Data collection near miss reporting system

In this chapter we will rephrase, summarise and extend the set of practical aspects related to designing and implementing near miss reporting systems. First five general factors will be listed, followed by a more detailed discussion of two of these data collection, and acceptability. Also the overall important factor of training will be briefly outlined, Finally the relationship between an organisation s prevailing view of human error and its safety culture will be discussed. 

Emphasis for prevention will be on changing individual behavior by symbolic or tangible rewards based on statistical evidence from the data collection system. "Hard" performance indicators such as lost time incidents will therefore be preferred to "softer" data such as near-miss reports. Accident prevention will also emphasize motivational campaigns designed to enhance the awareness of hazards and adherence to rules. If a severe accident occurs, it is likely that disciplinary sanctions will be applied. 

It is important to collect data from previous similar systems for hazards and their analysis. Accident, near-miss report, and expert judgments in all such previous similar... 

The critical incident technique was first described by Flanagan (1954) and was used during World War II to analyze "near-miss incidents." The war time studies of "pilot errors" by Fitts and Jones (1947) are the classic studies using this technique. The technique can be applied in different ways. The most common application is to ask individuals to describe situations involving errors made by themselves or their colleagues. Another, more systematic approach is to get them to fill in reports on critical incidents on a weekly basis. One recent development of the technique has been used in the aviation world, to solicit reports from aircraft crews in an anonjmrous or confidential way, on incidents in aircraft operations. Such data collection systems will be discussed more thoroughly in Chapter 6. 

Because of the emphasis on modeling accident causation, data collection systems based on the system-induced error approach are likely to modify their data collection strategies over time. Thus, as evidence accumulates that the existing causal categories are inadequate to accoimt for the accidents and near misses that are reported, the data collection philosophy will be modified, and a new accident causation model developed. This, in turn, will be modified on the basis of subsequent evidence. 

The initial results reported from a metrics system will often indicate performance below expectations. Initial data may be skewed until metrics data collection is reliably implemented, and performance may continue to drop as improvement opportunities are defined and implemented. This sometimes occurs when the historical perspective of performance is too optimistic because objective measures had not been used in the past. Implementing near-miss data collection is one example The number of reported near misses will probably increase as reliability of reporting improves, so the number of reported near misses is likely to climb during the initial implementation phases of near-miss data collection. Audiences of metrics reports should be prepared for such situations, so the result is expected and potential negative reactions are managed. 

As shown in Figure 1, the SMS contains several sub systems. First, a system of reporting and collection of experience data from the vessel itself is required. This is followed by a system of data processing, i.e. smnmarization and analysis in order to reveal causal factors and perform trend analysis, which forms the basis for the development of safety measures. One critical system requirement is the reliabihty and accuracy of input data, i.e. near miss and accidents reports. As long as the input is rehable, the overall system presupposes the possibility of developing efficient measures, in order to control operational... 

IMCA collects, analyzes, and shares data on industry incidents from work in offshore construction. One key system for distributing the data is an alert called a safety flash. Safety flashes are developed from reports submitted to IMCA and contain descriptions of incidents, near misses, and potential hazards. The reports also give the apparent cause (or causes) of the incident and any actions taken to prevent a recurrence. Before it is distributed publicly, a safety flash is stripped of identifying information and is sent to the contributing company for its approval. ... 

Drive out fear, and set up systems so that data can be collected for learning about error and near misses. The risk should be in failing to report, not in the act of bringing bad news. 

Aeronautics and Space Administration (NASA) for the aviation industry. NASA, external to the industry, accepts confldential narratives about near misses and accidents up to the point of a crash (Reynard, Billings, Cheaney, and Hardy, 1986). The system is voluntary, confidential, and nonpunitive, and its purpose is to collect and use incident data to improve the national aviation system. The ASRS supports aviation system policy, planning, and improvement and strengthens the foundation of human factors research in aviation by identifying deficiencies for correction by appropriate authorities. The Veterans Administration is the only health care entity to contract with NASA for a blameless reporting system at this time. 

Once you have a system that captures, accurately, over 30% of your real electrical contacts (i.e., near misses, incidents and accidents) you may be able to develop a system for fixing the causes. Preventive safety, not data collection and report writing, must be the reason for a safety reporting system. 

One test of the efficiency of a data collection system is whether near-miss incidents are reported and recorded. Their investigation will provide the same information on causation as real injury incidents. 

---