What is the Value of the Near Miss?

The “near miss” is a terribly misunderstood event. This blog is about the near miss as seen from my view, which is not only purely practical, but is intentionally divesting itself of most of the obscuring terminology used in “safety systems.” I abhor when people disguise desired outcomes as systems to escape the scrutiny of logic.

In my universe a near miss is probably better called a “no loss event,” but the terms are interchangeable.The near miss has enormous value as a tool to recognise control failures, modify controls against a given risk, and it is a practical opportunity rather than a threat.

An example of a near miss is easy enough to conjure from the real world. Calgary (Alberta, Canada) is a windy city, and high-rise buildings are bombarded by gusts that have an array of damage potential. Just this year, in one case, a falling piece of unsecured building materials killed a child. Other incidents of falling objects abound, some from that same worksite. Eschewing focus on any of those events specifically, let us consider just the idea of a falling object. Let us identify a risk, cite a control or two, and then explore the value of the near miss opportunity.

The risk, of course, we can just generically phrase as the “risk of falling objects.” This generic risk covers everything from wrenches to hunks of plywood. One applicable control we will call “secure all objects,” and another we will call “ensure safety netting below the immediate work site.” Again, we have chosen generic and simple controls, since our point is illustration.

Outcomes can range, so let us generalise those on a spectrum (see the previous blog post and its link to understand where these spectrum points come from):

• Fatality or Catastrophic Loss;
• Major Injury or Major Property Loss;
• Minor Injury or Minor Property Loss; and
• Near Miss or Non-Loss Event.

Let’s take a moment to shorten the terms just for ease of reference: Fatality; Major Loss; Minor Loss; and Near Miss.

Now, let us unwind a scenario to describe each, while recognising that though these are generic and imagined each has actually occurred in Calgary in 2010:

• Fatality: A tool falls off a high-rise site, striking a child and killing them.
• Major Loss: A tool falls off a high-rise site, and strikes a vehicle, totalling it due to striking it specifically so that it is not repairable.
• Minor Loss: A tool falls off a high-rise site, and strikes concrete, destroying the tool.
• Near Miss: A tool falls off a high-rise site, and lands in ploughed ground not presently developed, which results in not even the tool being destroyed since it landed in mud.

In every case here the “risk of falling objects” was encountered. Regardless of the cause of the encounter, the encounter is fundamentally the same. In every case an object fell, yet the effect of that risk encounter is, in each case, of different severity.

Details are irrelevant to the analysis of the controls that failed (in our example, at least). Either or both of our cited controls failed to some degree. For arguments sake let us say that there was a failure to secure all objects, and while netting was in place it did not contain the falling object. Via our investigation of the incidents, we determine for our purposes here that:

• None of the four tools was secured with safety lines, and all were heavy rivet devices just to avoid obscuring the simplicity.
• None of the netting in place was sufficiently preventative, and tore through due to the weight.

Now, while there is some edge of surrealism to the example, because we’re pretending the details were similar or identical, the illustrative value is clear: it is possible to have identical causes, identical control failures, and vastly different outcomes. The only variation in our scenarios presented is that in one case a human life was lost, in another an expensive asset, in the third the tool is destroyed, and in the final one nothing is lost. (Note that we’re pretending time was not lost, but in a near miss circumstance time will always be lost, meaning they cost us, which is why a non-loss event isn’t generally correctly named if you call it such. But our pretence is intact, to observe the basic fact of variant outcome.)

The value of a near miss is now obvious if you pretend the order of occurrence of these events is reversed from our list above: the near miss happened, before the other outcomes were seen. And therein lies the value of the near miss as an opportunity, because if you recognise it for what it is and analyse it properly, you will become aware that given the specific landing point, this near miss could have resulted in a fatal outcome. Extrapolating to that possibility, you can then focus on the nature of the control failures and harden those controls.

In our example, pretending the near miss came first, and pretending the safety professional isn’t just churning paper, there are two clear recommendations: secure the heavy tool by a separate tether; and double the strength of the netting (or add a secondary netting, etc.). The recognition of this near miss as an opportunity to harden controls is the difference between next weeks repeat having a more severe outcome, or a lesser one. In no way does the control improvement guarantee nothing can go wrong, but in every way it shows due diligence, productive focus, and risk management.

Near misses save lives, ultimately, by improving practical control measures.

The problem with this is that most people know it, but no one uses the opportunity to generate a competitive advantage. It is apparently easier to wait until someone dies, than it is to try to prevent the problem occurring. And the usual excuse? Because accidents happen. Just like the digging company that might repeatedly rely upon line identifiers who miss critical lines, people excuse control failures until the outcome severity forces recognition of the management failure.

One of the key problems getting a near miss to be recognised as an opportunity is that status quo “safety systems” rely upon statistical outputs and counts that can be negatively impacted by recognising too many opportunities. This negligence is an affront to the idea of operational risk management. Not respecting the near miss as the opportunity to harden controls is the quickest way to ensure that when the luck runs out, the cost is catastrophic.