Incident and Near Loss Investigations

A near loss, or a near miss (NM) is an undesired unexpected situation which given a slightly different change in circumstances (time, distance, human action, even weather conditions… etc.) would have resulted in injury or damage to equipment or property.

On the other hand, an incident is an undesired unexpected event or series of events that result in injury or damage to equipment or property.

A very thin line separates both scenarios, but the ability to distinguish between them is very important. All the difference resides in the tiny phrase “given a slightly different change in circumstances”. A single event as simple as a hand tool falling from a height at the workplace can be either an incident or a near miss.

Following up our above example, consider a maintenance employee working at a height with some unsuspecting personnel walking on the level underneath him. If for any reason one of the hand tools he was using falls on one of the people walking underneath him, it immediately becomes an incident. However, if the same tool had fallen merely centimeters away from that person, it becomes a near miss.

So arguably, one might say the difference between an incident and a near miss (near loss) is only chance, or even luck. Nevertheless, both must be followed immediately by a thorough investigation.

The Investigation:

A good investigation must answer five main questions:

  • Who?
  • What?
  • When?
  • Why?
  • How?

It must also be conducted immediately after the event has taken place, and by a qualified investigation team of at least two people. One of whom must be the supervisor present at the time of the event, and any one who was involved in the case. You could gather feedback only from eye witnesses to the event, but rely only on the facts supplied by those who were involved and their supervisors.

In case of an incident which resulted in a loss or injury, it is better practice to stop all relevant operations until the investigation is conducted and effective outcomes are reached.

Remember that the ultimate goal of any investigation is identifying what is called the "root cause" of an event, so that a relevant corrective action may be taken to ensure that a similar event doesn't happen again.

A common method of finding the root cause of an event is the multiple-why technique, which is carried out during questioning the person involved. It is basically asking an initial "Why did this happen?" question. Then following up his replies with a series of "Why?" until a valid root cause is identified.

Some common root causes are:

  • Lack of skill.
  • Shortcutting correct procedures, as the correct way takes more time and/or effort.
  • Lack of procedures.
  • Inadequate tools or equipment.
  • Inadequate equipment design.

Ultimately, the final corrective action must be according to the root cause identified. For example, if it was a lack of skill (the worker has no experience), then training sessions and proper coaching must be held for all personnel to further enhance their experience doing a specific task or operating a certain equipment.

If it was found that the workers were shortcutting correct approved procedures for any reason, they may be in a hurry or out of force-of-habit (with no history of previous incidents). In that case more stringint rules must be set in place to enfore the following of all facility rules and procedures. Remind them of the risks and dangers associated with each task and the importance of following up each task correctly and safely. Most of the time refresher training sessions must be held for workers and operators on doing their routine tasks.

Similarly, the root cause might be a failure in a machine or a shortage in an equipment specification. In that case, proper maintenance or an equipment modification must be done to accommodate it to the safe operation of the task at hand.

Important notes to remember:

One of the biggest mistakes a facility supervisor or manager can make is thinking that a incident or near miss reporting reflects negatively on their records. On the contrary, prompt and immediate reporting should be encouraged.

A good supervisor is one who drives his direct reports to submit quality near miss reports upon every observation, it is the most effective method in identifying points of risk that may be hidden or indirect, as well as trends in unsafe behaviours or conditions, ultimately resulting in a safe risk free work environment.

An operator should work in a secure area with no fear of submitting any input or suggestions to modify or improve his job, he should always feel comfortable to reach out to his supervisor suggesting new methods or bringing new ideas to the workplace without any fear of being disciplined or reprimanded.

Remember that a near miss or incident report must never include the name of the person involved!

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