Tilting At Windmills: The Madness of Near Miss Reporting


By Phil La Duke


 “There is no folly of the beast of the earth which is not infinitely outdone by the madness of man.”

Herman Melville, Moby-Dick


Perhaps the quickest and surest way to lose credibility with workers, if not the entire organization is to ask for information and then do nothing with it. Ask a worker for a suggestion for making the workplace safer and then (at least seemingly in the eyes of the worker) ignoring it, or dissecting it to the point that everyone has long since caring about it.

Collecting data for collection’s sake happens a lot in worker safety.  We love to gather information, hoard it, report it, and sometimes even analyze it. The unrelenting pursuit for near miss reporting is the great white whale that compels otherwise sane and reasonable safety professionals to a fool’s errand, the Seven Cities of Cibola of safety just out of grasp and wanted so desperately by safety professionals.  Why?

Recently I was discussing the latest retread of Heinrich’s Pyramid with a handful of overly academic and painfully earnest theoreticians who work ostensibly in the service of safety. The subject at hand, a crudely scrawled graphic of an iceberg splattered with PowerPointless mental salver, as if some virtual vandal had tagged it with inane graffiti.

The pictograph in question is the new metaphor for teaching the great unwashed the relationship between the number of hazards, first aid cases, recordable incidents, serious injuries, and fatalities. It’s another, “no kiddin’?”, ” hit ‘em over the head” condescension that safety autocrats trot out every so often to demonstrate how much smarter they are than the “ordinary” mortals of the shops, warehouses, wards, mills, mines, and shipping docks, who pushed to it, would admit that they care not one whit about the theories of safety.  Most workers would rather not die horribly in the workplace; that’s their primary concern safety theory, for them is just a lot of hot air from a lot of people who don’t work all that hard for a living.

The injury berg is more a cautionary tale about the unfettered access of safety professionals to clip art, than any useful or meaningful tool.  Hey safety professionals, listen up: we get it: if there are enough hidden hazards eventually someone will die. Well not really, it’s all about probability and if we’re going to talk about probability, we had ought spend a moment acknowledging that most of us (statistically speaking) won’t die in the workplace.

But this particular graphic abomination belies one of the most foolish pursuits in the world of safetydom: near miss reporting. On the surface, near miss reporting seems like a noble pursuit, but it is as misguided as Ponce D’Leon who might have gone down in history as a great explorer like Drake, or DeSoto, or Marquette, but instead became synonymous with a fool chasing after a ridiculous faerie tale. 

I should pause here and allow time for shouts of “heretic” and “blasphemer” among the safety true blue.  Near miss reporting is as cherished a part of a safety management system as injury reporting or root cause analysis. We take it for granted that in not gathering information on near miss reporting we are missing a crucial part of the safety puzzle. How can we reduce risk without reporting near misses?  Near miss reporting is a relic and we need to abandon it, at least in its current form.

Why? Don’t we want information on our near misses? Doesn’t a near miss portend a mystical connection between mishaps and gruesome fatalities? In fact, it doesn’t at; least not very often. Even though many in the safety community are coming to realize that safety is a complex system and that there isn’t necessarily a continuum on which a near miss is just a failed fatality.  Recent research has shown (look it up) that there really isn’t a statistical correlation between near misses and recordable incidents or fatalities.  They often have significantly different causes and since they originate from disparate sources the supposition that spending precious resources investigating near misses is likely to magically prevent fatalities is forced.

Near Miss Reporting Serves No Good End

If we accept Heinrich’s Pyramid or Nameless Goofball’s iceberg there will be a 300 (or more) to 1 ratio of recordables to first aid, and another 300:1 ration of first aid cases to near misses, so we have 9000 near misses (and don’t get hung up on the ratios—they’ve all been largely disproved (or at least called into question) so if you are going to try to shout me down by dying on that particular hill I should warn you, I’m not taking the bait.  So pick your poison, in any scenario you are likely to conclude that there are anywhere from tens of thousands to several million near misses that are happening in your workplace annually. Let us assume that tomorrow everyone reported every near miss.  Far from being a coup d’ gras for safety, few organizations are equipped to deal with this influx of information.  It cannot be processed so we can’t do anything with it.  Near miss reporting, if successful rapidly collapses under it’s own weight.  What’s worse if we asked for this information and people provided it in good faith. Yet again, we asked workers for information and then did nothing of value with it.

A Near Miss is Not A Near Miss

A big problem with near miss reporting is it creates another category of information that sounds like a logical grouping when it is nothing of the sort. A near miss that results in someone almost tripping isn’t the same as a near miss that almost gets someone killed.  One of these events is significant while the other is notable but probably benign.  By lumping all these near events into a single category we end up Pareto charting them—we have quantitative data when only qualitative data is useful.

So We Should Ignore Near Misses Then?

Near misses should be managed like any other hazard—contained, investigated, prioritized, and corrected.  We need to contain those conditions likely to injure workers, investigate the causes and contributors, prioritize those conditions so that we are able to focus our efforts on the those conditions that are most probably going to result in injury and those that are highly likely to produce an injury that is going to be severe.  We don’t need to worry about having a special name for these conditions—they are just hazards.  The fact that they are “near misses” are no more significant than whether they are behaviors or unsafe conditions.  It’s time for Safety to simplify its approach and to stop tilting at windmills.





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