The near miss is an incredibly powerful learning tool, and one that is largely wasted. It carries all the information regarding a potential accident without someone actually getting hurt. Why would the culture of a plant discourage taking advantage of this golden resource?
“Confessing” a near miss suggests that I’ve done something stupid, taken a dangerous chance or even knowingly cut a corner and violated a safety procedure. I will have to explain the situation to my boss and the safety committee, and in the process, might set myself up for disciplinary action or even termination.
Let’s take the case of James, a senior mechanic. He’s doing a routine equipment repair. Engineering has made modifications to the equipment, and James is aware of this. He removes the control-box cover, and, as he has always done, reaches in for the control switch to deactivate the machine before locking it out. The switch has been relocated, and he unexpectedly finds his hand in a pinch point just as he is trying to shut down the machine. He withdraws his hand, barely avoiding getting caught in the gears as they mesh.
James steps back, waits until the adrenaline rush passes, and looks around. He’s glad no one saw his error; at least he won’t have to explain himself to anyone. Very carefully, he looks in the control box, goes to the relocated switch, shuts the equipment off, locks out the controls, and proceeds to make the simple repair.
The same thing happens several nights later to TJ, one of the night shift mechanics. He missed the briefing where the engineering modifications were announced. But he too is lucky. And he too keeps quiet about it.