The Criticality of Near Misses

Don't ignore them. A near miss is a free lesson in proactive risk management -- a crystal ball.

More often than not, our daily activities have successful outcomes.We normally do not spend much of the day worrying about those potentially undesirable consequences of our work or play.We go about our business, content with the notion that all is well, or at least seems so.

We have learned to accept some measure of risk and to accommodate its intrusion into our lives— through practice, we have become skilled.However, we occasionally do not see the things that occur each day that are millimeters or milliseconds from dramatically changing our lives forever: the near misses.

Think, just for a moment, about the last near miss you recognized.Was it job-related? Was it in traffic on the way to the gym to work out? Was it at home as you tried to repair that light fixture? Was it crossing the road on your morning jog? Was it caused by you or someone else?

Now, take a deep breath and think about all of those near misses of which you were not aware. What about that intoxicated driver passing you on her way home Saturday night? Perhaps it was the guy at work who’s always in a hurry to get something done and failed to properly lock out a machine on which you were working.Maybe it was the pilot who stayed up a little late one night and was tasked to take you and your crew somewhere early the next morning. Or it might have been you, hurrying to get to the office and speeding through a yellow light. The list goes on and on.

Each of us experiences a myriad of events every day that could ultimately prove harmful to us and others.We’re aware of most of them and able to take appropriate action to alleviate the situation, but some we miss entirely.

Different Levels of Error and Risk
Any activity in which we participate can be error-free, or it can have an error or a series of errors as we attempt to complete it. Often, if the task is error-free, it will likely have a successful outcome and our mission will have been accomplished.However, even an event that is error-free, from our perspective, can be modified by outside influences such as weather, other people, or other events that result from our action.

Should an activity have an error or series of errors, each resultant hazard could be minor or major in its relation to the event. If the hazard is minor, it may have little impact on the outcome of the activity, even if it goes undetected. The danger could certainly be lessened in its impact if the hazard created by the blunder were detected and properly mitigated. On the contrary, if the error is major, detection is essential in allowing us the opportunity for immediate mitigation. Consequently, detection relegates the errors, and their related hazards, to near misses—but only if we have taken the appropriate action.

A minor error that goes undetected might create a hazard that could result in an adverse event. Such an event would be a negative or unfavorable result that was unintended, unexpected, unplanned, and unwanted, resulting in a temporary loss of organizational function. The fallout might cause someone to miss work for a couple of days or a piece of equipment to have to go in for repair, thereby limiting the organization’s capacity to implement its particular mission fully.

A major error undetected can create hazards that end in a death, a serious (debilitating) injury, or a major loss of equipment, resulting in a significant loss of the organization’s ability to perform its mission. However, it can also result in serious mission dysfunction because of the psychological impact such a dramatic event would have on the agency; it can and often does adversely affect everyone.

Not every minor or major error results in an adverse or significant event.Many times, even undetected errors do not preclude a successful outcome, yet they should still be reported.Near misses have the potential to cause serious physical or psychological injury, unexpected death, or significant property damage but did not actualize due to chance, corrective action, and/or timely intervention.

The concept of reporting near misses is to learn from situations where an accident “almost” happened so that real injuries or damage can be prevented. Everyday incidents occur that do not result in injuries or property damage but cause everyone involved to heave a sigh of relief. These incidents point to problems and possibly trends that, if not corrected, may well result in adverse or significant events in the future. A near miss is a free lesson in proactive risk management—a crystal ball.

Where is your next accident going to occur?

This article originally appeared in the August 2008 issue of Occupational Health & Safety.

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