(120a) Using near Misses to Improve Risk Management Decisions

In the process safety literature it is often claimed that the analysis of near-miss incidents can improve process safety performance. However, empirical research has demonstrated that near-miss events are interpreted as marginally successful, leading to riskier behavior due to lower perceived risk In other words, experiencing a near-miss incident can result in the false conclusion that the original risk was over-estimated. To be effective, the analysis of near-misses must be grounded in an objective evaluation of the event, the outcome, and the severity of the alternative outcome’s consequences. In this paper several examples are presented where a near-miss incident preceded a serious incident with significant human injury or property damage. If the near-miss had been investigated, properly evaluated, and appropriate corrective actions been implemented, the more severe incident would not have occurred. A recurring theme in these examples is the underestimation of consequence severity, i.e., the misinterpretation of the near-miss as a high-probability, low-consequence severity scenario rather than a narrowly averted low-probability, high-consequence severity scenario. A deliberate consideration of the lower probability, more severe consequence scenario would have facilitated a more thoughtful evaluation of corrective actions. A methodology is presented for evaluating near-misses. It combines events and causal factors charting with barrier analysis to identify the safeguards involved in the near-miss. The near-miss event is then evaluated across the range of potential consequences, and the significance of each identified safeguard is considered. In cases where the severity of the consequence had been underestimated, corrective actions consistent with corporate risk management guidelines should be considered. An equally important outcome of this analysis is the effective communication of the risk at operational and managerial levels of the organization.