Near miss (safety)

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A near miss, near death, near hit, 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.[ citation needed ]

Contents

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. [1] A near miss is often an error, with harm prevented by other considerations and circumstances. [2]

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%. [3] 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. [4]

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. [5] 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. [6]

In terms of human lives and property damage, near misses are cheaper, zero-cost learning opportunities (compared to learning from actual death, injury or property loss events)

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. [7]

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. [7]

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 to identify the defect in the system that resulted in the error and factors that may either amplify or ameliorate the result.[ citation needed ]

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.[ citation needed ]

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:[ citation needed ]

In a near miss, all the involved parties are alive to provide detailed information. In fatal incidents much of the critical information may be lost. In some cases the survivors may provide useful information on how a fatality was avoided.[ citation needed ]

Barriers to reporting

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 (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 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. [10] 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. [11]

In the United Kingdom, an aviation near miss report is known as an "airmiss" [12] or an "airprox", an air proximity hazard, [13] by the Civil Aviation Authority. Since reporting began, aircraft near misses continue to decline. [14]

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. [15] In 2005, the National Fire Fighter Near-Miss Reporting System 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. [16]

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. [17] 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). [18] 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 (IACP), the International Association of Directors of Law Enforcement Standards and Training (IADLEST), the Officer Down Memorial Page (ODMP) and the Below 100 organization. [18] The Police Foundation, a national, independent non-profit organization, operates the system and has received additional support from the Motorola Solutions Foundation. [19] 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, 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. [20]

The United States Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) developed the Patient Safety Reporting System modeled upon the Aviation Safety Reporting System to monitor patient safety through voluntary, confidential reports. [21]

Rail

CIRAS (the Confidential Incident Reporting and Analysis System) is a confidential reporting system modelled upon ASRS and originally developed by the University of Strathclyde for use in the Scottish rail industry. However, after the Ladbroke Grove rail crash, John Prescott mandated its use throughout the whole UK rail industry. Since 2006 CIRAS has been run by an autonomous Charitable trust. [22]

Underwater diving

There is a significant difference between professional and recreational diving. Professional diving has long established systems for risk assessment, incident mitigation, codes of practice and industry regulation, which have made it an acceptably safe occupation, but at considerable cost. [23] The professional diving industry delivers materials such as IMCA Safety flashes, which are anonymised reports of accidents and near misses from the offshore diving industry published by International Marine Contractors Association which inform the industry and encourage independent evaluation of the incidents. [24]

Recreational divers are personally responsible for their own actions and are largely unregulated. Risk awareness and personal and peer group attitudes are determining factors in triggering dive accidents. Recreational scuba diving operations are exposed to risks which can develop into incidents, injury or death of participants, with associated risk of liability for the operator and participants. [23] Certifying and safety agencies gather risk data reported in the recreational scuba diving industry, but there is no published research specifically regarding recreational divers and dive centres attitudes and perceptions of safety. [23] Avoidable accidents continue to occur in recreational diving in spite of long established education by the training agencies, which is mainly focused on essential skills specified by training standards. More awareness of risk, and a changed attitude toward safety would help to reduce the number of such incidents. [23]

There is a combination of a factors hindering the reporting of near misses in the recreational diving industry. There is a lack of structured reporting mechanisms, a lack of clarity of what would constitute a near miss, or reportable incident, as most recreational divers have very little personal background and no training in workplace health and safety, and not much more from the service providers. The competitive nature of the industry and in some countries litigious nature of the population, tends to discourage sharing of information which legal advisors may consider risky, and resource constraints contributes to the underreporting of near misses in recreational diving. [25] Safety requirements are generally imposed by certification agencies and to a lesser extent by commercial level occupational health and safety authorities. The service provider is mostly uninvolved beyond basic compliance with rules. Changing these attitudes would require either a cultural shift towards prioritizing safety and collaboration the major stakeholders in the diving community, or a clear threat to profits. [25] There are a few non-profit organisations involved in recreational diver safety, such as Divers Alert Network, British Sub-Aqua Club, the Rebreather Education and Safety Association, National Speleological Society, Cave Diving Group, and some of the member oriented technical diving organisations, which do the majority of research into recreational dive safety, and analyse what information on near misses is available. Part of the problem in getting divers to report near misses is the stigma attached to what are perceived by some as violations of safety rules, without due analysis of why the rules were violated, or even whether they were strictly applicable, as there is a tendency among training agencies to prescribe behaviour as appropriate, correct, and necessary without going into the reasons for the rules, and as a consequence most divers are not in a position to make a fair and informed judgement, or even to know that there may be an alternative or specific scope to the received rules.

Researchers recognise that more information on near misses would facilitate analysis of diving safety.

A book was published in 2021 providing personal recollections of near misses by a number of well known and influential technical divers to counteract this attitude and show that even the most respected divers are occasionally inattentive, unlucky, or make mistakes, and have survived by luck, skill or a combination of both. [26]

See also

Related Research Articles

<span class="mw-page-title-main">Safety-critical system</span> System whose failure would be serious

A safety-critical system or life-critical system is a system whose failure or malfunction may result in one of the following outcomes:

<span class="mw-page-title-main">Technical diving</span> Extended scope recreational diving

Technical diving is scuba diving that exceeds the agency-specified limits of recreational diving for non-professional purposes. Technical diving may expose the diver to hazards beyond those normally associated with recreational diving, and to a greater risk of serious injury or death. Risk may be reduced via appropriate skills, knowledge, and experience. Risk can also be managed by using suitable equipment and procedures. The skills may be developed through specialized training and experience. The equipment involves breathing gases other than air or standard nitrox mixtures, and multiple gas sources.

<span class="mw-page-title-main">Recreational diving</span> Diving for the purpose of leisure and enjoyment, usually when using scuba equipment

Recreational diving or sport diving is diving for the purpose of leisure and enjoyment, usually when using scuba equipment. The term "recreational diving" may also be used in contradistinction to "technical diving", a more demanding aspect of recreational diving which requires more training and experience to develop the competence to reliably manage more complex equipment in the more hazardous conditions associated with the disciplines. Breath-hold diving for recreation also fits into the broader scope of the term, but this article covers the commonly used meaning of scuba diving for recreational purposes, where the diver is not constrained from making a direct near-vertical ascent to the surface at any point during the dive, and risk is considered low.

<span class="mw-page-title-main">Diving medicine</span> Diagnosis, treatment and prevention of disorders caused by underwater diving

Diving medicine, also called undersea and hyperbaric medicine (UHB), is the diagnosis, treatment and prevention of conditions caused by humans entering the undersea environment. It includes the effects on the body of pressure on gases, the diagnosis and treatment of conditions caused by marine hazards and how relationships of a diver's fitness to dive affect a diver's safety. Diving medical practitioners are also expected to be competent in the examination of divers and potential divers to determine fitness to dive.

<span class="mw-page-title-main">Scuba diving</span> Swimming underwater, breathing gas carried by the diver

Scuba diving is a mode of underwater diving whereby divers use breathing equipment that is completely independent of a surface breathing gas supply, and therefore has a limited but variable endurance. The name scuba is an anacronym for "Self-Contained Underwater Breathing Apparatus" and was coined by Christian J. Lambertsen in a patent submitted in 1952. Scuba divers carry their own source of breathing gas, usually compressed air, affording them greater independence and movement than surface-supplied divers, and more time underwater than free divers. Although the use of compressed air is common, a gas blend with a higher oxygen content, known as enriched air or nitrox, has become popular due to the reduced nitrogen intake during long or repetitive dives. Also, breathing gas diluted with helium may be used to reduce the effects of nitrogen narcosis during deeper dives.

<span class="mw-page-title-main">Safety culture</span> Risk-averse attitudes

Safety culture is the element of organizational culture which is concerned with the maintenance of safety and compliance with safety standards. It is informed by the organization's leadership and the beliefs, perceptions and values that employees share in relation to risks within the organization, workplace or community. Safety culture has been described in a variety of ways: notably, the National Academies of Science and the Association of Land Grant and Public Universities have published summaries on this topic in 2014 and 2016.

<span class="mw-page-title-main">Underwater diving</span> Descending below the surface of the water to interact with the environment

Underwater diving, as a human activity, is the practice of descending below the water's surface to interact with the environment. It is also often referred to as diving, an ambiguous term with several possible meanings, depending on context. Immersion in water and exposure to high ambient pressure have physiological effects that limit the depths and duration possible in ambient pressure diving. Humans are not physiologically and anatomically well-adapted to the environmental conditions of diving, and various equipment has been developed to extend the depth and duration of human dives, and allow different types of work to be done.

Divers Alert Network (DAN) is a group of not-for-profit organizations dedicated to improving diving safety for all divers. It was founded in Durham, North Carolina, United States, in 1980 at Duke University providing 24/7 telephonic hot-line diving medical assistance. Since then the organization has expanded globally and now has independent regional organizations in North America, Europe, Japan, Asia-Pacific and Southern Africa.

<span class="mw-page-title-main">Confidential Incident Reporting & Analysis System</span> Transportation safety reporting service in the UK

The Confidential Incident Reporting & Analysis Service (CIRAS), formerly the Confidential Incident Reporting & Analysis System, is a confidential safety reporting service for health, safety and wellbeing concerns raised by workers in the UK transport industry. It is funded by members and run independently, though is a wholly owned subsidiary of Rail Safety and Standards Board (RSSB). The service covers the following sectors: passenger and freight train operators, light rail, Network Rail and its suppliers, London Underground, and Transport for London (TfL) bus operators.

<span class="mw-page-title-main">Accident</span> Unforeseen event, often with a negative outcome

An accident is an unintended, normally unwanted event that was not directly caused by humans. The term accident implies that nobody should be blamed, but the event may have been caused by unrecognized or unaddressed risks. Most researchers who study unintentional injury avoid using the term accident and focus on factors that increase risk of severe injury and that reduce injury incidence and severity. For example, when a tree falls down during a wind storm, its fall may not have been caused by humans, but the tree's type, size, health, location, or improper maintenance may have contributed to the result. Most car wrecks are not true accidents; however, English speakers started using that word in the mid-20th century as a result of media manipulation by the US automobile industry.

Human factors are the physical or cognitive properties of individuals, or social behavior which is specific to humans, and which influence functioning of technological systems as well as human-environment equilibria. The safety of underwater diving operations can be improved by reducing the frequency of human error and the consequences when it does occur. Human error can be defined as an individual's deviation from acceptable or desirable practice which culminates in undesirable or unexpected results. Human factors include both the non-technical skills that enhance safety and the non-technical factors that contribute to undesirable incidents that put the diver at risk.

[Safety is] An active, adaptive process which involves making sense of the task in the context of the environment to successfully achieve explicit and implied goals, with the expectation that no harm or damage will occur. – G. Lock, 2022

Dive safety is primarily a function of four factors: the environment, equipment, individual diver performance and dive team performance. The water is a harsh and alien environment which can impose severe physical and psychological stress on a diver. The remaining factors must be controlled and coordinated so the diver can overcome the stresses imposed by the underwater environment and work safely. Diving equipment is crucial because it provides life support to the diver, but the majority of dive accidents are caused by individual diver panic and an associated degradation of the individual diver's performance. – M.A. Blumenberg, 1996

<span class="mw-page-title-main">Fitness to dive</span> Medical fitness of a person to function safely underwater under pressure

Fitness to dive, specifically the medical fitness to dive, is the medical and physical suitability of a diver to function safely in the underwater environment using underwater diving equipment and procedures. Depending on the circumstances, it may be established with a signed statement by the diver that they do not have any of the listed disqualifying conditions. The diver must be able to fulfill the ordinary physical requirements of diving as per the detailed medical examination by a physician registered as a medical examiner of divers following a procedural checklist. A legal document of fitness to dive issued by the medical examiner is also necessary.

A confidential incident reporting system is a mechanism which allows problems in safety-critical fields such as aviation and medicine to be reported in confidence. This allows events to be reported which otherwise might not be reported through fear of blame or reprisals against the reporter. Analysis of the reported incidents can provide insight into how those events occurred, which can spur the development of measures to make the system safer.

Scuba diving fatalities are deaths occurring while scuba diving or as a consequence of scuba diving. The risks of dying during recreational, scientific or commercial diving are small, and on scuba, deaths are usually associated with poor gas management, poor buoyancy control, equipment misuse, entrapment, rough water conditions and pre-existing health problems. Some fatalities are inevitable and caused by unforeseeable situations escalating out of control, though the majority of diving fatalities can be attributed to human error on the part of the victim.

Diving safety is the aspect of underwater diving operations and activities concerned with the safety of the participants. The safety of underwater diving depends on four factors: the environment, the equipment, behaviour of the individual diver and performance of the dive team. The underwater environment can impose severe physical and psychological stress on a diver, and is mostly beyond the diver's control. Equipment is used to operate underwater for anything beyond very short periods, and the reliable function of some of the equipment is critical to even short-term survival. Other equipment allows the diver to operate in relative comfort and efficiency, or to remain healthy over the longer term. The performance of the individual diver depends on learned skills, many of which are not intuitive, and the performance of the team depends on competence, communication, attention and common goals.

<span class="mw-page-title-main">Outline of underwater diving</span> List of articles related to underwater diving grouped by topical relevance

The following outline is provided as an overview of and topical guide to underwater diving:

The civil liability of a recreational diver may include a duty of care to another diver during a dive. Breach of this duty that is a proximate cause of injury or loss to the other diver may lead to civil litigation for damages in compensation for the injury or loss suffered.

Investigation of diving accidents includes investigations into the causes of reportable incidents in professional diving and recreational diving accidents, usually when there is a fatality or litigation for gross negligence.

<span class="mw-page-title-main">Scuba diving tourism</span> Industry based on recreational diver travel

Scuba diving tourism is the industry based on servicing the requirements of recreational divers at destinations other than where they live. It includes aspects of training, equipment sales, rental and service, guided experiences and environmental tourism.

References

  1. ↑ Howard, Keith. "Everybody gets to go home in one piece". Safety+Health. National Safety Council. Retrieved 28 June 2021.
  2. ↑ My Near Miss DANIELLE OFRI, MAY 28, 2013
  3. ↑ When Doctors Don't Sleep, Talk of the Nation, National Public Radio, 13 December 2006.
  4. ↑ Aiken, LH; Clarke, SP; Sloane, DM; Sochalski, J; Silber, JH (2002). "Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction". JAMA . 288 (16): 1987–93. doi:10.1001/jama.288.16.1987. PMID   12387650.
  5. ↑ "Near Miss Reporting Software". HCSS. 15 December 2021. Retrieved 14 June 2022.
  6. ↑ McKinnon, Ron C. Safety Management: Near Miss Identification, Recognition, and Investigation.
  7. 1 2 Gains from Getting Near Misses Reported (PDF) (Report). Process Improvement Institute.
  8. ↑ Near-Miss Incident Reporting – It's About Trust (Report). CLMI Safety Training. n.d.
  9. ↑ Lock, Gareth (2 July 2022). "Surely if we blame and punish, things will be safer?". www.thehumandiver.com. Retrieved 3 July 2022.
  10. ↑ Wald, Matthew L. (October 1, 2007). "Fatal Airplane Crashes Drop 65%". The New York Times. Retrieved 2007-10-01.
  11. ↑ Walker, Mark (2023-11-15). "Staffing and Technology Woes Threaten Aviation Safety, Report Says". The New York Times. ISSN   0362-4331 . Retrieved 2023-11-19.
  12. ↑ Wragg, David W. (1973). A Dictionary of Aviation (first ed.). Osprey. p. 26. ISBN   9780850451634.
  13. ↑ "Air Proximity Hazard" (PDF). Archived from the original (PDF) on August 1, 2014. Retrieved August 29, 2014.
  14. ↑ Civil Aviation Authority: UK Airprox Board Archived 2006-08-13 at the Wayback Machine , Retrieved July 16, 2006
  15. ↑ National Fire Fighter Near-Miss Reporting System (www.firefighternearmiss.com): FAQ Archived 2006-07-18 at the Wayback Machine Retrieved July 16, 2006
  16. ↑ Mandak, Joe (September 18, 2005). "Database seeks to lower firefighter deaths". USA Today. Retrieved 2006-07-08.
  17. ↑ "National Law Enforcement Officers Memorial Fund: Law Enforcement Facts". www.nleomf.org. Retrieved 2016-11-14.
  18. 1 2 "LEO Near Miss". www.leonearmiss.org. Retrieved 2016-11-14.
  19. ↑ "Police Foundation Receives Public Safety Grant Award from Motorola Solutions Foundation". www.policefoundation.org. Retrieved 2016-11-14.
  20. ↑ AORN: SafetyNet Archived 2006-07-17 at the Wayback Machine Retrieved on July 16, 2006
  21. ↑ Lenert, L.A.; Burstin, H.; Connell, L.; Gosbee, J.; Phillips, G. (1 January 2002). "Federal Patient Safety Initiatives Panel Summary". J Am Med Inform Assoc. 9 (6 Suppl 1): s8–s10. doi:10.1197/jamia.M1217. PMC   419408 . PMID   12386172.
  22. ↑ CIRAS Charitable Trust CIRAS website, Retrieved December 20th, 2006
  23. 1 2 3 4 Lucrezi, Serena; Egi, Salih; Pieri, Massimo; Burman, Francois; Ozyigit, Tamer; Danilo, Cialoni; Thomas, G.; Marroni, Alessandro; Saayman, Melville (23 March 2018). "Safety Priorities and Underestimations in Recreational Scuba Diving Operations: A European Study Supporting the Implementation of New Risk Management Programmes". Frontiers in Psychology. 9: 383. doi: 10.3389/fpsyg.2018.00383 . PMC   5876297 . PMID   29628904.
  24. ↑ "Safety Flashes". www.imca-int.com. Retrieved 10 August 2024.
  25. 1 2 Lock, Gareth (5 April 2023). "Does The Sport Diving Community Learn from Accidents?". InDepth.
  26. ↑ Kas, Stratis (2021). Close Calls. ISBN   978-1-5272-6679-7.
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