In many companies, near-miss events receive little attention. Some clients say they feel enormous relief whenever they “dodge a bullet.” Everyone’s glad the event didn’t occur, and it’s tempting to quickly return to familiar routines. It is only when something catastrophic happens that organizations often discover a series of errors and process flaws that were present all along. When near misses occur, but no action is taken, the underlying causes are still present and will normally re-surface again in the future – often in different, significant events.
Hazards and near-accidents
Major events are almost always preceded by near misses. Has your organization:
- Narrowly avoided a shutdown, accident, customer service issue, or supply chain snag?
- Had near misses that went un-reported, got lost in bureaucratic procedures, or remain in limbo between divisions?
- Chalked up close calls to human error or inattention?
- Performed routine or incomplete investigations without implementing changes?
- Learned about near misses only after employees were disciplined, laid off or promoted?
- Realized that a recent incident was preceded by several similar close calls?
In our experience, near misses often go un-reported because the involved parties don’t want to alarm managers, colleagues or the public. After all, everyone has enough to worry about already. They may fear blame or repercussions – even though they avoided a colossal problem. Our clients also tell us that reporting procedures can be onerous, time-consuming or overly complicated. Sometimes people feel that there’s simply no point: the accident didn’t happen, so let’s move on and get back to work.
Opportunity for improvement
Near misses represent a potent opportunity for change. Many of our clients apply root cause analysis to find hidden patterns that could have had catastrophic consequences. Using cause-and-effect logic, they uncover systemic risks that elevate the potential for undesirable events to occur. The Sologic® method also goes beyond human behavior to focus on the multiple, controllable causes of every event. It’s scalable and universal.
Every close call shares many of the same causes as a major incident that does occur. The Sologic RCA solution suite helps you identify, correct and prevent the causes of significant events – with a strong return on your investment. We will train your team to work more cohesively and capitalize on the opportunities that near misses represent, while promoting an open environment for learning and risk reduction.
View a root cause analysis example report and chart template related to near misses.
Contact us to learn more about how Sologic root cause analysis (RCA) can help you minimize near misses.
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