Incidents in the crane industry are like the old saying in basketball: no blood, no foul. If an incident does not hurt anyone, and there is no damage, then it will not be reported, unless the company has a good safety culture. The client will never know, and the company will learn nothing.
Near misses are the incidents that did not cause any damage, but might have. If one does not track near misses, if employees are not reporting them, then nothing will prevent them happening again. US philosopher George Santayana said, ‘Those who cannot remember the past are condemned to repeat it.’
Near misses are more frequent than accidents, and so offer an insight into what is going wrong. Because they might have been an accident, they provide evidence as valuable as that from accidents. To prevent the biggest accidents, companies need to reduce the number of near misses.
Accidents do not come much bigger than the Space Shuttle Challenger disaster, which exploded in 1986, killing seven astronauts. Engineers realised that rubber O-rings in the fuel booster rockets degrade in cold temperatures. Management was warned the night before about the potential for catastrophic failure if the temperature was 53°F or below. The temperature at lift-off was 36°F.
There are two potential reasons why this information was not acted upon. Perhaps the engineers did not get the right information to the right people. Or perhaps the right people did not make the right choice. The pressure to get the job done must have been a factor. The Rogers Commission, formed after the disaster, found that NASA’s internal processes were partly to blame in the accident. There is pressure in the lifting industry too: for one last pick on a Friday after an 80-hour week, just one lift that exceeds the capacity of the crane.
The Challenger explosion threw burnt and twisted fragments of the shuttle over a wide area. Seven people could not be interviewed about the incident because they were dead. In contrast, near misses are important because they indicate that something is wrong, but enable a much simpler investigation. We can talk to everyone involved. We can look at all the equipment involved.
There are two causes of accidents in the crane industry: unsafe behaviour and unsafe conditions. Unsafe acts, such as improper lifting or walking under the load, are done by someone; people are involved. Unsafe conditions include damaged slings and missing equipment guards. OSHA tends to look for unsafe conditions in the aftermath of an accident, because they can be more easy to spot. But fixing unsafe conditions does not necessarily resolve unsafe behaviour. Equipment or computers can be fixed. But people are unpredictable. One can train them, supervise them, and just when they seem to be under control, they do something unexpected.
Finding the root cause
Near misses should be investigated just like accidents. Investigators should answer the questions: Who, what, when, where, why, and how? Who used the equipment? Who was nearby? Who was supposed to have checked it? Who was supposed to repair it? Was it moved? Was it damaged? Why? Why was the action not being supervised?
It takes time and effort to work out the real causes behind the incident. Safety directors should of course be involved, but they are not the only people responsible for safety in the company. Everyone should be involved. Many big companies have an accident, and then fire the safety guy. That misses the point.
Companies are responsible for the selection, use and maintenance (broadly speaking) of equipment, materials and people to carry out a job. All could hide causes of an incident. Looking at people, there are three causes of human behaviour: knowledge, skill and attitude. The practice of behavioural safety aims to impress top managers’ values on their employees’ behaviour.
At the core of an incident is a root cause, the action or the equipment failure that caused everything else. A root cause may cause other things to happen, and the sequence of events needs to be reversed until the cause is found. Former OSHA employee Bill Smith, now NBIS vice president of risk mitigation, argues that as a rule of thumb accident investigators should expect to ask the question ‘why’ five times to dig down to the root cause. If someone was injured when they fell off a ladder, for example, one might ask: ‘Why did the man fall off the ladder?’ Inspection of the ladder revealed a rung was missing. Then one might ask, ‘Why did he climb the ladder when a rung was missing?’ ‘Why did he not know better?’ ‘Why was he not prevented by a supervisor?’ Sometimes the causes of accidents lie within higher management.
Finding the cause of an accident is not enough. If nothing is done after an incident, the lack of action sends a signal that the company does not care enough to prevent it from happening again.
Those investigating near misses should do four things. First, investigators should find the root cause, and document their findings. Second, they should fix the problem that caused the near miss. Fixes might include improving the inspection process; better employee safety training; clearer definitions of responsibility for employees and supervisors; and/or pre-job planning. Third, they should make sure that their reporting processes are up to spec. Is there a standardised reporting form and format for near-miss reporting? Do employees know how to fill out the form? Is the form available? Do filled-out forms reach the right people? Are they stored in the right place?
Fourth, they should publicise the incident and the fixes. These procedures should help make sure that it never happens again.
Heinrich’s incident pyramid proposes that most unsafe acts have no serious consequences; a small proportion result in injuries. Those with no effect are near misses. Source:
HW Heinrich, Industrial Accident Prevention:
A Scientific Approach, 1931.The safety pyramid
