A typical real-life anecdote of near miss reporting

A TYPICAL REAL-LIFE ANECDOTE OF NEAR MISS REPORTING 

Ives (1991) gives the following example of the value and the pitfalls of near miss reporting in nuclear power plants  

The text of the standard contained a section about the importance of reporting near misses (precursors to accidents). In order to encourage reporting, examples of near-misses were given, with the classification of a near-miss, in general, being one class less than the corresponding hit . 

The standard required a site review, and a head-office level review of all reported occurrences. There was good cooperation between head-office and the plant to get the system underway. Apparent inconsistencies between the definition of the class, and the examples were fairly quickly resolved, with the help of head-office. A data-base of events was established, with an extensive sort facility. The system became very well respected and well used, and much improvement of performance was achieved through experience feedback. Near-misscs were reported freely, from which much information was gained in order to facilitate performance improvement and the development of error tolerant. and error recovery systems. 

Destroying a well functioning system by unthinking management is easy 

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