I came across a social media post several days ago that indicated that it is an order of magnitude (10X) more important to do an investigation on a “near miss”, then on a fatality. I understand the sentiment, but I wholeheartedly disagree. I’m not sure there is any empirical evidence that would support that more can be learned from a near miss, then can be learned from a fatality investigation. Yes, we should be to be conducting many more near miss incidents than fatalities and that conducting investigations on near miss incidents is extremely important to ensure continues improvement in risk reduction.
Generally, not everyone’s definition of a near miss is the same, therefore, many near misses are not investigated at all. In numerous surveys in the past several years, we have posed the questions regarding what is a “Near Miss”. Suffice it to say that there is very little consistency in the definition. Even the consensus standard, API 754, would not classify things as near misses as I believe they should. However, I also see the reasoning behind this. When an investigation is conducted on anything that is outside of the norm, a facility can spend significant time doing investigations, and eventually, the quality of the investigation becomes less than desirable and becomes something “we have to do”. Another factor to consider, is most facilities, not all, will do investigations in house for “near misses” but will use an outside resource or third party to conduct the more serious incident investigations. Therefore, the rigor involved for a serious injury or fatality can be much more significant than that of a near miss investigation.
There are many factors that can go into achieving risk reduction. One of the most important things we can do is to conduct investigations of incidents (near misses and actual events) and apply the learnings from both. Both types of investigations provide us significant information for continuous improvement if the proper analysis is conducted. Remember, the goal is to manage risk and understand that this is a never-ending process…we just continuously improve!