System for Managing Near Misses

From Paper Forms to Safety Culture: The Evolution of Near Miss Management

Building an effective system for identifying and eliminating near misses is a natural stage in the development of a safety culture at any manufacturing enterprise. The transition from recording actual injuries to proactively addressing their precursors not only reduces the number of incidents but also engages personnel in the risk management process. In her presentation, Veronika Ulyanova, HSE Manager at the Knauf Insulation plant in Tyumen, shares practical experience of implementing such a system at an enterprise with 129 employees.

The speaker details the plant's journey from its first steps in 2015 to achieving an impressive result — over 1,800 days without injuries. This success is based on systematic work with the foundation of "Heinrich's pyramid" — unsafe conditions and acts.

System Mechanics: From Identification to Elimination

The procedure for managing near misses is built on a clear algorithm of actions for every employee. The key principle is not just to report a problem, but to take initial steps to minimize it.

• Immediate Actions: Upon discovering a hazardous situation, an employee must first mark it, fence it off, or, if within their competence, eliminate the threat. This builds local responsibility and prevents the incident from developing in the moment.
• Multi-level Reporting: A system of paper forms is used (three self-copying sheets of different colors). The employee fills out the form, describing the problem and actions taken, and hands it to their supervisor.
• Assessment and Delegation: The supervisor assesses the hazard and the adequacy of the measures taken. If necessary, they involve adjacent departments for the final elimination of the problem, passing a part of the form to them.
• Control and Feedback: After elimination, the executor reports to the supervisor, who, in turn, informs the employee. The HSE department registers the fact and monitors deadlines.

Overcoming Barriers: Complacency and Formalism

The implementation of any new system inevitably faces resistance and objective difficulties. The presentation details the main barriers the enterprise encountered.

• "Complacency": Employees get used to their surroundings and stop noticing routine hazards. The solution was regular training and safety dialogues.
• Reluctance to "Snitch": A psychological barrier that makes workers reluctant to report unsafe acts by colleagues. As a result, statistics shift towards recording unsafe conditions (equipment or infrastructure defects).
• Conflict with Production KPIs: The fear that stopping a process to eliminate a risk will negatively impact output metrics.
• Formal Approach: Due to high workloads, responsible executors might close reports without actually fixing the problem. To combat this, multi-stage control and regular meetings to analyze unresolved risks were introduced.

Motivation and Engagement: Making the System Work

The speaker shows by example that simply setting quantitative KPIs (e.g., "at least 6 reports per year from everyone") is not enough. Such an approach can lead to decreased engagement among operational personnel, as engineers (technical staff) meet the quota faster by identifying more complex risks.

To solve this problem, the enterprise separated the goals: workers kept quantitative KPIs for identification, while technical staff focused on eliminating problems and conducting safety dialogues. Additionally, a system of material motivation was introduced: monthly selection of the best report by a committee and an annual lottery among all submitted signals with valuable prizes.

What You Will Learn from This Webinar:

• How to build a working algorithm for recording and eliminating near misses at a small enterprise?
• Why quantitative KPIs for risk identification can reduce worker engagement and how to avoid this?
• How to overcome the psychological barrier of employees reluctant to report unsafe acts by colleagues?
• What methods of material and non-material motivation actually work to stimulate reporting?
• How to organize control over the elimination of identified risks and avoid formal closure of requests?