When an accident occurs at the workplace, most employers have a procedure for conducting an investigation. The procedure sets out the roles of those involved in the investigation and provides relevant forms. Following the procedure should result in a determination of the root and direct causes of the accident as well as the appropriate corrective action required to prevent a recurrence.
However, less likely to be investigated are near misses that may not have been reported due to workplace culture or because they were not viewed as important. In the same way that chest pains are a sign that a person may be at risk of a serious health condition, a near miss in the workplace may provide an important warning that something is amiss that could result in a more serious workplace incident.
Accidents and their causes have been studied since 1919. For example, an early theory, the theory of "Accident Proneness", suggested that accidents occur because certain types of people are prone to accidents. In 1931, one researcher determined that for every major injury, 29 minor injuries and 300 near misses had occurred. In 1969, Frank E. Bird, Jr., a Director of Engineering Services for the Insurance Co of America analyzed approximately 1.8 million accidents from 21 different industries. He determined that 600 near misses resulted in one fatality. He theorized that while major injuries were rare events, they could often be avoided by taking action after the more frequent and less serious near misses.
When investigating a workplace incident (for example, an injury or an environmental spill) the investigation procedure should include an investigation of related near misses. Such an investigation often uncovers hazards that may have been overlooked by initial review and inspection as well as determine the root and direct causes. For example, was the near miss a result of an unsafe condition, an unsafe act or perhaps an unsafe process? Investigating a near miss may bring to light a risk associated with a process or controls that had been overlooked, and result in changes to the process or the controls that would otherwise not be identified until a more serious accident has occurred. Similarly, investigating a near miss may reveal that enforcement of the work procedure is lacking and that preventive maintenance has not occurred as scheduled on equipment. Flagging weaknesses in the OHS management system because of a near miss can assist employers to strengthen their procedures and improve their due diligence.
While it may seem that investigating a near miss is not worth the time and energy, in the long run, investigating these events are likely to uncover unknown hazards or conditions which may result in a serious injury or fatality. The time and energy spent investigating a near miss is trivial compared to the time, energy and emotional stress of investigating a more serious incident such as a fatality. Investigate those near misses.