Near miss/near hit investigations
Near misses present valuable opportunities to learn from mistakes and system deficiencies. In order to avoid disaster it is necessary to understand the risks that arise within an organisation. Underreporting near misses will hide issues that can be remedied before the problem develops into a disaster.
As Kletz observed:
"we should investigate all accidents, including those that do not result in serious injury or damage, as valuable lessons can be learnt from them. 'Near misses', as they are often called are warnings of coming events. We ignore them at our peril, as next time the incidents occur the consequences may be more serious." 10 F xi Surrounding any one single error are layers of steps, procedures and controls which were adhered to and followed. These are often taken for granted in the investigation of incident, which in turn undermines the resilience of a system. That vulnerability in the traditional is the motivation to focusing on what went right. But we can go further. We can uncover the success stories that meant the near miss did not result in a more serious incident. In that regard, the approach that we recommend is to investigate serious near misses by focusing on what factors allowed that potential injury causing incident to become 'harmless' (in the sense of causing no injury or harm). That is, trying to uncover what when right to avoid the incident's potential. Some may have effective defences. Understanding those deliberate or accidental defences provides rich material for building and maintaining resilience of a system. At the very least you know those defences work or at least worked on one occasion. The benefit of that approach is that the conversation with witnesses is an entirely positive one. It's not about what could have happened. It is not about the doom and gloom narrowly averted. Rather, it is about their heroic act, well designed process or lucky event that allowed us to avoid the adverse outcome. People love talking about positive things particularly if they have had something to do with them. Of course, few accidental defences can be adopted without modification or systemisation. The idea is not to blindly record this event but rather attempt to learn from what works and find a way to make that work by design rather than by accident. Identify what happened. In questioning witnesses and persons involved, use open questions. Start with positive statements such as: 'It's incredible that you were able to avoid this situation becoming worse. How did you do it?' Look for the factors that meant that the incident did not resolve in further harm. Conversely, identify what could have happened. Ask what went right that prevent the incident from causing serious injury or damage. The question 'what went right' is asked multiple times (although there is no magic in the number 5, Method
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