1. 12/19/06 Dealing with Close Calls Why should we mess with it??? Nobody was hurt

2. 12/19/06 What is a Close Call? (aka “Near Miss”) NASA Definition: A situation or occurrence with no injury, no damage or only minor damage (less than $1,000), but possesses the potential to cause any category mishap, or any injury, damage or negative mission impact. JSC also uses the Close Call System to report hazards before an “event” happens. Webster’s 9 th Collegiate Dictionary: A narrow escape.

3. 12/19/06 Close Calls vs. Injuries The only difference between an injury and a close call is in the outcome. And the outcome is only a matter of luck.

4. 12/19/06 Remember Whether the person gets hurt or not, there will probably be a human toll and a hit to productivity.

5. 12/19/06 Why Report Close Calls? Injury Report Investigate Fix!!!

6. 12/19/06 Why Report Close Calls? Close Call “Freebee” Opportunity to prevent an injury Opportunity to prevent another injury Report Fewer Hazards + Less Unsafe Behavior = Fewer Undesired Events Investigate Fix!!! Same causes and same learning opportunity Injury

7. 12/19/06 Going beyond Injuries Major Injuries Close Calls Attack the base of the pyramid or “iceberg” to bring it down Minor Injuries Unsafe Acts & Hazards System & Management Issues Bigger statistical base for trending.

8. 12/19/06 What do the Experts say? “Handbook of Occupational Safety and Health” Remembering the accident triangle, the greater the number of near misses (incidents), the greater the likelihood of minor injuries, therefore the greater the likelihood of more serious accidents and ultimately a higher frequency of fatalities. …major safety improvements cannot occur without a focus at the bottom of the accident triangle.

9. 12/19/06 How does JSC handle Close Calls? REPORTING Simple Form Ask for Suggestions Confidential or Anonymous TRACKING Database with Trending and Charting Status Management Getting things FIXED Work through Facility Mangers, Center Operations, & Others TRENDING FEEDBACK Email or Snail mail to Reporters Address Reporter Feedback

10. 12/19/06 JSC Close Call Poster

11. 12/19/06 JSC’s Top Level Close Call Process Flow Reporter Safety Office Actionee (Fac Mgr, COD, ISD, etc.) Reports Close Call Logs into database Sends to Actionee Investigates & develops action plan Sends Investigation Results to Safety (results and action plan) & proceeds with action Investigatio n Results adequate? Logs response into database Sends response to Reporter Actions complete? Forwards Comments to Actionee Note: After one cycle, Safety will decide how to proceed with resolving the issue to avoid an “endless loop.” Y Y N N Close the Close Call Track to completion Answers Reporter concerns and revises action plan if necessary

12. 12/19/06 What should we expect? We want to see this Instead of this Robust program model Weak program model Major Injuries Close Calls Minor Injuries Minor Injuries Major Injuries Close Calls

13. 12/19/06 What is JSC’s Experience? Fiscal Year 2002 44 CCs/Days Away Case 5.5 CCs/OSHA Rececordable Fiscal Year 1994 0.7 CCs/Days Away Case 0.28 CCs/OSHA Recordable We experienced a 80% drop in our Days Away Case rate and a 30% drop in our OSHA Recordable rate from 1994 – 2002. 1 Major Mishap 880 Close Calls 20 Days Away Injuries 86 Days Away Injuries 1 Major Mishap 60 Close Calls Started the JSC Close Call system Jan 1995.

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16. If You See an Unsafe Act or Condition, STOP IT! Use the following steps in order Emergency Call the local emergency number if you need immediate fire, medical, or security assistance: 281 483-3333 for Emergencies at JSC and SCTF 281 244-4444 for Fire + Medical help at Ellington Field Use 281 483-3333 for Ellington Field Security Assistance On the Ground Step 1 Fix it yourself (if qualified and authorized) or contact Work Control, 281-483-2038, & submit a Close Call Report if it is a safety issue, andClose Call Report alert your Supervisor or Facility Manager (Facility Manager contact information is on the first floor of each building and on the web.)Facility Manager or Call the JSC Safety Action Hotline (for Immediate Hazards) 281 483-7500 (24 hours a day, 7 days a week) or Call the Center Director's Hotline 281 483-1234 Step 2, if No Response Call the JSC Ombuds: Dr. Shannon LucidJSC Ombuds 281-244-8808 or Contact NASA HQNASA HQ or Step 3, if you still get no response Submit an NSRS (NASA Safety Reporting System) You can find Forms in building lobbiesNSRS or Call OSHA: 1 800 321-6742OSHA Space Flight Contact the appropriate Program Office if it is a flight program issue: International Space Station Program Weblink Space Shuttle Program Weblink Contact NASA HQNASA HQ Submit an NSRS (NASA Safety Reporting System)NSRS You can find Forms in building lobbies Shuttle Program Close Call Awareness Program Mishap Reporting If you or a co-worker are injured, go to the JSC Clinic. A follow-up report will be required when notified by Safety. If there is Damage to NASA Property, submit a Mishap Report with all known details.Mishap Report