1. SafeMARINERTM Helping Companies Get to Zero
Best-In-Class Practices
Near Miss & Incident Investigation
New Orleans PSC-January 20, 2014
Rick Dunn, CSHM
American Society of Safety Engineers Professional
Good morning. My name is Rick Dunn, let me tell you a little about my background, training and experience.
34 yrs ExxonMobil
18 years running ships
Tractor Tug Projects, LNG Terminals, inland, offshore and ocean auditor
Helped develop, train, and implement Exxon’s own fleet SMS,
Operations Management System Coordinator and audit for ExxonMobil: marine and pipeline Company.
SHE Manager
Certified Safety and Health Manager- an engineering accreditation focusing on management and business systems.
Advanced degrees in Engineering Systems Mgt & Reliability, Business and Project Management with graduate papers in Marine Safety Management (by the way Safety includes all)
Completed hundreds or internal, external and TMSA audits under ISO 9000, 14000, ISM Code and more.
I retired from ExxonMobil 4 months ago as the Marine Vetting Manager for North America. My group has oversight over TMSA, SIRE and other third party review programs. In ExxonMobil, the worlds largest charterer of tank vessels we tracked and reviewed about 350 companies world wide. We loaded and unloaded a vessel every 3 minutes somewhere on the globe. We never got it all perfect but we continually improved.

2. SafeMARINERTM Helping Companies Get to Zero
Discussion Points:
What’s a near miss?
High Learning Value Incidents
Direct Cause
Precursors to Serious Incidents, Fatalities & Spills
Mining the Diamonds
Sticky Lessons
Human Error & Violations
Revisiting Reasons Swiss Cheese
Find the Flaws

3. SafeMARINERTM Helping Companies Get to Zero
Near Miss-OSHA:
Near misses describe incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred
Note that OSHA considers a Near Miss and event where no damage or injury occurred, but with slightly different circumstances it COULD Have. This is similar to the definition the American Society of Safety Engineers uses.

4. SafeMARINERTM Helping Companies Get to Zero
Near Miss-ABS:
An incident with no consequences, but could have reasonably resulted in consequences under different conditions OR
An incident that had some consequences but could have reasonably resulted in much more severe consequences under different conditions.
ABS has two options in its definition. Note the second one, where some consequences occurred but more SEVERE Consequences could have occurred.

5. SafeMARINERTM Helping Companies Get to Zero
So what definition do we use?
It really doesn’t matter.
Best In Class organizations understand:
What’s important is to investigate near misses and incidents with High Learning Value (HLV)
These are the ones that had a higher potential to result in a Serious Injury or Fatality (SIF) or Spill to water
So the debate continues, but does it really matter. NO IT DOES NOT. High Performing Organizations understand: What’s important is that certain incidents or near misses offer HIGH LEARNING Value…we call those: SERIOUS INJURIES, FATALITIES and I would add SPILLS. Spills are that important to your customers.
Recently challenges to Heinrich’s Safety Triangle Theory have emerged. Companies like ExxonMobil, Shell, and Cargill data indicate that the SAFETY TRIANGLE theory may not be as accurate as once thought.
2007 RAND Study: appears to be no relationship between OSHA Injury Rates and Fatalities
2012 BST Study (Exxon, Shell and others): Reducing lessor incidents does not allways reduce the SEVERE incidents.

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How to determine what a HLV incident is?
It’s about RISK
We’re talking about
the precursors to
Incidents that had
Higher Risk
PRECURSORS: A high risk situation in which management controls are either absent, ineffective, or not complied with, and which will result in a serious or fatal injury if allowed to continue.

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Incident direct cause is usually the result of not controlling energy:
Electricity
Heavy objects (i.e. ratchets, barges, boats, WTDs)
Air & liquid under pressure
Temperature extremes
Fall for heights
Moving machinery
Chemical energy
Others
Injuries and many damage incidents are all about NOT CONTROLLING ENERGY. Even the fall from only 6 feet where a person strikes his head on the deck, the energy source is increased by the acceleration of gravity as the persons head falls through the air.

8. SafeMARINERTM Helping Companies Get to Zero
Determining the precursors:
Review your incident data (need good data)
Look at severity potential
Incidents where energy was involved
Precursors include incidents involving:
Electricity
Heavy objects
Air and liquid under pressure
Chemicals and Hydrocarbons
High Temperatures
Man Overboard Potential
Mass X Velocity (i.e. locking, docking, transits)
Over 2 gallons leaked outside normal containment
Closing valves against pressure, and more
There are other PRECURSORS and its best for each company to develop its own list. Start by looking at your injury data (if you have good data). SEVERITY POTENTIAL is key in determining PRECURSORS.. Look for ENERGY not being controlled among other things. In my work I am developing precursors to SPILLS to use a similar methodology to help Companies get to ZERO.

9. SafeMARINERTM Helping Companies Get to Zero
Emerging Safety Management thinking:
Spend time and resources on the near misses (and incidents) that offer Higher Learning Value (HLV)
This may represent ~20% of incidents
Makes sense
So in ExxonMobil, for example, the data suggests there a 7 Near Misses for each incident….thousands of NEAR MISSES are Captured, but are they all HIGH VALUE? The new study says, probably not, only about 21% are.
In ExxonMOBIL Marine, we would ROOT CAUSE 100% of Near Misses and minor incidents. This takes quite a bit of time and people resources. It makes sense to focus on a smaller set of events, the ones that offer HIGH VALUE Lessons.

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“Mining the diamonds”
A process where you use the precursors to serious injuries, fatalities and spills-to identify HLV’s and focus on prevention.
So you can design a NEAR MISS (and even incident investigation) program to focus on the important ones….we call this MINING THE DIAMONDS. They are worth more!

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First Aids / Near Misses
Recordable Incidents
Lost Time Incidents
Mining the Diamonds:
By creating some PRECURSOR criteria, the High Learning Value Near Misses and Incidents can be culled out of all the data, so that the organization can focus on prevention of Serious Injuries, Fatalities, and Spills. See the diamonds in this Safety Triangle, the study indicates those may represent about 21% of the data.
Heinrich 1931 Safety Triangle Theory (1 serious-10 minor incidents-30 property damage-600 no injury or damage) under question.

12. SafeMARINERTM Helping Companies Get to Zero
Surface Cause (easy)
Root Cause (hard)
Investigate:
-Gather the facts
-Develop a simple timeline
-Develop a brief description of the event
-Determine Surface & Root Cause(s)
-Develop Corrective and Preventive Action(s)
-Track the Action(s)
-”Sticky Lessons” are key
-Address Human Error
Lets turn to effective incident INVESTIGATIONS and ROOT CAUSE ANALYSIS (both are on the horizon with TSMS).
Talking through the steps….LETS Pay particular Attention to HUMAN ERROR.
Of course you need to have a repeatable ROOT Cause methodology in place, with practical training.

13. SafeMARINERTM Helping Companies Get to Zero
Successful Near Miss Programs:
Motivate your people to report near misses (no blame)
Triage the near misses & identify HLV’s
Investigate the HLV’s as if they were recordable
Determine Root Cause
Develop corrective & preventive solutions
Implement the solutions (“Sticky Lessons”)
Let the fleet know what the office is doing with the near misses (WIIFM)
Looking at many near miss programs, I would offer these 7 Steps as a good basis for an effective program.
STICKY LESSONS: just sending a Bulletin out to the Fleet to review does NOT LEARN A LESSON (Despite that inference in TMSA2). You need to make lessons STICK. In my work we teach Companies how to develop SMART Solutions that are scaled to the business size and MAKE SENSE. Sometimes it COSTS more and sometimes it DOES NOT>
Note Step 7: its really important that the Fleet folks get feedback from the OFFICE and are shown positive RESULTS from NEAR MISSES. With only 4 or 5 persons onboard its critical that everything they do have value. WHATs IN IT FOR ME is an essential concept in this case.

14. SafeMARINERTM Helping Companies Get to Zero
Numerous studies indicate: 80–95% of incidents have human failure as one or more causal factors.
Experts classify human failure in these areas:
SLIPS
LAPSES
MISTAKES
VIOLATIONS
Understanding human error is key to preventing incidents.
Engineering controls, competency assessment, systems thinking, clear concise procedures, checklists, accountability, supervision, signage and tough internal audits, all help reduce human error.
“Understanding Human Error is Key to Preventing incidents”
Understanding human error is important to effecting continual improvement, in xxxx xyz promotes the correlation between human error management and effective safety management. Lets talk about theses:
SLIPS-simple physical action that goes wrong (press wrong button)
LAPSES-memory failure (return to step 12 vs 9 after interruption)
MISTAKES-not understanding how something works or diagnose wrong
Violations- Absolutely not tolerable under any circumstances. Not enforcing SMS Rules or Looking the other way is deadly.
For Safety Management Professionals not to consider Human Error is a big mistake, why because it is and will always be present.
In fact Safety Management Systems, being designed by Humans are have built in “latent defects”, some we discover and some we don’t. Reason states that It can take years for some to appear, and even longer for the holes in his swiss cheese diagram to lineup. Human Error is an area of safety management that we have just started to understand.

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Lets take a look at some of the things that you can do to help REDUCE HUMAN FAILURE.

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Some Solutions for Human Failure
Better layout of controls and displays, design controls to make it difficult to operate them accidently
ABS has an Marine Ergonomics Guide that can be very useful to help engineer in solutions that address HUMAN ERROR.

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Some Solutions for Human Failure
Better layout of controls and displays, design controls to make it difficult to operate them accidently
Procedures with place makers to tick off steps, supervise key tasks, remove distractions, use checklists, set interruption rules

18. SafeMARINERTM Helping Companies Get to Zero
Some Solutions for Human Failure
Better layout of controls and displays, design controls to make it difficult to operate them accidently
Procedures with place makers to tick off steps, supervise key tasks, remove distractions, use checklists, set interruption rules
Competency Assessment, controlled knowledge transfer among peers, mock ups, maintain training & competency programs

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Some Solutions for Human Failure
Better layout of controls and displays, design controls to make it difficult to operate them accidently, double checks
Procedures with place makers to tick off steps, supervise key tasks, remove distractions, use checklists, set interruption rules, two man checks
Competency Assessment, supervised peer knowledge transfer, mock ups, maintain training & competency programs
Easy to follow procedures, no huge manuals, positive safety culture, clear expectations, supervision, accountability

20. SafeMARINERTM Helping Companies Get to Zero
Reasons Swiss Cheese Causation Model
James Reason, (PhD Organizational Psychology) made this model a few years ago. He and others have more advanced models, but this one, you’ve probably heard of is real good for illustrative purposes.
Some holes due to Active failures (errors and violations) and some due to Latent Defects. These moving holes, represent all the variables that must line up for the event to occur.
Why is continual improvement a moving target? Hint humans are involved.

21. SafeMARINERTM Helping Companies Get to Zero
Reasons Swiss Cheese Causation Model
System Design
System Implementation
James Reason, (PhD Organizational Psychology) made this model a few years ago. He and others have more advanced models, but this one, you’ve probably heard of is real good for illustrative purposes.
Some holes due to Active failures (errors and violations) and some due to Latent Defects. These moving holes, represent all the variables that must line up for the event to occur.
Lets talk about Inadequate defence or error recovery. I belive there is evidence that our industry has a huge opportunitiy to increase the effectiveness and readiness of Emergency Respose by implementing things suchs as realistic steering loss drills, combined with the development of user friendly check lists for BOTH NORMAL and EMERGENCY Operations. We react just as we drill. Learn from the Blue Water.
Why is continual improvement a moving target? Hint humans are involved.

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What does Human Error have to do with Safety Management Systems?
Management systems are designed by humans
Therefore they are subject to human error
And always have latent defects (flaws)
Effective incident investigation, Root Cause tools and solutions help reduce human error. The goal is to find the flaws using HLV incidents.

23. SafeMARINERTM
Your management system is designed to perfectly produce the results you are now getting. Don’t like the results-change it.
This is a parallel to that famous quote: Insanity is not changing what your doing but expecting different results!

24. SafeMARINERTM Helping Companies Get to Zero
Concentrating on the High Learning Value near misses, using proven Root Cause methods and addressing Human Error has benefits:
Efficient use of time and resources
Prioritizes work
Addresses Higher Risk incidents
Makes a Near Miss program more valuable
Helps get to Zero
Keep it simple, scale it, make it work for your company.
We've covered a lot of material, lets review some key items:

25. SafeMARINERTM Helping Companies Get to Zero
Thank You.
Questions on this subject, Vetting, TMSA, ISM Code, Internal Audits ?