Many organizations have near-miss reporting systems that are not working effectively. Conversely, one feature of world-class safety cultures is a thriving near-miss reporting (NMR) system with high participation, accurate and complete reporting, and helpful outputs. What can be done to optimize near-miss reporting? The science of behavior and decades of client experience gives us clear guidance on how best to design and implement an effective NMR process.
Safety professionals and management understand the value of near miss reporting. While near misses are undesirable, they provide unique opportunities to learn about mistakes and weaknesses in safety processes that, in turn, enable changes to be made to prevent future incidents. Most organizations work hard to create systems and processes that optimize safe performance; however those systems and processes do not always work the way they are intended. For example, one company was attempting to speed up the process of ordering safety gloves in order to prevent shortages. They gave the job to an office worker who, with good intentions, further streamlined the process by only ordering the most common size of glove. Near miss reporting highlighted an increase in hand injury close calls related to failure to wear gloves. Further analysis revealed those workers with very small or very large hands were unable to use the gloves available and so did the brief tasks without gloves. The intention was good—streamline the process so gloves were always available, but there was an unintended impact of leaving a small subsection of employees without gloves of the right size. Near misses allow us to see the impact of our management systems and safety systems on safe behavior. They provide a window into how decisions, systems and processes play out at the frontline. Are they working as intended or are they inadvertently encouraging the wrong types of behavior?
Ironically, one of the safety systems that often doesn't work as intended is near-miss reporting. From a behavioral perspective, the desired behavior in NMR is for employees to report into the system any event that others might learn from to prevent future incidents or injuries. In most systems, the actual behaviors include:
employees report only those events that were severe enough or had witnesses where there is no other option, and
employees report only "softball" near misses like paper cuts, a stumble in the parking lot or a deer on the shoulder of the highway on the way to work.
Why is there a significant gap between near miss reporting system's intent and ultimate impact? Even with the best of intentions, many NMR processes function to discourage the very behavior they require: reporting a situation where an injury or damage could have happened but didn't. The systems and those that execute the systems inadvertently punish reporting substantive near misses.
