The Link Between Near Misses and Significant Events
Introduction
The link between near misses and significant events within organisations can sometimes be misunderstood, not considered or go unnoticed. In these cases, the discipline around reporting near miss incidents is inconsistent and undermines a ‘good reporting’ culture across the business. Experiencing a near miss incident means something or someone has adversely effected the safety and efficiency required to complete a task as planned.
It would be irresponsible for an organisation to allow such events/incidents to not be identified, reported, analysed, and addressed; and then to not acknowledge the lessons learnt. While most organisations have robust reporting and investigation processes to manage events/incidents where actual consequences have resulted such as injury, damage to plant, etc; it is the understanding of, and analyzing of near misses which can identify safety system and cultural weaknesses and hence establish a proactive safety management system.
To understand the link, we first must consider; “what is a near miss?”
What is a Near Miss Incident?
The definition of a “near miss” or sometimes known as a “near hit” can vary slightly from organisation to organisation. The definition, from AS1885.1-1990 - Measurement of Occupational Health and Safety Performance, is “any unplanned incidents that occurred at the workplace which, although not resulting in any injury or disease, had the potential to do so.”
Whereas, an incident is typically defined as “any unplanned event resulting in, or having a potential for injury, ill-health, damage or other loss, including near misses and potential environmental or cultural heritage harm.”
The common factor in the two definitions is a near miss is a type of incident having emphasis on the word “potential.” The clear link is that both have deficiencies in the safe system design to perform a task safely and efficiently; but only one ended in tangible consequences.
So, with this information, “leading practice” organisations use a near miss incident in a positive way to enhance their safety management systems, operational discipline and efficiency.
Consider the following example.
Two electricians were installing electrical cable trays approximately 3 metres above level 1 floor in an operating plant. The height above ground level of the cable tray was 6.2 metres. To carry out this work scaffold was erected with fall protection and a secondary protection of a barricaded exclusion zone was set up below the works on the ground level. During this work an electrician unintentionally dropped a screwdriver.
Consider the following three scenarios:
The screwdriver misses the first defence of the fall protection and;
lands in the exclusion zone at ground level.
on the way down contacts a 100mm diameter pipe. This deflects the screwdriver out of the exclusion zone and lands approximately 2 metres from an operator conducting his routine inspections of plant.
on the way down contacts a 100mm diameter pipe. This deflects the screwdriver out of the exclusion zone and it strikes an operator, who is conducting routine inspections of plant, on the shoulder and neck area causing bruising and lacerations requiring medical attention.
Would all of these scenarios get reported in your organisation?
No.3 is an incident causing injuries and having higher potential consequences.
No.2 is a typical near miss and with potential to cause harm.
What about No.1? This event was contained in the layers of defence. However; was the risk identified and was there adequate protection with consideration given to potential consequences? Does the organisation need to learn from this event for future work?
Managing a Near Miss Incident
The difficulty for some organisations to successfully manage near miss incidents is where these incidents are not always reported to management. This can be for various reasons which include:
near miss incidents are not clearly defined and understood in the organisation;
fear of blame or embarrassment that someone had worked unsafely;
the organisation has no structure or clear reporting process to follow; and
the work member does not consider it worthy of reporting; because no one got injured.
Each of these reasons are evident in industry and business and must be addressed to develop and maintain a good reporting culture; because it is this reporting culture that management rely upon to, firstly, identify a problem within their safe system design.
Once identified, it is reported and treated like a typical incident through the organisation’s incident management procedures. Any event that undermines the organisation’s safe system design must be addressed / rectified with appropriate corrective actions. Including a near miss into a typical incident management process in “leading practice” organisations initiates the following to occur.
Identification and reporting.
Classification of the incident based upon potential consequence.
Analysis to determine the casual factors.
Corrective actions to address the causal factors.
Learnings for the organisation and formal report.
These above elements make up the incident investigation process aligning to the methodology of the Incident Cause Analysis Method (ICAM).
Link between Near miss and Significant Events
The majority of organisations today have a robust incident management process within their management systems; however, “do we know near misses are being reported at the level required to demonstrate continual improvement and moving the organisation closer to zero harm?”
The key to this lies in the application of a quality investigation process such as ICAM. The first stages of an investigation following a near miss incident are identification and reporting of the incident. Management can, and should, set the framework and expectations to manage these incidents; however, in most cases it is the operator, maintainer or the people at the point of the activity that witness or are part of the near miss event who must act. It is these people that need to understand the importance of reporting these events.
Two areas and questions that must be understood by these people include:
Do they know what a near miss is with respect to potential consequence?
Do they see the value to everybody across the organisation for reporting this incident?
Therefore, getting these messages across to all workers realises the link between near misses and significant events, in particular, identifying potential consequences.
The common thinking from the initial observations by those involved in a near miss is that luck, timing and where they were positioned are the main points of reference. This generally diminishes the recognition of potential consequence and relevance of reporting by the workers. Often the workers keep it to themselves because “we’re OK; that was close; we won’t let that happen again.”
That may appear to be fine for those workers; but what about other workers who may be in that similar circumstance at another time and where their position or luck does not afford them the safety of not being injured. Any lessons that could have been learnt from the original incident were never identified, let alone areas for improvement implemented to prevent the injury. The organisation was blind to any gaps or deficiencies within their systems because it was not reported. Therefore, the same adverse conditions were still present and not identified.
The opportunity to improve the organisation safe system design was missed.
With today’s organisations having emphasis on good safe design of systems and where a good reporting culture exists, a near miss is reported and becomes part of the incident management process flow. The level of investigation often relies upon consequence (using risk based logic) and in the case of a near miss incident, it is “potential consequence.” The casual factors are identified and analysed with corrective actions implemented.
The opportunity for improvement was provided and grasped by the organisation. The astute organisation recognizes near miss incidents as a “gift” to advance safety by improving systems, processes and culture.
Mentioned above was luck and timing. Where do these fit into the investigation process?
When we investigate and analyse an incident we might identify that 95% or more of the safe work system was followed, although an error was made by the operator. No injury occurred, but there was potential for significant injury if certain defences were not in place and applied. What we observe is the organisation had “layers of defences” in place and these were applied during the work. Having enough, and the relevant, layers of defences meant that the error made did not end in tragic circumstances. The consequences were mitigated due to the 95% or more of the application of the safe work system.
So sometimes this luck and timing overshadows the good operational discipline that allowed for those important defences to be in place. Unfortunately, an error was made but that can be managed and addressed through a fair and just culture model within the organisation. (for more information on error refer to linkedin article - Human Factors, Human Error and the role of bad luck in Incident Investigations)
Conclusion
A near miss incident has similarities to an event/incident with consequence; the only difference is the consequence is “potential” and not “actual.” A proactive organisation understands this link and manages near miss incidents with the same integrity and discipline as all incidents in the incident management system.
Additionally, the organisation must not ignore the positive behaviours and the layers of defences making up the safe system of work that were in place mitigating the consequences and categorising the incident as a near miss. This reinforces positive behaviour across the business.
This reinforcement of positive behaviour builds towards a good reporting culture which is critical for good management of near miss incidents.
The reporting of near miss incidents with a proactive approach my management to implement corrective actions focusing on continual improvement can be used effectively as a “leading indicator” as opposed to the traditional “lagging indicator” of incidents.
Interested in knowing more?
Further information on Safety Wise Solutions, ICAM Training and other services is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise Solutions also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Bruce Johnson (Investigator/Trainer)
Bruce's extensive experience covers engineering, organisational development and business improvement with large multifaceted organisations holding senior positions in both the private and government sector.
He has worked in both project management and change management, leading specialist teams to achieve business improvement outcomes within health and safety, maintenance management, role and business restructuring, and learning and development.
Through performing various roles across many industry sectors including manufacturing, construction, oil and gas, energy, mining, transport and dredging, Bruce offers a wealth of knowledge and the practical application of best practice management.
This experience combines to deliver the ICAM incident investigation training and independent investigations to a high standard, keeping ICAM as the benchmark across multiple industries. From the identification of business needs through to the strategic development and implementation of workplace improvement initiatives, Bruce provides a reliable and intergrated WH&S support service.
