(43u) A Framework for Managing near-Miss Incidents

Near-miss incidents are the incidents which have not resulted in loss of containment or injury or environmental impact; however, they have a potential to do so.  Some safety professionals call them “Oops!”.  As the definition suggests, some of the near-miss incidents would result into incidents with major adverse impact on safety and/or environment.

A number of safety professionals regard near-miss incidents as a  “blessing in disguise.”  Some experts regard near-miss incidents as leading indicators that give us warning about potential major events in the future with adverse consequences. Knowledge gained from analysis of near miss incidents can be used to reduce chances of future incidents with major consequences.

Analysis of near-miss incidents needs to be efficient. Thus, it is crucial to avoid resource-intensive and time-intensive techniques.  

This paper presents a framework that may be used to analyze near-miss incidents and identify  near-misses which could result into major events.  The framework is based the semi-quantitative concept of Risk Matrix. Risk Matrix concept has been widely used in Hazard and Operability (HAZOP) assessments. A modified risk matrix has been proposed  for estimating potential risk presented by a near-miss. Depending on the risk estimate arrived at from the near-miss Risk Matrix, action items are categorized into three categories:

Mitigation measures must be taken as soon as possible

Mitigation measures should be considered in a “reasonable time.”

Risk presented by near-miss is acceptable