Near-Miss Management: A Participative Approach to Improving System Reliability
III
Abstract
Investigations of many serious accidents in different fields have revealed that before every serious accident, a large number of related prior incidents occurred with limited impact and an even larger number of related incidents happened that resulted in no loss or damage. Collectively, these incidents are called near-misses. Near-misses provide insight into both potential failure points and weaknesses in the management system itself. Therefore, they can be a powerful tool to reduce risk and improve system reliability. Near-miss management systems (NMMS)s are designed to enable people and institutions to learn from high-frequency, low-impact incidents (near-misses) to prevent low-frequency, high-impact events (accidents). A comprehensive NMMS includes several important implementation steps, such as identification of near-misses, disclosure and reporting, prioritization and classification, distribution of the information, analysis of causes, solution identification, dissemination of actions and knowledge, resolution, and closure of the case. Successful implementation of an NMMS requires (a) strong management ownership, (b) participation and reporting of as many incidents as possible, and (c) use of quantitative tools to identify weaknesses and to improve the system.
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