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Near Misses

A "near-miss" is an event that signals a system weakness that if not remedied  
could lead to significant consequences in the future. As such, a near-miss is  also an opportunity – an opportunity to improve system structure and stability,   and an opportunity to reduce risk exposure to potential catastrophic events.   Near misses can also be observed in operational supply chains and logistics,   financial markets, and medicine and healthcare, among many others   disciplines. Some of the most salient examples are in the disciplines of   environment, health and safety (EHS). For example, the Space- Shuttle   Challenger explosion had near-misses on previous missions, where O-rings   (the mechanical source of the catastrophe) had potential for catastrophic   failure. The 1999 Paddington (England) train crash catastrophe where 31   people died, was preceded by eight near misses at the same location that the subsequent catastrophe occurred. And many other well-known, highly publicized disasters had numerous precursors, or near-misses, that were not properly recognized and managed. Had the near-misses been properly recognized and resolved these disasters would have been avoided. Safety Pyramind

The benefit of having a good near-miss program is clear. The well-known safety pyramid is shown in Figure 1. Near-misses, which constitute the base of the pyramid, occur much more frequently then more serious incidents. They are also smaller in scale, relatively simpler to analyze, and easier to resolve. Usually each major incident can be linked to a number of occurrences that happened earlier. Therefore, by addressing these precursors effectively, large and expensive incidents may be avoided.

Reporting of near misses by completion of the incident report form or simply emailing a member of the EH&S staff allows for the collection of data that may identify training, process or operational weaknesses at the University. The use of the data can often change processes that are part of normal operations. For example, the recording of slips and falls especially in the winter time enables the EH&S department to provide the Environmental Site Services group with a list of areas that should be prioritized for salting and clearing during snow and ice storms.

 
Last modified: March 14, 2008
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