Conventional wisdom tends to hold that people won’t report near misses because they are fearful of the repercussions of admitting that they screwed up in some way. I’ve been chewing on this for a while now and have concluded that this belief is, for the most part, wrong. But before we get into that, I should define my terms a bit. A near miss is any activity that almost resulted in an injury but didn’t.
Near misses provide us with an invaluable opportunity to learn about system failures and correct the root causes before a catastrophic incident happens (someone is killed or seriously injured or there is substantial property damage.) But people are reticent to report these mishaps and safety professionals and organizations struggle to convince people to document near misses. Why? Many, if not most safety professional land on “people are afraid they will get in trouble”, and I don’t doubt that is sometimes the case, but in recent weeks I have been working with a new organization and, as such, the pressure to conform to the new culture, while self imposed, is formidable. Three times in the past two weeks I have been involved with near misses and I did not report them. Why? Was I afraid? I was afraid of negative job repercussions, in fact, in each case I did nothing wrong. In the first case I was trying to turn off a light in a cubicle and as I felt along the front of the light in an effort to locate the light switch I instead crammed my palm into the clear plastic light cover; it hurt, but it didn’t injure me. Had I been hurrying or had the plastic been jagged or…a host of other conditions I could have been injured. From a safety stand point I could have been cut, burned or even received an electrical shock. Clearly this is a system flaw—I was not behaving unsafely or working out of process and yet the way cubes are lit is a poor design that encourages people to feel around for a switch instead of having the switch in plain view. At a minimum this condition is likely to eventually damage the plastic covering which presumably has some purpose and function.
The second near miss was a slip on the snow walking down concrete steps into a traffic area. I slipped but managed to grab the hand rail and while I was off balance I didn’t fall. So another near miss. I did a quick analysis and again, I as the worker was in no way negligent. I wasn’t walking too fast, I was wearing appropriate footwear, and I was walking in an area intended for pedestrians. The steps were sloped down and forward and being concrete and smooth the slightest moisture (never mind ice and snow) can easily cause a loss of traction. To further complicate things, there is no pedestrian crossing marked, no stop sign, and now speed bumps. There are also no sidewalks from this parking lot to the entrance forcing people to walk on the snow covered grass or in traffic. Not only is an injury probable but if an injury does occur the impact promises to be severe or even fatal.
The third near miss involved me catching the heal of my shoe on a step and falling forward. In this case I was also able to catch myself using the rail and felt only mild discomfort in my knee and ankle. Things most certainly could have been much worse but I was lucky. In this case, as with the others, I was not distracted, I was following procedures, and I was not behaving unsafely.
As I’ve said, I didn’t report any of these near misses and I’ve spent significant reflection on why I didn’t report them. Here’s what I learned:
- After the first incident I asked a colleague if the organization had a near miss reporting process. She asked me what that was. Clearly our safety jargon was getting in the way so i asked here differently, “how do we report injuries?” She explained that there was a system but she didn’t know what it was and that I should ask the department head. So reason number 1: Reporting an Near Miss is Hard.
- Sometime later I found the head of the department and I asked about near miss reporting and got the same general response: I don’t know. When she asked me why I was inquiring, not in an accusatory tone, but in more of a concerned, “Did you want to report something?” sort of way, I found myself dismissing the near miss as too trivial to report (when was the last time somebody died looking for a light switch?) Reason number 2: Because there wasn’t any serious consequence resulting from the near miss it wasn’t worth reporting.
- After my near slip on the ice I noticed a group of people talking about the fact that the lack of side walks meant that they had to walk into traffic and that the few sidewalks that did exist were slick with ice. I shared my experience with the icy steps and one person responded, if you call facilities they tell you that you have to fill out a work order and even when you do they don’t do anything. Reason number 3: Because people believe that even serious safety concerns are ignored so what is the point in reporting near misses? The organization does not value the information.
- By the time I caught my heal on the step and almost fell I was fully indoctrinated into a culture that did not report near misses, but I desperately wanted to avoid being one of those employees that ignored the problem. I mentally resolved to find the process and report these near misses. Then I mentally walked myself through the scenario of me reporting these three near misses and decided that I would look like a) an accident prone klutz, b) I would be seen as chicken little and c) nothing would be done with the information anyway. Reason 4: The risk to reward ratio is stacked against me; I risk being seen as a fool and there is no reward for doing so. I thought I would be seen as ridiculous reporting something so trivial and I wanted to make a good first impression.
For the record, this organization has an amazingly nurturing and employee-centric culture. Employees are developed and encouraged and training is a key priority. And yet I was clearly and quickly “told” that near miss reporting was not a priority, not valued, and not concerned with my safety, despite none of these things being true.
So what did I take away? Several things:
- People feel foolish when they do something that results in a near miss even if they did nothing wrong, and people who feel foolish are unlikely to advertise it.
- People will only report near misses if it is easy to do so and ideally if doing so is anonymous.
- If you solicit people to report hazards or near misses you had ought to be ready to respond quickly and effectively to the hazard.
- Even a veteran safety professional is not immune to organizational and peer pressure.
- If you insist on safety incentives, a good use for them is to provide incentive for near miss reporting.
- The fear of being made to look like a whiner or a wimp is greater than the desire to improve the safety of the workplace.
- If you want people to report things you have to have a system that is easy, accessible, and valued by the organization. Advertising the process is key.
- You absolutely must have a blame-free reporting process. If I was reluctant to report something that happened for which I was in no way responsible, how much more reluctant will I be for an incident where my behavior played a role in causing the incident?
- My guess is that near miss reporting will most likely only happen in cases where it is virtually impossible not to report it. This needs to change but unless near miss reporting is given the same priority as reporting a serious injury we are doomed to a world of ignorance.
- We get what we measure. Nobody seemed all that interested in collecting my information so i was certainly not going to push it and risk a negative outcome.
Sadly, while we as safety professionals preach a good fight when it comes to near miss reporting we don’t do a good job in executing because many of us start with the assumption that people won’t report them because they are afraid. Until we move beyond that mindset our organizations will be at significant risk and we will continue to significantly underestimate our risk of serious injuries and fatalities.