Whitepaper: Near Misses (Part 2)

NEAR MISS REPORTING

Tips to Establish Trust

For how beneficial they can be as a learning tool in accident prevention, it is surprising how difficult it sometimes is to report near misses. Perhaps you’ve experienced a near miss in the past. Even if you work in an office, it is possible to experience them while performing any daily task, such as when cooking or driving. Anyone who has driven for any amount of time has been cut off or had someone follow too closely. Some have even dealt with losing control momentarily due to ice, rain, or other hazardous conditions. Perhaps you have needed to brake or turn unexpectedly to avoid a collision.

How did you feel in that moment?
Can you remember fear?
Anger?
Embarrassment?
Relief?

Next, imagine a well-meaning official (e.g., a government agency, a local politician, the police, a civil action group, etc.,) in a concerted effort to improve road safety, mandates near miss reporting. Presumably, you are concerned about safety and desire to actively contribute to accident prevention, however, would you actively participate in such a policy? Do you believe this enforcement would ultimately make a difference? Would you be more concerned with how this regulation affects you?

When answering this hypothetical, certain questions come to mind:

Does the potential benefit outweigh the effort involved?
Is there trust in the process and authority figures handling the information?
Is there potential for self-incrimination?
Will there be repercussions?
Is the desire to protect reputations stronger than the desire for possible improvement?

These concerns can be expected to occur to someone regarding a topic as integral to everyday life as driving but think about the ramifications within the workplace and the sensitivities attached to job security. In a work environment where near miss reporting is encouraged or required, these questions certainly are in the minds of the employees. Even workers who perform with the highest principles will worry about the implications that their reports have when it comes to an event where, technically, there were no immediate adverse results (and potentially no one else was involved.)

Now that the cost is better understood, a more successful plan can be made to move forward. Firstly, when implementing a system for near miss reporting, you must consider who will be involved.

Three Broad Groups

Group 1

For near miss reporting to be initiated, top management will first need to be persuaded of the potential benefits. Sometimes this information will be intuitively
recognized, sometimes it will be rejected. While the choice for how to present the idea of reporting will differ between organizations, one fact must be solidly established: near misses are system failures. The vulnerabilities they reveal, if left unresolved, are likely to lead to more serious consequences and therefore, should not be ignored. For top management that remains stubbornly obstinate to acceptance of near miss reporting, consider the following:

The points made in “NEAR MISSES: Transforming Potential Incidents into Learning Opportunities.”
While near misses are undoubtedly occurring, they can only serve a purpose when management supports managers in taking action. This prevents repeat incidents from arising that have the potential to cause actual damage to individuals and the business.
It is not necessary to reinvent the wheel. User-friendly and proven systems for incident reporting currently exist.
Near misses do not adversely affect external regulatory reporting statistics. A comprehensive near miss reporting system can instead promote a safety
management system by demonstrating program efficiency and responsible corporate governance.

The returns to near miss reporting are all positive, and once top management has accepted this, the only potential for error lies in inadequate planning to ensure reporting practices are reliable. At times, the best to be hoped for is the communication of a new initiative and possibly an adjusted vision statement for the safety program. The essential component to ensuring successful implementation is positive reinforcement for reporting. Managers responding to near miss reports with negative ramifications or no visible action will likely lead to avoidance or intentional ignorance of the near miss reporting program. Trust must be established between this group and the other two for the positive results to be achieved.

Group 2

While enthusiasm from top management is a starting point, convincing the next group (the workers who will be the most closely involved in near miss cases) is equally important. In general, workers are aware when near miss incidents take place. Initiating reporting of near misses is a way to capitalize on that experience by establishing support for the managers to take action to address these failures. However, workers are aware that those same managers have the power to respond positively or negatively. Therefore, an understandable resistance and suspicion towards any directives from top management is often the immediate response from the group of workers involved.

Naturally, some may be reluctant to readily admit a self-made error or even one from a co-worker. Unreliable reports may also be the result of the opposite scenario, in which a worker is overly zealous about reporting when a near miss occurs as the result of someone else’s error. Workers will pay close attention to whether management will act on near misses reported and what consequences they will face if they do. The chance that they will be blamed or appear incompetent can greatly hinder the adoption of a near miss reporting system.

The success of implementing a near miss reporting system is increased by the presence of:

Trusted supervisors clearly communicating why near misses are being reported. Reassurance for workers that reporting near misses helps
improve safety and will not be met with accusations is essential.
Transparent requirements for what is reported.
A manageable method for reporting with minimal interference to everyday work.
Immediate action and an explanation for every absence of it. A minimally acceptable response is the reiteration that each report adds to data for
tracking trends.
Celebration for every win. This reinforces that the program is a successful addition to safety programs and every contribution is valued.

Group 3

The final group in the organization is the supervisors between top management and workers, or “The Integrators,” as Barry Oshry refers to them. Their first responsibility is translating the directive from top management into a workable operation for the ones performing the reporting. Secondly, they must effectively coach and encourage compliance. This can be especially challenging if there is the opportunity for near misses to go unnoticed by anyone except those workers directly involved. The expectations and reactions of supervisors will greatly affect the overall adoption and success of near miss reporting. It has been identified that workers will follow the example of the supervisors they daily interact with more than top management in decisions such as near miss reporting. A supervisor has their reputation to concern them, and workers will sometimes appreciate their opinions on protocols more than top management’s. Others will observe the reception of the supervisor to near miss reporting and respond accordingly.

Ways supervisors can successfully convey their support and commitment include:

Taking the time to explain the benefits of near miss reporting.
Providing a simple process for near miss reporting and investigation.
Clearly explaining the material that they will be using with workers.
Reassuring workers that near miss reports will be celebrated.
Transparently and positively addressing near miss reports.
Tracking and displaying trends based on near miss reporting data. Separating trends by type (e.g., involving ladders, forklifts, etc.) lends to the creation of proper measures for improvement.
Utilizing the Plan-Do-Study-Act cycle 3 when responding to near misses.

Developing a Successful Near Miss Reporting Process

With the commitment to report near misses firmly established and accepted throughout an organization, the next step is building an efficient and effective system.

Motivation that ensures quality input. Successful near miss reporting can only be accomplished when employees are engaged, which requires understanding and trust in the process by all groups. Commitment from supervisors should be prioritized over more unproductive motivation tactics such as rewards and numbers-based bonuses. Creating a target to be reached, whether at the corporate or group level, may result in unreliable or trivial reporting. A way to determine whether this is the case in an organization is by analyzing the profile of reported near misses. A significant lack of intermediate near misses, with the majority being trivial and a few serious near miss reports, is an indication of misconducted reporting. Offering incentives or reward programs to motivate near miss reporting allows for the same issues as focusing on quantity. Additionally, this concept has the potential to communicate to employees that reporting is optional, as not doing so is only a choice to not “reap the benefits.”
Actions to reinforce quality processing. In responding to near miss reports, appropriate investigation, analysis, and correction are essential. Quality processing entails acceptance of all reports while sifting out the trivial (the data that will only be used to track trends or that can be immediately addressed by supervisors.) After this, more significant near misses can be acknowledged (explaining that the resolution of such incidents will take longer) and given more attention so that they can be logically and comprehensively addressed.

Communication of quality output. It is essential to continuously reiterate that near miss reports improve safety. Acting on reports develops a sense of purpose and value for the process to the workers who are recording this data. Celebrating and publicizing improvements reinforces participation.

Concern for an organization’s future safety is the central reason for encouraging near miss reporting. Learning from failures is one way improvement happens. However, considering the ramifications of admitting failure naturally causes some different reactions. Will involvement be affected by prioritizing concerns for the present over hopes for the future? Whether mere perception or reality, negative consequences discourage participation. Apparent indifference from supervisors or a misunderstanding of the requirements involved can lead to faulty reports. Establishing trust in the results and managerial response is crucial for those directly involved in or privy to near misses to remain properly motivated. This trust is only achievable when supervisors understand and convey top management’s commitment to near miss reporting and incident prevention. Provided there was no intention behind the incident, there should not be any question of negative consequences for reporting.

Too often, enthusiastic top management bypass supervisors’ influence and bring directives straight to workers without considering the negative attitudes or
misunderstandings that this can generate. Without full conviction and participation from every group, there will be no success in reporting. An increase in reported near misses should be welcomed, as it can signify incidents no longer being hidden from management’s view. As each incident is addressed, safety in the workplace is growing, bettering the lives of all. While more near misses are not desirable, more effective communication from near misses being accurately reported is desirable.

References

Larkin T.J. & Larkin S., 1996, Reaching and Changing Frontline Workers. Harvard Business Review, May-June
Oshry B., 1996, Seeing Systems. San Francisco, CA: Berrett-Koehler Publishers Inc.
Deming, W.E., 1993, The New Economics. Cambridge, MA: MIT

Whitepaper: Near Misses (Part 2)

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NEAR MISSES

How to Initiate an Effective Reporting System