Near misses

Introduction

A near miss is an unplanned event that had the potential to result in injury, illness or damage – but fortunately it did not. In workplaces, near miss situations are common occurrences, though they are often ignored. However near misses can be looked on as a free lesson to learn how to prevent accidents from occurring. Therefore, gathering information about near misses and analysing the information to initiate the appropriate corrective actions is a way to promote safety in the workplace.

Definition of near misses

A generally accepted definition for "a near miss" is that it is an unplanned event which did not result in injury, illness, or damage – but had the potential to do so. The occurrence of near misses, i.e. precursors of real accidents, demonstrates a high level of safety culture and operational control which is needed to successfully protect human beings from suffering the consequences of a potentially harmful event^[1].

According to the "iceberg theory" ^[2] for every reported major injury, there are several minor accidents and 300 near misses. Subsequent studies have come to rather similar conclusions, even though the ratio between major injuries and near misses may differ. However, the importance of identifying near misses is widely recognized, because when the potential causes of accidents are eliminated, the possibility of major injuries diminishes.

Prevention of accidents

Learning from near misses

The causes of accidents are often same as the causes for near misses. According to the Zero Accident Vision all accidents are preventable. An important tool in accident prevention is to learn from those accidents that have occurred, and through this learning process, to initiate corrective actions to prevent similar accidents occurring again in the future. In addition, learning from accidents and near miss situations helps people to react in a similar situation later. A near miss should be regarded and treated as an important warning that an accident could well occur. In an uncertain situation, for example a situation with a huge potential risk, people tend to find a solution from memory, from past experience and knowledge. Thus, investigating accidents is crucial. Workplaces with advanced safety practices undertake similar investigations for near miss cases. In fact, one can state that near miss cases provide a free lesson in accident prevention.

In accident prevention, it is essential to analyse what has happened in the past. It is important to understand why accidents or near miss cases have occurred and what actions can be taken to make sure they will not happen again. Finding the root causes for all accidents and near miss cases helps to identify hazards and risks in the workplace based on which corrective actions need to be taken.

Typically after distributing information or carrying out campaigns on the importance of reporting near miss cases, the number of reported near misses increases in all workplaces. However, this does not mean that there are more risks than before, but rather that the awareness of near miss situations and potential hazards have increased. There is an inverse relationship between the number of reported near misses and the number of accidents. This was shown for example in Norsk Hydro, a Norwegian aluminium and renewable energy company, where the accident rate decreased when the number of reported near misses increased^[3]. The rate of near miss reports can be seen as an important numerical indicator of an industry’s safety awareness^[4].

Collecting the information about near misses

Analysing the near misses is part of an effective safety management system. Workers are in a key position to report near misses. The challenge is how best to transmit the information about near misses from the workers to the management. The collection of near miss reports requires co-operation between employees and the employer. Typically the most comprehensive reporting of near miss cases is carried out in workplaces with high levels of safety culture. In these highly safety oriented workplaces, workers are encouraged to report all near misses, and the management's commitment to safety is tangible.

The basics (why, when, and how) of gathering information about near misses should be clear to everyone in the workplace. Workers need to understand that the motivating factor is to gather information and not to find who is guilty. Instead the aim is to learn and prevent further accidents. When workers understand the message that they will not be punished because of the near misses, this usually encourages them to better report the near misses.

The reporting of each near miss case should include the following main points:

• what happened
• when
• where
• to whom
• influencing factors
• the factors that prevented the incident from occuring
• suggestions about how to prevent similar cases in the future
• the name of the person (in case there is need to obtain additional information).

Learning from near misses

In order to prevent accidents, it is essential to gather the information about near misses that have occurred in the workplace ^[5]. Gathering of the information about the cases needs to be performed systematically if it is to be successful.

The process of reporting near misses

Everyone at the workplace should be aware of how to report near misses and where they should be reported. Each workplace should have a process for reporting and analysing near miss cases. Reporting near misses should be everybody's responsibility all the time – not only the responsibility of those in the internal OSH organisation or in management. The procedure of gathering these cases should be simple and everyone should have easy access to the system irrespective of whether it is an electronic or paper-based reporting system. Thus everyone in the workplace needs to be trained to report these cases. For new workers, the training can be included in an orientation process. However, it may be necessary, and it is certainly advisable, to remind all workers every now and then about reporting near misses.

The key is to make reporting of near misses straightforward. If reporting is expected to be performed on a paper, there needs to be a common understanding on what facts to report and where to return these reports. Depending on the type of the workplace, it might at times be useful to have paper report forms available for workers, however electronic and online reporting systems are quite common nowadays when most workers have access to computers. If paper forms are used, the process of converting these reports into an electronic format needs to be agreed upon in advance, i.e. who will do the conversion and when.

If near miss reports are informed orally, the receiver of the oral report may be a foreman, who in his/her turn has to make a more formal report either on paper or online. It is important that the process should not simply come to a stop with the oral report; the oral report needs to be properly processed.

Receiving near miss reports

A successful process will always include information on who receives the near miss reports and who handles the reports. It is necessary to appoint a person who is responsible for receiving the reports and to provide for back-up in case of absence (holidays, illness, etc.) There should also be a common understanding about how long it takes to handle the near miss reports. Even though it will not be possible to implement all corrective actions immediately, the reports should be handled quite soon after reception.

Handling of near miss reports

After receiving and processing the near miss report (for example registration into the database), corrective actions need to be considered. An investigation of near misses should be performed in a similar manner as an investigation of occupational accidents, for example by performing the root cause analysis. Corrective actions should be considered in co-operation between management and workers, because worker participation in devising corrective actions increases their commitment to implement these decisions.

When investigating near miss cases, the focus is on the question: What might have happened? Those near miss cases that require immediate corrective actions (for example icy and slippery surface), need to be corrected immediately. Often it is not possible to execute corrective actions promptly. In such cases, the immediate danger needs to be resolved and permanent, long term, solutions can be considered afterwards.

Choosing the corrective actions

Planning of the corrective actions requires resources, such as staff and time. It is possible that the first solution is not the best, and therefore these initial actions should be evaluated after a period, and perhaps new corrective actions instituted. A good practice is to always have a person of authority with official decision-making capabilities involved in the selection of corrective actions, particularly if the corrective actions require new investments. Another option is for the workers and foremen to consider the corrective actions first and to present this to the top management for approval and decision making.

When choosing the corrective actions, the focus should be on eliminating the risks. This can be done for example by removing the hazard or by changing the work processes. Sometimes the risks cannot totally be eliminated. Then it is essential to choose corrective actions in such a way that risks are reduced to an acceptable level.

Implementation and follow-up

After the decision on the corrective actions is made, the implementation should be ensured by naming a person in charge and agreeing on the schedule for implementing the corrective actions. The implementation of corrective actions should be followed-up after the deadline. The optimal situation will be if the corrective actions can be implemented immediately. However, this is not always possible. In such a case that the implementation takes more than one month, then information about the future implementation should be shared at the workplace.

Feedback

Transparency in communication of occupational safety issues is important in order to create a commitment to safety. A person who has reported a near miss situation should receive feedback from those handling the reports. The first feedback could simply be that the report has been received and include a note on the report processing schedule. This is important especially in the cases when the corrective actions will not be taken immediately.

After the corrective actions have been decided, the person who has made the original report, should be informed. This will encourage others to provide additional near miss reports, since they will see that actual concrete changes will result from reporting and that the reports are being taken seriously. If the near miss report does not require any corrective actions, this should also be informed to the person who made the original report. This will increase the commitment of workers to report near miss cases, they can be satisfied if they receive assurances about why modifications are not necessary, i.e. they can see that their report has been handled and corrective actions have been considered; this provides some encouragement to the worker that a change might happen at a later date.

Success factors for learning from near misses

Accident prevention is continuous work. Neither a worker nor an employer can think that everything is in good order as long as a risk assessment has been done. Risk assessments have to be reviewed regularly depending on the nature of the risks in the workplace in question, the degree of change likely to occur in their work activity, or as a result of the findings of an accident or a near miss investigation.

All accidents and near misses should be investigated and root causes need to be found, even though corrective actions were taken immediately. The reason for this is that the same potential for an accident may exist elsewhere in the workplace and the same corrective actions may also be needed elsewhere.

A common pitfall is that when a workplace seems to be concerned about obtaining near miss reports and puts on some effort into collecting these reports, but after receiving the reports makes no visible changes or provides no feedback. When workers cannot see any benefits in the reporting, this typically leads to an unwillingness to fill in near miss reports. Thus the number of near miss reports gathered should not be the key objective in this process. The most important objective of the reporting should be to identify the hazards that need to be tackled and to implement corrective actions for achieving a safer workplace.

The following lists some success factors to improve gathering information on near miss cases:

1. Motivating personnel to report near misses: A workplace where every worker has the feeling that their safety is highly valued by the employer has good possibilities to develop the wellbeing of the workers. While workers know that their safety is paramount, this will encourage also the workers to develop the workplace's safety. For example motivating can be performed by campaigns or handling the near miss reports visibly in meetings.
2. A possibility for workers to be listened to: If a worker notices an acute hazard in the workplace, she/he should have some way to inform about it immediately. This increases the commitment of the workers to safety when they can influence safety promotion. However it also means that their warning needs to be heeded.
3. Choosing the corrective actions: Discussions between workers and the management is important when choosing the corrective actions. The first corrective action which comes to mind may not necessarily be the best solution. This is why the ideas should be developed together with the workers who perform the daily operations in the working environment and have a practical view of how the corrective actions will actually work.
4. Informing the organisation - transparency: Comprehensive safety communication is essential whenever changes are initiated in the workplace. Some brief, basic information about why the near miss reports are collected and why certain corrective actions are performed will increase safety awareness of workers and highlights the management's commitment to safety.

Utilising near miss reports in risk assessment

The process of handling near misses is rather similar to the process of risk assessment. The first step in risk assessment is to identify hazards and the workers who may be exposed to these hazards. After the identification, the evaluation of risks can be performed. Near miss reports provide valuable information on identifying hazards, exposed workers and evaluating risks. They contain information about the hazards that are present in the workplace. Furthermore, they can give an indication about the likelihood that a hazard represents a risk for the exposed workers (evaluation of risks).

A risk assessment may also be necessary after corrective actions in case they cause significant changes in the workplace ^[6]. Every new near miss report (both oral and written) should lead to a risk (re)assessment.

Risk assessment could start by going through all near miss reports. The valuable information present in near miss reports should not be dismissed or allowed to gather dust.

Reported near miss cases can be seen as positive safety indicators at workplaces. The more reports are received, the more committed the personnel is to safety. However as mentioned earlier, the amount of near miss reports collected should not be the aim of this exercise. The focus should be on defining and implementing corrective actions in order to minimize the risks of occupational accidents.