Investigating Near-Miss Incidents

| OSHA, USF Safety Florida

Written by Luis Silva, USF SafetyFlorida Health Consultant

What is a Near Miss?

Is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Other familiar terms for these events are a “close call”, “narrow escape”, or in the case of moving objects, “near collision”, or a “near hit”.

Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near. A faulty process or management system invariably is the root cause for the increased risk that leads to a near miss and should be the focus of improvement.

How Do Near Miss Reporting Systems Prevent Future Incidents?

Many safety activities are reactive and not proactive, and some organizations wait for losses to occur before taking steps to prevent a recurrence. Near miss incidents often precede loss-producing events but may be overlooked, as there was no harm (no injury, damage or loss). An organization may not have a reporting culture where employees are encouraged to report these close calls. Thus, many opportunities to prevent the incidents are lost. History has shown repeatedly that most loss producing events (incidents), both serious and catastrophic, are preceded by warnings or near miss incidents. Recognizing and reporting near miss incidents, can significantly improve worker safety and enhance an organization’s safety culture.

There are important best practices in establishing a Near Miss Reporting System:

  • Leadership must establish a reporting culture reinforcing that every opportunity to identify and control hazards, reduce risk and prevent harmful incidents must take priority.
  • The reporting system needs to be non-punitive and, if desired by the person reporting, remain anonymous.
  • Investigate near miss incidents to identify the root cause and the weaknesses in the system that resulted in the circumstances that led to the near miss.
  • Use investigation results to improve safety systems, hazard control, risk reduction, and lessons learned.
  • All of these represent opportunities for training, feedback on performance and a commitment to continuous improvement.
  • Near miss reporting is vitally important to preventing serious, fatal and catastrophic incidents, that are less frequent but far more harmful than other incidents.

Near Miss Reporting System Elements:

  • Must capture sufficient data for statistical analysis, correlation studies, trending, and performance measurement (improvement over baseline).
  • Provide convenient opportunity for “employee participation,” a basic component of a successful safety management system.
  • Create an open culture whereby everyone shares and contributes in a responsible manner to their own safety and that of their fellow workers.
  • Provide leading indicators of performance used in balance with other leading and lagging measures of performance. The near miss reporting can be used as a leading indicator and report back to the organization on the positive steps taken to improve workplace safety.

Encourage workers to participate in Near Miss Reporting. Create a policy and procedure that are communicated to all employees with the backing of senior management. Promote a culture of reporting with the support and help of all managers and supervisors.

Educate employees as to why near miss reporting is a necessity, the important role that they play, and the process for reporting. Ensure that the near miss reporting process is easy to understand and use. Reinforce with employees that near miss reporting is non-punitive. Consider incentives that encourage reporting and enhance the culture. (Incentives that have the potential to discourage reporting must be avoided). An example of a good incentive is one that recognizes the participation of workers in the recognition and reporting of hazards. This activity helps to enhance a reporting culture, engage workers in meaningful safety activities, and continue a process of risk reduction. An example of a poor incentive is one that recognizes supervisory and management performance based on OSHA recordable rates. This type of incentive has been shown to suppress reporting and can lead to punitive actions that further undermine safety efforts. Include training for new employees as a part of their orientation. Celebrate the success and value of the near miss reporting process with all employees.

For more information and recommendations about incident investigation, please visit the OSHA website at www.osha.gov/dcsp/products/topics/incidentinvestigation. More information about safety and health programs, recommended practices and tools can be found by visiting the “OSHA Recommended Practices for Safety and Health Programs” at the www.osha.gov/shpguidelines web page. Please visit the USF SafetyFlorida Consultation Program website at www.usfsafetyflorida.com and request a consultation visit.