My secret passion at the moment is to show how near miss reporting can contribute to effective design. The idea of the near miss is not new; let's just say that 'the worst did not happen and that what did happen is considered to be relatively minor in the scheme of things.'
There is such a wealth of knowledge there in the minds of people who have been working in safety and prevention, but little of this appears to directly connect with the design process. I have some searching questions to ask here around attention and motivation:
1. How aware, moment to moment, are we to the situations in which we work?
2. If we are aware, then how simply can we describe that to others?
3. Are we motivated to become more aware?
4. If aware, are we motivated to report what we notice?
Here are nine reasons listed by La Duke from Rockford Greene International in 2011 for why near misses are not getting reported:
5. Peer pressure
6. Loss of reputation
7. It's easier not to
8. Lack of interest from the organization
9. Perceived as pointless
Lets add a local context. Yesterday, a colleague of mine who is local chair of a large safety community listed his reasons why reporting does not happen:
1. It ruins the measures the safety performance, often for the supervisor whose pay is linked to this
2. The issue is minor, it's not possible to make business case to do anything so why bother
3. Reporting a small issue is evidence that the people reporting are not part of a 'better workforce' so why look bad?
4. Chronic issues are not necessarily linked with them in event, so these are not a 'miss'
5. In some workplaces, the reaction is just to go straight to a claim; there are many motivations for this.
6. It takes time out of the normal workday to report any near miss
7. Not everyone is equally motivated to report, issues can only be escalated if everyone agrees that it is important
8. English is not the first language for many workers doing more manual work. This is a barrier for reporting.
Near miss reporting is really a missed opportunity for understanding the consequences of work for people and designing better work. The list of reasons above, though these can be refined further, show how many barriers we have to overcome to get better at this. I'd love to hear about case studies where there is true excellence in near miss reporting. My belief here is that even the best systems miss opportunities because of our limitations for paying attention are unlikely to be overcome if we're not motivated to report what notice. To be blunt, it's a vicious cycle worth breaking.