Near miss (safety)
A near miss, near death, near hit, or close call is an unplanned event that has the potential to cause, but does not actually result in human injury, environmental or equipment damage, or an interruption to normal operation.
OSHA defines a near miss as an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near misses also may be referred to as near accidents, accident precursors, injury-free events and, in the case of moving objects, near collisions. A near miss is often an error, with harm prevented by other considerations and circumstances.
Causes
There are factors for a near miss related to the operator, and factors related to the context. Fatigue is an example for the former. The risk of a car crash after a more than 24h shift for physicians has been observed to increase by 168%, and the risk of near miss by 460%.Factors relating to the context include time pressures, unfamiliar settings, and in the case of health care, diverse patients, and high patient-to-nurse staffing ratios.
Notable examples
Nuclear close calls
During the Cold War, several incidents nearly triggered nuclear war. These were often caused by benign events misinterpreted as signs of an enemy attack, due to the tense geopolitical climate and limitations in early warning systems.In 1962, during the Cuban Missile Crisis, a Soviet nuclear submarine was surrounded by US Navy destroyers using depth charges to force it to surface. Without the ability to contact Moscow, the captain and another officer advocated for launching a nuclear torpedo, but Vasily Arkhipov vetoed the decision. Similarly, in 1983, after an early-warning system raised an alarm, Stanislav Petrov judged it to be a false alarm, and violated the protocol by not reporting it as an attack. The alarm for this incident was later found to be caused by unusual atmospheric conditions rather than missile launches. High alert states have also been caused by a scientific rocket launch, by a mishandled training tape, and by a bear in the dark interpreted as an intruder.
Such events can both be caused by technical or human errors. Decision-makers often only had minutes to determine whether to retaliate, due to the fact that nuclear explosions could destroy land-based nuclear missile launchers, although nuclear submarines provide nuclear second-strike capabilities. One proposition to reduce risks is to wait for an actual explosion rather than relying on alarm systems. Another one involves requiring consensus among multiple decision-makers, or even a vote from Congress. China also has a "no first use policy", and stores warheads and missiles in different locations.
Another nuclear safety accident, the 1961 Goldsboro B-52 crash, occurred when a bomber flying over North Carolina lost a wing after a fuel leak. The two nuclear bombs it was carrying fell. For one bomb, 3 of the 4 safety mechanisms were armed, and the explosion was only averted by a switch.
Reporting, analysis and prevention
Most safety activities are reactive and not proactive. Many organizations wait for losses to occur before taking steps to prevent a recurrence. Near miss incidents often precede loss producing events but are largely ignored because nothing happened. Employees are not enlightened to report these close calls as there has been no disruption or loss in the form of injuries or property damage. Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and reporting near miss incidents can make a major difference to the safety of workers within organizations. In the heavy construction industry, near miss reporting software allows crews to find and document opportunities that help reduce safety risks as the software tracks, analyzes and calls attention to near misses on the job site to help prevent future incidents. History has shown repeatedly that most loss producing events were preceded by warnings or near accidents, sometimes also called close calls, narrow escapes or near hits.In terms of human lives and property damage, near misses are cheaper, zero-cost learning opportunities
Getting a very high number of near misses reported is the goal as long as that number is within the organization's ability to respond and investigate - otherwise it is merely a paperwork exercise and a waste of time; it is possible to achieve a ratio of 100 near misses reported per loss event.
Achieving and investigating a high ratio of near miss reports will find the causal factors and root causes of potential future accidents, resulting in about 95% reduction in actual losses.
An ideal near miss event reporting system includes both mandatory and voluntary, non-punitive reporting by witnesses. A key to any near miss report is the "lesson learned". Near miss reporters can describe what they observed of the beginning of the event, and the factors that prevented loss from occurring.
The events that caused the near miss are subjected to root cause analysis to identify the defect in the system that resulted in the error and factors that may either amplify or ameliorate the result.
To prevent the near miss from happening again, the organization must institute teamwork training, feedback on performance and a commitment to continued data collection and analysis, a process called continuous improvement.
Near misses are smaller in scale, relatively simpler to analyze and easier to resolve. Thus, capturing near misses not only provides an inexpensive means of learning, but also has some equally beneficial spin offs:
- Captures sufficient data for statistical analysis; trending studies.
- Provides immense opportunity for "employee participation," a basic requirement for a successful workplace health and safety program. This embodies principles of behavior shift, responsibility sharing, awareness, and incentives.
- One of the primary workplace problems near miss incident reporting attempts to solve directly or indirectly is to try to create an open culture whereby everyone shares and contributes in a responsible manner. Near miss reporting has been shown to increase employee relationships and encourage teamwork in creating a safer work environment.
Barriers to reporting
- Fear of blame and other repercussions: A just culture is a prerequisite for free reporting. An environment in which the organisation is quick to apportion blame without first analysing what went wrong, and why it went wrong will discourage full and accurate reporting.
- Failure to report feedback: People are discouraged from reporting near misses if there is never any feedback provided.
Reporting systems by industry
Aviation
In the United States, the Aviation Safety Reporting System has been collecting confidential voluntary reports of close calls from pilots, flight attendants, air traffic controllers since 1976. The system was established after TWA Flight 514 crashed on approach to Dulles International Airport near Washington, D.C., killing all 85 passengers and seven crew in 1974. The investigation that followed found that the pilot misunderstood an ambiguous response from the Dulles air traffic controllers, and that earlier another airline had told its pilots, but not other airlines, about a similar near miss. The ASRS identifies deficiencies and provides data for planning improvements to stakeholders without regulatory action. Some familiar safety rules, such as turning off electronic devices that can interfere with navigation equipment, are a result of this program. Due to near miss observations and other technological improvements, the rate of fatal accidents has dropped about 65 percent, to one fatal accident in about 4.5 million departures, from one in nearly 2 million in 1997. Furthermore, according to a report in The New York Times on Wednesday, November 15, 2023 in response to a series of near collisions, the Federal Aviation Administration sought the input of external experts. The experts recommended addressing the shortage of air traffic controllers and upgrading outdated technology.In the United Kingdom, an aviation near miss report is known as an "airmiss" or an "airprox", an air proximity hazard, by the Civil Aviation Authority. Since reporting began, aircraft near misses continue to decline.