Near misses are unplanned events that under slightly different circumstances could have resulted in injury, property damage, or environmental harm, but did not. Reporting near misses allows organizations to understand how accidents could have happened and to prevent future accidents. There are several factors that can lead to near misses, including unsafe conditions, lack of safety procedures or training, improper tools, risk-taking behaviors, and human error. To improve near miss reporting, organizations should establish a just culture that encourages reporting without punishment, publicize corrective actions taken, share lessons learned, communicate actions taken in response to reports, and track near misses as a leading indicator of safety performance.

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