Safety Management--Article Index and Topic Introduction

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1 Introduction

2 The Safety Philosophy behind Near Miss Incidents

3 Safety Management Functions That Relate to Near Miss Incidents

4 Safety Management Principles Relating to Near Miss Incidents

5 Near Miss Incidents, Myths and Safety Paradigms..

6 Safety and Health Policies

7 Near Miss Incident Risk Management and Assessment

8 Safety Auditing

9 Near Miss Incident and Accident Recall

10 How to Motivate for Safety

11 Implementing a Near Miss Incident System: Introduction

12 Implementing a Near Miss Incident Reporting System: Implementation

13 Implementing a Near Miss Incident Reporting System: Follow Up

14 Investigating High Potential Near Miss Incidents

15 Summary

Safety Management--The Art and Science of Near Miss Identification, Recognition, and Investigation Safety Management

Close calls, narrow escapes, or near hits. History has shown repeatedly that these near miss incidents often precede loss producing events, but are largely ignored or go unreported because nothing (no injury, damage or loss) happened.

Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and reporting near miss incidents can make a major difference to the safety of workers within organizations.

Supported by more than 30 years of international safety experience and research, this guide discusses the safety philosophy behind near miss incidents and clearly demonstrates the accident sequence showing the Three Luck Factors that determine the outcome of the event. The author highlights the fortuity of the event and how a simple risk assessment can be used to identify the causes of the event and rectify them. He also explains the management functions of safety and how they relate to near miss incidents.

• Explains and reaffirms safety philosophies first proposed more than 80 years ago.

• Applies the technique of risk assessment on near miss incidents to identify high potential loss events.

• Includes real-life examples of near miss incidents to support the importance of near miss recognition and investigation.

• Provides examples of reporting forms, report tracking and near-miss incident awareness training.

Near miss incidents are truly the foundation of major injuries, the building blocks of accidents, and warning signs that loss is imminent. They can also form the impetus for proactive, preventative actions. This guide explores how to implement a near miss incident identification, recognition, investigation, and rectification program.


Near-miss incidents, close calls, or close shaves have often been referred to as "safety in the shadows," as this is where the heart of the accident problem lies. Near miss incidents offer management an opportunity to rectify a system breakdown before it happens. They are inexpensive learning opportunities. Because there are no losses as a result of an undesired event does not necessarily mean that the event is insignificant. Many of these seemingly unimportant events have high potential for injury and other losses. If recognized, reported, and rectified, near miss incident root causes will be eliminated leading to a radical reduction in injury-causing accidents.


For many organizations, the term near miss is not only misunderstood, but it’s underrated with regards to the potential for a near miss incident to become a profit-draining accident and possible injury at a workplace. The term near miss incident also can be defined as a narrowly avoided mishap. What that means in the manufacturing, construction, or mining industry is that a person narrowly avoids an injury due to an unforeseen mishap or when there is an undesired event, which, by a stroke of luck, narrowly avoids damaging a piece of equipment, property, or material. These are missed safety signals.

Reporting and rectifying the causes of near miss incidents has many benefits. Studies of adverse events, such as accidents, indicate that near misses occur more frequently than accidents and are often precursors to accidents. In many cases, the same near miss incident has occurred numerous times prior to the actual accident.


Research of thousands of undesired (accidental) events has shown that the outcome of the event cannot be predicted and that, under slightly different circumstances, the consequences could have been better or worse if it were not for some factor of luck or good fortune.

The principle of multiple causes indicates that accidents are usually the result of a multitude of causes and there are usually many immediate causes and numerous root causes behind every event.

These loss-producing events are termed accidents. Some refer to them as incidents, but, for clarity, they will be referred to as accidents in this publication. No-loss events with potential for loss will be termed near miss incidents. The high risk acts of a worker or a high risk work environment riddled with hazards, or a combination of both, are the immediate causes or the closest causes of an accident, which results in accidental losses, such as death, injury, property damage, fire, or business interruption. High risk acts and/or conditions are the most obvious accident causes, or the causes that lead to the contact with a source of energy that causes the subsequent loss.

Root, or basic, causes are the deep hidden person and job factors that give rise to the immediate causes in the form of high risk acts and/or conditions. If they are not identified and rectified, the accident problem won’t be eliminated. Fixing the immediate causes rectifies the symptom, but not the root or basic cause.

Risk assessment of all near miss incidents will determine which near miss incidents warrant a full investigation to track and eliminate the source of the problem at the root.

A Proactive Approach

S. L. Smith writing in Occupational Hazards (1994) says:

Near miss incidents challenge the tradition of using an accident to initiate a thorough review of safety conditions, practices, and training. Tracking near miss incidents offers organizations a better opportunity to focus their preventative efforts.

If based on near miss incident information, these efforts will be proactive rather than reactive. As another safety professional put it:

Letting a near miss incident go unreported provides an opportunity for a serious accident to occur. Correcting these actions or conditions will enhance the safety within your organization and provide a better working environment for everyone involved. Don't let yourself or co-workers become statistics-report near miss incidents to your supervisor. Prevent an accident that's about to happen!

H. W. Heinrich

More than 80 years ago, H. W. Heinrich suggested that one should focus on the accident rather than the injury. He was the first to propose a ratio existed between injuries and accidents that produced no injuries.

Accidents and not injuries should be the point of attack. Analysis proves that for every mishap resulting in an injury there are many other similar accidents that cause no injuries whatsoever.

Explaining his ratio, the first ever published, he said:

From data now available concerning the frequency of potential-injury accidents, it’s estimated that, in a unit group of 330 accidents of the same kind and involving the same person, 300 result in no injuries, 29 in minor injuries, and 1 in major or lost-time injury.

Heinrich's Third Axiom

In 1931, H. W. Heinrich drew up a list of 10 axioms based on his safety research, which was published in Industrial Accident Prevention, 3rd ed. (McGraw-Hill, 1950). Axiom 3 has great significance for the concept of near miss incidents and he was the first person to derive the following conclusion:

The person who suffers a disabling injury caused by an unsafe act, in the average case has had over 300 narrow escapes from serious injury as a result of committing the very same unsafe act. Likewise, persons are exposed to mechanical hazards hundreds of times before they suffer injury.

His fourth axiom was the first recorded theory that fortune or luck may play a part in determining not only the outcome of an undesired event, but also the severity of consequent injury.

The severity of an injury is largely fortuitous-the occurrence of the accident that results in injury is largely preventable.

Despite these major findings, near miss incidents have mostly been overlooked in industry despite history of major-loss events confirming the theory that there are many near misses or warnings before the occurrence of major accidental losses. Near miss incidents are truly the foundation of major injuries, the building blocks of accidents, and warning signs that loss is imminent.


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