1. Near Miss
There are manywaysto describe anear miss,close call,ornear hit.
Definition:
A nearmisscan be describe asan unplannedeventwheregivenslightlydifferentcircumstances,
injurytopeople,damage topropertyorprocessor harm to the environmentcouldoccurred.
All NearMissesinvolve people andsome type of action.
What isa NearMiss?
Unsafe actionsof people whichindifferentcircumstancescouldcause anaccident,property
damage,processinterruptionorcreate anenvironmental hazard.
What isa NearMiss?
Pre-shiftworkplace examinationsare designedtolookforunsafe conditionsinthe workarea.These
are correctedbefore workbegins.
Unsafe actionsare observationstocorrectthe sometimes‘unthinking’actsthatwe commit.
The eventwhichultimatelyresultsinaloss,hasusuallyoccurredmanytimespreviously.However,
because nolosswas experienceditwasnormallyleftuninvestigated.
Reportinganear missor a “close call” can provide waysforpeople tounderstandhow anaccident
couldhave happenedandhowto preventanaccidentinthe future withoutanyone gettinghurt.
The National SafetyCouncil offersthe following
definitions,whichare recognizedbyOSHA:
– An accidentisan undesiredeventthatresultsin personal injuryorpropertydamage.
- An incidentisanunplanned,undesiredeventthatadverselyaffectscompletionof a
task.
- Nearmissesdescribe incidentswhere nopropertywasdamagedandnopersonal
injurysustained,butwhere,givenaslightshiftintime orposition,damage and/orinjuryeasilycould
have occurred.
Benefitsof ReportingNearMisses
–
–isa “Do Over” withoutaCost or
PenaltyorInjury.
correctedtimely –but that theymustbe Used as a LearningExperience.
2. Reportingof a NearMiss and the subsequentInvestigationof –will more thanlikely reveal –acts,
conditions,etc.thatwill needtobe corrected.
EXISTING CONDITIONS– Do not be surprisedwhen
investigatingNearMisses –to findUnsafe Conditionsthat
have beenpresentforsome time.
NO STANDARD WORK PRACTICE – NearMiss Incidentsare oftencausedbyhavingnosuch
standardpractice or procedure inplace – whichresultsinhavingvariousandmostlikelyunsafe ways
to accomplishatask or responsibility.
LACK OF TRAINING – AnotherconditionthatleadstoSafetyIncidents –isthe lackof Trainingof
the Workersinvolved –i.e.,HowtoSafelyuse a Come-Along.
USING IMPROPER or UNSAFE TOOLS – Can a Near
Miss Incidenteverbe causedbyManagement?
eitherimproperorunsafe touse forthe Jobthat that
theyare askedtoperform.
CUTTING CORNERS – Commonplace inthe Work Place – will be Employeesthat“CutCorners” –
i.e.,notfollowingthe stepsthatneedtobe performedinorder.
omplacencyandthe belief thattheywill notgethurt – or it may include
simplytryingtospeeduptheirworkprocess.
LACK of SAFETY AWARENESS– A leadingcause withinmyOrganization –isthe lackof Safety
AwarenessbyourPeople involvedinNearMissesandAccidents.
–not seeingCo-Workersintheirimmediate WorkArea –to placingtheirBody
Parts betweenPinchPoints –to notcheckingtheirworkarea priorto settingupor beginningtheir
work.
OUTDATED PROCEDURES – Organizationsmustensure thatwhentheirProcesseschange –that
theyupdate theirProcedurestoreflectsuchchanges.
How Do Accidents/Incidents/NearMisses Happen?
• Hard vs SoftDefenses
– Hard Defenses
• Engineeredsafetyfeatures
• Physical barriers
3. • Sensingdevices
• Warningsandalarms
– SoftDefenses
• Rules
• Regulations
• Procedures
• Supervision
• Sign-off procedures
• PermittoWork Systems
How Do Accidents,Incidentsand Near
MissesOccur?
Active Failure + Latent Condition= Accident/
Incident/NearMiss
Active failures
mistakes,andprocedural violations).
Latent conditions
active failuresandlocal triggerstocreate an accidentopportunity.
Human Error
• Humanerror isthe mostcommonaccidentcause:
– Accordingtothe mostcomplete surveys,over90% of all highwayaccidentsare causedfullyorin
part by humanerror.And of these,90% are causedbyperceptual errorand10% by response error.
In short,perceptionisa factor inover80% of all highwayaccidents.
Managing Risk – The Three Behaviors
• At-riskbehavior: Everyone knowsthat“toerr ishuman,”but
we tendto forgetthat “to driftishuman,”too.
4. • Behavioral research:we are programmedtodriftintounsafe
habits,tolose perceptionof the riskattachedtoeveryday
behaviors,ormistakenlybelieve the risktobe justified.
• Overtime,asperceptionsof riskfade andthe tendencyisto
take shortcutsand driftaway frombehaviorswe know are
safer.
Managing Risk – The Three Behaviors
• At-riskbehavior,ctd.:
• The reasonsworkersdriftintounsafe behaviorsare often
rootedinthe system.
– Safe behavioral choicesmayinvoke criticism, and
– At-riskbehaviorsmayinvoke rewards.
• For example:
– Time tocomplete agivensetof tasks
• Thereinliesthe problem. The rewardsof at-riskbehaviors
can become socommon thatperceptionof theirriskfadesoris
believedtobe justified.
• The incentivesforunsafe behaviorsshouldbe uncoveredand
removed,andstrongerincentivesforsafe behaviorsbe created.
Recklessbehavior:
– Alwaysperceive the riskhe orshe istaking
– Understandthatthe risk issubstantial
– Behave intentionally,butare unable tojustifythe risk(i.e.,
do notmistakenlybelieve the riskisjustified)
– Knowthatothersare not engaginginthe same behavior
(i.e.,itisnotthe norm),and
– Make a consciouschoice todisregardrisk
5. • The differencebetweenat-riskbehaviorandreckless
behavior:
– 70mph vs 90mph
Managing Risk – The Three Behaviors
• Three typesof behaviorcanbe involvedin
error:
– Human error
– At-riskbehavior
– Recklessbehavior
• Each type of behaviorhasa differentcause,
so a differentresponse isrequired.
How to Improve Near Miss Reporting
Just Culture:
A justculture recognizesthatcompetentprofessionalsmake
mistakesandacknowledgesthatevencompetentprofessionals
will developunhealthynorms(shortcuts,“routinerule
violations”),buthaszerotolerance forrecklessbehavior.
How to Improve Near Miss Reporting
In addition to these Factors (con’t) –
PUBLICIZE YOUR EFFORTS – In order to make Near Miss
Reporting successful – you must Publicize Your Efforts.
You need to find a way to report how corrective actions taken as
a result of Near Misses – have helped the Organization and your
People – by making their Workplace Safer.
You will have People reluctant to report Near Misses – until they
see that they have something to gain from so reporting.
SHARE WITH OTHERS – Near Misses can and should be a
Learning Tool for all applicable Organizational Employees.
Makesure that you take time to not only share the Near Miss
Incident – but also how it occurred and what actions were taken
to prevent its reoccurrence.
COMMUNICATEACTIONSTAKEN – It is very importantthatyou
communicateany findingsand actionstaken to thoseinvolved with the
Near Miss.
This includes both the Individual(s) that reportedthe Near Miss – as well as
anyIndividual(s) that were actuallyinvolved in the Near Miss.
In addition, it would be beneficial to advise anyWork GroupMembers that
are involvedin similar workactions.
USE AS A LEADINGINDICATOR – Taketimeto track and record your
Near MissIncidents.Such can beused asan indicatorof your Safety
6. Performanceto come.
Various factors can be interpretedfrom Near Misses including – are they
major vs. minor innature, is their primarycause from either lackof
awareness or lack of training, etc.
Near Misses can point to what SafetyEfforts are neededin the Workplace –
to address what is causing them– andanynegative trends inPerformance
