Your company has a strong safety culture with outstanding employee participation. Everyone is committed to safety and goes out of their way to do things in the safest way possible. As a safety professional, everything is great in your world until suddenly, a “near-miss” report lands on your desk. Supervisors, managers, and company executives are now concerned, worried, or even stressed out about the fact that something unsafe just happened at their company! Many would-be quick to speculate that a near miss is a bad thing; however, as a safety professional, you know that this is not necessarily the case. The reality is, a near-miss or “good catch” report can be one of the most valuable tools for improving your company’s safety program.
What is a Near Miss?
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.
Heinrich’s Law and Bird’s Safety Triangle
In 1931, Herbert Heinrich published Industrial Accident Prevention: A Scientific Approach where he proposed a concept that would eventually become known as “Heinrich’s Law.” Heinrich’s law states that for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injury (i.e., 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.
Near Miss Reported – Now What?
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:
- Why was the puddle there in the first place?
- Where there changes in the environment, weather, conditions, or a process?
- What was the source of the water?
- What tasks were being performed when the water was spilled?
- Why was the water not cleaned up?
- How long was the water there?
- Was the spill reported?
By performing a root cause analysis, you may learn that it was raining on the day of the near-miss and that the roof in your warehouse has developed a leak, causing a puddle of water to form, creating the unsafe condition that led to the incident. Simply instructing the employee to be more aware of the surroundings may prevent them from slipping again; however, it will not prevent the unsafe condition from reoccurring. The true root cause needs to be addressed; the roof must be repaired.
OSHA provides a great resource for Root Cause Analysis here.
Improving Your Company’s Near Miss Program
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?
- Keep the reporting process simple.
Consider implementing google forms, phone applications, or even a universal near-miss email address. The key is to make the process to submit a near-miss as easy, quick, and painless as possible. For example, many companies now create QR codes that can be scanned, taking personnel right to the form to complete and submit. This can all be done for free with readily available resources around the internet.
- Train employees on the importance of near-miss reporting.
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.
- Keep near-miss reports non-punitive.
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.
- Incentivize the program.
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.
- Celebrate and communicate your success.
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.
Chris McGlynn is a dynamic safety leader who serves as the Director of Safety at Roco Rescue and is dedicated to amplifying the company's safety success. As a Certified Safety Professional, Confined Space and Rope Rescue Technician, and Paramedic, Chris leverages his expertise to provide employees with the necessary tools, training, and support to work safely and efficiently. He also oversees Roco Safety Services, offering high-caliber safety professionals for special projects and turnarounds. As the VPP Coordinator, Chris ensures that Roco maintains its status as an OSHA VPP Star Worksite, continuing the company’s unwavering commitment to excellence in safety and health. Roco has been an OSHA VPP Star Worksite since 2013.