Near Miss vs Accident.pdf

“WHAT WENT WRONG-CAUSE, EFFECT & LEARNING”
Ordnance Factory Ambajhari
(A Unit of Yantra India Limited)
Govt. of India Enterprise,
Ministry of Defence
OFAJ SAFETY&EMS CELL
• Benefits of Accident
Investigations are as follows:
• Helps prevent future accidents
• Help to identify and eliminate
hazard
• Expose deficiencies in processes
• Based on the near-miss incidents
happened in OFAJ; in the current Yr
2022, “what went wrong-cause,
effect & learning” series is being
prepared.
• Accident is happened because of
unsafe condition & unsafe act. Hence,
• Expose deficiencies in processes
or equipments
• Reduce injury and workers
compensation cost
• Maintain and improve employee
morale
• Here, all the incidents were
investigated by S&EMS and
suggested remedial measures
were forwarded to concern
section for implementation
unsafe condition & unsafe act. Hence,
these case study will act as pro-
active measures to ensure safe
practices at the workplaces.
• The accident investigations are
intended to determine the cause of
accident, to identify unsafe
conditions and unsafe acts and to
recommend corrective actions so that
similar incidents don’t occur in the
future. The purpose is to eliminate
the cause and reoccurrence of
accident.

Near-Miss Vs. Accident
Near-Miss Vs. Accident

Ministry of Defence
• A near Miss
Today Could Be
An Accident
Today Could Be
An Accident
Tomorrow:
• Report All Near
Misses!!

Ministry of Defence
Definition:
• Definition:
• “Near miss” is unplanned
event or situation that
did not result in injury,
illness or damage – but
had potential to do so.
illness or damage – but
had potential to do so.
• Sometimes called a
“Near-Hit” or “Close
Call” – signals a system
weaknesses that if not
corrected could lead to
significant
consequences in future.

Ministry of Defence
Near miss reporting is
• Near miss reporting is
the only recognised
incident management
structure that identifies
and reports near misses,
effectively communicates
and reports near misses,
effectively communicates
risk tolerance measures
to employees, eradicates
the root cause of the
hazard and prevents
future accidents or
injuries from taking place.

Ministry of Defence
• Near miss incidences are
• Near miss incidences are
valuable source of
information.
• Near miss incidences
provide the opportunity
to identify hazards or
weaknesses in the risk
to identify hazards or
weaknesses in the risk
management program and
correct them to prevent
future incidents.
• Proactive monitoring –
Near misses are
symptoms of
undiscovered safety
concerns.

Ministry of Defence
Why it is important to
• Why it is important to
investigate near misses
in the workplace?
• The main reasons for
investigating incidents is
to try and identify the
to try and identify the
root cause/s that
contributed to the
incident or near miss
occurring, so we have
greater opportunity to
prevent the same type of
incident from potentially
occurring again.

Details of Near-Miss Incidents occurred at
OFAJ during the Year 2022 :
Near-Miss Incident
Collapse of false ceiling in IE’s rest Room in Section DC

Near-Miss Incident
Collapse of false ceiling in IE’s rest Room in Section DC
Place: Section Die
• Place: Section Die
Casting, IE’s rest Room
• In Section DC on dtd
07/11/2022 in day work,
the false ceiling of the
IEs rest room suddenly
IEs rest room suddenly
collapsed and fell down at
around 08:45 am. At the
time of incidence, no
Industrial Employee was
present inside the rest
room; hence no one was
injured during the
incidence.

Near-Miss Incident
Collapse of false ceiling in IE’s rest Room

Near-Miss Incident
Collapse of false ceiling in IE’s rest Room
Place: Section Die
• Place: Section Die
Casting, IE’s rest Room
• Probable cause of
Accident:
Accident:
• The false ceiling channel
holding overhead wire is
corroded and weakened in
strength is the probable
reason for the collapse of
false ceiling structure.

Near-Miss Incident
Remedial Measures for the instant incidence
• 1) The holding wire of the false ceiling structure
• 1) The holding wire of the false ceiling structure
is corroded and weakened in strength; hence the
adequate repairing action to be initiated for the
false ceiling structure by Section CE. Further, all
the existing false ceiling structures to be
checked/inspected from Section CE and adequate
strength for the existing false ceiling structure to
checked/inspected from Section CE and adequate
strength for the existing false ceiling structure to
be ensured. The caution board to be displayed in
damaged false ceiling structures area and entry
inside such structures to be restricted.
• 2) In addition to above, the ceiling fans located
inside the false ceiling structure to be checked
for the strength of the holding rod. It is to be
inspected and checked by Section EM & CE.

Near-Miss Incident No. – 01
Remedial Measures for the instant incidence
3) The identified defective/weakened false ceiling structures to be
• 3) The identified defective/weakened false ceiling structures to be
rectified on priority basis. The repair works; to be carried out by
CE & EM to be reviewed frequently by the HOS of the concerned
section.
• 4) The Section HOS along with the Section Level Safety Committee
Members; should form the special committee for the inspection of
the existing false ceiling structures available in their concerned
section. Inspection to be carried out and report to be submitted to
the existing false ceiling structures available in their concerned
section. Inspection to be carried out and report to be submitted to
section CE & EM & Safety & EMS. As preventive safety measure
the periodic inspection of the existing false ceiling and other unsafe
conditions at the workplace to be carried out by line I/c and the
same to be discussed in the Section level safety committee meeting
for necessary compliance.
• 5) Considering the instant near –miss incidence; all HOS of the
concerned section is being intimated through this report to carry out
the special inspection of the existing false ceiling structures and
report to be submitted to Section CE Safety & EMS for necessary
compliance.

overhead electric cable tray due to monkey menace
Collapse of the corroded structure of

Place: Section EDS(FS)
• Place: Section EDS(FS)
• In Section EDS on dtd 24/02/2022
in day work, the production activity
related to anodizing and chromatising
was in progress as per the instruction
of line I/c. Employees Shri
Manjunath, Electroplater, Shri
Mangesh More, Electroplater, Shri
Mangesh More, Electroplater, Shri
Vinod Tekam, Electroplater, Shri
Manoj Wankhede, Toolsetter were
working in anodizing jigging area and
chromatising passivation area. At
08:50 AM a troop of monkey (10-15
nos) suddenly entered the workplace
area and during their movement &
jumping on the overhead structures
inside the workplace area at 09:10
Hrs; the existing corroded overhead
electric cable tray support structure
was broken and collapsed. No one was
injured during the incidence.

• The process activity of
electroplating/anodizing/chromat
ising carried out in this workplace
and due to exposure of corrosive
environment the existing
structure degraded with time and
structure degraded with time and
high exposure to corrosive
environment. Due to this
corroded atmosphere at the
workplace; the existing overhead
cable tray support structure was
weakened and due to monkey
menace the damaged structure
fell down/collapsed. The existing
corroded structure and the
monkey menace was the reason
for the collapse of the overhead
cable tray structure.

Remedial Measures
Remedial Measures
1) The structure is heavily corroded and the same
• 1) The structure is heavily corroded and the same
was pointed out by the Regional Controller of
Safety during Safety Audit level-III held on dtd
13/05/2019. Hence, the production activities of
EDS/FS to be shifted from the location at the
earliest and PDC to be given.
earliest and PDC to be given.
• 2) The employees working inside the workshop area
to be alert while doing the job and the line I/c
insist for the use of safety helmet while working.
• 3) Caution board “falling hazard from overhead;
always use safety helmet” to be displayed in local
language at conspicuous location in the workplace.

Remedial Measures
Remedial Measures
• 4) Inspection of the existing structure to be carried
• 4) Inspection of the existing structure to be carried
out by the section CE/MM & EM and adequate safety
measures for strengthening the existing structure to
be ensured. As preventive safety measure the periodic
inspection for the unsafe conditions at the workplace
to be carried out by line I/c and the same to be
endorsed in logbook and to be intimated to concerned
endorsed in logbook and to be intimated to concerned
section for necessary compliance.
• 5) The overhead exhaust fan in between column U-1 &
U-2 blades were corroded and broken; the same to be
repaired on priority.
• 6) The mesh guard of axial box fan available in the
shopfloor was very much corroded & damaged; which
may create untoward incidence, if the blades were
broken. Hence, mesh guard to be replaced and fan
blade strength to be ensured.

Section EDS anodising hoist was fell down during the operation
The near-miss incidence was occurred on dtd
• The near-miss incidence was occurred on dtd
09/07/2022, at about 13:00 Hrs in Section
EDS.
• The anodising hoist fell down due to breaking of
the wire rope during the operation and the
the wire rope during the operation and the
hanger along with Jigs & components fell down
on the bus bar of Anodising Tank no 1. This
near-miss may lead to untoward incidence but
fortunately no one was injured. With adequate
action the unsafe condition from the workplace
had been removed temporarily and production
activity was restored.

Section EDS anodising hoist was fall down during the operation
• Cause of the incidence:
• The wire rope of the
Anodising Hoist No.
2(OJ/579) is broken;
2(OJ/579) is broken;
although it was tested
periodically (Testing date
12/02/2022 & due date
11/08/2022) from the
competent person. The
hoist is heavily corroded
due to corrosive
environment.

• Remedial Measures:
• Remedial Measures:
• Wire rope to be replaced and
the load testing to be carried
out. The painting job to be
carried out.
• Additional support to be
• Additional support to be
provided for the existing
cable tray. The operators
working in this area should be
suitably warned and adequate
safety to be ensured.
• Further, caution board of
falling hazard from overhead
to be displayed in this area.
• Good housekeeping should
always be maintained.

Non-Reportable Accident
Section EXTN while material handling
underneath the extrusion press OJ/5611

Details about Accident:
• Details about Accident:
• On dtd 07/11/2022 Shri Santosh Kumar,
Rigger, EXT/14/9662 reported in the day
link shift in Section Extrusion. In the
extrusion press (OJ/5611) after
extrusion of billet the discard and the pad
fell down inside the pit of the press. The
individual Shri Santosh Kumar alongwith
crane operator Shri K R Meshram,
EXT/94/9431 was deployed for removal
of the hot discard and the pad from the
EXT/94/9431 was deployed for removal
of the hot discard and the pad from the
pit. The individual lifted the discard and
the pad with the help of wire rope sling &
EOT crane and put the same on the
discard collection tray. EOT crane was
disengaged with wire rope sling and while
removing the wire rope sling from the
material the sling got twisted and touched
the right arm of the individual due to
which he received minor burn injury near
right elbow. The individual was wearing
hand gloves at the time of the incident.
• The individual was immediately sent to
O.F.Hospital for treatment and after
treatment he resumed his duties on same
day.

Cause of the Accident:
• Cause of the Accident:
• While removing the hot
wire rope sling from
the discard by the
rigger, the wire rope
rigger, the wire rope
sling got twisted and
hit the individual’s
right arm causing burn
injury.

Remedial Measures
Remedial Measures
• 1) The stop plate to hold the discard and pad
• 1) The stop plate to hold the discard and pad
after extrusion of billet did not operate due
to which the discard and pad fell inside the
pit. Action to be taken to prevent
malfunctioning of the system and ensure that
discard or pad should not fall inside the pit.
discard or pad should not fall inside the pit.
• 2) Necessary fixture to be designed to hold
& lift the hot discards and pad easily and
place them in collection tray.
• 3) The inside of the extrusion pit is found
slippery due to oil leakages. Oil should be
periodically cleaned and leakages to be
arrested.

Remedial Measures
Remedial Measures
• 4) No handrail is provided to the platform
• 4) No handrail is provided to the platform
over discard collection tray over which crane
operator stands and operate the crane. Hand
railing to be provided to the platform.
• 5) Whenever any discard or pad fall inside
the pit the Line Incharge should be present
5) Whenever any discard or pad fall inside
the pit the Line Incharge should be present
at the site and coordinate/guide both the
workers for safe removal of the material
from the pit.
• 6) SOP to be prepared for the operation and
displayed near the press and proper
implementation to be ensured by Line
Incharge.

Summary on Importance of
Near-Miss Incidences Reporting
1) Near-miss identification and reporting is
• 1) Near-miss identification and reporting is
an integral part of any good safety program.
• 2) A near-miss reporting and tracking system
should be developed and implemented.
• 3) Employees should be encouraged to report
near misses without fear of discipline or loss
of job.
• 4) Reporting and tracking near misses can
provide valuable information so we have
greater opportunity to prevent the same type
of incident from potentially occurring again.

Think Again
•
•Safety Is
Safety Is
Everyone’s
Everyone’s
Responsibility.
Responsibility.
Responsibility.
Responsibility.
•
• “Safety First,
“Safety First,
Production Must”.
Production Must”.

Near Miss vs Accident.pdf

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