Root cause 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. 

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. 

Step 4. Every element in such a tree will be classified according to the chosen human behaviour model, or at least every "root cause" (the end points of the tree) will be. In this way the fact that any incident usually has multiple causes is fully recognised. Each near miss report is analysed to produce a set of classifications of causal elements instead of the... 

The first three of the above problems are particularly relevant for near miss reporting, because it requires why information to backtrack the root causes any selection bias in terms of actual consequences must be changed into one in terms of potential consequences and finally safety management must switch from ad hoc analysis of anecdotes to structural analysis of patterns of causes. 

An alternative way to regard this Selection phase is to see it as the point at which it is decided that a lot or just a little is to be learned from processing a particular near miss report this in turn justifies a substantial amount of time and effort to be spent in the following NMMS modules, or just the bare minimum of resources, respectively. In the former case a complete analysis will be performed, tracing the near miss situation back to all its root causes, while in the latter case only the most obvious, direct factor will be classified as the cause of the entire incident, which will then be added to the database for statistics . Of course such a case of "coarse" description and analysis might always later be selected again for further detailed processing. 

We tried to arrive at a representative picture of CCR task performance by having a series of extensive, confidential interviews (based on Flanagan s (1954) CIT) with CCR operators before implementation of the first NMMS modules had started. In each interview a different operator was asked to report on a CCR near miss during the last year and of his own choice, which had not been previously reported. The near miss was then described (as if it were a forced near miss report) in the form of an Incident Production Tree, after which all its root causes were classified according to the RAP model described earlier. After each set of five subsequent interviews the overall pattern of classification results was checked for stability it turned out that the results (i.e. the relative frequencies of classified root causes) after 30 interviews did not differ overall from those of the first 25 therefore the series of interviews was stopped after 35 operators (about two thirds of the available CCR population at the time) had participated. 

The main benefit is the reduction in the number of accidents that cause injury to employees and damage to property. Another major benefit of near miss reporting is that it is easier to get to the root causes of the event since nobody has been injured or killed, so there is no pressing need for a cover-up. According to Jones et al. (1999), case studies of offshore oil rigs have indicated a 60-percent reduction in disabling injuries after the 10-fold increase in near miss incident reporting. Other reports indicate that there is a definite correlation between the number of near miss incidents reported and the reduction in the number of serious injuries experienced. The results... 

During facility operation, a chemical reactivity incident or near miss may occur despite all efforts to effectively manage chemical reactivity hazards. An essential element of managing chemical reactivity hazards is to appropriately report and investigate every incident or near miss involving chemical reactivity hazards. By investing the time and effort to determine the root causes and take corrective... 

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. 

Root Cause—There is no effective system to record all near-miss incidents. Secondary Cause—The incident was not reported to senior management. Contributory Factor—The cap was reportedly only dislodged 6 to 8 inches in the air and no personnel injury resulted. 

The investigation of incidents identifies the specific root causes and contributing causes for incidents. There is less emphasis on identifying the specific individuals responsible. Disciplinary actions are rare but likely if there is a history of repeated occurrences. There is usually a greater amount of explanatory detail in the incident report. There is greater tendency in a fact finding organization to report near-miss as well as minor incident events. 

Information from production loss events is stored in the databases (as shown in Fig. 2). Root causes of failures and near misses are documented in offshore databases in the form of reports that include a summary of actual event(s), field observations, corrective actions and recommendations. These reports include documentation such as alarm logs, summary of personnel interviews/ observations, process diagrams and pictures etc. 

Safety, patient safety, sentinel event, medical accident, near miss, good catch, Office of Patient Safety, JCAHO, focused event analysis, disclosure, peer review, confidentiality, maltreatment of minors, root cause analysis, patient safety report, accident, documentation... 

All high potential, near miss incidents should be reported and investigated to determine and rectify root causes. 

To define the methodology for reporting and investigating noninjury (loss producing) accidents and near misses so that the immediate, and basic (root) causes of the events are identified and recommendations to prevent a recurrence are proposed and implemented. 

All accidents that result in injury or damage, and aU near misses, shall be reported promptly so that an investigation can be launched to determine the root causes, so that corrective action can be taken to prevent recurrence. 

Near miss incident recall reveals the events that could have injured someone or damaged something. Near miss incident recall is the ideal way of getting near miss incidents reported, so they can be investigated and positive steps can be taken to eliminate the root causes. 

Once the near miss has been reported, it is the supervisor s responsibility to evaluate the severity and probability of the loss. Near misses with a medium-to-extreme potential severity or a medium-to-extreme likely recurrence are required to be investigated by the supervisor. As part of the investigation, the supervisor shall identify the root/hasic causes of the unsafe act or condition, and then implement corrections to prevent recurrence. The near miss program includes a standardized investigation form that aids the supervisor in the investigation and documentation of the near miss. 

It is essential that all incidents are reported promptly, and in detail—even those that have only minor consequences or that are first aid cases or that are near misses. In the United States, incidents that meet the OSHA guidelines for recordability must also be documented and reported. (The topics of Incident Investigation and Root Cause Analysis are discussed in Process Risk and Reliability Management). 

---