THE IMPORTANCE OF NEAR MISS INCIDENTS

THE IMPORTANCE OF NEAR MISS INCIDENTS

Near miss is an incident where any unsafe act, unsafe condition, hazardous situation or sequence of events could have caused a major accident, but narrowly missed in time and position, simply put – It is an unplanned event that did not result in any damage or injury but had the potential to do so

If these near misses are not properly investigated and analysed can reasonably lead to a “Major accident “.  This is due to the safety management systems inadequacy and ineffectiveness in capturing and analysing of near misses and ignoring the specific warning signals during the sequence of events which were not interrupted resulting in a major accident.

Example of near-miss incidents? 

·      A leaky oil pipeline drips on the walkway resulting in employee slipping and nearly falling but regains his position without injury 

·      Poor lighting resulting in contract worker tripping and almost falling over an extension cord which was not visible but he was able to keep his balance 

·      Two incompatible chemicals unknowingly mixed up leading to runaway reaction and pressure build-up, later the pressure was released under controlled conditions without affecting anybody. 

 

Why near misses collecting and analysing are important for any safety management systems?  

 

The main purposes for collecting Near miss incidents is that 

 

1)   They provide the necessary attention to a sequence of events which can suddenly lead to accidents within the organization especially during smooth production running times.

2)   The information collected out of near misses can quantify the occurrence of factors and their interaction leading to an accident.

3)    They provide the understanding of how small failures lead to errors which can potentially lead to dangerous occurrences

4)    The near misses usually occur many times before it gets converted to a major accident, since no loss was experienced during at any point of time during the past occurrences, near misses are  normally not subjected to  investigation, this results in a major accident, hence a  proper near miss management system can provide employees to take controls before near-miss incidents turn out to be disasters

 

To have a systemic approach of managing near-miss incidents there should be a comprehensive near-miss management system in place which lays a standardized approach for incident management. The near-miss management system should ensure that everyone is provided with the necessary resources to record near miss incidents and report 

 

Understanding Near misses through BIRDS accident theory: The bird’s theory or triangle is based on the relationship between the near misses and injuries. 

 

The above triangle shows a visual representation of the statistical relationship between the number of near misses, property damage, minor and major accidents.  At the base of the pyramid are near misses which are incidents without adverse consequences, the next three layers are where the severity increases. Any unsafe act or condition may not result in an accident immediately, but if unsafe acts or conditions are continuously made to occur, such as failing to wear proper PPE, not following safe working procedures, or using the wrong/broken tool for a job, then the wider the base of the pyramid becomes.  Over time, this increases the probability of an injury.  Hence an effective identification process of near misses should be incorporated into the safety management system.

 

NEAR MISS MANAGEMENT PROCESS: The following steps can be followed for an effective near-miss management system

 

STEP 1: Process of identifying near misses

STEP 2: Reporting these near misses

STEP 3: Prioritization of these near misses

STEP 4: Identification of causes for these near misses

STEP 5: Controls required for these near misses

STEP 6: Implementation of Controls.  

STEP 7: Continual improvement

 

STEP 1: Process of identifying near misses:  This is the most important step in the industry, every employee should be in a position to recognize an incident or event as a near miss. For this, there should be a clear understanding of near-miss and this definition of a near miss is understood by all the employees at all times

 

STEP 2: Reporting these near misses: This is the next important step, the identified near miss should be disclosed in a written form, hence a simple and very easy way of the reporting system will make employees/workers come forward and record the near-miss incident observed.

 

STEP 3: Prioritization of these near misses: This is the next logical step where the company set it owns key factors for prioritizing critical high priority near misses from nor critical near misses, the key factors framed should be based on proper technical criteria. The prioritization can be taken up during safety committee meetings. 

 

 STEP 4: Identification of causes for these near misses: This step identifies root causes. It is important to consider all possible questions

 

·      What happened?

·      How did it happen?

·      Why did it happen?

·      What needs to be corrected?

Many tools can be used to conduct root causes like

·      Brainstorming 

·      Checklists 

·      Event tree analysis 

 

Conducting a thorough investigation that Identifies root causes by thorough investigation will help organizations to prevent similar incidents from happening again.  This will help employers reduce the risk of fatalities or injury to workers/off-site and on-site emergencies and environmental damage.

 

STEP 5: Controls required for near misses: Depending upon the resources of the company and a practical approach hierarchy of control to be considered, elimination of root cause to be considered, the engineering control, then administrative control and finally the last resort is to provide Personal protective equipment (PPE).  

 

STEP 6: Implementation of controls: This step is a major hurdle because many organizations fail to communicate properly to the employees the new controls that are kept in place to prevent the near-miss and their role in implementing correctly. The functional managers have to be taken into confidence and necessary permission to be obtained from the concerned department before the necessary resources are kept in place.

 

STEP 7: Continual improvement: It is important to track the implementation of controls and their effectiveness in eliminating or mitigating the risk for that particular incident to happen. The results of the implementation process to be checked and if they are found to be ineffective this should be again reviewed in the committee and accordingly new solutions should be brainstormed.

 

 CONCLUSION: Workers/employee safety can be significantly improved by having a proper near-miss incident reporting process which eventually will lead to enhanced organizations safety culture along with leadership taking an active role  in driving safety management system

 

Article by PJ Mohan

Sr. Faculty, NIFS