Near miss reporting: the sounds of silence

October 8, 2009
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“I say nothing…”


There is no doubt that near miss reporting is important… very important. As safety professionals and leaders, we know that a free lesson learned today is an injury avoided tomorrow. And there are dollars associated with near misses — serious dollars.

If we ignore the tremendous “human” and emotional impact of serious injuries and fatalities and only compare their financial costs with the costs of near miss injuries, it might be an eye-opening exercise.

According to some estimates, near miss events may cost twice as much as serious incidents or fatalities. According to a Houston Business Bureau, CII and Exxon Chemical report, a near miss event is estimated to cost about $1,300 and they estimate about 1,000 near miss events for every fatality. Using 2004 Bureau of Labor Statistics data, 5,703 workplace fatalities were reported across the United States. At an estimated million dollars per fatality, near misses cost the private sector more than a trillion dollars more, on the monetary side of the equation, than fatality. And, if estimated costs are shifted, near misses can move this ledger amount to twice that of fatalities.

As safety professionals, we already agree about the importance of near miss reporting. Add to this foundational understanding a cost basis rational, then a question flows naturally — why don’t we encourage reporting and thoroughly analyze near miss events? After all, how many near misses have you worked on this week, or this month? Chances are, you can count them on one hand…one finger probably. In truth, there are five key reasons why these events are not reported and analyzed. Five truths that no one wants to talk about, until now.

Unspoken Truth I — Reports come with a cost
Any article or training class dealing with near miss reporting will frame a near miss event as a “free lesson” or a “golden nugget” that must be analyzed for learning. The truth, however, is that these events are not free.

If you are still skeptical, then tell me how many near miss reports have come across your desk in the last week…I rest my case. In most organizations there is a cost to near miss reporting. That cost can come in many forms such as loss of credibility by the worker reporting the near miss. The price might be in an intimidating reporting system or unspoken signals from line-management. The cost might be in the perceived time and hassle to make the report. Our critical role is to identify these costs and work to reduce them.

Questioning attitude: What are the hidden costs to near miss reporting within your organization? How can we put ourselves in the shoes of our workers to truly understand these costs?

Unspoken Truth II — Reporting requires motivation
The next truth that no one talks about is this: free isn’t enough. There must be an incentive or motivator in order for our people to engage in a near miss reporting process and work an incident through the process.

Put yourself in the place of your workers. It’s a typical afternoon, and things seem to be going fine. All of the sudden, bam. The worker is almost injured due to a part defect. She quickly replaces the defective part and begins the task, as she does this she realizes that she was lucky. Had she not noticed the defect, there is a great chance she would have been injured. At that moment, the worker thinks… “I wonder if I should report it?” The thought that comes next is key… will she be motivated to do so or not? In most cases, “free” isn’t enough, there must be a positive motivator established so our workers will answer the “should I report it” question with a strong positive.

Questioning attitude: Is there motivation to report near miss events? At the moment a worker realizes a near miss occurred, what can be the motivating factor to allow him/her to report the event? What is the “right” type of motivator for your organization? Should I overcompensate with a motivator in the short term to establish a long-term habit?

Unspoken Truth III — Reporting requires too much work
If we refer back to our college days and reference the great H. W. Heinrich’s accident triangle from his book “Industrial Accident Prevention: A Scientific Approach” we recall that for every major injury there are 29 minor injuries and 300-near miss events. In looking at these ratios in your organization, it is probably safe to say that if reported, a line-manager could have at least one, if not more, near miss events a week.

That being said, how busy are your line-mangers right now? Chances are they are swamped. What are they going to do with another one or two near miss report events per week? Chances are they won’t do anything with them…and that’s the fear.

In all honesty, what would your organization think of a supervisor who managed over 100 near miss events in a year? While safety professionals would think its great, do you think managers would perceive an issue with the supervisor’s performance?

Questioning attitude: What kind of near miss reporting system can speed up the process, be effective in eliminating future exposures and assist line-managers at the same time? How can line-managers be rewarded and motivated to follow near miss events through the process? How can upper management recognize a high number of near miss reports as “effective supervision” instead of “poor performance” by a line manager? Does an organization need a separate position just to manage near miss events?

Unspoken Truth IV — A near miss is hard to define
One of the most effective football coaches of all time, Vince Lombardi, used to say, “It’s hard to be effective when you are confused!” The fact is that our people have a hard time defining a near miss and have a hard time translating a field event to a near miss report. And when there is uncertainty, people will withdraw into silence and status quo.

Questioning attitude: How can we design a near miss definition that is both effective and easily understood? How can we evaluate our employee’s current understanding of near misses?

Unspoken Truth V — Hours of pointless questions
Think about it: something happens and the result is that no one gets hurt, yet the employee or crew is dragged into a room with management for an “investigation.” After a couple hours of seemingly pointless questions that meeting ends, few, if any, changes are made…what’ doesn’t stink about that?

Questioning attitude: How can technology be used to help the process, how about a near miss blog? How can the process be turned from “stink” to roses? What if employees ran the process with a fostering eye and consistent support from management?

A sharing process that works
Having worked more than a decade and a half in the utility industry, it is safe to say that the most dangerous work for utilities workers is during storm restoration. After a storm, weather conditions are generally poor and electrical hazards extreme. To help mitigate these hazards and maintain a high level of safety awareness, crews will gather every morning to review hazards and then meet again in the evening to review the day.

It’s in these evening sessions that line workers will openly share near miss events. It’s a free exchange motivated by a general intent to keep a “brother or sister” from being injured by the same or similar exposure.

The process is supported by line-management and safety staff alike, it is free, workers are motivated by a sense of genuine caring and a desire to help, it’s not full of process or forms and it is done in a timely manner. Yet, after a storm, most of this free sharing is lost as crews revert back to “normal” hazards and office politics.

Near miss reporting is one key to safety success, yet it is lost in most organizations. In the end, it’s up to us as safety leaders and professionals to speak the unspoken truths and make a process where experiences are shared and supported for one common goal: to eliminate that human side of loss-before it happens.

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Recent Articles by Matt Forck, CSP, JLW

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