Greetings from Barnsley, England located in South Yorkshire. Last week I received a comment and two thought provoking questions from a subscriber. They were as follows:
“What are your thoughts on fixing targets on near miss reporting / investigation, as a part of measuring safety performance?
Other question, How deep should the near miss incident investigation go?. Should it be as much as a first aid incident investigation. Thanks”
Thank you for this and the positive feedback! Here are my quick thoughts. I encourage others to “weigh in” as they see fit. To respond to your questions, I would like to first provide some background information.
I’m a believer that history tends to repeat itself and if you aren’t learning from the past, you are as often said “doomed to repeat it”. – Moreover I believe that safety can seem like a numbers game when you look at the severity ratio aspect of accidents/incidents. I am of the school of thought (like Dean Gano) that most accidents have both behavioral/precautionary and conditional prevention opportunities. There are low probability risks that occur daily in the normal work that people do. If a task has a 1 in 1000 chance of resulting in an incident/accident and if several people perform the task 3 times a day for a few years, eventually someone’s luck will run out.
For all of the risks that take place, a percentage of them become near-misses/close-calls/near-hits a smaller percentage turn into first aids and even fewer turn into recordable/reportable types. If you haven’t, I encourage you to listen to the previously recorded podcast titled: The Cliff Analogy.
Consider that some people who are working at the edge will come close to falling and catch themselves (near-miss) some fall off but just receive a bump or minor scratch at the bottom (first aid) and fewer will fall and receive a more serious injury (recordable). Now not everyone who walks out to the edge of a cliff will fall off. However everyone who falls off walked out to the edge. This is what is referred to as a risk pool. Near-miss reporting offers an opportunity to identify the risk pools prior to someone getting seriously hurt. (“Wow someone was working at the edge and almost fell off? Well what can we do to ensure this doesn’t happen again or prevent someone from actually falling off?)
It is important to report this type of information because one can not predict severity in accidents. I have been at sites where a person had fallen off two steps and it resulted in a fatality. I have been at another site where someone fell two stories and only broke a bone. I knew a man that slipped on a magazine that was on his carpet at home and he hit his head. Unfortunately he lost his life. I’m sure there are several of you (admittedly like myself) that have also slipped on something at home and got away injury free. As I’m writing this, one of our associates came in my office to tell me about an accident she saw on the way to the office. She said “had I been 150 feet further up the road I would have been hit by the driver” Sometimes the difference between a near-miss and a serious incident is 150 feet; many times it is just inches.
I do believe that there will always be an element of risk in many things people will do. While I believe zero accidents is a possibility (as I’ve seen it first hand in some very dangerous environments), zero risk isn’t possible. It is impossible to completely engineer out all of the risks so we must continue to work to identify those hidden risks and develop other ways to minimize the exposure. This is why we have to change the definition of “Safe” from no accidents to meaning “not at risk”. The better we can identify those areas without someone getting hurt to tell us, the better off we are. This also creates the necessity to help people understand the precautions they can take when exposed to the different risks in their environment.
As a site gets better and better in safety before the accidents go completely away and you sustain zero accidents the incident data does a nasty thing to you, it loses it statistical significance. It no longer provides trends to respond to, only random data points. This of course is why many sites hit a plateau and experience slight ups and downs over a few years. Moreover this is what has lead to the global popularity of Behavior-Based Safety (BBS). Rather than just relying on “reporting” to understand safety challenges, this process (if done correctly) looks at common practice to better see the hidden dangers and possibility of taking very specific precautions to minimize the exposure to the inevitable risks.
Prior to creating performance targets for reporting near-misses and deeply trying to investigate the almost events; I would first encourage an organization to, as Covey would say, ”Seek first to understand, then to be understood.” It is important to understand what perceptions exist in the organization. Perception surveys can provide you part of this answer. So can simply talking with the population during your normal conversations.
- First understand how people define a Near-miss. I have asked this same question to thousands of employees and have received many different incorrect responses. If you expect a person to report something that falls into a certain category, ensure the expectations are clear. Don’t let incorrect perceptions determine your success.
- Second, I encourage you to understand how population views the context of measurement. Far too often measurement is looked at as a fault finding/blame placing tool, rather than to help understand and improve. A great book for this is called “Transforming Performance Measurement”. A link can be found at:
- http://www.safetycultureexcellence.com/recommended-reading/
- Third I encourage you to look at how people view the current effectiveness of first aid and recordable reporting. If people report something and nothing happens or there is no follow up or communication back… If the system is viewed as a black hole safety system, it will be difficult to get people to report additional things. Unfortunately ineffective employee suggestion systems will have an impact on incident reporting as well. Resulting in both being lumped into the commonly heard perception “why keep telling them about the issues, when nothing is happening to fix them.”
- Fourth, look at what might demotivate people first and work to remove those demotivators before adding the motivators. The belief is that the motivation is already there, just remove the barriers! Rather than finding ways to motivate reporting, first understand what the barriers to reporting are. As I learned from the teachings of Ferdinand Fournies, people are intrinsically motivated to do the right thing, however barriers exist that end up demotivating the performance. Try to identify what might demovitate someone to report and neutralize those aspects within the culture. Consider that there are three elements of motivation: Reducing de-motivators, adding motivators and rewarding. In looking for the general demotivators, look for: Constant change, withholding information, hypocrisy, dishonesty, unfairness, unproductive activities, internal competition, lack of follow-up, over-control, ignoring input. Conversely for motivators continue providing input, a sense of ownership in safety (programs, processes), involvement, teamwork, a scorekeeping mentality (achieving success not avoiding failure – TRIR), improvement, winning, variety and of course recognition. Lastly, if you want the near-miss reporting to continue, create a positive consequence for the activity.
- Fifth, work to continuously communicate the reason for reporting Near-misses and build in real life examples from both at work and home. Consider how powerful it can be when people understand that they can report an almost event and there would be new insight and a positive outcome. If there are trust issues, consider an anonymous system to build the trust and most importantly demonstrate how the tool will be used. Recognize you might be sacrificing the ability to perform a deep analysis when it is anonymous; sometimes this is worth it in the beginning to build trust in the tool. As a side effect consider that this will help strength the safety culture. Consider communicating examples of how a hidden issue was found and solved, without someone having to get hurt, or in trouble.
I believe having a goal for near-miss reporting can be a great idea, because an organization should measure more than just “did we have fewer accidents this year than last?” We have helped many organizations develop their own custom Balanced Scorecards for Safety (Leading & Lagging, Impacting & Interactive Safety Metrics) and near-miss reporting is a common indicator.
The danger lies in focusing too much on the requested number and not enough emphasis on the rationale and necessity; thus creating a fiction writing contest. Deming once said “the numbers are critical but relatively unimportant”. In other words, the numbers are critical but not the end goal.
Several organizations perform a full root cause analysis on a near-miss to identify the contributing factors and precautionary control points. I always encourage investigators to look beyond employee behavior/actions, if this is found as a “root cause” or contributing factor. Many people will stop there because they can not answer the next “Why Question”. If one person is or feels encouraged to take a risk, usually others are as well. It is important to always look at the cultural aspects during an investigation/analysis. I believe that when the culture supports the measurement and understands why we need to investigate near-misses, an in-depth analysis can be a very positive thing. Consider that if people are fearful of the method and outcomes of first aid or recordable investigations, near-misses reporting will be negatively impacted. If you do not address the perceptions and cultural aspects of performance measurement, you will have little data to analyze; making this post unfortunately, a moot point.
Thank you again for the topic idea, keep them coming!
Shawn Galloway
President & Chief Operating Officer
Founder & Coauthor
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