A near miss, 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
OSHA or Osha may refer to:
Work
* Occupational Safety and Health Administration, a federal agency of the United States that regulates workplace safety and health
* Occupational Safety and Health Act (United States) of 1970, a federal law in the Un ...
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%.
[When Doctors Don't Sleep](_blank)
Talk of the Nation, National Public Radio, 13 December 2006.
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.
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 (no injury, damage or loss) 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 (accidents) 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 (compared to learning from actual injury or property loss events)
Getting a very high number of near misses 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 misses 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 (for incidents with high loss potential) 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
In science
Science is a systematic endeavor that builds and organizes knowledge in the form of testable explanations and predictions about the universe.
Science may be as old as the human species, and some of the earliest archeologic ...
to identify the defect in the system that resulted in the error
An error (from the Latin ''error'', meaning "wandering") is an action which is inaccurate or incorrect. In some usages, an error is synonymous with a mistake. The etymology derives from the Latin term 'errare', meaning 'to stray'.
In statistics ...
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
A continual improvement process, also often called a continuous improvement process (abbreviated as CIP or CI), is an ongoing effort to improve products, services, or processes. These efforts can seek "incremental" improvement over time or "breakth ...
.
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.
Safety improvements by reports
Reporting of near misses by observers is an established error reduction technique in many industries and organizations:
Aviation
In the United States, the Aviation Safety Reporting System
The Aviation Safety Reporting System, or ASRS, is the United States of America, US Federal Aviation Administration's (FAA) voluntary confidential reporting system that allows pilots, air traffic controllers, cabin crew, dispatchers, maintenance te ...
(ASRS) 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
Trans World Airlines Flight 514, registration N54328, was a Boeing 727-231 en route from Indianapolis, Indiana and Columbus, Ohio to Washington Dulles International that crashed into Mount Weather, Virginia, on Sunday, 1974. All 92 aboard, ...
crashed on approach to Dulles International Airport
Washington Dulles International Airport , typically referred to as Dulles International Airport, Dulles Airport, Washington Dulles, or simply Dulles ( ), is an international airport in the Eastern United States, located in Loudoun County and Fai ...
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
Air traffic control specialists, abbreviated ATCS, are personnel responsible for the safe, orderly, and expeditious flow of air traffic in the global air traffic control system. Usually stationed in air traffic control centers and control ...
, 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.
In the United Kingdom, an aviation near miss report is known as an "airprox", an air proximity hazard, by the Civil Aviation Authority
A civil aviation authority (CAA) is a national or supranational statutory authority that oversees the regulation of civil aviation, including the maintenance of an aircraft register.
Role
Due to the inherent dangers in the use of flight vehicles, ...
. Since reporting began, aircraft near misses continue to decline.
Fire-rescue services
The rate of fire fighter fatalities and injuries in the United States is unchanged for the last 15 years despite improvements in personal protective equipment, apparatus and a decrease in structure fires. In 2005, the National Fire Fighter Near-Miss Reporting System
The Fire Fighter Near Miss Reporting System was launched on August 12, 2005 by the International Association of Fire Chiefs. It was announced at a press conference in Denver, Colorado, after having completed a pilot program involving 38 fire depar ...
was established, funded by grants from the U.S. Fire Administration and Fireman’s Fund Insurance Company, and endorsed by the International Associations of Fire Chiefs and Fire Fighters. Any member of the fire service community is encouraged to submit a report when he/she is involved in, witnesses, or is told of a near-miss event. The report may be anonymous, and is not forwarded to any regulatory agency.
Law enforcement and public safety
A total of 1,439 U.S. law enforcement officers died in the line of duty during the past 10 years, an average of one death every 61 hours or 144 per year. There were 123 law enforcement officers killed in the line of duty in 2015. In 2014, the Law Enforcement Officer (LEO) Near Miss Reporting System was established, with funding support from the U.S. Department of Justice's Office of Community Oriented Policing Services (COPS Office). Since its launch, the LEO Near Miss system has established endorsements and partnerships with the National Law Enforcement Officers' Memorial Fund (NLEOMF), the International Association of Chiefs of Police
International Association of Chiefs of Police (IACP) is a nonprofit organization based in Alexandria, Virginia (United States). It is the world's largest professional association for police
The police are a constituted body of persons em ...
(IACP), the International Association of Directors of Law Enforcement Standards and Training (IADLEST), the Officer Down Memorial Page
The Officer Down Memorial Page, Inc. (ODMP) is a non-profit organization that maintains a website listing American law enforcement officers, prison officers and police dogs who have died in the line of duty.
History
The ODMP was established i ...
(ODMP) and the Below 100 organization.[ The ]Police Foundation
The National Policing Institute, formerly known as the Police Foundation, is an American non-profit organization dedicated to advancing policing through innovation and independent scientific research. It is headquartered in Arlington, Virginia. ...
, a national, independent non-profit organization, operates the system and has received additional support from the Motorola
Motorola, Inc. () was an American Multinational corporation, multinational telecommunications company based in Schaumburg, Illinois, United States. After having lost $4.3 billion from 2007 to 2009, the company split into two independent p ...
Solutions Foundation. Law enforcement members are to submit voluntary reports when involved in or having witnessed or become aware of a near-miss event. Near miss reports take minutes to submit, can be submitted anonymously and are not forwarded to regulatory or investigative agencies, but are used to provide analysis, policy and training recommendations to the law enforcement community.
Healthcare
AORN
The Association of periOperative Registered Nurses (AORN) represents more than 41,000 registered nurses in the United States and abroad who facilitate the management, teaching, and practice of perioperative nursing, or who are enrolled in nursin ...
, a US-based professional organization of perioperative registered nurses, has put in effect a voluntary near miss reporting system called ''SafetyNet'' covering medication or transfusion reactions, communication or consent issues, wrong patient or procedures, communication breakdown or technology malfunctions. An analysis of incidents allows safety alerts to be issued to AORN members.
The United States Department of Veterans Affairs
The United States Department of Veterans Affairs (VA) is a Cabinet-level executive branch department of the federal government charged with providing life-long healthcare services to eligible military veterans at the 170 VA medical centers a ...
(VA) and the National Aeronautics and Space Administration
The National Aeronautics and Space Administration (NASA ) is an independent agency of the US federal government responsible for the civil space program, aeronautics research, and space research.
NASA was established in 1958, succeeding th ...
(NASA) developed the ''Patient Safety Reporting System'' modeled upon the Aviation Safety Reporting System to monitor patient safety
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of a ...
through voluntary, confidential reports.
Rail
CIRAS CIRAS can mean:
* Combat Integrated Releasable Armor System, a modular protective vest designed for US Special Operations Forces
* Confidential Incident Reporting & Analysis System, a confidential safety reporting service for transport and infra ...
(the Confidential Incident Reporting and Analysis System) is a confidential reporting system modelled upon ASRS and originally developed by the University of Strathclyde
The University of Strathclyde ( gd, Oilthigh Shrath Chluaidh) is a public research university located in Glasgow, Scotland. Founded in 1796 as the Andersonian Institute, it is Glasgow's second-oldest university, having received its royal chart ...
for use in the Scottish rail industry. However, after the Ladbroke Grove rail crash
The Ladbroke Grove rail crash (also known as the Paddington rail crash) was a rail accident which occurred on 5 October 1999 at Ladbroke Grove in London, England, when two passenger trains collided almost head-on after one of them had passed a ...
, John Prescott
John Leslie Prescott, Baron Prescott (born 31 May 1938) is a British politician who served as Deputy Prime Minister of the United Kingdom from 1997 to 2007 and as First Secretary of State from 2001 to 2007. A member of the Labour Party, he w ...
mandated its use throughout the whole UK rail industry. Since 2006 CIRAS has been run by an autonomous Charitable trust.[CIRAS Charitable Trus]
CIRAS website
Retrieved December 20th, 2006
See also
* , example of a nuclear close call
A nuclear close call is an incident that might have led to at least one unintended nuclear detonation or explosion, but did not. These incidents typically involve a perceived imminent threat to a nuclear-armed country which could lead to retal ...
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References
External links
Columbia Journalism Review:‘Near Miss’
{{Authority control
Safety
Error