It takes guts to share your mistakes and near misses with your colleagues. Who wants to look foolish when they can keep mum, silently vowing not to repeat said mistake? The Materials Sciences Division (MSD) not only gets people to freely admit their mistakes and near misses, but it rewards the year’s best close call in an annual competition.

“We’ve learned a lot of things and identified some significant problems since we started the near-miss program six years ago,” said Rick Kelly, MSD safety coordinator.

It all started after a gas cylinder rolled off a gas cylinder cart in Paul Alivisato’s campus laboratory in 2006. This wasn’t the first time a cylinder had rolled off the cart. But it was the first time an injury happened because of it. Instead of reporting the cart so that it could be modified and made safe, lab personnel had worked around the problem. That behavior had to change. Creating the competition allowed for a fun way to learn from near misses, like the cart, and turn potentially embarrassing episodes into learning opportunities for all.

Now, every year MSD workers look to similar situations to make their workplace safer, Kelly says. Sharing what almost went wrong, or what did go wrong but did not result in injury has been a staple of the aviation industry for the last four decades. The Aviation Safety Response System (ASRS) collects voluntarily submitted safety incident/situation reports from pilots, controllers, and others to help maintain and improve safety in that industry. The ASRS was created after misunderstandings during a 1974 cockpit and control tower conversation resulted in a crash killing all on board.

ASRS has become an industry standard where concerns can be raised in a safe, non-punitive environment, just as it is with the near miss program. As long as the incident happened at an MSD facility, it is eligible for the annual competition, where winners are chosen using an applause-o-meter to gauge the loudest audience-generated response. Students and post-docs are the judges and the grand prize is a cash reward.

Last year’s entrants included a hot plate that was in the “off” position but actually was on “high,” discovery of a chemical stored in a glass jar that should have been in a plastic container, a clogged sink with unknown chemicals that nobody fessed up to, exposure to a concealed high-voltage power source, a clogged valve on a liquid nitrogen tank, and the improper delivery of volatile chemicals.

All of these situations could have escalated into something more dangerous. Some were mechanical and had nothing to do with operator error. Others arose from shortcomings during the performance of lab procedures. However, an open environment and “Just Culture” that promotes awareness and the ability to learn from past mistakes lifts the stigma associated with making mistakes and fosters a more effective safety culture.

The winner of the 2012 competition was Karl Walczak from the Division’s Joint Center for Artificial Photosynthesis. Coolant from a piece of equipment was leaking all over the floor so he closed the coolant valves, cleaned up the puddle of chilled water, poked around the inside of the machine for additional leakage, and posted a note explaining what he’d done. Crisis averted; he had eliminated a potential tripping hazard.

Months later inspectors noted that Karl had removed a metal cover on the device during his clean up, exposing a high voltage energized power transformer. Walczak realized he previously had been cleaning the water spill near a live power source. He admitted he should have better assessed the situation, like unplugging the device, before cleaning the spill.

The saying goes that hindsight is 20/20, where time and perspective allow us to see problems differently. The near-miss program encourages this type of analysis in a non-punitive environment. And, it makes the process fun.

Caption: A pressure-relieving lid didn't do its job and caused a container of "Piranha Etch" to rupture during the night, spewing caustic material throughout a closed fume hood. The takeaway is that the researcher has since developed a way to catalyze the chemical breakdown, thus preventing a potential gas-generating reaction.