It makes sense that anything that might have led to a safety incident is a good starting place for prevention. The tricky thing is that there are only so many resources to fix the things we believe are our current problems, so the other, less obvious things, the ones which haven't yet caused us much grief, go low down the priority list. If we don’t pick up the near failures, how can we get to safety by design?
Here are some examples
1. a pedestrian texting while crossing the road
2. a stroller rolls away on a train platform
3. a lady books in with an office masseuse
4. a man is frustrated while using his computer at work
5. two airliners almost crash mid-air
6. The crew on a moored boat get off before the vessel crashes into a wharf
You will easily pick a difference between the first and last two ‘near misses’. The first two might seem to be positively benign but the setting (a road, a railway line) tell us how close disaster was. The last two show how major catastrophe is just a question of timing, scale and distance and whether money or people are important. The middle two look rather ordinary. The reality is that near misses are a bit difficult to get to the bottom of, but are clearly worth understanding.
Lead or lag? What’s your near miss measure?
I like Nick Gardener’s thinking on what is meant by a near miss. He makes it clear that we can't really use the idea unless we have to agree to disagree on definition and start being more active around how we make sense of these opportunities to learn. It doesn’t make sense to worry much about whether near misses are a lead or a lag indicator. Here are some statements which show why more thinking is needed:
- It’s a near miss... no it’s near hit. We are more likely to pay attention if the focus was on how close to damage the situation was rather than the escape. Lead indicator.
- Really, lucky nothing happened this time. A near miss is like a glimpse into the future. Lead indicator
- Near misses have costs but they are low. Property was damaged but not people. Lag indicator.
- A near miss is an unsafe condition; the condition can exist without any incident. Lag indicator.
Jones and colleagues make the point that "near misses are, quite simply, indicators. They straddle the descriptions of lagging and leading. They represent something that was unsafe (but you are lucky); they are weak signals to provide evidence in advance of the possibility for injury or damage what matters is that near misses can be a relatively plentiful and rich source of data for learning and improvement"
Seems like paying attention to near misses can be a relatively cheap way to get ahead on safety and design, so my questions to you are
- how are near misses turning up in your world
- are you making the most of them
- are they a 'missed' opportunity?
Gardener, Nick. (2014). What are near misses? Retrieved from http://www.predictivesolutions.com/safetycary/what-are-near-misses/
Jones, Simon, Kirchsteiger, Christian, & Bjerke, Willy. (1999). The importance of near miss reporting to further improve safety performance. Journal of Loss Prevention in the Process Industries, 12(1), 59-67.