2020 Near Miss Analysis January - September

 

Marine Corps Air Facility
Quantico

2020 Near Miss Analysis

Covering Near Miss Reports between
January—September 2020

All sections should evaluate this document and apply applicable controls to their
hazard and risk reduction strategies.

Printed 13 October 2020

Marine Corps Air Facility Quantico
Trend Analysis Program

2100 Rowell Road, Quantico, VA 22134 - Phone: (703) 432-1365 - Email: [email protected]

  Marine Corps Air Facility Quantico

Over the past several weeks (or longer) the question has been asked “why is near miss reporting such a big
deal.” To be honest, that is a fantastic question I will try to explain as succinctly as possible.

First, near miss reporting has been a Marine Corps requirement (MCO 5100.29) for over a decade but the
order failed to clearly define what “near miss” meant other than an event that occurred we would recognize
as a “close call.” To complicate the process further, reporting methods were cumbersome with no tangible
benefit to the reporting unit since feedback or trend data was never provided by higher headquarters
regarding the submitted reports. So in short, the requirement has been there for some time but no effective
vehicle to submit the report, then turn the data into usable information. However, the intent behind the
requirement was nonetheless valuable as data clearly shows an effective near miss reporting program has
significant benefits, so, working to continuously improve the MCAF Safety Program, in 2019 the MCAF
Safety Office completely restructured and redefined our near miss process to what you see today. So
enough of the history lesson, let’s answer the question of why it is so important.

In the safety profession we are surrounded by “data points” that we use to help manage our safety programs.
We use this data to anticipate or influence a change to future events, as well as measure the effectiveness of
our efforts. These data points are known as “LEADING” and “LAGGING” indicators. A leading indicator is a
predictive measurement prior to an incident, where a lagging indicator is an output measurement of known
data following an incident. The primary difference between the two is a leading indicator can influence
change and a lagging indicator can only record what has happened.

All too often we concentrate on measuring results, outputs and outcomes. Why? Because they are easy to
measure and they are accurate. These are lagging indicators. They are an after-the-event measurement,
essential for reporting and measurement purposes, but useless when attempting to influence the future.

To influence the future a different type of measurement is required, one that is predictive rather than a result.
To get a better understanding look at the image below. Leading indicators (these are just some) are used to
proactively work towards reducing mishaps, where lagging indicators are used to measure the outcome.

So - why is near miss reporting so
important? The way we have structured
our near miss reporting program is an
incredibly effective BLEND of using both
leading AND lagging indicators in an effort
to influence the future and reduce mishaps.
By analyzing data from the four reporting
categories, we improve our ability to
develop strategies to hopefully prevent
accidents and injuries in the future.

Look at the four reporting categories to
understand the “blend:”

1. A traditional “near miss” where an accident could have been worse but wasn’t. (Lagging Indicator because
the event actually happened)

2. A hazardous condition that could results in an injury, but hasn’t yet. (Leading indicator because an event
hasn’t happened and the condition is being reported.)

3. A hazardous behavior that could result in an injury, but hasn’t yet. (Leading indicator because an event
hasn’t happened and the behavior is being reported.)

4. A failure to follow an established process or procedure. Lagging Indicator because the action has already
happened and can be addressed.

2100 Rowell Road, Quantico, VA 22134 - Phone: (703) 432-1365 - Email: [email protected] 2

 

Finally, more “reasons” this process is important.

1. Will accurately capture changing facility conditions
and human behaviors.

2. Will provide a way for everybody to be involved
and engaged in mishap reduction efforts.

3. Will provide a data collection method to help
identify trends.

4. Will provide a method to identify shortfalls in
processes, PPE, or training.

5. Will aid in preventing injuries, or damage to
equipment or property.

6. Will foster a healthier culture of reporting within
the command.

7. Will encourage greater accountability to process
compliance and adherence to published
standards.

8. Will provide a proactive approach to mishap and
hazard reporting.

9. Will provide information that will help us improve.

So, there it is. Near Miss reporting is extremely helpful
when done correctly. It helps me, it improves the
program, but more importantly, can shape a better
and safer working environment for you. If you have
questions, feel free to swing by. Mr. H

Table of Contents

CY 2020 Reports Submitted Page 3
MCAF Reports by Quarter Page 4
Reports Submitted—S1 Page 4
Reports Submitted—S4 Fuels Page 5
Reports Submitted—S4 Log Page 5
Reports Submitted—S3 ATCM Page 6
Reports Submitted—S3 ATC Page 6
Reports Submitted—S3 ARFF Page 7
Reports Submitted—S3 HQ/FC Page 7

2020 Near Miss Report Breakdown Page 8
Slips, Trips, and Falls Page 8
Facility/Infrastructure Page 9
Hazardous Conditions Page 9
Office Page 10
Vehicle / Pedestrian Page 10

Submission Participation by Section Page 11

AFO 5100.4F Near Miss Requirement Page 11
Commander’s 2020 Safety Goals Page 12

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2100 Rowell Road, Quantico, VA 22134 - Phone: (703) 432-1365 - Email: [email protected] 4

 

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2100 Rowell Road, Quantico, VA 22134 - Phone: (703) 432-1365 - Email: [email protected] 9

 

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2020 Safety Goals

To ensure on-going efforts and improvements to our world class
safety program, I am establishing the following goals for calendar
year 2020, and require all personnel to be actively engaged and in-

volved where possible in achieving these goals.

R. S. VUOLO, Commanding Officer

1. To increase the frequency of Near Miss reports, and to come into greater compliance with
AFO 5100.4F Chapter 5 paragraph 5002.6, each work center will increase their near miss
reporting by 10% per month until, at a minimum, 75% of the work center is submitting reports
on a monthly basis as required. This will require each section to develop and implement
unique strategies that promote Near Miss reporting and be accountable to the Commander’s
guidance.  

2100 Rowell Road, Quantico, VA 22134 - Phone: (703) 432-1365 - Email: [email protected] 12