Near miss, definition

From the view of both actual and potential impact, the cyclohexane release affects all business aspects. The incident is a near miss for safety, and a minor-major incident for other aspects of the business. Performing six or more investigations would be fruitless. Performing one investigation that meets the needs of all business aspeas is ideal and simpler. The near miss definition and related training will need to explain the potential impact of an... 

Phimister recommends a broad near-miss definition that can be easily understood by all employees, one that focuses on identifying a situation from which site environmental, health, and safety (EHS) performance may be improved ... 

To meet this requirement, a company must define an incident in specific terms for their facility. This includes an operational definition that indicates the number of pounds of the substance used in a particular process that would qualify as a catastrophic event . Defining an incident in site-specific terms also includes defining the terms "could reasonably have resulted in . Appendix C of the regulation provides guidelines for clarifying this point. It includes definitions of "near misses in which a catastrophic failure occurred, but a chemical release did not occur. Clear guidelines should be established that provide the employee with a quantifiable means of defining those incidents that require a violation report. 

Before scientifically sound research can be performed on a subject, clear definitions must be set. Although, this may seem a logical step, Osborn (Osborn et al., 1988) highlighted that this has been a stumbling block for research in safety science since its inception. Definitions of concepts like accidents, incidents, near misses, risk, and safety, are known in the field of safety science, but interpreted differently in various situations. Unclear and ambiguous definitions lead to misinterpretations and confusion and must be avoided. Therefore, some general concepts used in safety science and the definitions used in this thesis are discussed in this Section. In the remainder of this thesis specific concepts will be defined where appropriate and can also be found in a list of acronyms and definitions presented in the beginning of this thesis. 

By way of definition, a near miss is an unplanned sequence of events that could have caused harm or loss if conditions were different or were allowed to progress, but actually did not. Incidents include both near misses and actual loss events. 

It is often difficult to make a determination whether a specific event is a near miss or a "nonincident" (neither an actual loss event nor a near miss). If the users of the investigation system do not identify an event to be at least a near miss, then the event will not be investigated and valuable lessons may be lost. Depending on the definition of a near miss, roughly 50 to 100 near misses occur for every actual loss event and 50 to 100 precursors for every near miss. Figure 4.6 depicts the general relation between precursors, near misses and loss events. 

This definition is meant to include both accidents and near misses. Thus, the definition covers all cases where there was, or could have been, injury, damage to property, or the release of hazardous or toxic material to the environment. 

Uncovering and analyzing the precursors to incidents is more cost effective than only investigating losses. Chapter 5 discusses the definition of a near miss and how to get these precursors reported and investigated. 

This definition may be difficult to use in practice without examples. Different companies may interpret it in different ways. To develop a common understanding of the term, a company may choose to develop a list of examples it believes to be near misses. Some stated common examples of near miss incidents might include ... 

Given an understanding of the definition of a near miss, enhanced by specific examples for a facility, it may be possible to estimate how many near misses one might expect to be reported compared with the number of accidents that occur. A greater number of erroneous acts or undesirable conditions may occur compared to the number of near misses. Figure 5-1 illustrates the relationships among accidents, near misses, and nonincidents. 

The ratios shown above depend heavily on the definition of a near miss and depend on the type of loss. For example, regarding quality-related incidents, there appear to be far fewer near misses and errors or failure conditions per operational interruption. The reason for the lower ratio is that quality-related incidents typically result from excursions that are less severe than personnel safety or process safety occurrences. Chemical processes are... 

Consider having one incident reporting system with one approach for teaching employees the definition of a near miss and with one approach for doing incident investigations including one approach for root cause analysis. 

Reactive Chemicals Near Miss - A Near Miss event involving an uncontrolled or unexpected chemical reaction that has the potential for injury, property loss or environmental release. Near Miss is defined as an extraordinary event that could reasonably have resulted in a negative consequence under slightly different circumstances, but actually did not. (AIChE/CCPS definition)... 

Lagging Metrics—process safety incidents that meet the threshold of severity and shouid be reported as part of the process safety metric Near-Miss Incidents—incidents that did not meet the definition of process safety incident metric... 

But they should not worry The important point is not to develop a crisp definition to delineate the differences among the terms, but to capture and document that a failure of some sort occurred (Hopkins, 2009). Regardless of whether a particular metric is classified as a lagging indicator, a near miss, or a leading indicator, the purpose of the metric is to establish good indicators of conditions that could ultimately lead to a severe event. 

The ultimate goal of the process safety system is to prevent process safety incidents. The Center for Chemical Process Safety s Process Safety Leading and Lagging Metrics Report (CCPS, 2007b) defines a consensus from several chemical and allied processing industries for definitions of process safety incidents and process safety near misses. If an organization adopts these definitions, a... 

Words and phrases such as incident, accident, and near miss tend to be used quite loosely in general conversation. They also tend to have different connotations in English, American, and Canadian usage. However, in the context of formal incident investigation and analysis such words need to be tightly defined. The definitions used for these terms in this chapter are provided below. 

It is apt at this stage to redefine the modem safety management terms and definitions used in this book. There still exists confusion in the safety industry concerning the words accident and incident. The term incident is so widely used and misused that the term near miss has almost become obscure. Because near-miss incident recording is one of the main elements in a world s best practice (i.e., meeting the highest international safety standards) SMS, it s important that it be redefined and renamed so that its important identity can be maintained and recognized. 

As stated by the principle of definition, if the real causes of accidents and near-miss incidents are not found, how can real solutions be proposed If all the contributing factors are not investigated, how can the causes of the events be identified and rectified ... 

Some of the main reasons belonging to the understanding category are confusion over definitions of near misses and errors, no perceived benefits, disagreement with the organization s definition of error, providers bias about which incidents should be reported, providers unaware that errors occurred, and some incidents (i.e., near misses) thought too trivial to report [38-40,42,43,47]. 

Patient Safety Reporting System (PSRS) (6) A prototype blameless reporting system established in 2000 by NASA and the Veterans Administration. The PSRS emphasizes the reporting of near misses (see definition above). 

Based on the research, the following definition is suggested an accident is an unexpected, unplanned event in a sequence of events, that occurs through a combination of causes it results in physical harm (injury or disease) to an individual, damage to property, a near-miss, a loss, or any combination of these effects. ... 

This definition suggests, correctly, that an accident can occur without injury or damage resulting. Different terms are often used to describe an accident when there are no visible signs of injury or damage. Terms such as near miss , dangerous occurrence , and critical incident are in common use however, they are still accidents. 

Occupational safety legislation and people in industry have traditional recognized the adverse role of the accident in the workplace and have accepted the need to identify causation for the purpose of avoiding repetition. However, the statutes have generally resisted an attempt to provide a workable definition of an accident or have defined accident in terms of an outcome, i.e. injury, near miss, dangerous occrrrrence, incident, etc. 

A near miss is described as an undesired event that under slightly different circumstances could have resulted in harm to people, damage to property, equipment or environment or loss of process. (32) Comparable and broadly applicable definitions of near misses appear elsewhere. 

The key actors from an educational perspective are most definitely the teachers and administrators who have control for establishing policy and practice. The best management practices for safety are well established for most circumstances either specifically or holistically. Here specifically, we have mentioned the standard practices and teachings for roadway crossings. Obviously, measures of success might include the number of child pedestrian injuries and near misses of students, but they might also be an observed measure of behaviors exhibited by the child while at school and in the community. 

The relative numbers in this sort of relationship are not important, what is important is that it is recognised that there is a continuum from near miss to fatality and that definitions such minor, three day and major are arbitrary points on this continuum. 

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