If near misses are such a rich source of information for accident prevention, why is it sometimes difficult to get near misses reported?
Recall a time when you were driving or cycling and had a near miss. Maybe some other driver endangered you with their actions – jumped lights, cut sharply in front of you, or followed too closely and almost hit you. Perhaps you found it necessary to swerve or brake hard to avoid a collision. Maybe it was some scary overtaking. Or perhaps water or ice on the road caught you off guard and you lost control for a short period.
Focus on a near miss that you have had. Try to re-live it for a moment.
How did you feel afterwards? Annoyed? Angry? Scared? Embarrassed? Relieved? Excited?
Now imagine that some official organization, with best intentions, wishes to improve road safety by asking people to report near misses. It could be the police, a government department, the local mayor, a motoring organization, or a group campaigning for greater protection of children from being hit by vehicles.
If you are reading this, you are presumably concerned about safety and in principle wish to help reduce accidents. But do you think participating in such a scheme would make a difference? How might it affect you?
Ask yourself these questions:
Is it worth the effort?
What’s the probability that any action be taken?
Do you trust the way that your information would be used?
Might you incriminate yourself?
Should reporting be anonymous?
How would you respond if reporting a near miss could potentially result in you losing your license?
To what extent do your answers vary depending on who is involved?
Would your participation differ depending on whether you were reporting your own mistake rather than something done by someone you don’t know?
How much would you want to protect those close to you rather than look to the potential benefits of reporting for possible improvement?
How much does your public image of being safe matter to you?
How does your response vary according to who is asking for the near miss to be reported?
Now switch to the workplace. These are the sort of questions that will be going through employees’ minds in a workplace where near miss reporting is being encouraged, or required. Even workers who are otherwise responsible will be making judgments about the implications of reporting something where, this time, no harm was actually done – and often no one else knows about it.
So how do we get started?
Consider the players involved when implementing a near miss reporting system. Work by T.J.Larkin & Sandar Larkin and Barry Oshry (see references below) suggest there are three broad groups involved.
Three Groups – Top Management, Workers, Managers/Supervisors
Group 1: Top management needs to be convinced of the benefits of near miss reporting. Some managers will recognize the benefits intuitively. Others may regard it as a waste of time. But near misses are failures of the system. They show a vulnerability that, unresolved, could lead to more serious consequences on another occasion. Can we afford to ignore that?
For those who are unconvinced at this stage, the following may be helpful:
- Consider the points made in a previous article “What are Near Misses?”
- Recognize that near misses ARE happening, but only when they are visible to management can managers take action to prevent future accidents from similar causes but with possibly worse consequences to both the individual and the business.
- Easy- to-use but effective near miss reporting systems already exist. Your organization can adopt a standard incident reporting system, or learn from others to create one tailored to suit your organization’s needs. Internal or external safety professionals can advise.
- Note that near misses have no adverse effect on mandatory external reporting statistics. On the contrary, if declared, a comprehensive near miss reporting system can actually demonstrate good safety management and responsible corporate governance.
Once convinced, top management will want near misses to be reported. It is all positive. The problem is typically this group will set an aim “We want near misses reported!”, and not think about the method to achieve reliable reporting. At best there may be a directive from the top with a reporting system established, and an accompanying message on how beneficial it will be for safety.
What matters though is how managers react to near miss reports. If a near miss report results in blame and punishment, or even no visible action, those at the sharp end will likely react to avoid or ignore reporting near misses, if at all possible. The benefits will only be achieved if there is trust up and down the organization in the ways to be described below for the other two groups.
Group 2: Contrast top management enthusiasm with workers at the sharp end – those who are most likely to be involved in or close to the near misses.
Workers are generally aware of the occurrence of near miss incidents. Near miss reporting merely liberates existing experience to the managers, who are in a position to do something about these failures that are showing up as near misses. But these same managers are also in a position to respond negatively.
The workers in this second group are likely to be suspicious of a top management directive to report near misses. There is a natural reluctance to admitting to an error you have made, or one made by a fellow worker. Even if you don’t work closely with them on a daily basis why would you report a fellow worker?
An angry or indignant person may be only too happy to report a near miss caused by someone else. A cynical or embarrassed person may not report. Workers will be looking to see if management really will act on near misses reported and what consequences there are for those involved. A natural reaction will be to ask yourself “could I be blamed or appear foolish?”
Workers are more likely to report near misses if there is:
- Clear and committed briefing from trusted supervisors on the need for near misses to be reported. Briefing must include genuine reassurance that workers reporting near misses will be valued for helping to improve safety, not held responsible and blamed.
- Clear understanding of what needs to be reported.
- A clear and easy method of reporting that does not get in the way of the job they do.
- Active support from their supervisor, demonstrated with each near miss reported, especially in the early days of reporting.
- General acceptance by a critical mass of workers that it is “OK” to report near misses.
- Acceptance that some workers will be reluctant to participate, at least in the early days. Reporting should be encouraged not enforced. Trust takes time.
- Action taken without undue delay. If action will take time or will not be taken at all, a sound explanation is provided. There is likely to be a limit to how much rejection will be accepted before near miss reporting drops off. The minimum response should be to confirm that each report adds to data being tracked for trends.
- Evidence of overall benefit to safety and being a valued part of that process. Celebrate your wins!
Group 3: The third group, those between top management and workers, is sometimes bypassed, but they are crucial – in particular, the supervisors. Barry Oshry describes this middle group as “The Integrators”. Their first role is to take top management’s requirement for near miss reporting and translate it into something workable. Then second, and essentially, to coach and encourage their workers to comply, even when no-one else is aware of the near-miss and it would be possible to avoid reporting.
The attitude of this middle group is what will influence whether near misses are reported or not. They have reputations at stake too. As Larkin & Larkin say, workers will look to their supervisor, who they see every day – not to top management – to decide whether or not to report. Some may ask their supervisor what they think about this idea of reporting near misses. A supervisor who has not been involved may feel alienated and more aligned with their workers’ concerns than top management enthusiasm. Other workers may simply look for clues from how enthusiastic and diligent their supervisor is in encouraging near miss reporting – and act accordingly.
There are ways to achieve supervisor support and commitment:
- Take time to explain why near miss reporting is beneficial.
- Provide a simple, clear process for reporting and investigating near misses.
- Provide clear briefing material for supervisors to use with workers.
- Provide reassurance that reporting a near miss is something to be celebrated.
- Recognize that supervisors still have a legitimate role to tackle incidents arising from deliberate/willful acts. These are NOT near misses. Supervisors are not losing their authority to supervise; they are helping to improve safety.
- Follow up by responding visibly and positively to near miss reports.
- Track and show trends on near misses. Separate them by type (e.g. those involving forklifts, ladders) so that each type of incident can be worked on, as appropriate, to improve.
- Involve supervisors actively in the PDSA (Plan-Do-Study-Act) improvement process when responding to near misses.
An Efficient and Effective Near Miss Reporting Process
Having established the will and commitment to report near misses, it is important that the system runs efficiently and effectively. You must encourage reporting, all reporting, but not get bogged down with more reports than you can handle. A balanced approach is required involving:
• Good quality input – as discussed above, getting near misses reported requires employee engagement to achieve understanding, trust and belief in the process. Frequent and genuine support from committed supervisors is the key to this. But beware of setting targets and offering incentives for reporting.
A target can be met most easily, and with least risk of blame, by reporting trivial near misses of the nearly slipped variety. Of course some of these MAY be serious, but it’s an easy way to “make the numbers”. Look at the profile of near misses reported. Are there a large number of trivial near misses reported and then a jump to a few, high profile, serious near misses where reporting couldn’t be avoided? Ask yourself why there are so few, if any, intermediate near misses. This does not just apply to corporate target setting. A target may have been set unofficially by a supervisor or manager to make their group look good.
Incentives carry the same risk as targets of focusing on quantity, but also risk a further problem. By providing an extrinsic reward, employees are in effect being told it is their choice whether or not to report: report and be rewarded, or not bother and forego the incentive. This is sending the wrong message!
• Good quality processing – aim for proportionate investigation, analysis and remedial action. “Proportionate” means accept all reports but filter out the trivial – supervisors can deal with those issues on the spot, and maybe use the data to track trends.
With a fast-track way to process the trivial near misses, attention can be given to investigating and taking appropriate remedial action on the more significant near misses in a logical and comprehensive process.
Note it is still important to give an immediate response to the near misses that represent a significant risk if unaddressed – acknowledge the “good catch” – but explain that those incidents will inevitably take longer to resolve.
• Good quality output – ensure that near miss reports are used to improve safety. Taking action on reports shows people who report near misses that they are valued. Publicising improvements can reinforce participation by a wider group.
The previous article argued that understanding the importance of near misses should encourage organizations to get near misses reported. The aim is to learn from these failures and improve – a concern for safety in the future. However, if you considered the driving / cycling example in this article, you may have felt differently. Those involved in a near miss may be much more concerned with the present. What will be the consequences as a result of reporting a near miss? Real or perceived, negative consequences will discourage reporting. Even an apparent indifference or an option not to report can lead to under-reporting – why bother?
Those involved in, or witnessing, a near miss at work must trust their management to respond fairly to a near miss report. Such trust will only be achieved if supervisors understand and represent top management’s commitment to near miss reporting. Everyone will understand that near miss reporting is good because it concerns future prevention. There is no question of blame for something that has already happened, provided it was an accident and not done intentionally.
The problem however is that too often an enthusiastic “initiative” from the top is directed to the shop floor and misses bringing the supervisors on board first (or ever). Workers will take their cue from their supervisor’s attitude. Wittingly or unwittingly, it is the supervisors who can wreck any chance of success if they are not convinced.
Top management for their part should encourage and welcome an INCREASE in reported near misses – as incidents previously hidden from management view become apparent. In time, as each type of incident is addressed, the potential for safe working increases. Management will understand the apparent paradox: we don’t want near misses; we want more near misses reported.
Larkin T.J. & Larkin S., 1996, Reaching and Changing Frontline Workers. Harvard Business Review, May-June
Oshry B., 1996, Seeing Systems. San Francisco, CA: Berrett-Koehler Publishers Inc.
Nick Gardener spent many years working in the chemical, nuclear and automotive industries. He is now a global risk and HSE consultant working for Risk International Services Inc. He can be contacted at: firstname.lastname@example.org