Gains from Getting Near Misses Reported

摘要

The need for effective root cause analysis is finally gaining the spotlight in the chemical process industry. If we do not find out about an incident, we cannot investigate the root causes. We find out about accidents (harm done) because they are difficult to hide. However, there is only one accident for about 10,000 errors and failures (sometimes called unsafe acts and unsafe conditions). The definition of a near miss (a potentially damaging sequence of events and conditions, but without harm) can be vague and varies from site to site. However, data indicates that there are probably about 100 near misses for every accident. Learning from near misses is much, much cheaper than learning from accidents, yet many companies get less than one near miss reported for each accident. This paper describes the reasons why near misses are not reported and shares how companies have increased the reporting ratio to as high as 105:1; it is an update of the basis for Chapter 5 of Guidelines for Investigating Chemical Process Incidents, Second Edition (CCPS, 2003).