Going to Work? 59

60 Near-Miss Prevention Activity 7

Making Program Decisions

Purpose To work as a team to make important decisions to guide your program.

This Activity has three tasks.

Use the Factsheet Reading Method for Task 1, Factsheets 1 through 7.

Activity 7: Making Program Decisions 1

Factsheet 1: Disclosure Must Be Quick and Simple It must be easy to disclose a near-miss or most workers won’t do it. Forms should be:  Simple;  Easy to get;  Easy to turn in; and  Able to be completed by others on behalf of the worker disclosing the problem.

Source: Phimister, J.R., Oktem, U., Kleindorfer, P. R., Kunreuther, H., “Near-Miss System Analysis: Phase 1,” Wharton School, Center for Risk Management and Decision Processes, December 2000, p. 12.

62 Near-Miss Prevention

Factsheet 2: Speed Kills Saves! When designing a near-miss reporting system, workers should be encouraged to report hazards immediately.  Some corrective action may be immediately possible, which could prevent someone getting hurt.  Details are fresh in the memory and may be crucial to finding root causes.  Evidence of what caused the near-miss may remain intact. The near-miss reporting system must be designed to make rapid reporting easy.

Activity 7: Making Program Decisions 63

Factsheet 3: Have Forms Easily Available The near-miss reporting form will likely be the way that most near-misses are reported. There must be many easy ways to get the forms. Workers should have options to get a form without others seeing what he/she is doing. Consider having forms available:  In every department;  In each building and work location;  In the union office;  On union bulletin boards;  In the Near-miss Office;  In any environment, health and safety office;  Managers’ offices;  As a downloadable file from union and company websites and Internet;  By e-mailing somebody (though this is both labor intensive and not anonymous);  In lunchrooms or break areas; and  Other areas you think appropriate.

64 Near-Miss Prevention

Factsheet 4: Don’t Let Them Run Out Forms should not be allowed to run out at any regular location. It can lead to frustration and even cynicism if a worker tries to report a near-miss and then can’t find the form with which to do it. The Near-miss Team needs to take responsibility for checking each location to ensure that the supply of forms is adequate. As the program begins, check the locations frequently until you establish their normal use rate. This may also alert you to:  Somebody throwing the forms away or damaging them;  The forms being “buried” by other material in the area;  Workers not knowing that the forms are available in a particular location; or  A location that is particularly well used, which would suggest that you should set up similar locations elsewhere.

Activity 7: Making Program Decisions 65

Factsheet 5: Decide Where Anonymous and Confidential Forms Can Be Submitted The Near-miss Team must choose an address to print on all near-miss reporting forms where workers can feel safe to report anonymously or confidentially. Also consider setting up no-hassle drop boxes and listing their locations. Other means of openly reporting near-misses can also be made available. These can include such people and places as:  Near-miss Team members; and  USW e-mail or website addresses. Don’t spread the locations for submitting reports too thinly or some are likely to fall through the cracks.

66 Near-Miss Prevention

Factsheet 6: Keep It Secure The only way to ensure the success of your program is to keep your information secure and limit access to the database. Assigning a serial number to each incoming near-miss report will help. This will eliminate the need for tracking by dates and names. This can be done several ways:  A hand-held stamp that does the counting for you;  A computer generated number; or  By recording a tracking number by hand, being sure to keep the numbers in sequential order. Nobody should have access to the database except the qualified users from the Near- miss Team.

Activity 7: Making Program Decisions 67

Factsheet 7: Keeping Track Keeping track of the near-miss reports is key to the success of your program. One way to do this is by creating a system that would include the following but not be limited to:  Date;  Area in which the incident occurred;  Time of day reported;  Serial number assigned;  Key descriptor words for identifying patterns and clusters;  Recurring conditions;  Initial correction made;  Investigator;  Recommendations made;  Recommendations implemented;  Date recommendations made;  Date fixes completed; and  Safety system used in fix.

68 Near-Miss Prevention

Task 1

List ways that your Program will meet the following goals: 1. Make it easy for a worker to report a near-miss.

______

______

______

______

2. Get action quickly, when possible.

______

______

______

______

3. Make forms available and in constant supply.

______

______

______

______

continued

Activity 7: Making Program Decisions 69

Task 1 (continued)

4. Keep information secure.

______

______

______

______

5. Track the reports.

______

______

______

______

Use the Factsheet Reading Method for Task 2, Factsheets 8 through 12.

70 Near-Miss Prevention

Factsheet 8: Investigate Near-misses Using the Same Techniques as Investigating Incidents To investigate near-misses, use the same process used for investigating incidents:  Gather facts;  Organize the facts using logic-tree analysis;  Identify root causes; and  Determine which safety system failed. Investigators should:  Photograph and examine the scene;  Collect evidence (damaged parts, samples, etc.);  Perform relevant tests;  Interview witnesses; and  When openly reported, interview the person who revealed the near-miss.

Activity 7: Making Program Decisions 71

Factsheet 9: Avoid Spotlighting When near-misses are reported confidentially or anonymously, the worker believes he or she has reasons to remain unknown. Any person being interviewed to gather facts could be the one who made the report. All interviews with witnesses must be conducted in a non-threatening manner and only for the purpose of finding the facts.  Interviews should be conducted as soon as possible and done privately and individually with each witness.  Interviews need to be held in a comfortable and neutral place.  Assure the person being interviewed that you are just looking for facts and not trying to place blame.  Be sure to let them know the investigation is from a Systems of Safety viewpoint and we are looking for ways to prevent recurrence of the incident, not a scapegoat.  To help them get started, you may want to start by asking them if they can clarify or add to what is on the report.

Source: The Labor Institute, USW Systems of Safety Initiative Training for Investigators, Draft 1, New York City, July 2004, pp. 94-96.

72 Near-Miss Prevention

Factsheet 10: Things to Consider While Prioritizing As the program grows, the goal is to have an average of each person submitting two reports per year. This fact identifies the need to prioritize near-miss reports. This is a very important step that helps determine:  The level of attention that will be given to an incident;  When it will be investigated;  The number of people needed for investigation, if any;  The amount of time needed to fix the recommended item; and  How soon the incident should be communicated.

Sources: Phimister, J.R., Oktem, U., Kleindorfer, P. R., Kunreuther, H., “Near-Miss Incident Management in the Chemical Process Industry,” Risk Management and Decision Process Center, Operations and Information Management, The Wharton School of Management, University of Pennsylvania.

Activity 7: Making Program Decisions 73

Factsheet 11: Elements of Prioritizing Most near-misses may have quick-fix recommendations. The reporter or supervisor may recommend temporary fixes. However, some near-misses will be flagged as being higher priority. “High priority” incidents may have some of the following characteristics:  Potential for serious injury;  Potential for major loss;  Potential for environmental damage;  The incident is part of a pattern or cluster; and/or  The potential for “lessons learned” is apparent in the report. Most near-miss reports require a full investigation.

Sources: Phimister, J.R., Oktem, U., Kleindorfer, P. R., Kunreuther, H., “Near-Miss Incident Management in the Chemical Process Industry,” Risk Management and Decision Process Center, Operations and Information Management, The Wharton School of Management, University of Pennsylvania.

74 Near-Miss Prevention

Factsheet 12: Level of Hazard When assigning the priority (high or low) to a near-miss report, consider your answers to the following questions:  How often are workers exposed or injured?  How many workers are exposed?  How severe are the consequences of exposure to the hazard (actual and potential effects, short-term and long-term exposure)?  What are the chances that someone will be made ill or hurt by the hazard? After taking all this into consideration, assign a level of hazard to the reported near- miss. Remember, the most important thing in assigning a level of hazard is that it helps you decide which hazards are most important to go after and fix first.

Source: Utility Workers Union of America, Local 1-2 and The Labor Institute, Systems of Safety Hazard Mapping, Edition 1.1, The Labor Institute, New York City, 2004, p. 14.

Activity 7: Making Program Decisions 75

Task 2

List ways your program will meet the following goals: 1. Assign investigators:

______

______

______

______

2. Decide which near-miss reports to handle first:

______

______

______

______

Use the Factsheet Reading Method for Task 3, Factsheets 13 through 20.

76 Near-Miss Prevention

Factsheet 13: Reviewing the Making of Recommendations In the Training for Investigators we learned that: 1. As systems thinkers, we know that we can only eliminate the hazard in the Design Safety System. All other systems may mitigate or lessen the severity of the hazard but do not eliminate it. 2. Recommendations don’t have to involve the same systems as those the logic tree identified as having failed. Strive for solutions and higher-level systems. 3. Design is our first line of defense. Other systems are secondary and should be considered as backup to higher level systems. 4. Our first concern in any investigation is to immediately get the worker out of danger. Some major design changes may take time to implement. 5. Any recommendation we make can affect other operations. We have to make sure we consider all areas and all of the workers when making recommendations. 6. The recommendations mean very little if they are not implemented, so it is important to have a way to track all recommendations to completion.

Source: Tony Mazzocchi Center/Labor Institute, “PACE Systems of Safety Initiative Training for Investigators,” Draft 1, The Labor Institute, July 2004, p. 60.

Activity 7: Making Program Decisions 77

Factsheet 14: Recommendations The most important step is to make the right recommendation for the recognized near- miss. Elimination of the potential hazard is critical to your work site.  Sometimes, several hazards can be fixed with one recommendation.  There may not be a feasible, effective recommendation for elimination of a hazard, so a less ideal action may be needed.  All solutions, even “no solution for the time being” or a classification as a “turn around item,” need to be noted. Before the near-miss can be signed-off, these will have to be addressed.

78 Near-Miss Prevention

Factsheet 15: Tracking Recommendations Once the recommendations are identified and they are sent to the appropriate people for fixes, it is important to track their progress.  Affix reasonable time frames to all recommendations. Set up an electronic notice or a tracking board so recommendations do not fall “between the cracks.”  When a job is complete, return the work order to the Near-miss Coordinator noting the fix or changes to the fix.  If it is corrected to the team’s satisfaction, remove it and have the investigation team sign-off on it.  If the changes are a quick fix and the appropriate recommendation could not be done at the time, review it periodically until it is totally eliminated. Two important things should be noted:  To get the full benefit from a near-miss system (lessons learned and corrective actions) all of the above steps should be done as completely as possible.  Near-miss reporters should be informed of the progress of their near-miss report all the way through the system.

Activity 7: Making Program Decisions 79

Factsheet 16: Lessons Learned Must Be Shared Sharing lessons learned is an important tool that can help lead to accident and incident prevention. Root causes identified in near-miss investigations need to be communi­ cated throughout the site. When we share these experiences with workers, it brings to light incidents that could happen in your work area as well as other areas at your site. Lessons Learned can be shared by any available means of communication. Examples:  Tool box meetings;  Union meetings;  Bulletin boards;  Newsletters;  E-mails and web sites; and  Near-miss team members telling workers.

80 Near-Miss Prevention

Factsheet 17: Tell the Person Who Reported the Near-miss The most important person to share lessons learned with is the person who reported the near-miss. This is important since it:  Resolves the problem for the person who cared enough to take the time to submit a near-miss report;  Encourages future participation in the near-miss program by the near-miss reporting worker; and  Is likely to encourage the reporter to spread the word that the program works. If the near-miss was reported openly, the name of the person who initiated the process should be on the reporting form.

Activity 7: Making Program Decisions 81

Factsheet 18: Share Lessons Learned With Similar Work Areas Broadcasting lessons learned to the general workplace population:  May bring attention to problems in unexpected places;  Gives positive reinforcement to all workers to report near-misses; and  Builds support for the near-miss program. The Near-miss Team should target areas where the lessons learned could correct similar situations. Decide who would be the best people to share the lessons learned with in each of these priority areas. Don’t rely solely on general newsletters, which might not be read by the key people facing similar situations.

82 Near-Miss Prevention

Factsheet 19: Turning Adversity into Advantage There may be times when the most effective fixes are not made. It is also possible that for some reason no fixes are made from a near-miss investigation. This progress or lack of progress report should also be communicated. Sharing this with all of your fellow workers:  Is not an admission of defeat;  Builds pressure to have the more effective fixes made;  May activate management to make the best fixes;  Involves all members in our union; and  Demonstrates that the Near-miss Team is honest, accountable and committed to getting the most effective fixes made.

Activity 7: Making Program Decisions 83

Factsheet 20: Example of Report Cards Share data trends and stories over time. 1. Number of reports; 2. Number of investigations; 3. Number of recommendations made; and 4. Number of fixes made. 5. Highlight of reporting period:

 Story to show how well we are doing; and  Story of how we still have progress to make.

84 Near-Miss Prevention

Task 3

List ways your program will meet the following goals: 1. Making most effective recommendations:

______

______

______

______

2. Tracking recommendations to completion:

______

______

______

______

3. Sharing results of investigations with workers:

______

______

______

______

Activity 7: Making Program Decisions 85

Summary: Making Program Decisions 1. It must be easy to disclose a near-miss or most workers won’t do it. 2. Near-miss reporting forms should be easily available and should not be allowed to run out. 3. The only way to ensure the success of your program is to:  Keep your information secure by limiting access to the database;  Make sure anonymity and confidentiality are protected; and  Develop a good system to keep track of reported near-misses. 4. Investigate near-misses using the same techniques as investigating incidents. 5. Near-miss reports need to be prioritized. 6. The most important step is to make the right recommendation for the recognized near-miss. 7. It is important to share lessons learned from a near-miss with all workers, especially with the person who reported the near-miss.

86 Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment Activity 7: Making Program Decisions

Learning Objectives:

27. To work as a team to make important decisions to guide your program. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

28. It must be easy to disclose a near-miss or most workers won’t do it. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

29. The only way to ensure the success of your program is to keep your information secure by limiting access to the database; make sure anonymity and confiden- tiality are protected; and develop a good system to keep track of reported near-misses. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

30. The most important step is to make the right recommendation for the recognized near-miss. How much do you agree or disagree with the following statement? Under­ standing and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

Activity 7: Making Program Decisions 87

88 Near-Miss Prevention

Activity 8

Building a Plan

Purpose To design a plan that will assist you in using the Near-miss Prevention Project in your workplace. This Activity has one task.

Activity 8: Building a Plan 89

Task

This Near-miss Prevention Project was designed for workers to use to eliminate hazards in their workplace. Eight important next elements of the project are listed below. 1. Build a local union team to lead your program (include the training needed). 2. Design the needed forms (reporting, tracking and feedback). 3. Determine the location of forms and plans to distribute and collect them. 4. Design a plan to use investigators as needed. 5. Design a plan to get feedback to workers. 6. Share Lessons Learned from your investigations. 7. Get employer buy-in to provide time for running the program and agreement to make fixes. 8. If you cannot get employer buy-in, list ideas of ways you can still run the program. Each of the above elements will probably require several steps by workers at your workplace in order for each element to be successful.

90 Near-Miss Prevention

Task: To kick start this Near-miss Prevention Project, complete the chart on pages 92 and 93 and use it as a guide.  Use the chart to list your steps.  After you determine each step, decide who should make sure this happens and when it should be completed.  If you determine more than three steps are needed for any one of the six elements, you should use extra paper.  Then use the chart to track the progress of your Near-miss Prevention Project. During report-back your facilitator will put one element per flipchart (six flipcharts) and will list the steps your group determines will be needed for each element.

continued

Activity 8: Building a Plan 91

Task (continued)

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Step 2

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Step 1

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92 Near-Miss Prevention

? s e sure ho will Step 3 W happen mak and when

Step 3

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Step 2

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ts of t company Progra e gations. your investi- Share Less agreement to make fixes. to workers. of ways you can still run the program. G If you cann Design p buy-in to pr time for runnin the program get feedbac Learne get employ buy-in, list i Elemen 5. 7. 6. 8.

Activity 8: Building a Plan 93

Summary: Building a Plan 1. It is important to have a plan to put action to our ideas. 2. Many times several steps are required to complete one element of a plan. 3. Someone should be responsible to ensure that each step is completed in a specified amount of time. 4. The plan should be used on a continuing basis to determine progress of the program.

94 Near-Miss Prevention

Tony Mazzocchi Center Proficiency Assessment Activity 8: Building a Plan

Learning Objectives:

31. To design a plan that will assist you in using the Near-miss Prevention Project in your workplace. How much do you agree or disagree that the training met this learning objective? O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

32. It is important to have a plan to put action to our ideas. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

33. Many times several steps are required to complete one element of a plan. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

34. Someone should be responsible to ensure that each step is completed in a specified amount of time. How much do you agree or disagree with the following statement? Understanding and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

35. The plan should be used on a continuing basis to determine progress of the program. How much do you agree or disagree with the following statement? Under­ standing and applying this learning objective will assist me in improving health and safety at my workplace. O O O O O Strongly agree Agree Neither agree Disagree Strongly nor disagree disagree

Activity 8: Building a Plan 95

96 Near-Miss Prevention

Class Name ______Date ______Location ______

End of Class Evaluation Form

1. Overall, how would you rate this training session? (Check one)  Excellent  Good  Fair  Poor What about the training led you to rate it this way?

2. Thinking about the materials used in the training, how would you rate them for being easy to understand? (Check one)  Excellent  Good  Fair  Poor What about the materials led you to rate them this way?

3. To what degree will you be able to apply what you learned in this training to your work? (Check one)  Will apply a lot  Will apply somewhat Will not apply What about the training led you to rate it this way?

4. What would make this training more effective?

5. Additional Comments:

End of Class Evaluation Form 97

98 Near-Miss Prevention

Tony Mazzocchi Center Final Proficiency Assessment Near-Miss Prevention

Trainee Name ______Print

Trainee’s ID No. ______- ______(The two-digit month and two- digit day of trainee’s birth date and the last four numbers of the trainee’s social security number. (For example, someone born September 22nd and whose last four digits of their social security number are 1234 would enter 0922-1234.)

Trainer Name ______Print

By initialing below, I (the trainee), have assessed that I have successfully achieved the minimum levels of knowledge and skills communicated in activities in which I have participated.

Activity Trainee’s Initials

Activity 1: Near-miss Programs and Their Flaws

Activity 2: A Functional Near-miss Program — Your Right; Not an Option

Activity 3: Identifying Near-misses

Activity 4: The Early Days of an Incident

Activity 5: Near-miss or No Near-miss

Activity 6: How’s the Program Going to Work?

Activity 7: Making Program Decisions

Activity 8: Building a Plan

Number of Course Hours completed ______

Please turn page over to finish completing this form.

Final Proficiency Assessment 99

To be completed by the Trainee:

1. I, the trainee, agree that I have successfully completed the Near-miss Prevention Training.

Trainee signature ______Date: ______

2. I, the trainee, agree that the trainers have effectively facilitated the Near-miss Prevention Training.

Trainee signature ______Date: ______

To be completed by the Trainer:

3. I, a member of the team of trainers, confirm that this trainee has successfully completed _____ hours of the Near-miss Prevention Training.

Trainer signature ______Date: ______

4. I, a member of the team of trainers, agree that our team has successfully facilitated the Near-miss Prevention Training.

Trainer signature ______Date: ______

100 Near-Miss Prevention

Appendices:

USW Policy on Sexual Harassment A-2

Tony Mazzocchi Center Worker-Trainers and Worker-Centered Training A-3

Tony Mazzocchi Center Green Policy Statement A-4

Attendance Form A-5

Sign-in Sheet A-7 Cards for Activity 3, Task 1 A-9

Sample Forms A-29

Appendices A-1

USW POLICY on SEXUAL HARASSMENT The Steelworkers want to effectively educate all our members about the harm done to everyone when sexual harassment is tolerated in our workplaces. We also want to make sure we provide and maintain a harassment-free environment at all USW workplaces and activities. We have passed tough anti-harassment policies for all USW Conferences and Conventions, and we have negotiated policies to protect our members. These are not just words. We take them seriously. Cooperation, understanding and mutual respect must be the foundation of all interaction among trade unionists. The USW will not tolerate and will not condone behavior by its employees, or by others doing business on our property, such as vendors, if that behavior is likely to undermine the dignity or self-esteem of any individual, or if it creates a hostile or offensive environment. Sexual harassment is particularly demeaning and the following policy shall apply to allegations of such harassment.

SEXUAL HARASSMENT POLICY1

Sexual harassment is not a joke. It creates feelings of This policy is based upon a desire to mediate resolutions uneasiness, humiliation and discomfort. It is an expression of complaints in an amicable and non-adversarial manner. of perceived power and superiority by the harasser over Because, in most cases, the individuals involved are both another person. There are two principles fundamental to members of our union, emphasis will be placed on resolving complaints informally in the first instance. Where such the trade union movement: human rights and solidarity. resolution is not possible, a formal complaint can be Sexual harassment strikes at the heart of both. processed. A substantiated complaint will result in Sexual harassment is illegal discrimination in both the United appropriate action, up to and including termination of employment for USW employees. All complaints will be States and Canada. It is commonly defined as: handled in a confidential manner and all formal complaints (1) unwanted sexual attention of a persistent or abusive should be directed to the International President. nature, made by a person who knows or ought reasonably In addition to the contractual complaint and grievance to know that such attention is unwanted; or provisions governing USW employees, the International (2) implied or expressed promise of reward for complying has established a Committee on Sexual Harassment with a sexually oriented request; or composed of representatives from the International, exempt employees, SRU, USW Local 3657 and OPEIU Local 343. (3) implied or expressed threat or reprisal, in the form This Committee will be responsible for developing an either of actual reprisal or the denial of opportunity, for educational program on sexual harassment for all USW refusal to comply with a sexually oriented request; employees and for recommending procedures for responding to informal complaints under this policy.

(4) sexually oriented remarks and behavior which may The Committee will also provide for the investigation of any reasonably be perceived to create a negative, intimidating, complaints referred to it by the International President. hostile or offensive environment.

Unwanted sexually directed behavior can include: Adopted this 17th day of June, 1992,by the USWA International Executive  assault Board.

 physical abuse (touching, pinching, cornering) ¹This policy covers USW International employees in the United States and Canada. It does not apply to USW members generally since they are covered  verbal abuse (propositions, lewd comments, by policies established by their employers. However, USW members can sexual insults) request investigation of a claim of sexual harassment by a USW employee under this policy. The policy also does not cover Local Union officers and Local Union  visual abuse (display of pornographic material employees. However, Local Unions are encouraged to adopt similar policies. designed to embarrass or intimidate). The policy does apply to the conduct of others doing business on USW property, such as vendors. Some forms of harassment may not violate the law. For example, harassment allegations concerning an ²This includes complaints about conduct by Local Union officers or members International employee and a Local Union member would against other members where that conduct takes place at International USW Junctions. In such cases, the Local Union will be notified of the results of the normally not affect the member's employment or working investigation so that appropriate action can be taken by the Local Union. environment. But such harassment does violate the basic principles of the union. The USW considers sexual harassment of any kind a serious offense. Complaints of United Steelworkers harassment in the workplace and at USW activities will be Five Gateway Center investigated.² Pittsburgh, PA 15222

A-2 Near-Miss Prevention

Tony Mazzocchi Center Worker-Trainers and Worker-Centered Training

USW International Union, with its long Part of the task often includes history of environmental safety and looking at factsheets and reading health activism, believes that workers short handouts. are really the best resource for making 2. Report-Back: For each task, the our facilities safe and for protecting the group selects a scribe whose job it community from harm. To put that is to take notes on the small group belief into practice: discussion and report back to the  The training is designed to be workshop as a whole. During the conducted by USW rank and report-back, the scribe informs the file worker-trainers. entire workshop about how his or  Workers are the center of the her group tackled the particular learning process. problem. The trainer records these reports on large pads of paper in  Experience and knowledge front of the workshop so that all can of the workers in class is refer to it. After the scribe’s report, considered one of the most the workshop is opened to general important resources for discussion about the problem at education in the class. hand. Trainers, acting as facilitators and 3. Summary: Here the trainer using the current workbook as a highlights the key points and brings resource and guide, lead the class up any problems and points that through activities which refresh may have been overlooked in the and reinforce topics dictated by report-back. Good summaries tend the regulations. to be short and to the point. Worker-Centered Training is based Worker-centered training is based on on Activities. An Activity can take the idea that every workshop is a place from 30 minutes to an hour. Each where learning is shared. Learning is Activity has a common basic structure: not a one-way street, running from 1. Small Group Tasks: The trainer to worker. Rather, worker- workshop always operates with centered training is a structured people working in groups at tables. procedure that allows us to share (Round tables are preferable.) Each information. It is based on three Activity has a task, or set of tasks, learning exchanges: for the groups to work on. The idea  Worker to worker; is to work together, not to compete. Very often there is no one right  Worker to trainer; and answer. The tasks require that the  Trainer to worker. groups use their experience to tackle problems and to make judgments on key issues.

Appendices A-3

Tony Mazzocchi Center Green Policy Statement The environmental and health and safety movements were born together during the 1960s. The very first health and safety training programs in the country were called “Hazards in the Workplace Environment.” The TMC believes that the only difference between worker health and safety and the environment is the facility fence. Therefore, it is the policy of the TMC to integrate environmental concerns in all of our programs and in the ways in which we carry out our training. The TMC strives to:

 Connect environmental and health and safety issues as much as possible in our training;  Look for workplace solutions that improve the environment outside of our facilities;  Work extensively to reduce the use of hazardous substances;  Encourage our employers to reduce energy use and reduce the emission of greenhouse gases that cause global warming;  Use recycled paper (at least 50 percent post-consumer content) when producing our training materials;  Encourage workbook reuse and recycling;  Promote the use of (union-made) non-chlorine paper products and environment-friendly toners and inks; and  Conserve paper by reducing the length of our texts.

A-4 Near-Miss Prevention

Attendance Form

Please print clearly

Name: ______Home Number: ______

Cell Phone #: ______

Address: ______Work Number: ______

______Email: ______

______Union/Mgt. ______

Employer: ______District # ____ Local # ______

Workplace Location: ______

Name of Class: ______Completion Date: ______

Instructors: ______

Would you like to be contacted at a later date to participate in an evaluation of this training’s effectiveness? (Circle one)

Yes No

Would you like to participate in additional trainings and programs offered by the Union and the TMC? (Circle one)

Yes No

Your Signature: ______

Appendices A-5

A-6 Near-Miss Prevention

SIGN-IN SHEET (PLEASE PRINT CLEARLY)

Class Title: ______Completion Date: ______

Location (City, State)/Facility: ______

Grant Program: ______Dist. & LU#: ______

Instructors: 1) ______2) ______

3) ______4) ______5) ______

Name (print first and last) Hourly Management

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Appendices A-7

A-8 Near-Miss Prevention

Cards for Activity 3, Task 1

Appendices A-9

A-10 Near-Miss Prevention

Near-miss Prevention, Edition 5.0, October 2013 Card 1 of 9

Appendices A-11

A-12 Near-Miss Prevention

Near-miss Prevention, Edition 5.0, October 2013 Card 2 of 9

Appendices A-13

A-14 Near-Miss Prevention

Near-miss Prevention, Edition 5.0, October 2013 Card 3 of 9

Appendices A-15

A-16 Near-Miss Prevention

Near-miss Prevention, Edition 5.0, October 2013 Card 4 of 9

Appendices A-17

A-18 Near-Miss Prevention

Near-miss Prevention Project, Edition 5.0, August 2013 Card 5 of 9

Appendices A-19

A-20 Near-Miss Prevention

Near-miss Prevention, Edition 5.0, October 2013 Card 6 of 9

Appendices A-21

A-22 Near-Miss Prevention

Near-miss Prevention, Edition 5.0, October 2013 Card 7 of 9

Appendices A-23

A-24 Near-Miss Prevention

Near-miss Prevention, Edition 5.0, October 2013 Card 8 of 9

Appendices A-25

A-26 Near-Miss Prevention

Near-miss Prevention, Edition 5.0, October 2013 Card 9 of 9

Appendices A-27

A-28 Near-Miss Prevention

Sample Forms

Appendices A-29

A-30 Near-Miss Prevention

Appendices A-31

A-32 Near-Miss Prevention

Appendices A-33

A-34 Near-Miss Prevention