The value of a good Near Miss Reporting System is clear. When well-executed, such systems not only help maintain a safe physical environment, they also build engagement, trust, and improve communication. Two years ago, with the help of Aubrey Daniels International (ADI), Brown-Forman, makers of famous brands such as Jack Daniel’s, Old Forester, and Sonoma-Cutrer, embarked on a behavioral safety journey. In the Stevenson Mill, they applied what they learned about behavior to build a more robust Near Miss Reporting System. ADI Senior Consultant Bart Sevin, who has worked with all of the Brown-Forman sites, talked with Howard Burcham, Mill Manager, and Dan Parker, Maintenance Manager and BBS Site Champion, to hear firsthand about what they did that led to their success.
SEVIN: What was it specifically that prompted your work to improve near miss reporting at Stevenson?
BURCHAM: Four years ago our facility had 12 injuries. Three years ago we had 5. Two years ago we had 2. Last year we had none. If we went from 12 to none in one year I would be less impressed than I am by our true journey. I have been in manufacturing for 30 years. One question that has always troubled me is, “How can we manage our safety?” I had watched facilities (some that I was a part of) hit milestones in safety to only exhale and regress backwards, often times having injuries again. It's the kind of thing that wakes me up at night. I couldn’t answer the question, “What can my team do to manage their safety and not just be lucky?” My goal was to be able to point precisely to the reasons for our success if asked how we did it. The Near Miss Program is something we can point to. We always say that team members have the power to stop the plant operations for an unsafe condition or act. The Near Miss Program gives them the power to run the plant safely. This system provides an avenue for our team to point out (and even fix on their own) things in our plant that cause unsafe conditions or acts.
SEVIN: Stevenson casts its net a bit wider than is typical, so how do you define a near miss?
BURCHAM: One thing that has made a difference for us is identifying upset conditions as precursors to near misses. These are usually seen as throughput or production issues, not safety issues. But we realized that upset conditions often lead to risk and are therefore important for near miss reporting. Traditionally near misses might be something like a puddle on the floor, but we ask our people to think further upstream and now the operator writes up things that caused the puddle in the first place. Another example is a seam in a conveyor that causes product to jam and stop the line. To un-jam the line, the operator must use his LOTO locks, alternative LOTO (interlocks), and a crow bar to clear the jam. There are a lot of potential injuries in that process. If we start by fixing the seam issue, there is no possibility of a jam. Our motto is, “The operator is at his/her safest standing there doing the job—anything else exposes them to risks.”
SEVIN: What suggestions do you have for the reporting process itself? How do you make it as simple as possible for people to escalate a near miss?
BURCHAM: First and foremost, I think organizations over-think the process. It’s best to make the forms readily available in an area like the break room. We recognize that some people are shy; they don't want to hand it to their supervisor. Others are willing to hand it to a supervisor but they shouldn't have to chase one down. Make it easy. Have a place for the employee to drop the form off and the check it often! If parts need to be ordered just let the employee know and keep moving. Some plants want to meet two or three times with the employee and engineering and make a lengthy, detailed process out of it. Life is busy. Often there isn’t time for all the formality and it leads to unnecessary delays. Getting things fixed quickly is important. A great example of that is last year one of our employees turned in a form at 7:00 a.m. I picked up the form at 7:15 from the tray in the break room. Dan (maintenance manager) fixed it at lunch. At 3:30 p.m. the employee said, "Someone else must have already turned in the Near Miss I did this morning." I asked him why he thought that. He said, "It was fixed so quickly." I told him, "No one else reported it. We got your form and fixed it, that's all." There is no need for formal close out meetings with a panel of people. Trust me, if you fix their Near Miss they will notice and it spreads from there.
SEVIN: You mentioned that you once had everyone look for sharp edges after a near miss at another mill. Are there any other group activities like this have you done around near misses?
BURCHAM: As of today we have gone 365 working days with no injuries! I monitor the other plant's First Aid and Near Miss entries to capture trends or "targets" we can check against our own facility. It can range from machine guarding issues, wiring, you name it! If anyone else has seen something, it could easily be here at Stevenson as well. I also look at what I call "nags;" nagging items like, "I always have to monitor the gates at the machines to make sure the tool tight guarding is in place." We put this out in the morning meeting for everyone to check. We do "wall-to-wall" inspections where we grab a couple of people and give them a few items to check and let them cover the plant wall-to-wall looking at these items. We also have to do biweekly environmental walks of the entire property for EPA compliance. I always have the inspectors carry a handful of Near Miss Forms. We have done "360" inspections where I will have a team with Near Miss Forms go completely around the outside of the building 360 degrees and look for safety or environmental issues.
SEVIN: There is a reward of sorts at the end of each month for employees who submit near misses, but what are the positive reinforcers (R+) for reporting near misses besides the bottle they may be awarded?
BURCHAM: Honestly we have very few formal meetings. We stop at the employee's workstation and update them on a form they filled out, but nothing formal. The poker chip is the cornerstone of the program. Team members receive a poker chip for every Near Miss form turned in. It is worth roughly a dollar and is redeemed for company merchandise from our company store. We also have a competition between sister plants. The plant with the most forms submitted wins the "Gold:" a bottle of Jack Daniel’s No 27 Gold. It is fairly rare and retails for $150.00. We raffle this off to a lucky team member if our plant wins. Some people only turn in one form or so a month and some turn in dozens. The more that are turned in the better your raffle chances (our plants are small so the chances of winning are pretty good). We have one employee who turns in dozens a month and she redeems her poker chips for shirts and other clothing so she does not have to buy work clothes. But the real value in the poker chip is that it gives us the opportunity to open up a conversation about their Near Miss form or anything else they might want to talk about. In the beginning I did more coaching and maybe even allowed a Near Miss Form on some very low priority stuff but the seeds needed to be planted and built from there. I still get a lot of people that come up and say, "I don't know if this is a Near Miss or not." or "Is this a Near Miss?" I have never rejected one. I may have to coach or "lead" them into a better or different version of what they have questioned, but I never reject it. Growing up, my Dad always said you may not like how a new dog trees a squirrel but if you mistreat him and don't train him you'll be treeing squirrels yourself (not that our team is a bunch of dogs)!" In my opinion, this is the best way to get employee engagement. The average rank and file employee feels like they have no power. This empowers them to actually help run and change things. It's easy for managers to overlook that.
SEVIN: What suggestions do you have for other companies looking to find success with their Near Miss Reporting Systems?
BURCHAM: When you use something tangible, like the poker chip, remember it’s not really about the poker chip but the conversation it allows. I have seen plants making grand presentations with the poker chips and making a big deal of the Near Miss form but I have found if I go up to someone, hand them the poker chip and strike up a conversation I gain so much more. The military uses "challenge coins" much the same way. It may only be worth a dollar but it breaks the ice and creates a relationship. I also believe it is important to have casino grade chips. They have heft; they clink and clank in your hand. People can easily collect and not lose them. You want those coins to mean something and you make that happen through the conversation you have. That silly little poker chip—worth a dollar— gives us so many opportunities to give social positive reinforcement.
PARKER: It is also important to acknowledge that the process puts more work on maintenance personnel. In order to give encouragement and appreciation, Howard purchased small items (e.g., hats, shirts, hoodies) as reinforcers for the maintenance personnel. This also helped to encourage operators to correct small things on their own. They get two poker chips instead of one when they do this so they can really rack up the chips and purchase what they want, even sooner.
SEVIN: What impact has your Near Miss Reporting System had?
BURCHAM: The two years before we introduced the Near Miss system we had 0 Near Misses turned in and had 5 and 12 injuries respectively. The first year we introduced it we had about 200 Near Misses reported and 2 injuries. This past year we have addressed over 1,900 Near Misses and have had ZERO Injuries. I believe one of the fastest ways to impact engagement and morale is to have a robust safety program. It breeds pride in the facility and it empowers the team members to manage and run it themselves. It is a short leap to improved productivity and higher morale leads to lower absenteeism. Our Near Miss system has become an important part of our safety program.