Near-Miss Reporting: Uncovering Deeper Safety Issues

While on a family vacation I was discussing my work in safety with Paul, my brother-in-law.  He is a software engineer with a major defense contractor.   He shared that his worksite has earned VPP status and that the people there are very proud about the achievement.  I asked him about the VPP process and if he had much involvement given his type of work.  Paul smiled and told me that beyond seeing posters and newsletters about safety, he hadn’t been involved nor even very interested until recently.  To him safety had been buckling his seat belt and not speeding too much.    Then he sat forward in his chair and said “except for something just recently”, and began to tell me about it. 

The Incident

Every workday Paul enters the office building through the same entrance.  This day was like any other, briefcase in hand and swiping his security badge to gain entry.  As he proceeded he tripped on something, stumbled forward and caught himself before falling.  Looking back at where he had just walked, he noticed that the fixed floor mat system, designed to remove water and grit from shoes, had a section of frame that appeared to be sticking up or loose.  This must have been what he tripped on.

Just then a custodial employee that he had talked to before came up to him and said, “You know you should file one of those Near-Miss Reports for that.”   Paul had no idea what the custodian was talking about, so he asked her about it. 

The way the story went, the custodian had noticed the problem with the mat system when it was first installed a several weeks ago and reported it verbally to her supervisor.  She cleans this section of the building , mopping and sweeping this specific section several times daily.  The supervisor said he’d look at it, but nothing had been done to correct the obvious problem.  Paul said that the custodian went on to say that she had observed several people trip, thankfully with no injuries…..yet.

The custodian thought that because she was such a lowly employee that her supervisor and management discounted her input.  She said, “If a high level engineer like you reports it I bet they’ll do something about it.”  As they talked, she followed him to his work area a short way down the hallway and showed him how to access the Near-Miss Report system on the company’s internal website.

The Near-Miss Report

Filing the report was easy: name, ID, job title, department, and then a description of what Near-Miss happened and some more descriptive detail.  Paul read the report and then hit the SUBMIT button.  The custodian thanked him and went on her way back to work.  Paul had no idea what would come next.

Within 15 minutes he received a phone call from the safety department. They wanted to know if he had been injured or intended to file an injury report.  No injury, no report.  They thanked him for the report and told him that he would be informed of the progress in correcting the problem.  Next, the director of his department came to his office to see if he was OK.  Surprised, Paul said that “of course I’m OK”.  Then, the director asked Paul to take him to the area and show him the problem.  When the got to the entrance the safety manager and a person from facility engineering were already there.  Within a couple of minutes a sign was put on the outer door warning of the trip hazard and an orange cone was placed over the loose framing.  After everybody there looked at the problem and decided it was legitimate, it was decided that the facility engineer would follow up with the contractor and have the frame replaced.  Problem solved!

Later that day Paul got an email from facility engineering (copying several other people) letting him know that the contractor would be in the next day to replace or repair the mat framing.  Again, he was asked if he was feeling OK.   Later that day, as he left the office a security person was at the door warning him and others to watch their step due to the loose flooring.  Paul found this all quite amusing.  After all, no one had been hurt.

Sure enough, when Paul showed up for work the next morning the contractor was already there and nearly finished with the new frame installation.  Problem solved…or was it.  When he he got to his desk and then later that day Paul received email progress updates.  Then, the next day he receive a copy of his initial Near-Miss Report with the corrective action listed and signed by facility engineering, the safety manager, and his department director.  All this over a loose floor mat frame! 

Uncovering Deeper Safety Issues

When he filed the Near-Miss Report there was a section asking if anyone else knew about or saw the problem.  Paul answered “yes’ and mentioned the custodian and her supervisor knew about it.  What happened next opened Paul’s eyes to just how serious his company is about safety.  About a week later he was asked if he could schedule to be part of a meeting in the safety department.  The meeting was to discuss the near-Miss Reporting system, reasons or barriers to reporting, how to increase reporting, sharing what is learned from the reports, and something they called “safety culture”. 

At the meeting the safety director explained that the floor mat problem should have been corrected immediately when it was reported to the supervisor.  For some reason the supervisor discounted the problem and didn’t take any action.  He said that he had thought about it though and figured he’d write up a work order later.  Later never happened.  The custodian feared that if she wrote it up herself that her supervisor would get mad and maybe fire her.  They discussed a few other situations that were similar, where fear or complacency got in the way of reporting, and what might be done about it.

Paul had been included in this meeting because as a more senior software engineer his thoughts and ideas were valued.  When he was told this he recalled what the custodian had said to him, ” because she was such a lowly employee that her supervisor and management discounted her input”.  Maybe she was right.  He shared this information, as well as how eager and helpful the custodian had been.  The meeting lasted an hour, focused on the barriers to reporting, taking action to remedy hazards, the fears that are inherent to supervisor/direct reporting relationships, and how to increase reporting.

Paul was asked to attend one other meeting on the subject.  Here he learned about a new training initiative for all employees, including all levels of management.  It would focus on the importance of driving fear from the organization, similar to some of the quality and “lean” training they had received earlier.  It seems that there were much deeper safety issues and problems than a simple loose floor mat frame.

Expand The Number Of People Involved In Safety

When Paul finished telling me the story I asked him what he thought about the whole ordeal.  He was glad that he had made the report and now actively looks for safety stuff that could be reported.  Before, he never would have thought to even look for, or much less report hazards or near-misses.  He said he now feels involved in the VPP effort and really looks out for others.  Then he asked me if I knew why they are called them “near-misses” and not “near-injuries” or “near-hits”.  I smiled and told him it was time to go to the beach and enjoy the afternoon.

Near-Miss or Near-Hit reporting can have a huge impact on your safety program.  Done in a non-punitive, learning and rewarding manner can greatly increase the number of employees actively involved.  Paul provided a great example of how the system can work well.  Though the story was a bit long for a blog, I hope you found it helpful.