Near-miss reporting

Once again this reporting system, which may be the most important in the safety system, should be anonymous. Near-miss incidents, which may have been loss-producing events under slightly different circumstances, need to be reported. The focus should not be on who reported and why he or she didn t do something about it. A strong safety culture is about how we fix the problem so that it doesn t happen again. 

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Incident Investigation Major incidents Near-miss reporting Follow-up and resolution Communication Incident recording Third-party participation as needed... 

As you review each of the tasks, you should also consider what other resources (other than time of staff) may be needed. For example, improvements to incident/near-miss reporting might require modem communications between facilities and headquarters or a particular training module could be purchased to address an identified gap. 

The value of near miss reporting has been emphasized at a number of points in this book. Near misses represent an inexpensive way to learn lessons from... 

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. 

Incident Investigation—In assessing this element, consideration must be given to major incidents, near-miss reporting, follow-up and resolution, communications, incident recording, and third-party participation as needed. 

Reason J., 1991. Too little and too late a commentary on accident and incident reporting systems, in Schaaf van der, et al. (Eds.), Near miss reporting as a safety tool, Butterworth Heinemann, Oxford. 

Schaaf van der T.W., 1992. Near miss reporting in the chemical process industry, PhD thesis, Eindhoven University of Technology, Eindhoven. 

These goals are listed in the order of importance to a company. Of greatest importance is to get near misses reported so that investigation can be used to learn from the incident. Note that incident investigation techniques are essentially the same whether applied to chemical reactivity hazards or to other hazards. 

Bridges, W. G. Get Near Misses Reported, Proceedings of the International Conference and Workshop on Process Industry Incidents, Orlando, FL. New York Center for Chemical Process Safety (CCPS), AIChE, October 2000. 

This chapter describes near misses, discusses their importance, and presents the latest methods for getting near misses reported and investigated. The term near miss has a long history of use, but the terms near hit or close call more closely describe what actually happens. The term near miss is used throughout this book since it is so widely accepted as the term for incidents that are direct precursors to accidents. 

Many chemical companies indicate that they have one or fewer near misses reported for every accident. Although some companies achieve a ratio of 20 or higher, many see fewer near misses reported than accidents, which raises the following general question. 

Obstacles to Near Miss Reporting and Recommended Solutions... 

These two concepts, according to all survey respondents with high near miss reporting ratios, provide the best approach for overcoming this obstacle. 

Some solutions that will enhance near miss reporting include ... 

Ensure that all employees understand the importance of near miss reporting. 

Hold regular meetings with employees to discuss the successes of and obstacles to near miss reporting. Praise employees for submitting near misses. 

Hold management accountable for achieving realistic near miss reporting. 

An apparently high level of effort is required to report and investigate near misses. The costs of this effort are quantifiable. The benefits of these investigations are not as easy to tabulate. The actual number of accidents that have been prevented by improved near miss reporting may never be known. However, organizations that have seen dramatic increases in near miss reporting have also seen dramatic reductions in losses. The root causes of near misses of safety consequences may be the same management system weaknesses that adversely affect operability, quality, and profitability. 

Share both subjective and tangible benefits that are expected from increased near miss reporting with the entire workforce. 

One company increased its near miss reporting ratio from 1 to roughly 80 in just a year. The company entered all the data in a simple database developed in house and then queried the data regularly. They... 

Track the benefits of near miss reporting and trend these versus the near miss reporting rate or the near miss ratio. 

Ensure that goals affecting profit sharing incentives are not tied to lower overall incident reporting rates. This discourages near miss reporting. 

The company will learn that reporting and investigating near misses will enhance overall business performance, particularly because the near misses of a safety incident or environmental release have the same root causes as incidents that detract from quality and productivity. Safety personnel can assist in defining an appropriate near-miss reporting culture. All managers intuitively understand the return on investment from preventing incidents. The effort pays for itself directly through improvements in productivity. 

There is legitimate concern that near miss reports can be used against a company. This may occur when... 

Despite the possible liabilities, many companies decide that it is better to get near misses reported and to learn how to prevent incidents than to... 

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