Reducing Near Miss Incidents: A Shikake Approach to
Safety Awareness in Manufacturing Plant
Litvina Angelina 1
1

Naohiro Matsumura1∗

Graduate School of Economics, Osaka University

Abstract: Safety in the workplace is one of the key factors for the successful development of
a company, as it is closely tied to productivity and eﬃciency. This is why safety issues require
immediate action to prevent and preclude potential accidents. Not all unsafe actions result in
employee injuries. Such incidents are known as “near misses,” and by evaluating them, it is possible
to identify problematic areas in the production process or deﬁciencies in equipment and training.
In this study, we examined a company in Russia that manufactures crane components. The
company maintains a detailed record of near misses, which revealed a prevalent issue: most of theseincidents occurred due to a disregard for safety rules, particularly concerning hands and ﬁngers.
An experimental “shikake” implementation was introduced to increase employees’ awareness ofsafety rules. As a result of the experiment, a reduction in near miss incidents, especially thoserelated to hands, is expected.

1

Introduction

With the rapid changes in industrial production,
it is always necessary to ensure a safe working environment for the company’s employees. The eﬀective
management of workplace safety not only safeguards
the workforce but also contributes signiﬁcantly to theoverall eﬃciency and productivity of the manufacturing process and is directly linked to a company’s reputation. Moreover, it is connected to the amount of
insurance payment that can compensate for losses or
injuries, so the fewer incidents happen, the better.
This imperative holds true for a Russian-based company specializing in crane production, where the pursuit of excellence in safety practices is both a moral
obligation and a strategic necessity.
Safety in manufacturing environments is traditionally assessed through various metrics, and one key
indicator often employed is the accident ratio triangle. This method is based on Heinrich’s theory, whichindicates the link between near miss incidents and injuries and involves tracking incidents that come close
to causing harm or injury, serving as a valuable precursor to identifying potential hazards. While theoverall safety record of the company under study iscommendable, a noteworthy issue emerges: the inci∗ Graduate School of Economics, Osaka University,

1-7 Machikaneyama, Toyonaka, Osaka 560-0043 JAPANE-mail: matumura@econ.osaka-u.ac.jp

dence of near misses is relatively high.
This paper proposes a new way to address this challenge by introducing the concept of “shikake,” a term
derived from Japanese culture, which translates to’trigger’ or ’catalyst.’ The shikake method involves
employing subtle yet inﬂuential interventions to encourage desired behaviors or outcomes. In this case,the aim is to enhance safety awareness among workers
in the manufacturing plant.
The proposed intervention consists of a simple but
potentially transformative strategy: the distributionof pens of diﬀerent colors, each inscribed with one ofeight unique safety messages, and the placement ofcorresponding cups for their return. Each day, workers select a pen that resonates with them, read thesafety message, and return the pen to the cup bearing the same message at the end of their shift. The
underlying hypothesis is that this shikake method willreinforce safety awareness and foster a culture of vigilant adherence to safety protocols.
The central research question guiding this study isstraightforward yet pivotal: Can the implementationof the shikake method eﬀectively reduce the numberof near misses within the manufacturing plant?
To address this question, this research paper draws
upon the shikake concept developed by Matsumura
Naohiro, a framework rooted in behavioral psychology and design thinking that aims to inﬂuence humanbehavior through subtle environmental cues. Additionally, it delves into the theory of near misses, recognizing their signiﬁcance as early warning signals insafety management.
By investigating the potential impact of the shikake
method on safety awareness and near miss reduction
within the context of a crane manufacturing company,
this study not only contributes to the growing body ofliterature on safety management but also oﬀers practical insights and recommendations that can enhance
workplace safety in similar manufacturing settings.
In the following sections, we will explore the research background, methodology, results, and implications of this novel approach, shedding light on thetransformative power of subtle interventions in fostering a culture of safety within the workplace.

2

Research Background

2.1

Focus Company

First of all, it is essential to know the backgroundof the focus company to conduct case study research.
The focus company is a manufacturing company thatprovides cranes and other lifting solutions and has ﬁve
manufacturing plants in diﬀerent parts of Russia. The
research is focused on one of the plants (hereinafter– Plant A) that has undergone some core changes in
the last four years.
At ﬁrst, Plant A was lossmaking for the company,
and, to make it proﬁtable again, it was downsized
greatly (both in size and number of employees), andall the processes and production lines were deeply revised and cut to make it easier and more eﬃcient tomanage. Part of manufacturing was moved to anotherplant of the company. As a result of this downsizing
project, the plant improved its performance a lot andbecame one of the most productive plants in the area.
Plant A has a foundry and metal processing. To
be speciﬁc, the plant receives raw materials in metal
charge, then the materials undergo a smelting processwith the addition of chemicals, after which the liquid
metal is cast into supports and covered with a nonstick solution. Then, the metal cools down, and thecasting is hammered out. The metal is ready to beformed into the product shape. Metal processing is
divided into two stages of turning operations: teeth
miling and heat treatment. The ﬁnal production steps
relate to ﬁnish metal cutting and quality control procedures.

As the whole production process is connected tometal smelting, cutting, and chemicals, it is considered to be a hazardous work, work of high risk for theplant workers.
Therefore, Plant A faced some diﬃculties with safety:
the company continuously records all the accidents
and near misses of all the plants, and it is clear thateven if the number of accidents resulted in injuries isquite low, the statistics of near misses are concerning.
The reason for choosing plant A among the other fouris that near misses happen more frequently than onother plants (See Table 1). As the number of employees in plant A is the smallest compared to otherplants, every worker ends up making more mistakesthat lead to near miss incidents. It is important toimprove the safety awareness of the plant workers tomake their work conditions better and avoid any injuries.
What is a near miss in the present can potentiallyturn into an accident in the future, especially in situations where almost all the processes can lead to a
cutting or burning injury. That is why it is a problem
that is clearly addressed and should be resolved.

2.2

Deﬁnition of shikake and diﬀerenceswith similar concepts

The term “shikake” (trigger) was ﬁrst described in2013 by N. Matsumura, a professor at Osaka University, who deﬁned it as “an embodied trigger for behavior change to solve social or personal problems”[17]. In other words, using shikake can help to change
people’s behavior to solve various kinds of issues, andoccupational safety issues are one of them.
Often, shikake interacts with human curiosity andplayfulness, giving a person a choice of an action thatis more exciting than the ordinary one, and by choosing this particular action, people change their behavior, solving some issues. For example, to make people
want to take the stairs instead of the elevator or escalator, the stairs were painted black and white like a
piano and made a similar sound when being steppedon. As a result of using this shikake, signiﬁcantly more
people chose to take the stairs because it was interesting to interact with. By this experiment, the problem
of low mobility of healthy people was partially solved.
Shikake can be used in various situations because
the concept of it is simple and easy to implement.
Also, it does not have any particular form, so, again,

Table 1: The number of personnel per plant and the average number of near misses per worker for each plantover the 21-month period of 2022-2023.
Number of personnel
Plant A
Plant B
Plant C
Plant D
Plant E

Near misses per worker

direct worker

employeedirect worker

employee

42
166
292
368
111

75
266
482
617
149

10.12
4.75
1.68
1.46
4.19

5.67
2.97
1.02
0.87
3.12

it does not have any limitations as long as it meets thethree FAD requirements deﬁned by N. Matsumura:fairness (the shikake should not discriminate its users
and be equally used by diﬀerent groups of people),
attractiveness (it should attract the attention of potential users and make them want to interact) andduality of purpose (it should fulﬁll two purposes: oneof the people who interacts with shikake and the otherof the person who set the shikake) [16].
Shikake is divided into two categories by the triggers
used: psychological and physical [18]. Psychologicaltriggers refer to the triggers that “directly arouse apositive or negative impulse” or the triggers that show
the inﬂuence of social structures, such as social proof,
for example. Physical triggers, as the name implies,
show the inﬂuence of physical objects. Each category
should be wisely chosen for every particular case toincrease eﬃciency.
There is a similar concept called nudge, which waspresented by R.H. Thaler and C.R. Sunstein [20]. However, there are some key diﬀerences between shikake
and nudge, which should be clariﬁed. Despite thesame purpose of implementing both concepts – behavioral change, shikake encourages this through consciousness, so the target group is fully aware of the
choice of actions and consciously changes behavior.
When using a nudge, the main goal is to change people’s behavior unconsciously, engaging in the processof the so-called Automatic System, by which a person makes decisions immediately and without thinking [20]. Also, as it was mentioned above, shikake
takes advantage of curiosity and playfulness, while
nudge is based mostly on people’s systematic biases
that simplify decision-making greatly. As a result, unlike nudge, shikake can be implicated more widely tosolve issues in diﬀerent academic ﬁelds.
J.J. Gibson also formulated a theory close to shikake
called “The theory of Aﬀordance.”[6] He deﬁned “af-fordances” as the possibilities and opportunities foraction that are inherent in the environment and canbe perceived by an observer. In other words, objects
and environments are meant to provide some possible
actions to the user; for example, a chair aﬀords sitting, a pen aﬀords writing, etc. However, dependingon the user, the perception of the environment mightvary because it values context, so the observer cannot expect one or two distinguishing choices of action,
unlike setting shikake. That is why shikake might bemore eﬀective in terms of problem solving.
Although shikake can be implemented in many forms
and in various situations, as this concept is quite new,there is not much evidence of whether it is eﬀective
in terms of solving occupational safety problems ornot. This study will provide analysis and add more
applications of shikake.

2.3

Near misses and occupational safety

Another concept that is used in this study is ’near
miss’. Near miss refers to a situation that had thepotential to become an accident but was narrowly
avoided without any damage to the equipment or injury to a person. Near misses ﬁrst emerged as aconcept around the ﬁrst half of the twentieth century. This is when the rudiments of occupationalsafety theories began to develop, actively incorporating this concept to explain the relationship between
near misses and accidents.

2.4

Accident Ratio Triangles

The ﬁrst such theory is the theory of Herbert W.
Heinrich. Heinrich’s theory, which emerged in the
1930s.

Fig. 1: Heinrich’s accident ratio triangle.

Fig. 2: Bird’s accident ratio triangle.

In his work, Industrial Accident Prevention: A Scientiﬁc Approach, he argued that there is a hierarchical relationship between minor incidents and nearmisses, mild injuries, and fatalities in the workplace.
Although this work was ﬁrst published in the ﬁrst halfof the 20th century, it is not outdated, and Heinrich’s
theory is still widely applied by many organizations
and cited by researchers. Of course, this theory has
been criticized several times because of the insuﬃcient
statistical basis in its basics and simplicity, but it is
impossible to deny its importance for controlling risks
in production even now [3, 23, 4].
Speciﬁcally, Heinrich’s theory presents a triangle divided into three parts, which is illustrated in Fig. 1.
The top of the triangle represents major injuries, thepart below is minor injuries, and the base of the triangle, respectively, is a number of near misses. The
ratios for all the parts are 1-29-300, which means thatin 330 similar accidents occurring to the same person,
300 will cause no harm, 29 will end in mild injury, and1 will be the cause of serious injury (Heinrich et al.,1980). Heinrich’s theory posits that by reducing thenumber of near misses and minor incidents, organizations can respectively reduce the number of serious
injuries and fatalities.
Heinrich’s theory was then further reﬁned by FrankE. Bird ten years later (Fig. 2). Bird conducted alarge-scale study in which he analyzed about 1.75
million accidents that occurred in the workplace andidentiﬁed the following ratio: 1-10-30-600 [2]. Thus,
another division in the triangle was added, denoting
damage to equipment. Therefore, for every 641 incidents, there are 600 near misses, i.e., incidents with novisible disruption of equipment and no injury to theworker, 30 equipment damages, 10 minor injuries, and1 serious injury. Unlike Heinrich’s triangle, the structure of Bird’s triangle is more complex and makes it
clear that if an organization focuses all its eﬀorts only
on preventing serious injuries, there will be equipment
losses and, consequently, costs [23]. This can presumably result in more near misses as workers would attempt to ﬁnd an easier way to complete the task by
replacing faulty equipment with homemade tools oreven working on the same equipment.

2.5

Domino Models

Later, in 1959, Heinrich developed another theory
that linked the cause of the near miss to the injury afterward, building it up like dominoes. There are ﬁvepieces in total, each representing a stage that theoretically leads to injury . Heinrich identiﬁed the following
factors in accidents:
1. Ancestry and social environment. This factor isrelated to a process of inheritance of undesirable
traits such as recklessness, stubbornness, etc.,
in a workplace. The occupational environment
may develop these traits.
2. Fault of person. Inherited personal shortcomings are immediate causes for engaging in unsafe
behaviors.
3. Unsafe act and/or mechanical or physical hazard. The unsafe actions of individuals lead directly to accidents.
4. Accident. Incidents that are caused by unsafe
acts and result in injuries of any kind.
5. Injury. Bruising, fractures, etc. that are theresult of accidents.

Fig. 3: Accidents can be prevented by removing thecentral piece.
Dominoes are arranged one after another so thatthe “falling” of one piece inevitably leads to the fallingof the next. Therefore, if you remove any of the central pieces, a near miss will not turn into an accident,
which is represented in Fig. 3 [10].
The domino model was updated by Bird in 1974 .
He presented the same ﬁve dominoes but emphasizedthat the occurrence of accidents and injuries is also
inﬂuenced by insuﬃcient control on the part of thecompany management. The new names assigned tothese ﬁve dominoes are as follows:
1. Lack of control – Management. Insuﬃcient control, lack of training, and regulations.
2. Basic cause – Origins. If a highly dependable
loss control system is absent, it allows for thepresence of personal and job-related factors, which
are commonly known as the fundamental or root
causes of accidents or incidents leading to reduced safety. Personal factors include lack ofknowledge, skills needed to accomplish tasks,
lack of motivation, etc. Job-related factors include, for example, inadequate work standards
and abnormal usage.
3. Immediate causes – Symptoms. Unsafe acts orconditions.
4. Accident – Contact.
5. Injury – Damage – Loss. This factor includes
loss or damage of property, as well as injuries topersons.

Thus, there are some major diﬀerences between Heinrich’s and Bird’s models. Firstly, in Heinrich’s model,
the greatest attention is paid to the human factor of
the enterprise worker: he/she observes other workers
who perform unsafe actions and repeats them, consciously or not, and this sooner or later leads to consequences in the form of a near miss or, in a bad case,injury. Secondly, the role of organization and management in the fact that this or that accident happened is
not deﬁned. Third, the model oversimpliﬁes the links
leading to an incident.
Bird’s model is more complex and comprehensive,emphasizing the role of the organization in causing
accidents, i.e., Bird says that it is wrong to blame
one worker for the incident [10]. It is also the faultof the company as a whole, which failed to explain
safety rules to employees in a suﬃciently accessible
way and to provide working conditions in which theinﬂuence of the human factor on the processes will
not be increased. Unlike Heinrich’s model, this model
has more complex relationships. However, in many
modern industries, they are even more complex, sothey are not applicable to all cases. The applicabilityof these models in practice is better considered in thecontext of a particular industry and the complexity of
the links between employees within an organization.
This study utilizes both of these theories because
it is important not only to count the number of nearmisses but also to determine what actions should betaken to reduce them. To do this, a domino model isessential because it tells us exactly how near misses
result in injury at some point.

2.6

Human factor and organization inﬂuence on near misses emerging

By many researchers besides Heinrich, [11, 21], nearmisses are seen as an important indicator that something works wrong in the system. However, many organizations focus on the accidents that actually happened rather than on nearly safe incidents. This attitude towards near misses should be reconsidered because they give valuable information about ﬂaws ofdiﬀerent kinds that can be analyzed. Such analysis
gives the opportunity to search for the problem andﬁx it before it leads to an accident, not after it has
already happened [5, 22]. Incidents that end in injury
do not provide enough information on how to prevent
such accidents from happening. It is important to fo-

cus on the moments that almost caused the injury,
and then the cause can be identiﬁed [1].
So, there is a need to record and analyze near misses
to prevent their repetition and detect weak zones inthe system.
There are several fundamental causes of near misses.
Heinrich stated that there are three main categoriesof near misses: behavioral, technical, and organizational [10]. Behavioral near misses mostly include
human factors of workers: fatigue, unsafe behavior,task omissions, pressure, stress, lack of motivation,
the distraction of attention, task miscomprehension,etc. Technical near misses are strongly related to thefailure of the equipment, defective tools, and lack ofproper instructions for using the equipment, as wellas the diﬃculty of its usage. Finally, organizational
near misses are connected to organizational failures,such as managerial and supervisory miscommunication with workers, especially lack of proper instructions, directions, and motivation [10]. All three categories might be presented in every company to someextent, as near misses and accidents happen for a variety of reasons. Moreover, they can be mixed because
sometimes it is not easy to determine which speciﬁc
category an error belongs to.
The human factor is considered to play a factor ofgreat role in near misses as it becomes a reason forthe majority of behavioral near misses [9, 7, 14, 19].
Thus, the importance of employee training that can
improve safety awareness and proﬁcient managementin accident prevention should not be overlooked [15].
The importance of human factors in occupationalsafety has also been researched widely. Karanikas,N., Melis, D. J., & Kourousis, K. I., in their study
on safety and productivity in aircraft manufacturing,
stress that human factors such as workers’ fatigue,
training, and experience inﬂuence much on overall
productivity and on safety. Also, they argue that
communication between managerial and worker staﬀ
can also inﬂuence both productivity and safety. So,
in order to be proﬁtable and productive, an organization should provide adequate training, set safety rules
suitable for the industry, and communicate with theirworkers as well. Other scientists have come to thesame conclusion. Although the circumstances of thestudy are completely diﬀerent, as it is a work thatanalyzes near misses on a tanker ship, Hasanspahić
N, Vujičić S, Kristić M, Mandušić M. stress that the
combination of safety engineering and communicationis the best to reduce the number of accidents [8].

However, it is worth noting that even if work isdone to improve the environment in terms of safety
technologies, there is still a risk of near misses because
the human factor is deﬁned as something that can leadto consequences even if the system is working properly[12]. Therefore, the problem should be addressed ina holistic manner: improving the security of the work
environment from a technological point of view andimproving communication between managerial staﬀ
and subordinates will help to signiﬁcantly reduce theimpact of human error on work processes. And thus
reduce the number of near misses.
This paper will explore the solution of reducing
near misses by increasing employee safety awarenessthrough messages that clarify managers’ instructions
and thereby help deliver information accurately.

3

Research Details

This study will provide information on the practicaluse of shikake in the occupational safety sphere. As
the shikake method has not been widely researched,
it is not certain that it can be implemented in suchareas, although it is believed to be eﬀective in diﬀerent
academic ﬁelds. The eﬀectiveness of shikake in various
social spheres was studied but not detailed. Thus,
this study will be helpful for those who are willing topractically use shikake for safety improvement.
Both quantitative and qualitative research methods
were used in this study to provide a more detailed
analysis based on statistics data and observations ofpeople’s behavior, as using just one approach may
result in a lack of understanding of the inﬂuence of
shikake on the focus group.
For collecting data, experimental research was applied as shikake must be implemented to analyze its
eﬀect on human behavior. The experiment preparation was divided into several stages.
Firstly, a meeting with the managerial staﬀ of theplant was held to formulate the main goals that were
expected to be achieved after the experiment. This
helped to gain an understanding of the problems thatthe plant is facing and what shikake will be the mostsuitable solution. As the plant processes are quite
hazardous and connected to various kinds of risks,
hand injuries were selected as the most frequent typeof injury in the plant.
In the second stage, a shikake idea was created. As
the majority of injuries are related to hands and ﬁn-gers, it was considered that the best way to change
behavior is to create a strong association of this topic
with shikake. Thus, pens were selected as the best
choice for the subject of the research. There were
two reasons for that. Firstly, pens are the most frequently used objects on the plant because the workers
must ﬁll up their individual checklists after completing each task. Secondly, in the Russian language, theword ’pen’ has a similar pronunciation and spellingas ’hand,’ so this object can possibly remind users ofhands.
The main idea of the experiment is to improve workers’ safety awareness by using pens every day. To dothat, a message was printed on the body of each pen,eight diﬀerent messages altogether. The messages are
as follows:
1. I’m working safely.
Fig. 4: Pens were used in the experiment.
2. I’m always careful.
3. I wash my hands before eating.
4. I’m working with proper equipment.
5. I’m cutting with a knife away from myself.
6. I’m protecting my ﬁngers.
7. I’m using PPE (Personal Protective Equipment).
8. I’m aware of sharp edges.
These pens are of eight colors, and the messages
are randomly printed on them; therefore, people canchoose their favorite color every day and still get different messages (See Fig. 4).
Also, two cups were placed near the plant’s locker
room. At the beginning of the working shift, eachworker should get dressed in the uniform and take apen. It is supposed that they would read the message
right away, but it is not necessary. After the shiftends, they must return pens in the most suitable cup.
There are a pair of cups: one cup is for messages
concerning overall safety (messages 1-4), and anotheris particularly for the pens with messages about handsafety (messages 5-8). Workers are likely to read themessage once again and then place the pen in theright cup (See Fig. 5). This pair of cups is located inthree diﬀerent places in the plant: the passage area,
the machining shop, and the foundry. Thus, it makes
it easy for workers to return the pens to the correctcups. There are about 40 people on shift at a time, so

if only two cups are placed at the exit, there will be a
crowd, and the experiment will not be fully realized.
Each section, on the other hand, holds an average of
10-15 people, making it much easier to interact withthe shikake.
The reason for using two cups instead of multiple
cups is much the same: it might become an obstacle,and sooner or later, workers would get tired of ﬁnding
the right cup. However, using two cups to group pensby meaning of the messages might probably increase
the eﬀectiveness of the shikake.
The experiment meets all three FAD requirements[16]: it can be fairly used by all the workers, it attracts attention, and there is a duality of purpose.
The workers want to place the pens right, and the
managers want the workers to learn safety rules.
Since the company is concerned about the safety of
its employees, a number of events are held annually toraise awareness of safety rules at the company. The
largest of them is Safety Day, which is held in August
every year since 2020. The start of the experiment was
timed to coincide with this event so that employees
would pay attention to it, but it is worth noting thatfor the purity of the experiment, they were not given
any explanation of how to interact with the shikake
beforehand.
The data will be collected as before by the managerial staﬀ responsible for health and safety at the plant(hereinafter, H&S Coordinator), using the same data
sheets to compare the results to those before and afterTable 2: Near misses, distribution by groups in all theplants and in Plant A.
Near misses inall the plants (%)

Near misses in
Plant A (%)

24
52
23

16
56
28

Technical
Behavioral
Organizationalhands in work.

Fig. 5: Workers put pens into a cup.

Fig. 6: Incident recording triangle.
the experiment. For this purpose, a triangle, which issimilar to a combination of Heinrich’s and Bird’s models, is used, albeit slightly altered by the managementof the company (See Fig. 6). It is divided into threemain parts: the top part, which is referred to fatalities
and heavy injuries, the middle part, which is mostly
connected to time loss at the plant and mild injuries,
and the bottom part that represents near miss incidents and ﬁrst aid cases. To understand what canbe deﬁned as near miss, the H&S Coordinator refers
to the deﬁnition based on GRI 403 (Global Reporting Initiative): near miss is a work-related incident
where no injury or ill health occurs but which has thepotential to cause these.
It is expected that right after the start of the experiment, nothing will change for a short period of time,then probably the number of near misses will go up as
workers become more aware of the hands’ safety, andafter, it will slowly go down as the workers get used
to the rules and become more conscious about using

4

Research Results

Statistics have been taken since 2019 at all the company’s plants in Russia. Near miss data is recorded
several times each month by the H&S Coordinator
during safety walks. The H&S Coordinator notes
where and at what time a potentially dangerous situation occurred and brieﬂy describes the circumstances,
attaching a photo. This is important for assessing
which causes are the most common and what should
be avoided in the workplace to minimize the numberof such situations.
The near miss data for all the years of observation (2019-2023) was divided into three categories ofnear misses according to Heinrich: behavioral, organizational, and technical. If we analyze the data for
all the plants, we can see that the cause of more thanhalf, namely 52% of the total near misses, is employee
behavior (See Table 2). At plant A, the situationis the same - 56% are behavioral near misses. Thismeans that potentially dangerous situations arise because workers neglect safety or, due to personal reasons (poor state of health, unwillingness to work thatday, fatigue, etc.), decide to simplify the processes
performed in the production.
If we refer to the detailed statistics of near misses(See App. 1), it can be said that the reason for mostof the nearly missed incidents that could end up withinjuries to hands or the whole body (for example, asa result of using the handmade tool (See Image 3) isthat the direct workers intentionally neglect the safety
rules to complete the task fast. That is undoubtedly
done for a behavioral reason, which was described byHeinrich and others.
Also, workers often overlook a potentially dangerous situation that they have created for behavioral
reasons. For example, a worker puts a mug with aFig. 7: A handmade tool that wasused instead of an arm ﬁle.

Fig. 8: A mug on an electrical
panel.

drink on an electrical panel (See Image 4) or puts asoldering iron inside an electrical panel (See Image 5).
Issues at the organizational level rank second, accounting for approximately 28% of cases, implying
a lack of eﬀective management or unclear directives.
The remaining 16% indicate technical shortcomingsof the organization, speciﬁcally problems related toequipment.
This experiment addresses both prevalent categories.
Firstly, through the shikake method, employees are
expected to become more attentive to their interactions with equipment and their adherence to the factory’s safety protocols. Secondly, the experiment isanticipated to enhance workers’ comprehension of safety
instructions, aligning with the plant manager’s objectives.
After the experiment was set up, the H&S Coordinator noted that the workers started using the shikake.
Also, most of the employees looked at the pens andread the messages written on them at the beginningof the shift and at the end of the day when it was time
to put the pen back into a cup.
Also, the data on near misses was collected. As
mentioned before, there are some cases where thecause of near misses is mixed, so it can be interpreted from all the perspectives concerning categories
by Heinrich (organizational, behavioral, and technical). It may contain the H&S Coordinator’s subjective judgment, as when the Coordinator registers anear miss event, he decides which category it belongs
to. Thus, to be more precise and objective, the totalnear miss count was the central object of this research.

Fig. 9: A soldering iron inside anelectrical panel.

If we look at the statistics of all near misses at Plant
A in Fig. 10, we can see that, based on four years ofobservations, it is diﬃcult to identify obvious trends
that could be called seasonality of errors. In otherwords, when the highest or lowest number of errors
are committed at the same time each year. It is also
worth noting that observations are made by the H&S
Coordinator, who, at the time of summer vacation,
New Year vacations (in Russia, New Year holidays
last on average two weeks after the New Year), or due
to illness may be absent, and as a consequence, may
record fewer near misses.
However, what is certain based on the statistics for2023 is that this year’s data is signiﬁcantly diﬀerent
from previous years.
To make a detailed chart description, one should
also compare the charts for previous years in the sameinterval – three months before Safety Day and threemonths after, starting in 2020. Also, it is worth adding
the context of the events held each year to the reviewof the schedules so that the result is more informative.
In 2020, meetings were held to explain the safety
rules in detail. Brochures were also given to eachworker to duplicate the content of the meetings, withchildren’s drawings on each page. In 2021, similar
activities were carried out, but instead of brochures,
posters explaining safety were put up on the plantpremises. In 2022, magnets with safety information
printed on them were added to the previous year’s
activities, and employees used them to attach documents required for their work to the machines.
Of all the years of observation, only in 2020, thereFig. 10: Near misses in total, Plant A. 2020-2023.
was a decrease in near misses after Safety Day (from35 to 25 cases). In 2021 and 2022, the statistics increased, albeit slightly. In the following months, thestatistics level oﬀ and reach the average level of nearmisses committed by employees. However, if we turnto 2023, there is a clear spike in near misses. In thegraph, it can be seen that the number of near misses
ﬂuctuated between 22 and 27 for several months prior
to the Safety Day at the plant, but afterward, it sharply
increased to almost double by August (44 cases). Thiswas followed immediately by a gradual decrease incases, ﬁrst to 35 cases in September and then to 21 in
October, i.e., below the pre-survey period.
A decrease or insigniﬁcant change in the numberof cases immediately after the start of the experiment may indicate that the activities have not had
the expected eﬀect on the target audience. If they
are successful, workers become more attentive, ﬁrst
becoming accustomed to behaving in a diﬀerent manner than they are used to, and then gradually changing their behavior to safer ones. If there is no spikein the number of incidents, it may indicate that the
information was not perceived as important by em-

ployees or that it was delivered in the wrong way. For
example, the problem with the magnet campaign in
2022 is due to the fact that most employees took themagnets home rather than using them daily in thework environment. Therefore, the graph for this year
shows the smallest change.
Other campaigns were also not so successful since
the content of the meetings is likely to be quickly forgotten by workers, and the brochures and posters are
viewed and read by few. Also, the frequency of exposure to safety rules plays a great role. The more often
a worker sees a safety rule, the more likely he or she
is to follow it.
The purpose of the shikake experiment is to haveworkers look at a message each day about what to do
to stay safe at work and then consciously select thecategory where the message should be placed. Also,
because there are many pens, these messages rotate
each day, making it diﬃcult to foresee which one tobe picked the next day. This encourages workers toread the safety rules time after time and eventuallymemorize them.
The sharp increase in the number of incidents inthe month of Safety Day 2023 indicates that the H&S
Coordinator became more attentive to catching nearmisses related to hands than before. But why? Probably due to the so-called Observer (or Hawthorne) Effect [13]. This phenomenon suggests that people mayalter their behavior when they are aware that they arebeing observed or studied; thus, they feel motivated totry to present the best performance for the task thatis being observed. As a result, an increase in the encouraged or expected behavior can be observed after
the experiment begins because the person pays more
attention to the action than before the study. For
example, when the police launch an anti-shoplifting
campaign, policemen become more attentive, possibly
increasing their visibility in stores. Paradoxically, instead of deterring shoplifting, the campaign may leadto an increase in reported cases in the short term dueto the increased attentiveness to this particular offense.
This is similar to the experiment made in the plant.
Thus, it can be said that shikake had its eﬀect ﬁrstly
not on the direct workers of the plant but on the H&S
Coordinator who registered near misses.
Then, from September onwards, the number of cases
decreased consistently and reached its lowest point inall previous years during the period from Safety Day
in August to the end of the year (15 cases). Therefore,
it can be concluded that the plant workers graduallychanged their behavior to comply with safety rules
and minimize the risks of near misses.
There is no doubt that follow-up observations will
be needed for a more accurate assessment, but at thisstage, it can be said that a) the shikake experiment
had a more pronounced eﬀect compared to all previous experiments; b) in the ﬁrst month, the eﬀect
on the H&S Coordinator was probably the greatest;c) the reaction of the direct plant workers showed thegreatest response to the experiment, and thus resulted
in a change in workers’ behavior and a reduction in
the number of near misses.

5

Discussion

This study presents a new approach to solving safety
problems in the workplace. The results of the experiment showed that shikake can be used to increase thesafety awareness of employees and, as a result, reducenear misses and, consequently, help to avoid serious
injuries.

Of course, this study has some limitations. First,
since it is a case study, it is diﬃcult to say whether thismethod would be suitable for solving similar problems in other settings and in other types of enterprises. This method is probably most suitable for
reducing near misses in relatively small-scale plants
where the number of employees does not exceed 100.
Secondly, the author suggests that the eﬀectivenessof this method in Russian-speaking societies is higher
than in societies where other languages prevail since
there is an associative link between the words “hand”
and “pen.” Finally, in this paper, the concepts ofHeinrich and Bird (domino model) were taken as abasis because, in the context of plant A, the author
considered them to be the most applicable for solving
the problem of near misses since the safety problems
at the plant can be evaluated as consistent – nearmisses do lead to injuries of diﬀerent types of severityin the end. However, there are other concepts thatwould be more appropriate for other industries (e.g.,chemical, I.T., service, etc.) where the injury rates
and sequence of operations are quite diﬀerent.

6Conclusion

This study showed that the use of shikake, namely
safety message pens and return cups, was eﬀective in
reducing the number of near misses at Plant A. Twomonths after the start of the experiment, the numberof near misses decreased to a level lower than before
the experiment. Follow-up observations will undoubtedly be needed to understand whether the applicationof shikake in the long term aﬀects the number of nearmisses committed by workers. However, it can be concluded that in the short term, namely at ﬁve monthsof observation, shikake had the expected eﬀect.
This allows us to say that the main objective of
this study has been fulﬁlled, and the hypothesis has
been proven: shikake can be applied in manufacturing plants to reduce the number of near misses, and,
therefore, reduce the subsequent injuries to workers
and improve the company’s reputation.
From the above, it follows that this experiment canbe introduced in companies with similar conditions inorder to solve safety problems in a novel and original
way.

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