(187b) A Miss, Amiss, a Near Miss

Working Titles:

Here a Miss, There a Miss, Everywhere a Near Miss

Has your Near Miss Program Gone Amiss?

Amiss, A Miss, A Near Miss

Catastrophic incidents, while common in the world, are rare events to any single facility or even company.  Were anyone to count catastrophic incidents to measure Process Safety performance, it is likely the facility would be gone before they counted to two.  So we turn to Near Miss incidents as a measure of Process Safety performance.  We count them and measure their frequency.  We implement corrective actions to prevent recurrence.  We look beyond the specific incident to apply the lessons in other areas.  And most importantly, we look for faults in our management systems that permitted the near miss to occur.  Defining a near miss, identifying their occurrence, and fully learning the lessons they can teach us can be a difficult undertaking.  Simply communicating these incidents can be problematic.  And learning lessons from a brief description of an incident occurring outside your fence line can challenge even the broadest-minded people.

This paper will describe the near miss learning process that has evolved at one specialty chemical company.  It will include definitions of specific types of near misses, how data is gathered and communicated, and data on the number and type of incidents collected.  It is hoped that the reader will gain ideas on how to classify and collect data on specific near miss incidents, and ways to communicate the information throughout a company.