An employee using a GFCI-protected extension cord had to push the reset several times to get the cord to work. The cord reset finally held, and he finished his task and returned the cord to the tool room. A few days later, another employee – using the same GFCI-protected cord – noticed the GFCI breaker on the cord was warm. He also had trouble keeping the cord from tripping when he plugged it in. The cord reset finally held, and the employee finished his task and returned the cord to the tool room. Within days, a third employee selected that same defective cord from the tool room. When he plugged it in, the GFCI module on the cord flashed in his hand. He received a shock and flash burn, resulting in his death.
Few people would imagine that an extension cord reset issue could rise to the level of a fatal event, but that precisely illustrates the value of a strong near-miss and good-catch program. Unusual events prompt reports and out-of-service orders, maintenance or repairs, preventing potential incidents.
Near Miss and Good Catch Defined
Before we go any further, let’s define near miss and good catch.
A near miss is an event during which no property is damaged and no personal injury is sustained, but where – given a slight shift in time or position – damage and/or injury easily could have occurred. For example, let’s say an employee grabs a 3/4-inch drill motor with a paint-mixer blade from a gang box. Previously, someone had removed and bypassed the switch. When the employee plugs it in, the drill motor starts unexpectedly, and the mixing blade causes the unattended drill motor to bounce wildly around the work-area floor.
A good catch is recognition by an employee of a condition or situation that had the potential to cause an incident but did not cause one due to corrective action and/or timely intervention by the employee. For example, a good catch occurs when an employee inspects a piece of electrical equipment prior to use and notices damage or an unusual condition, which prompts him to immediately tag the equipment out of service.
Why Do Near Misses and Good Catches Need to be Reported?
There are three primary reasons why these occurrences must be reported.
- Near misses good catches are warning signs that a piece of equipment, or even a policy or a procedure, is not working properly.
- Reporting these events will enable the employer to investigate each occurrence, so everyone can learn from the events and take action to prevent them from happening again.
- This reporting also helps management find trends and faults within the system.
Reports of near misses and good catches are not to be taken lightly; these situations need to be carefully investigated to determine the root causes, after which the appropriate controls must be implemented. In addition, near misses and good catches should be ranked by potential severity. If an incident could have resulted in an injury or death, a full investigation needs to be conducted. If the event created a condition that is less serious – such as a trip hazard due to an electrical cord – the hazard should immediately be removed and the risk should be communicated to everyone. Communication can be accomplished through a toolbox talk or, if the event is significant enough, a company wide safety stand-down.
Three Key Elements
There are three key elements of a successful near-miss and good-catch program.
The program – and its importance – must be well-communicated to employees. Workers also need assurance that the information being collected through the program will be used to learn and improve, not to punish anyone. At leading companies, near-miss reporting is genuinely encouraged, and employees are recognized in a positive manner for these reports.
- Ease of Use
The process for reporting near misses and good catches needs to be easy for employees. If the process is complicated, or if employees have to fill out too much paperwork, the process likely will not be used. At our company, the employee only has to notify his or her supervisor and/or safety representative, and that individual will take it from there.
Employers must provide details about actions taken in response to reported near misses and good catches. At our company, the information reported is tabulated in our trending software to identify leading indicators. Additionally, it is used to enhance training course materials, toolbox talk topics, safety alerts and meeting agenda topics.
The intent of a near-miss good-catch program is to learn a lesson once, implement appropriate controls and share information among project team members in order to prevent similar occurrences from happening in the future. It is important that we emphasize this and avoid doling out negative or critical feedback to employees when an event is reported, especially when it comes to good catches and near misses. Reporting should be encouraged, not discouraged. Negative feedback will only result in hesitation on the part of employees to report future events, or worse, they may decide not to report them at all.
Safety and operations professionals have the same goal: to have employees return home each day the same way they arrived on the job – healthy and uninjured. Tracking and trending good catches and near misses, in addition to incidents, are useful exercises to help us achieve that goal.
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