Safety awareness on near miss

Indian Oil Corporation LimitedMathura Refinery

Examples of Near miss cases

Safety Awareness for Near miss reporting

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Immediate cause > Examples of Unsafe acts & unsafe conditions

Unsafe Acts• Operating equipment or machinery without permission• Defeating safety devices• Using defective equipment• Using the wrong tool for the job• Not using personal protective Equipment• Incorrect lifting techniques• Working while intoxicated

Hazardous atmospheres• Horseplay• Non-authorized personnel entering

restricted areas.• Falling or flying objects that do not

make contact with individuals nor cause any significant property damage.

• Exceeding equipment operating conditions.

• Deliberate/willful disobeyance to safety rules

Unsafe Conditions• Lack of guarding on machinery• Crowding workers into one area• Using the wrong tool for the job

Inadequate alarm systems• Fires & explosions risk• Housekeeping• Excessive noise• Inadequate lighting• Faulty equipment• Waste going into the wrong waste

stream.• Failure of any equipment  or

associated systems that are in place to protect health and safety.

• Failure identified by statutory testing.

• Failure of building facilities e.g lift lack of FW supply, room temperature problems etc.

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Unsafe Acts• Operating Vehicles without license or

authority• Bypassing safety interlocks without

authorization• Not tagging filed equipment when

isolated from electrical Sub Station• Starting maint job on

machines/pump/motor without isolating power locally and from sub station

• Opening of flanges on live equipment/line as happened on MJPL HSD line

• Miscoordination between two working groups in same enclosure

• Fueling running vehicles/cranes• Carrying a suspended load over

personnel.• Keeping files on floor in movement

area.

Unsafe Condition• Working on perforated roof or weak

roof • Blocked exit/entry/stairs• Undressed cable /wire of computer

/printer etc • Open manholes /Open trenches • Working in areas with oil spillage • Broken/missing wire net on revolving

fan/machines.

Immediate cause > Examples of Unsafe acts & unsafe conditions

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Basic Cause >Factors which can lead to unsafe acts or conditions

Personal Factors Job Factors

Lack of knowledge or skills due to inadequate training

Substandard equipment design

Improper motivation Poor equipment maintenance

Physical limitations of the worker Purchase of substandard equipment , material , tools and tackles

Distractions which interfere with the worker’s ability to concentrate on task

Unusual increases in usages ofequipment

Non-existent or poorly developed work standards

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Basic Cause of accident > Lack of Knowledge • Cable pulling job at height and walking haphazardly without providing

side railing/guide rope . Lack of knowledge of making extra provision for temporary work at height etc

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

• Leanings through SOP not available for critical equipment• Lack of skill in using specialized PPE like BA set, trolley BA set• Changes in process design, work methods, equipment, materials, etc.

not understood properly /followed in actual job performance• Instead of using DCP/CO2 fire extinguisher on electrical fire , using

water hose which can result in electrical shock• Lack of knowledge of plant /equipment by contract workers where they

work in running plants• Lack of knowledge of consequences of operating /playing wrongly with

local push button switches for stating /stopping motor in units and resulting in shutdown of equipment

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Lack of awareness occurs when there is a lack of alertness and vigilance in observing.This usually occurs with very experienced persons who fail to reason out possible consequences to what may normally be a good practice.

Examples continues: • Lack of knowledge of hazards of chemicals being transported /handled in

units or from stores and getting involved in spillage or wrong unloading.• Lack of knowledge in painting job and coloring paint on threaded bolts.• Entry of vehicles in restricted area by occasional drivers.• Lack of knowledge in selecting right lifting tackles for the right load.• Using unlabelled/ wrong labeled chemicals• Using medical/ lab equipment with overdue calibrations

Many more examples can be added

Basic Cause of accident > Lack of Knowledge

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Measures to improve Skill & Knowledge

Some of the measures are:

• Task Observations by superiors and knowledgeable persons • Planned Personal Contact by Superiors /controlling officers • Setting examples/ Role models through actual demonstration • Display of SOPs and observing adherence to laid down steps • Writing down steps of safe operation where task procedure is absent• Changes in process design, work methods, equipment, materials, etc. may

result in additional training needs.• One of the technique to check for lack of awareness is to ask more “what ifs” if

there is conflicting information or things don’t quite seem right.

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COMPLACENCY- The biggest threat

Complacency :This is where we become so self-satisfied that we lose awareness of dangers. It is sometimes called overconfidence and creeps in as we become more proficient at what we do. Awareness of this insidious contributing factor is one of the cause of accident and needs action to reduce it/prevent accidents.

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Basic cause > System related causes

 • Inadequate Leadership/Supervision • Inadequate Engineering • Inadequate Purchasing•  Inadequate Maintenance• Inadequate tools /equipment • Inadequate work Standards • Wear and Tear • Abuse or misuse • Other, specify----------

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Behavior based attitude

Apart from Knowledge and Skill, One more important thing that plays an important role

is

Attitude (Behaviour Based)

Vikas Bhandari

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7/8 Ice Berg is inside the water

only 1/8 Ice Berg is above the level of water

Vikas Bhandari

The iceberg

SEA LEVEL

KNOWLEDGE&

SKILLS

ATTITUDE

Unknown to Others

Known to many

Vikas Bhandari

The iceberg

SEA LEVEL

BEHAVIOR

VALUES – STANDARDS – JUDGMENTS

ATTITUDEMOTIVES – ETHICS - BELIEFS

Known to many

Unknown to Others

Wheel chocks not in placeat rear wheels of trailer

30,000 Hazards- Unsafe Acts

- Unsafe Conditions

30,000 Hazards- Unsafe Acts

- Unsafe Conditions

3,000 Near-Misses or First Aid

3,000 Near-Misses or First Aid

Lift truck is driven into truck trailer and trailer moves

300 Recordable Injuries

300 Recordable Injuries

Truck trailer moves, driver jumps to ground and sprains ankle

Truck trailer moves, driver jumps to ground and breaks leg

30 Majors

(LWCs and RWCs)

30 Majors

(LWCs and RWCs)

1 Fatal

1 Fatal

Truck trailer moves, driver jumps to ground and truck rolls over him/her

Real improvement requires a disciplined approach to understand and reduce root causes of incidents and injuries

The Hazard Pyramid

Du Ponts’Model

Actions & approach

To achieve safety excellence

Hazards- Unsafe Acts

- Unsafe Conditions

Near-Misses or First Aid

Recordable Injuries

Majors

(LWCs and RWCs)

Fatal

1

30

300

3000

30000

Shrinking the base by eliminating

unsafe behaviors and …

…shrinking the height by

establishing inherently saferprocesses and

practices

To improve Process & practices

Behavior