User talk:Swaggie73

Incident, Near Miss, Dangerous Event or Hazard AUSTRALIA VERSION
Incident, Near Miss, Dangerous Event or Hazard - By Mark Donnelly

We often hear the term “Near Miss” when talking about safety at the workplace, we also hear the term “Hazard”. Well this brief paper is going to help settle the confusion about what each term means using a simplistic approach. Note: the term “Near Miss” is not mentioned anywhere in the Workplace Health and Safety Act 1995 (although is mentioned in the Risk Management Code 2007)

What is a near miss? It simply means an incident that almost had the potential to cause and incident to people, environment, machinery or plant.

What is a hazard? A hazard simply means it is something with the potential to cause an incident to people, environment, machinery or plant.

Ok, I know you’re saying that they sound much the same; well you would almost be correct in saying this. These two terms can be mistaken to mean the same thing, and many people make this mistake. But it depends on one factor; did an incident occur or not?

What is an incident? An incident is an unplanned event resulting in, injury, ill health or damage or an incident resulting in a dangerous event

What is a Dangerous Event? A dangerous event means an event caused by specified high risk plant, or an event at a workplace or relevant workplace area, if the event involves or could have involved exposure of persons to risk to their health and safety.

I know, now you’re saying that a Dangerous Event sounds the same as a Near Miss! well yes, it could be classed as the same, as the words “Could Have” can easily be interpreted as a “nearly”, which would be a Near Miss. So I would class the term Near Miss as the same meaning as a Dangerous event, which would then be classed as an Incident, not a hazard.

Firstly let’s look at the difference between a near miss and a hazard. Picture 1 shows how simple it is to decide whether or not an HSE event is a Near Miss or Hazard.



Examples of a Hazard;

1.	You are walking along in a work site and see a shovel lying on the ground, you pick the shovel up and put it in a safe location; this is a Hazard.

2.	You are working under someone who is working at height and they are not using a lanyard on a hammer they are using; this is a Hazard.

Corresponding examples of a Near Miss;

1.	You are walking along in a work site and you have to jump over a shovel lying on the ground at the last minute to avoid tripping over it, you did not fall to the ground nor did you hurt yourself at all; This is a Near Miss.

2.	You are working under someone who drops a hammer, you see the hammer falling and if you don’t move it’s going to hit you. You jump out of the way to avoid being hit; this is a Near Miss. Even if you do not see the hammer falling and it lands next to where you are standing, just missing you, this is also a near miss.

As you can see by these two examples, the difference is that the hazard was noticed in time to make a change and the near miss was not.

In the first near miss example, the trip on the shovel should be reported as an incident, but noted as a “Near Miss” in the incident report/hazard register in a separate subsection, if needed for trending purposes. A near miss should not be a main title for a HSE event. Just because no injury occurred in this example, does not mean it was not an incident and should be treated as such. Keep in mind, you jumping over the shovel is in fact an incident.

Why do I class it as an incident? Because something happened outside the current task you were doing.

What do you mean by this?

Your task was walking across the worksite, you did not plan to see or even trip over a shovel; It was unexpected and unplanned, and resulted in you taking instantaneous action to avoid injury.

If the shovel was not in your direct path, but you had noticed it off to the side while you were walking along, it then becomes part of your task, which is to report it as a Hazard. The point to remember here is that you had time to think and act, thus making it part of your task.

When doing the investigation (if the near miss was serious enough to warrant an investigation) or filling out the hazard register (if classed as a non serious HSE event), the hazard (being the shovel) will be addressed and recommendations put in place to ensure the “Near Miss” won’t happen in the future.

Picture 2 is a common unsafe workplace, see how many near misses you can find.



There are no near misses in the picture above, they are all hazards. But, if the guy walking down the stairs at the last minute sees the spill and jumps over the spill because he has no time to stop, this is an incident categorised as a Near Miss or Near Miss Incident.

So in summary: in the work place there should only be Incidents or Hazards.

Near misses, dangerous events, close calls, etc are all Incidents.

Noticed hazards, things that don’t look safe, could happens, etc are all Hazards. Statistics seem to tell us that for around 300 near misses, there is one serious injury. I would have it a guess that there would be a few thousand hazards before a serious incident.

What does this tell us about incidents? Using these figures, if you reduce the number of hazards on the worksite, then probability tells us that we will reduce the number of total incidents (both actual and near misses) in the work place also.

I hope this brief paper clears up some of the questions and makes your worksite incident free.

Hazard Registers
'''The Problem with Hazard Registers For; DEPARTMENT OF JUSTICE AND ATTORNEY-GENERAL Office of Fair and Safe Work Queensland - Advisory Services Paper presented by; Mark Donnelly'''

Purpose of this paper

The objective of this paper is to question the principle that we base a hazard score on predicting factors such as probability and exposure. Trying to predict when an event might occur or guess probability cannot be done; no-one can predict an event in the future. These questions are therefore not fundamental questions, as risk assessments on various degrees should be conducted prior to undertaking any task. It is therefore my belief that the only real accurate way to rate a hazard is by looking only at the consequence.

Most hazard registers being used in workplaces today are not being completed correctly due to the confusion of guessing to many “what ifs”. Due to this confusion, many companies are allowing medium to high risk activities to be done, all because a score is classed as low risk. This is opening up many legal ramifications if inaccurate documentation is compiled.

What I would like to achieve by the end of this paper is;

Firstly; I want to prove that the only way to ensure a hazard is calculated/scored correctly is by looking at the current consequence. The hazard consequence validates the task for it to be done safely, and that the proposed and agreed risk control measure to mitigate that risk makes the task acceptable to proceed.

Secondly; I want to prove that a score (if a score is required) should only be used as a way to trend how well the company is implementing controls to mitigate the risk. The score is calculated using 7 work controlled measures.

Thirdly; I want to prove that no level of risk or ranking of control measures should be higher than acceptable on a SOP, JHA etc. I believe that accepting any level injury is not acceptable. What is a Hazard Register

Basically a hazard register is a tool used by supervisors or management to manage hazards in the workplace outside standard operations or non routine tasks. It allows supervisors or management to implement and validate control measures that will reduce the risk to as low as practically possible, or to an acceptable risk level for that industry. The register is usually the first formal step in calculating the risk for a non routine task before the hazard is either closed or escalated in varying degrees to a more formal risk assessment process. The main function of a hazard register should be to list those hazards that are outside the normal scope of operation. Meaning, these would be hazards observed outside the general scope of work or work tasks or outside what is commonly known as a Standard Operating Procedure (SOP). I will be referring to an SOP as including a risk assessment or job hazard analysis (JHA).

All specific job tasks listed in a SOP or JHA should have corresponding hazards noted for each step. These hazards should have all been reduced down to an acceptable level by way of control measures before the task has been allowed to commence, therefore these hazards should not be entered into the hazard register. The exception here is if a particular hazard in the job task has not been reduced down to an acceptable level or cannot be closed in time and is still rated as a risk. This type of example would go into the hazard register. Then once this particular hazard has been closed, the control measure can be included into the SOP or JHA to which then the task can then commence at an acceptable risk level. NOTE - All new corrective actions should be approved by a competent supervisor before that task is started by way of the using the JHA. This approval validates the right to proceed with the task in an approved safe way and safe guards against any legal implications if an injury occurs while conducting that task.

Another way the hazard register should be used is in general observations of potential risks on a worksite. These are risks that are outside the scope specific work task activities, meaning hazards that do not fit within SOPs or standard work activities. These are hazards such as warn parts, loose items, slippery surfaces, oil leaks, broken parts, noisy equipment, damaged tools, wildlife, terrain, weather etc etc.

Confusion and Misunderstanding

There seems to be a lot of confusion and misunderstanding when determining the probability and exposure of a hazard or near miss incident at the workplace, and or giving an appropriate close out timeframe on a particular corrective action. It’s not hard to understand why it’s so confusing to get it right if you understand that predicting the future is near impossible to do. The likelihood of having an accident driving to work is rare, but everyone knows (in various levels of seriousness) that each time you drive a vehicle could be the day that someone t-bones you through a red lighted intersection.

Driving a car has a certain level of acceptable risk; such as getting a blow out, car suddenly catching fire, running off the road because you fell asleep, someone colliding with you etc. We still drive knowing that at any time driving the vehicle could be your last day alive. So why do we drive a vehicle if it could kill us? well, other than the car being a very important form of transport and we need to travel vast distances for work etc (a necessary evil so to speak), we have a myriad of control measures that are in place to make driving as safe as possible, such as well designed cars, driving tests, seat belts, airbags, road rules and police. These control measures make the task of driving an acceptable practice, even though the task of driving is in itself still a dangerous activity regardless of any of these measures. Using control measures is what makes a task safer, and I will return to this topic further in this paper.

In the workplace, just like driving a car, there are many hazards that can cause an incident at anytime, and depending on what type of work you are doing, all jobs have or should have certain levels of acceptable risk. These risks can be categorised in two ways; overall job risk and singular job risks. Overall being; an overview of your industry i.e. working in construction is dangerous and or singular being; a task you do inside that industry i.e. using that particular tool is dangerous.

A company should run 2 forms of hazard registers

Master Organisation Hazard/Risk Register; over-all risks in the industry. This hazard register should be available at all times and to all employees. Hazards such as wet weather, hot days, working on earth ground, what PPE is to be warn etc, should all be documented in this register.

Site Specific Hazard/Risk Register; Site specific risks in the organisation. This register is available to a specific area or group within an organisation. All hazards outside standard operating procedures, hazards not listed on the master hazard register such as, equipment damage, warn parts, loose items, slippery surfaces, oil leaks, broken parts, noisy equipment, damaged tools etc. These specific registers are under constant review by management and any hazard that may affect the whole organisation would then be added to the master register. I make a point here that a Hazard Alert or Safety Meeting Topic should be instigated in each one of these instances.

What do I mean by acceptable risk?

Point 1; Take a secretary; part of their job is stapling, binding, and shredding paper, an acceptable risk in this job is suffering from the odd paper cut. The secretary knows this can happen and will happen at any time, but she does her job anyway with a level of comfort knowing this fact.

Point 2; Take a SAS soldier; part of their job is dealing with guns, explosives, and terrorists, an acceptable risk in this job maybe being shot. The SAS soldier knows this can happen at any time, but he does this job anyway with a level of comfort knowing this fact.

My points above obviously have very different levels of risk and consequence outcomes, but in context of the expectation of each job, they are acceptable. If they were not acceptable, you or society would not allow the job to occur. I could not see the secretary wanting to be shot at. It is unacceptable that a secretary would be in a position to be shot at, unless it was in her job description.

Everyone will have a different perspective when deciding on the probability and or exposure for any particular observed hazard in the workplace. Ask one person what the probability would be of a person falling down from a 2 meter ladder, and they may say “1 in 100 chance” ask another person and they may say “could happen today”. Similar can be said when asking people the question; what is the occurrence of someone climbing a ladder. The answer can be anything from now to infinity. It all depends on the perspective of the person answering the question and or how educated or experienced the person is in making the “educated guess”; I use educated guess in the term that it is still a guess.

All workplaces today expect zero injury, so using this point aggressively; a cut finger from using a knife is an event that a work place does not want to happen as much as someone falling to their death. (Please take my point on the context, not severity of; meaning that it is obvious to anyone that a company would prefer a cut finger over a death, although neither is acceptable if they can be avoided). If all workplaces expect or advertise a zero injury policy, all incidents should be treated the same. Meaning; if there is a chance that you could cut your finger doing the “non-acceptable” task, then I would not allow you to do the task in the first place. Likewise if I think you may die doing the “non-acceptable” task, again, I would not allow you to do that task.

This is why every job that is conducted in an organisation should have an acceptable level of risk. Going back to the secretary that gets paper cuts when handling paper; if the company feels this injury is acceptable, then having a policy saying to wear gloves while handling paper is not needed.

A hazard remains an “incident in waiting” when the hazard is still present. My philosophy on this point is based on the fact that an “Incident” regardless of any law of probability or exposure, can occur at “any time” while the task is being completed. Trying to calculate a risk score by saying that the likelihood of an incident occurring is 1 in 100 years is mistaken against the fact that the incident can occur whenever you are undertaking that task. I know that every time I bang a nail in a piece of wood, the chances of me hitting my finger is going to be (in my mind) 1 in 1000, but yet the first nail I hammered in, I hit my finger; how is that possible? Did I let the law of probability cloud my judgment? If I had of said that the chance of me hitting my finger was that I could do it the very first time, I doubt I would have hit my finger at all, as I would have been more vigilant and careful the first time. Needless to say even though I misjudged the probability, it was still acceptable that I could do the job as I know that people do hit their finger when hammering, it is an acceptable risk of hammering in a nail.

We should use the terms Probability and Exposure collectively in the industry we are covering. Looking at the SAS example, we can work out from history that being shot is for example a 1 in 100 chance. When talking about the risk of the current operation, the risk is that you can be shot while carrying out that particular operation; the law of probability cannot be used for one task, because each time they conduct an operation could be the day they get shot. If there is a chance of an incident occurring from an observed hazard, it would be best practice to treat the hazard as if it could happen today and now if the task is being done, and by using a “worst case injury” scenario, even though it might not happen in 100 years.

For some reason unbeknown to me, we seem to have a need to have a mathematical score or some calculated level to tell us how serious a hazard is. Keep in mind this calculated mathematical score is based on human judgement, and we all know our judgement is often very flawed; which is the main reason people have incidents in the first place.

Making a guess that the probability of an incident occurring is 1 in 100 years should not be used to calculate a prediction of an event. Why do you need a score to tell you that the risk is low or high? If I say the exposure is low, what does that matter? The real consideration is; what will happen to me if I do this task today, and is it acceptable to proceed.

If I was to climb a ladder up a 50 meter communication tower, do I really care that my chance of falling is 1 in 100? No. Do I really care that I only climb the ladder once a year? No. What I do care about is; what have I done to make sure I don’t fall today. I have been trained to climb a ladder, I am fit to climb the ladder, and today I am wearing a safety harness that will be attached to ladder as I climb. There is no way I can possibly fall to my death because of what control measures are in place. I have done as much as practically possible by way of implementing control measures to make the task acceptable. Laws of probabilities do not matter, nor does the fact that this task does not get done very often, what does matter is that I am climbing this ladder today and I don’t want to fall. The injury outcome to me is what matters the most, and falling to my death is not something I want to take a risk on. Likewise if you are a supervisor allowing a person to climb this ladder without control measures, you are the one accepting to take on the risk liability, and is it worth putting someone in harm’s way? No.

The commonly used Risk Score Calculator and risk score matrix (appendix 1) points out the oversight I have been explaining. In this example a hazard has been observed; a bolt looking like it is coming out of a pulley/block in a crane that is not used often. The pulley weighs 20kg and if it does come loose it will fall from a height of 50 meters, and anyone standing under the falling pulley would be killed instantly. But doing the calculation using laws of probability and exposure, the score comes up as a LOW RISK. How can a death be low risk and acceptable or even tolerable? The hazard has been observed, it has been documented, therefore it is a risk, and this risk needs to be dealt with by way of practical control measures on what can happen now.

In this example, an investigation needs to be carried out to find out why the bolt could fall out. There are many innovations and procedures that can stop such things as bolts from falling or coming out; such as safety pins and resin glues. Also maintenance and pre-check schedules can also be done to insure the bolt is regularly checked and secure. An engineer may rate the bolt to be fitted with a resin to secure it in place, but resin can degrade and break down over a period of time and often at different timeframes, depending on climate, vibration and use etc, so these type of factors also need to be noted.

I know, I may be re-writing the basic principal here of the known and accepted risk score calculator concept and various other hazard registers, but I cannot see how the current approach in dealing with low probability and rare exposure risks can score low when the worst case consequence is a fatality. Currently, any incompetent employee that inputs incorrect data into the hazard register will see a level show as a colourful green (Low Risk), and then say, “It’s only a low risk, we do not have to worry too much about this hazard”, but in fact, it is more serious than the calculation shows.

It is often these misjudged hazards that cause the serious incidents. How many incidents do you hear of that are explained as “I never thought that would happen” or “What was the chance of that happening” well yes, 1 in 100 years, but they did not identify the laws of probability; in that there is no way of knowing the exact results that you are going to get in any particular situation. You may be applying all the laws of being safe today, yet you may be having an unsafe day or a safe day. There is no way to predict the outcome for any particular occasion. Just like guessing the flip of a coin.

A hazard register should only be used as a way to document hazards in the work place outside what is known as already acceptable hazards. By this I mean continually documenting the same hazard at a workplace is not how the register should be used. If the hazard is documented for a second time for the same event, repair etc, then the company has failed to close the hazard the first time it was documented. I do not believe that common hazards that are known in the industry should be noted on a site specific hazard register more than once. Continually saying that a hammer may fall on a construction site is a waste of time. All construction workers understand that things such as hammers may fall from a height; this is part of my acceptable risk theory. To mitigate the risk of injury, the construction industry as a whole requires that a hard hat (amongst other controls such as lanyards an safety nets) must be warn and used. Wearing the hard makes the risk of being hit by a falling hammer acceptable.

All other known hazards should be included in standard operating procedures (SOP), work method statement (WMS) or Job Hazard Analyse (JHA) etc. These hazards should be discussed before any task is carried out to ensure that all personnel in the work party are familiar with the task and corresponding hazards, and that there are no questions.

Note; If a near miss or dangerous event is observed, then it is not a hazard but an incident, therefore an observed near miss or dangerous event would go into the incident register (although some companies rule both incident and hazard in the same document). The incident register would deal with any hazards. Any hazards that may affect the whole organisation would go into the master hazard register.

Close Out Timeframes and Priority

The level of consequence is what should determine the priority of a particular hazard. This decision should be made by competent person/s that have a very good understanding of the industry and on the task. Saying a critical hazard must be closed out in 14 days and a moderate hazard in 60 days etc, gives the operator/company the chance to do nothing until the closing date gets closer i.e. the bolt has been reported, death is a possible outcome, the company has nothing in place to check or maintain the bolt in the meantime, and because it has a low risk score (as the chance is very unlikely and may never happen), no-one does anything about it. The next day, ‘Murphy’s law’ comes into play and the bolt falls out, and an employee lays dead. OH&S visits to investigate the death and the company representative says, Oh... the register said it was a low risk hazard and that we had 14 days to fix it. This answer is not good enough in today’s working environment. An employee is now dead because the company representative did not fully understand the current consequences of the hazard, and the register did not calculate the risk against what the company had in place to lower the risk down to an acceptable level.

All hazards should be closed out as soon as practically possible in a level of consequence order, high first then low second etc. Keep in mind here acceptable risk. If a hazard is classed as a high risk, then that task should not be done, it’s that simple. As I have mentioned throughout this paper, if a boss asked you to climb the 50 meter ladder without wearing a safety harness, would you do it? No.

The problem with most hazard registers is that if you have for example 3 critical hazards to deal with at once, a supervisor, manager, HSE representative etc maybe unsure how to prioritise them. But in basic terms, all are critical and all need to be closed before that task is carried out. Instead of guessing the exposure (how many times the task is done in certain timeframe), the register (appendix 2) that I have developed simply asks for the date when the hazard actually becomes a “real time hazard” or when the task needs to be done next. This date is what prioritises the hazards and tells you the time frame that the hazard needs to be closed by. Keep in mind here, that no task should be done if it is unacceptable and or outside the organisations acceptable hierarchy of control. So in real terms you cannot do the task until the hazard has been closed or returned back to this acceptable level.

In the second part of my register shown in (appendix 3), even though a hazard may cause a fatality (worst case), the calculations that provide the company score are related to what the company has in place to mitigate the risk in the first place, i.e. SOPs being used, training, what engineering is involved etc (hierarchy of controls). If in the ladder incident example I used earlier, the company is using a fully engineered ladder, has policies and procedures in place, training and has available appropriate PPE and safety gear, nothing more can be done to improve safety and the hazard becomes a low score or acceptable. If no controls are in place, then the score rises and becomes high.

This score is only used to trend the controls against the hazard. If the scores are continually showing up as high (between 3&7) then the organisation is not being proactive in their Safe Systems of Work. A further trending scale would most likely show a company that is consistently scoring high, to have a higher frequency of incidents.

What this new register does is take into consideration the company’s “Safety Attitude” or “Safety Culture”. I.e. Company (A) has very high expectations towards safety, has a great safety culture and has everything in place to ensure safety comes first; this is a company that will constantly have low risk scores. Company (B) on the other end has very low safety expectations, poor safety culture and cannot even supply workers with a safety lanyard, will score constantly high.

This score makes it very easy to observe how well an organisation, department, group or work team is doing in regards to safety and would be a the first thing senior members, governmental agencies and clients would look at to check for poor safety performance within their organisation. Instead of having a culture of “target counting” the most hazards observed in a year, they would use the overall score. This would have to have more merit the shear numbers.

A New Register Concept

This new register simply cannot be fooled into giving a risk level or score based on what one person deems to be either a high level hazard, or a low level hazard derived from guessing probability or exposures. This principle is simply based on worst case scenario thinking and as mentioned, only competent and industry experts should fill out the hazard register.

Note; I am currently working on a way to avoid further possible human fault by developing a list that can cover possible consequence based on the job task and job risk acceptance. For example; 1.	Climbing a 10 meter ladder = Serious Injury 2.	Climbing a 2 step ladder = Moderate Injury

The closure of hazards in my register is determined only by the fact the hazard has been reduced back to As Low as Reasonably Possible or Acceptable by Management.

Although my register may look a little more complicated at first inspection than most registers being used today, I feel that due to the drop down menus offered, not having to guess probability or exposure the process is made far more user friendly and a employee will quickly understands how to complete it.

Alterations points;

a)	Have taken away Probability – I does not matter when an incident from a hazard may happen or how often one think it may happen. The issue is; the hazard has been raised it needs to be dealt with, by appropriate means before the task can be completed. b)	Have taken away Exposure – I does not matter how often the task may be done with the hazard present. The issue is if a hazard has been raised it needs to be dealt with, by appropriate means before the task can be completed. c)	Lists the hazard to – This is a way to conduct tending on what are the main hazards onsite over time, you can use this to target areas for improvement i.e. we seem to be having a lot of environmental hazards. d)	Taken away timeframe close out dates – My opinion is that it is just not needed. All hazards should be closed out as soon as practically possible or before the task is started. At KPI time instead of overdue, it lists all hazards that are above a Moderate score that are still open, it calculates days since hazard was raised. This should be sufficient to see if hazard close out is/was acceptable by company standards. e)	It asks what the corrective action was to close hazard - Again used for trending i.e. Lack of training seems to be the issue

Can include other trending columns such as;

a)	The Zone of the hazard b)	The Operation the hazard is part of c)	Experience level of person finding hazard

Simplified Risk Matrix

There are many risk matrixes being used alongside the risk score calculator to calculate a hazard such as shown in (appendix 4). Why these fail has been explained throughout this paper; i.e. allowing for human guesswork to decide on levels, scores and close out timeframes. But what I want to further elaborate on is the zero injury policy of almost every company today.

I believe these matrixes should only be used as an action matrix. This would be to make reference to whom in that organisation has the overall authority to sign off on the single hazard or whole task and to whom should be involved in the assessment process to reduce the level down to being acceptable.

Note on being acceptable; the term acceptable throughout this whole paper is described as “no consequence is acceptable” or “acceptable by approval only”. Incidents happen that had consequences, but hazards observed should not have unacceptable consequences. This point can be easily proved by a simple question; are you prepared to suffer an injury or damage to something if you do that task? If you answer yes, then it is acceptable, if you answer no, then it is not. No-one can be really sure of a consequence until an incident occurs, but it is the only thing as mentioned we should use for a priority.

You will see in my risk matrix (appendix 5)., that every level of consequence has an action, which is to stop the job and reduce the level down to As Low As Reasonably Practicable (ALARP). In my register the lowest level is classed as acceptable, not low. The simple reason for this is when conducting a SOP, JHA, WMS, safety meeting, stop the job etc, for which you need to do for every new task, the person/s evaluating the hazard needs to do this before the job commences anyway. So stopping the job actually occurs for each new step so to speak. A hazard outcome in an SOP/JHA etc, even one classed as low, should not be acceptable. It should make no difference whether the hazard is high or low. Again it comes down to the acceptability of the risk within that workgroup or organisation

There should only be one process to managing risk/hazards in the workplace and this process should be outlined in a risk management procedure. I.e. stop the job, evaluate the risk, decide on a control measure, and then approve. This process should be used for every hazard. If it has been reduced to acceptable, then the task can be done.



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