According to OSHA, a Near Miss is an unplanned event that did not result in an injury, illness, or damage – but under different circumstances, could have. Your company may have another term for a near miss such as “close call,” “good catch,” “narrow escape,” “near hit,” “cliffhangers,” or a number of other terms. However, at the end of the day, these are all near misses. Near misses are caused by the same things as accidents: unsafe conditions and/or unsafe behaviors. Near misses are often precursors to accidents and should not be ignored. In fact, according to the National Safety Council (NSC), 75% of all accidents are preceded by one or more near misses.
Years later, Frank Bird analyzed nearly 2 million incident reports from over 300 companies and used his findings to amend and expand upon Heinrich’s theory. Bird developed the “Safety Triangle” (depicted here) which states that for every fatality, there will be 10 serious accidents, 30 minor accidents, 600 near misses, and an unknown, but significant number of unsafe acts. The important thing to take away from this is that near-miss reports should be taken seriously, investigated, and used to prevent future incidents.
A Near Miss report is submitted. You’re thankful that it wasn’t an injury report, but you also realize that this could have easily been one under different circumstances. You also realize that this is a potential precursor to something worse, so now what? The answer – Root Cause Analysis. There are many different models to choose from when conducting RCAs. The “5-why” is one of the most popular choices due to its simplicity; it is also recommended in ANSI Z-10 Standard for Occupational Safety and Health Management Systems. There are other formats that are equally effective such as the fishbone diagram, also known as the Ishikawa diagram, Failure Mode and Effects Analysis (FMEA), scatter plots, and many others. What format or method you choose is not as important as actually performing RCAs in the first place. The key takeaway here is, use whatever format you are most comfortable with, as long as you ensure that RCAs are performed when necessary.
There’s almost always a deeper root cause to why a near-miss occurred. While there may be an obvious reason on the surface level, by digging a little deeper into the situation, you may find that there’s more than meets the eye. Correcting the immediate cause may help to resolve the symptom of the problem, but not the problem itself.
For example, a worker at your facility slips in a puddle of water on the floor and falls. The worker is not injured and as a result, a near-miss report was submitted. The investigation should not conclude with “employee slipped in puddle and fell – instructed employee to be more aware of their surroundings.” An effective root cause analysis would instead look for deeper issues, such as:
OSHA provides a great resource for Root Cause Analysis here.
You’ve received a near miss, conducted an investigation, identified a true root cause, and took corrective action to eliminate it; now you see the tremendous benefit of near-miss reporting. Then ask what can you do to improve your company’s near-miss program?
If employees don’t recognize the importance of near-miss reporting, they will have no interest in doing so. Ensure that employees know the benefits of near-miss reporting.
No one wants to willingly broadcast their mistakes, especially if they will be punished for doing so. Punishing an employee who submits a near-miss report is a sure-fire way to send a message that safety may not rank as high on the priority list as you claim. This is also a guaranteed way to discourage employees from participating in the program. On the other hand, when near-miss reporting is rewarded, it can change their mindset.
Even if employees know the benefits of a near-miss program and know that it will be non-punitive, they may still need a little encouragement to do so. Consider implementing a periodic drawing for all who submit near-miss reports. Alternatively, consider highlighting the best near-miss submitted for the month to promote quality participation.
Perhaps the most important part of a successful near-miss program is communicating your findings and celebrating your success. Communication should be transparent but does not have to be so transparent that it includes every detail of the situation. Include highlights of the near-miss and the corrective actions that will be taken to prevent them in the future. Communicating your findings could help prevent other incidents as well.
When your employees know they can openly report an incident or mishap without being reprimanded, it can encourage more open communications and improved safety awareness. Most certainly, it gives you the opportunity to take corrective action and prevent a more serious injury, or worse. Actively promoting employee involvement via near-miss reporting will provide a boost to your overall safety program and result in a safer worksite for everyone. A “good catch” is a good catch for all concerned.