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Safety Awareness for Near      miss reporting Examples of Near miss cases     Indian Oil Corporation Limited           Mat...
Immediate cause > Examples of Unsafe acts & unsafe conditions     Unsafe Acts                                   Unsafe Con...
Immediate cause > Examples of Unsafe acts & unsafe conditions     Unsafe Acts                                Unsafe Condit...
Basic Cause >Factors which can lead to unsafe acts or conditions             Personal Factors                          Job...
Basic Cause of accident > Lack of Knowledge•   Cable pulling job at height and walking haphazardly without providing    si...
Basic Cause of accident > Lack of KnowledgeLack of awareness occurs when there is a lack of alertness and vigilance inobse...
Measures to improve Skill & KnowledgeSome of the measures are:• Task Observations by superiors and knowledgeable persons• ...
COMPLACENCY- The biggest threatComplacency :This is where we become so self-satisfied that we loseawareness of dangers. It...
Basic cause > System related causes•   Inadequate Leadership/Supervision•    Inadequate Engineering•    Inadequate Purchas...
Behavior based attitudeApart from Knowledge and Skill, One more important thing that plays animportant role               ...
Vikas Bhandari                 11
7/8 Ice Berg   is inside the wateronly 1/8Ice Berg is above the        level of water
The iceberg                        KNOWLEDGEKnown to many               &                          SKILLS                 ...
The icebergKnown to many        BEHAVIOR                                                 SEA LEVEL   Unknown to Others    ...
Du Ponts’Model   Real improvement requires a disciplined approach to understand           and reduce root causes of incide...
Actions & approach          To achieve safety excellence Shrinking the base by         1                           To impr...
Safety awareness on near miss
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Safety awareness on near miss

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Safety awareness on near miss

  1. 1. Safety Awareness for Near miss reporting Examples of Near miss cases Indian Oil Corporation Limited Mathura Refinery
  2. 2. Immediate cause > Examples of Unsafe acts & unsafe conditions Unsafe Acts Unsafe Conditions• Operating equipment or • Lack of guarding on machinery machinery without permission • Crowding workers into one area• Defeating safety devices • Using the wrong tool for the job• Using defective equipment Inadequate alarm systems• Using the wrong tool for the job • Fires & explosions risk• Not using personal protective • Housekeeping Equipment • Excessive noise• Incorrect lifting techniques • Inadequate lighting• Working while intoxicated • Faulty equipment Hazardous atmospheres • Waste going into the wrong waste• Horseplay stream.• Non-authorized personnel entering • Failure of any equipment or restricted areas. associated systems that are in place• Falling or flying objects that do not to protect health and safety. make contact with individuals nor • Failure identified by statutory cause any significant property testing. damage. • Failure of building facilities e.g lift• Exceeding equipment operating lack of FW supply, room conditions. temperature problems etc.• Deliberate/willful disobeyance to safety rules 2
  3. 3. Immediate cause > Examples of Unsafe acts & unsafe conditions Unsafe Acts Unsafe Condition• Operating Vehicles without license or • Working on perforated roof or weak authority roof• Bypassing safety interlocks without • Blocked exit/entry/stairs authorization • Undressed cable /wire of computer• Not tagging filed equipment when /printer etc isolated from electrical Sub Station • Open manholes /Open trenches• Starting maint job on • Working in areas with oil spillage machines/pump/motor without • Broken/missing wire net on revolving isolating power locally and from sub fan/machines. 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. 3
  4. 4. Basic Cause >Factors which can lead to unsafe acts or conditions Personal Factors Job Factors Lack of knowledge or skills Substandard equipment design due to inadequate training Improper motivation Poor equipment maintenance Physical limitations of the worker Purchase of substandard equipment , material , tools and tackles Distractions which interfere with the Unusual increases in usages of worker’s ability to concentrate on equipment task Non-existent or poorly developed work standards 4
  5. 5. 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 5
  6. 6. Basic Cause of accident > Lack of KnowledgeLack of awareness occurs when there is a lack of alertness and vigilance inobserving.This usually occurs with very experienced persons who fail to reasonout 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 calibrationsMany more examples can be added 6
  7. 7. Measures to improve Skill & KnowledgeSome 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. 7
  8. 8. COMPLACENCY- The biggest threatComplacency :This is where we become so self-satisfied that we loseawareness of dangers. It is sometimes called overconfidence and creeps in aswe become more proficient at what we do. Awareness of this insidiouscontributing factor is one of the cause of accident and needs action to reduceit/prevent accidents. 8
  9. 9. 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---------- 9
  10. 10. Behavior based attitudeApart from Knowledge and Skill, One more important thing that plays animportant role is Attitude (Behaviour Based) 10
  11. 11. Vikas Bhandari 11
  12. 12. 7/8 Ice Berg is inside the wateronly 1/8Ice Berg is above the level of water
  13. 13. The iceberg KNOWLEDGEKnown to many & SKILLS SEA LEVEL Unknown to Others ATTITUDE Vikas Bhandari
  14. 14. The icebergKnown to many BEHAVIOR SEA LEVEL Unknown to Others VALUES – STANDARDS – JUDGMENTS ATTITUDE MOTIVES – ETHICS - BELIEFS Vikas Bhandari
  15. 15. Du Ponts’Model Real improvement requires a disciplined approach to understand and reduce root causes of incidents and injuriesTruck trailer moves, driver jumps to ground and truck rolls over him/her 1 The Hazard Fatal Pyramid Truck trailer moves, driver jumps to 30 ground and breaks leg Majors (LWCs and RWCs) Truck trailer moves, driver jumps to ground and sprains ankle 300 Recordable Injuries Lift truck is driven into truck trailer and trailer moves 3,000 Near-Misses or First Aid Wheel chocks not in place 30,000 Hazards at rear wheels of trailer - Unsafe Acts - Unsafe Conditions
  16. 16. Actions & approach To achieve safety excellence Shrinking the base by 1 To improve eliminating Fatal Process & practicesunsafe behaviors and … 30 Majors (LWCs and RWCs)…shrinking the height by 300 establishing Recordable Injuriesinherently safer processes and 3000 practices Near-Misses or First Aid 30000 Hazards Behavior - Unsafe Acts - Unsafe Conditions

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