Understanding near miss accidents in health and safety

“Near misses” are unplanned events or situations that have not caused injuries but had the potential to do so, where a negative consequence did not occur only due to a series of favorable and/or random circumstances.

In the safety field, the concept of a “near miss” (often also referred to as a “near collision,” “near accident,” or “narrow escape”) refers to an unexpected event that, although having the potential to cause harm to people, the environment, or equipment, does not actually result in such consequences. These events do not disrupt normal operations but are significant risk indicators.

The Occupational Safety and Health Administration (OSHA) in the United States, for example, classifies a near miss as an episode in which there is no damage to property or personal injury, but where a slight change in time or position could have easily caused them. These events are sometimes described using terms such as incident precursors, injury-free events, or, in the context of moving objects, near collisions. A near miss is often the result of an error, and only due to certain circumstances and additional considerations does it not turn into a disaster.

If identified and addressed properly, they represent very important risk indicators for improving workplace safety. In fact, a near miss can be used as an opportunity to enhance safety practices, eliminate risks, and prevent future incidents.

Proper management of near misses requires the adoption of specific procedures for reporting, data collection and analysis, and the implementation of preventive actions.

What is a “near miss”?

The term “near miss” is a work-related event that did not result in injury or illness.

It is a situation that has been resolved without harm to the worker thanks to fortuitous circumstances that have prevented the negative consequence. Therefore, these are events that, although not resulting in harm, have the potential to cause an injury.

Difference between injury and “near miss”

There is a significant difference between an injury and a “near miss.” In evaluating an accident, these terms are often used interchangeably, but they have very different meanings.

An injury refers to any incident or event caused by a fortuitous, violent, and external cause that occurs during work activities, resulting in traumatic injuries to the individual that can cause:

• death;
• permanent disability;
• temporary disability requiring absence from work for more than 3 days.

A near miss, on the other hand, is an event generated by unforeseen and sudden situations in the presence of causes that prevented an incident with negative consequences from occurring.

Correlation between “near misses” and injuries: Heinrich’s pyramid

The correlation between “near misses” and injuries was analyzed by Herbert W. Heinrich. In his analysis of 550,000 industrial injuries in the United States, he identified an almost constant ratio between serious injuries, minor injuries, and “near misses.” For every serious injury (resulting in severe/fatal injuries), there were 29 minor injuries and 300 near misses.

This ratio of 1-29-300, represented in the form of a pyramid, serves as a visual representation of the relative frequency of different types of injuries.

Safety pyramid according to Herbert William Heinrich

Even Bird introduced a fourth level in the pyramid by distinguishing between fatal accidents and near misses that result in a loss of work hours.

Safety pyramid according to Frank E. Bird

Another safety pyramid was produced in 2003 on behalf of Conoco Phillips, with the addition of risk behavior as an additional level at the base of the pyramid.

Safety pyramid according to Conoco Philips

Examples of “near miss”

To better understand the concept of “near miss,” it is useful to provide some examples: a tool falling from a height at a worksite reaching the ground without hitting any workers along the way and therefore causing no damage; a load falling from a shelf inside a warehouse. The events that fall into the category of “near miss” are numerous and occur daily even in environments considered safer than a construction site, such as an office.

Causes of a “near miss”

The causes of “near miss” can be divided into 3 categories:

• human resources management: lack of control over the professionals’ work and undefined assignment of work tasks;
• company organization: inadequate safety measures, unclear work procedures, and work activities that do not consider the real risks to which workers are exposed;
• immediate causes: malfunctions of personal protective equipment, malfunctions of machinery used during work activities, and errors made by workers.

Reporting and managing “near miss”: roles and procedure

Recognizing near misses represents the first step in correctly reporting a “near miss.”

Involved Figures

There are several figures involved in reporting “near misses,” each with a specific role:

• Worker reporting the incident: may be directly involved in the incident or have knowledge of it. Usually, they are part of the company’s staff, but in certain cases, the report may also come from an external individual, such as a subcontractor’s worker;
• Subject involved in the incident: directly involved in the near miss and can be an internal employee or an external individual. In some cases, the subject involved may also be the first to report the incident, so the figures of Subject involved in the incident and Worker reporting the incident may coincide;
• Group for receiving, transmitting, and evaluating incidents: includes various professional figures, including the workers’ safety manager, the prevention and protection service manager, and the supervisor. In construction sites, the Safety Coordinator during the Execution Phase is required. The task of the Group for receiving, transmitting, and evaluating incidents is to receive the near miss report and evaluate it properly. Based on this evaluation, specific preventive measures are taken to avoid the recurrence of the incident;
• Delegate: not part of the Group for receiving, transmitting, and evaluating incidents, receives the report from the Worker reporting the incident and communicates it to the Group for receiving, transmitting, and evaluating incidents, then proceeds with the documentation’s recording and archiving;
• Incident resolution group: responsible for resolving the incident if the Group for receiving, transmitting, and evaluating incidents is unable to do so satisfactorily. The members of this group may vary depending on the company department involved in the event;
• employer: receives communications from the Incident resolution group and verifies the effectiveness of the solutions adopted in the case of an incident that cannot be resolved within the department, or in the case of an incident that cannot be resolved within the company but can be resolved by subcontractors. Furthermore, the employer ensures that the incident’s practice is correctly closed by the Incident resolution group.

Procedure

The procedure for reporting a “near miss” is organized according to feedback (or modules) of different levels, corresponding to the different actions taken by the involved parties:

• the Worker reports the incident to the Group for receiving, transmitting, and evaluating incidents through the delegate;
• the delegate communicates the start of the procedure to the reporter (feedback I);
• the Group for receiving, transmitting, and evaluating incidents evaluates whether the report should be considered an incident. If it is not a “near miss,” it informs the worker reporting the incident and closes the case (feedback I bis). If further investigation is deemed necessary, it decides whether to manage the case internally or involve the Incident resolution group:
  • in the first case, the Group for receiving, transmitting, and evaluating incidents handles the case and informs the worker reporting the incident of the procedure’s closure (feedback II – closing module);
  • in the second case, the Group for receiving, transmitting, and evaluating incidents involves the Incident resolution group using the incident resolution module, which also includes the employer. The Incident resolution group is responsible for resolving the issue and communicating the closure of the procedure.
• The Incident resolution group assesses the conditions, determines an internal resolution within the company, and sends an incident resolution communication (feedback IV) to the Worker reporting the incident and the Group for receiving, transmitting, and evaluating incidents, explaining the executive and logistical procedures involved in the process.

Feedback can be provided at different levels such as:

• response to the initial report (the report has been taken into account);
• update on the progress and handling of the report (the report has been taken into account by the purchasing department);
• final outcome (the case has been resolved).

The importance of feedback lies in its ability to maintain a close relationship between the organization and the worker and its strength in creating a climate of involvement and participation.

“Near miss”: the importance of training

Ensuring adequate training is essential even when it comes to preventing near miss incidents.

The training program should focus on various aspects such as:

• terminological definitions;
• conceptual framework, motivations, and objectives;
• safety culture (individual growth as collective growth);
• worker leadership;
• assumption of individual responsibility;
• roles and functions responsible for managing the near miss reporting process;
• constructive alliances and teamwork;
• communication flows and possible interlocutors;
• practical exercises, including group exercises, aimed at identifying the root causes of incidents.