Gains from Getting Near Misses Reported

摘要

The need for effective root cause analysis is finally gaining the spotlight in thechemical process industry. If we do not find out about an incident, we cannotinvestigate the root causes. We find out about accidents (harm done) because theyare difficult to hide. However, there is only one accident for about 10,000 errors andfailures (sometimes called unsafe acts and unsafe conditions). The definition of anear miss (a potentially damaging sequence of events and conditions, but withoutharm) can be vague and varies from site to site. However, data indicates that thereare probably about 100 near misses for every accident. Learning from near misses ismuch, much cheaper than learning from accidents, yet many companies get less thanone near miss reported for each accident. This paper describes the reasons why nearmisses are not reported and shares how companies have increased the reporting ratioto as high as 105:1; it is an update of the basis for Chapter 5 of Guidelines forInvestigating Chemical Process Incidents, Second Edition (CCPS, 2003).