Matrices Used in Safety Management

Near Hits

The Near Hit document is designed to give field operations the ability to convey

field, tool and equipment conditions as well as personnel actions to the office. The

document does not fix, control or protect workers from hazardous conditions or

situations on the site. It is, however, a tool that can be used by both the field staff as

well as the office to help track and identify areas of concern, not just for that particular

project but areas of concern for the entire Branch. Depending on the scope of work, it

may have the potential to affect the entire company.

To initiate this process, the field staff must first identify the near hit condition; this

is the single most important aspect of the Near Hit Program. Next is to communicate

their findings to the field leadership to enact the Near Hit Protocol. Utilizing the Matrix,

the field leadership along with the crew can determine an actionable plan which could

either be to mitigate the hazard or at a minimum determine that no hazard exists and

continue to work. The Matrix Protocol can be found using the Matrix Flow Chart on the

following page. This flow chart takes the user through the necessary steps to ensure

proper use of the Near Hit form. The end result is to ensure safe working conditions for

employees, protection of company property and the safety of anyone else potentially

exposed to hazardous conditions or actions.

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

Identify
Hazard

Communicate to Field Leadership

1/2
4/5 Matrix Share w/
Stop Work
Evaluation Crew

1/2
Share w/ Crew

5 Contact Sup/PM for

Abatement Approval Fill out Near
Develop Hit form
Abatement Plan

4 Abate if Feasible

Abate Hazard Finish filling out

Near Hit form

Send form to office for Send form to office by weeks

review w/ in 24 hours end for possible review

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

Near Hit Reporting and Recording

Once the Near Hit form is turned into the Project Manager (PM), the form should

be evaluated to ensure that the Matrix was properly used. The PM then must decide if a

Near Hit Incident Review should be performed. This review could include the Division

Manager (DM), PM, Project Engineer (PE), General Superintendent (GS), Foreman and

any individuals directly involved with the initial near hit. This review would be treated the

same as an incident review where a loss has happened. Not all near hits would require

this type of review but; near hits scoring a 4-5 on the Matrix scale would indicate serious

conditions that warrant further investigation.

If the investigation or evaluation turns up a condition that could affect other

projects the near hit should be discussed in the following OPS meeting. If it determined

that this could have an impact in other Branches, this should be shared with the SPS

and Corporate Safety Teams. Past experiences have shown that the sharing of this

information has been highly successful in identifying conditions elsewhere in the

company. As an example, in one part of the company, a hard hat inspection ended in

the replacement of dozens of defective hard hats across the country.

Once the Near Hit Forms are complete, the information gained from the Near Hit

Form must be recorded. This recording process aids in future statistical analysis of

potential problem areas. Documented information such as time of day, body part

effected, root cause analysis, and contributing factors create a data base of information

that can be used for future focused areas. An example might be that several near hits
Confidential: Any unauthorized use or distribution is prohibited.
/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

indicated lack of training or knowledge as a contributing factor. We would then need to

take a close look at that part of our system in which training needs are determined.

Risk Analysis

The application of the Matrix allows us to focus on areas that pose the greatest

risk. Past data has shown that less than 20 percent of the reported near hits are

considered significant in terms of overall risk. In a study performed for the U.S Atomic

Energy Commission and published in The Management Oversight and Risk Tree

(MORT) by W.G. Johnson, reference to the Pareto Principal as a management

emphasis tool in the decision making process for focusing on the “critical few” or the

“insignificant many”. The critical few, refers to the few conditions that will be the most

costly in terms of loss or injury. The insignificant many is in reference to the bulk of

instances that have little or no effect to the overall safety.

Matrices have been used to analyze deployment of preventative measures by the

United Kingdom Atomic Energy Authority since 1967. Three areas of emphasis are

generally brought up by these matrices:

1. focus on all issues found,

2. focus on high frequency, low severity issues

3. or, focus on low frequency, high severity issues.

Most studies have concluded that the area of emphasis involving low frequency and

high severity should be the focal point of concern.

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

Heinrich’s early observations of incidents showed that the frequency of unsafe

acts and conditions were relative to the number of injuries. Though there were several

more unsafe acts and conditions than injuries, the thought was that by lowering the

number of unsafe acts and conditions, that this would create a relatively lower number

of injuries. This would require acting on all incidents from the insignificant many to the

critical few. Per the Pareto Principal we would be spending 80 percent of our time on

the 80 percent that did not make an appreciable difference.

A degree of residual or acceptable risk must be calculated to determine levels of

priority. Risk assessment requires a measuring tool that takes into account severity of

an exposure to a hazard and the potential of an incident to occur. Using past incidents

including near hit data, incident reports and personal experience, ratings can be given

variables such as likelihood and severity to determine and calculate exposure.

Probability
The likelihood of the occurrence could be rated in the following:
0 = Will not happen
1 = Very unlikely
2 = Could happen
3 = Has happened
4 = Likely to happen
5 = Will occur (imminent danger)
(example 1)

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

Severity
In terms of rating the severity of the occurrence the following example could be used:
0 = no harm
1 = first aid only
2 = Dr visit no lost time
3 = Dr visit w/ lost time (temp disability/ temp partial/ temp total)
4 = Dr visit w/ lost time (perm. Disability/ perm part/ perm total)
5 = Death
(example 2)

Utilizing the parameters, 0-5, with the associated descriptors, we can calculate

numbers along an index (discrete variable).

The following mathematical formula can be used to determine the score for each

task:

Index Calculation
R=SxL
Where L equals the Likelihood of an occurrence,
S equals the severity or potential severity of an incident,
R would represent the number given on the index.
(example 3)

The parameters for severity and likelihood are zero to five (0-5) with the index

(discrete variable) ranging from 0 – 25, zero being the lowest risk and 25 the highest.

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

Index
0 = 0x0, 0x1, 0x2, 0x3, 0x4, 0x5
0 = 1x0, 2x0, 3x0, 4x0, 5x0
1 = 1x1
2 = 1x2, 2x1
3 = 1x3, 3x1
4 = 1x4, 4x1, 2x2
5 = 1x5, 5x1
6 = 2x3, 3x2
8 = 2x4, 4x2
9 = 3x3
10 = 2x5, 5x2
12 = 3x4, 4x3
15 = 3x5, 5x3
16 = 4x4
20 = 4x5, 5x4
25 = 5x5
(example 4)

Determinations can then be made along the line from 0 to 25 using supporting

data. Labels then can be applied to these determinations such as minimum, minor,

moderate, high, imminent danger.

Determination Labels
Minimum risk (0-2)
1x2 very unlikely x Dr visit no lost time
2x1 could happen x 1st aid only

Minor risk (3-4)

1x3 unlikely x temp disability
3x1 has happened x 1st aid only
1x4 unlikely x perm disability
4x1 likely x first aid only
2x2 could happen x no lost time Dr visit only
Confidential: Any unauthorized use or distribution is prohibited.
/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

Moderate risk (5-8)

2x3 could happen x lost time
3x2 has happened x no lost time
2x4 could happen x Dr visit/ lost time/ temp disability
4x2 likely to happen x Dr visit no lost time
1x5 very unlikely x death
5x1 will occur x 1st aid only

High risk (9-12)

2x5 could happen x death
3x3 has happened x lost time temp disability
3x4 has happened x Dr visit perm disability
4x3 likely to happen x lost time temp disability

Imminent danger (15+)

3x5 has happened x death
5x3 will occur x lost time temp disability
(example 5)

Charting these numbered pairs we can apply a color coding to give a visual

representation of areas with the highest risk. Red would be representative of those

areas requiring immediate action, yellow would represent areas of concern, while green

would represent areas that would not require immediate action.

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

Ordered Pairs (1)

5 5x0 5x1 5x2 5x3 5x4 5x5
4 4x0 4x1 4x2 4x3 4x4 4x5
3 3x0 3x1 3x2 3x3 3x4 3x5
2 2x0 2x1 2x2 2x3 2x4 2x5
1 1x0 1x1 1x2 1x3 1x4 1x5
0 0x0 0x1 0x2 0x3 0x4 0x5
0 1 2 3 4 5
(example 6)

Another example would change the parameters from 1-5, removing the

descriptors “would not happen” for probability and “no harm” for severity since their

presence makes no appreciable difference.

Ordered pairs (2)

5x1 5x2 5x3 5x4 5x5
4x1 4x2 4x3 4x4 4x5
3x1 3x2 3x3 3x4 3x5
2x1 2x2 2x3 2x4 2x5
1x1 1x2 1x3 1x4 1x5
(example 7)

Other Uses for the Matrix

The premise of this section is to present the operational steps for the reporting,

recording and analysis of near hits however, matrices can be used in other safety

management areas to assess tasks and process with recognized hazards that have the

potential to cause harm. As was discussed in the beginning of this paper, the purpose of

assessing risk is to determine areas of greatest liability by prioritizing tasks, equipment

and procedures that require immediate action. Performing a task hazard analysis prior

to an operation is an excellent way to investigate areas of exposure and place controls

Confidential: Any unauthorized use or distribution is prohibited.
/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

to prevent exposures. Controls can be prescribed after evaluation using a risk based

matrix that takes into consideration both the severity and probability of occurrence.

Task Hazard Analysis (THA) for Radial Arm Saw Operation

Task step Hazard Severity Probability Index

1.Pick up
boards Back strain 3 2 6
2.Carry to saw Slip,Trip,falls 3 1 3
Pinch
3.Stack boards fingers 1 4 4
4.Place board No known
in saw hazard 0 0 0
5.Cut board Cut finger 4 2 8
(example 8)

In example 8, under task steps, step number one indicates that boards are

picked up. The potential injury would be back strain. This has a severity rating of three

for possible lost time injury (example 1) and a two in the probability column for the

potential of occurrence (examples 2). This example gives us an index score of nine

(example 4). Per the ordered pair, 3x2, this would be found in the Moderate Risk

category (example 6). Step five also scored in the Moderate range with an eight.

Though eight is in the moderate range it is on the high end only one point from the high

risk category.

The last step for consideration is the control of hazards. The hierarchy of controls

are as follows:

1. Elimination

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

2. Substitution

3. Engineering Controls

4. Administrative Controls

5. Personal Protective Equipment (PPE)

The order in which the controls are used should remain the same with elimination of

hazards remaining as the first choice for hazard control and PPE as the last line of

defense.

No Matrix With Matrix

Confidential: Any unauthorized use or distribution is prohibited.
/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

A B C D E F
W/ W/ W/
Matrix Matrix Matrix
Respondents Ex 1 Ex.2 Ex.3 Ex.1 Ex.2 Ex.3
1 1 4 5 5 4 5
2 3 5 4 5 4 4
3 5 5 3 5 4 5
4 2 4 5 4 4 5
5 3 5 5 5 4 5
6 5 4 3 5 4 5
7 4 3 5 5 4 5
8 3 4 4 4 4 5
9 4 4 5 5 4 5
10 2 4 5 5 4 5
11 3 5 5 5 4 4
12 5 5 4 4 4 5
13 2 4 3 5 4 5
14 3 5 5 5 4 5
15 5 4 5 5 4 5
16 4 3 3 5 4 5
17 3 4 5 5 4 5
18 4 4 4 4 4 5
Mean 3.3889 4.2222 4.3333 4.7778 4 4.8889
Stan. Dev 1.13 0.6667 0.8864 0.4278 0 0.3234
Mode 3 4 5 5 4 5
Median 3 4 4.5 5 4 5
The columns A, B, and C are ratings given 3 separate Near Hits Reports by 18 respondents.
Example number one (1), a ladder inspection that located a ladder with split rails and a bent rung.
Example number two (2) included sparks falling to a lower public area during a torch cutting operation.
Example number three (3) involved a hole located on an elevated deck large enough for someone to fall
through that was not protected.
Columns H, I and J are the exact same scenarios, but the respondents were asked to use the Near Hit
matrix represented on sheet 2 of this spread sheet to determine their ratings.
With the data distribution being approximately normal then about 68% of the values are within 1 standard
deviation of the mean, about 95% of the values are within two standard deviations, and 99.7% lie within 3
standard deviations. With a statistical certainty we can say that the use of the Matrix format would result
in more reliable data for the field for use in determination of actions immediately after occurrence and
achieve more reliable data for documentation of near hits throughout the company.

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10
Matrices Used in Safety Management

Catastrophic Critical Negligible

fatality/permanent lost time injury Medical only Marginal incident report
disability Ilness no lost time first aid only only

Frequent
common or 25 (5) 20 (5) 15 (5) 10 5
repeated Operation not Operation not Operation not Operation not High Priority
occurrence permissible permissible permissible permissible Remedial Action

4
Probable Acceptable risk
known to occur 20 (5) 16 (5) 12 8 remedial
"it has Operation not Operation not Operation not High Priority action is
happened" permissible permissible permissible Remedial Action discretionary

Occational 3
could occur, "I've Acceptable risk
15 (5) 12 9 6 remedial
heard of it Operation not Operation not Operation not High Priority action is
happening" permissible permissible permissible Remedial Action discretionary

4 2
Acceptable risk Acceptable risk
Remote 10 8 6 remedial remedial
Not likely to Operation not High Priority High Priority action is action is
occur permissible Remedial Action Remedial Action discretionary discretionary
Improbable
practilly 4 3 2 1
impossible Acceptable risk Acceptable risk Acceptable risk Acceptable risk
may assume it 5 remedial remedial remedial remedial
will High Priority action is action is action is action is
not happen Remedial Action discretionary discretionary discretionary discretionary

Confidential: Any unauthorized use or distribution is prohibited.

/opt/scribd/conversion/tmp/scratch2311/27923771.doc 01/21/10