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Dealing with Close Calls

Why should we mess with it???

Nobody was hurt

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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 9th Collegiate Dictionary: A narrow escape.

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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.

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Remember

Whether the person gets hurt or not, there will probably be a human toll and a hit to productivity.

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Why Report Close Calls?

Injury

Report

Investigate

Fix!!!

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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

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Going beyond Injuries

MajorInjuries

Close

Calls

Attack the base of the pyramid or “iceberg” to bring it downAttack the base of the pyramid or “iceberg” to bring it down

MinorInjuries

Unsafe Acts & Hazards

System & Management Issues

Bigger statistical base for trending.

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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.

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How does JSC handle Close Calls?

REPORTINGSimple Form

Ask for SuggestionsConfidential or

Anonymous

TRACKING

Database with Trending and Charting

Status Management

Getting things FIXED

Work through Facility Mangers,

Center Operations, & Others

TRENDING

FEEDBACKEmail or Snail mail

to ReportersAddress Reporter Feedback

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JSC Close Call Poster

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JSC’s Top Level Close Call Process Flow

Reporter Safety OfficeActionee

(Fac Mgr, COD, ISD, etc.)

Reports Close Call Logs into database Sends to ActioneeInvestigates &

develops action plan

Sends Investigation Results to Safety

(results and action plan) & proceeds

with actionInvestigatio

n Results adequate?

Logs response into database

Sends response to Reporter

Actions complete?

Forwards Comments to ActioneeNote: 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

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What should we expect?

We want to see thisWe want to see this Instead of thisInstead of this

Robust program model Weak program model

MajorInjuries

Close

Calls

MinorInjuries

MinorInjuries

MajorInjuries

Close Calls

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What is JSC’s Experience?Fiscal YearFiscal Year

2002200244 CCs/Days Away Case

5.5 CCs/OSHA Rececordable

Fiscal YearFiscal Year19941994

0.7 CCs/Days Away Case0.28 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.

1MajorMishap

880 Close Calls

20 Days AwayInjuries

86 Days AwayInjuries

1MajorMishap

60 Close

Calls

Started the JSC Close Call system Jan 1995.

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Slip, Trip, & Fall Close Calls

0

5

10

15

20

Month

Num

ber

Slp,Trp,Fall 2004

Slp,Trp,Fall 2005

Slp,Trp,Fall 2006

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If You See an Unsafe Act or Condition, STOP IT! Use the following steps in order

EmergencyCall 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 GroundStep 1Fix it yourself (if qualified and authorized) or contact Work Control, 281-483-2038, & submit a Close Call Report if it is a safety issue, andalert your Supervisor or Facility Manager (Facility Manager contact information is on the first floor of each building and on the web.)

orCall the JSC Safety Action Hotline (for Immediate Hazards)281 483-7500 (24 hours a day, 7 days a week)

orCall the Center Director's Hotline 281 483-1234

Step 2, if No Response Call the JSC Ombuds: Dr. Shannon Lucid 281-244-8808

orContact NASA HQ

orStep 3, if you still get no response Submit an NSRS (NASA Safety Reporting System) You can find Forms in building lobbies

or

Call OSHA: 1 800 321-6742

Space FlightContact the appropriate Program Office if it is a flight program issue: International Space Station Program WeblinkSpace Shuttle Program Weblink

Contact NASA HQ

Submit an NSRS (NASA Safety Reporting System) 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.