Near Misses in Non-medical Domains
"We defined a near miss as any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome." Note: National Fire Incident Reporting System (NFIRS) was not included in the report of near misses in nonmedical domains.
Dust Explosion Hazard Awareness / Imperial Sugar Management and Workers
(Page 54 .pdf) "The CSB concluded that the small events and “near-misses” caused company management, and the managers and workers at both the Port Wentworth, Georgia, and Gramercy, Louisiana, facilities to lose sight of the ongoing and significant hazards posed by accumulated sugar dust in the packing buildings."
CSB Key Findings: Imperial Sugar Refinery
Page 48 .pdf) # 4 "Company management and the managers and workers at both the Port Wentworth, Georgia, and Gramercy, Louisiana, refineries did not recognize the significant hazard posed by sugar dust, despite the continuing history of “near-misses’”
(Page 14 ,pdf) "Operators and mechanics reported being involved in multiple flash fires during their employment at the Gallatin facility. At the time of the incidents, many were aware that the iron dust could burn or smolder. However, they were not trained to understand the potentially severe hazard when accumulated dust is dispersed in air. Rarely would operators report the minor flash fires and “near-misses” that periodically occurred."
(page 27 .pdf) CSB Recommendations to Hoeganaes 2011-4-I-TN-R9
"Develop and implement a “near-miss” reporting and investigation policy that includes the following at a minimum:"
• Ensure facility-wide worker participation in reporting all near-miss events and operational disruptions (such as significant iron powder accumulations, smoldering fires, or unsafe conditions or practices) that could result in worker injury.
• Ensure that the near-miss reporting program requires prompt investigations, as appropriate, and that results are promptly circulated throughout the Hoeganaes Corp.
• Establish roles and responsibilities for the management, execution, and resolution of all recommendations from near-miss investigations
• Ensure the near-miss program is operational at all times (e.g. nights, weekends, holiday shifts).