Focus on Near Misses to Cultivate a Culture of Risk Management
A group of teenage students on an overnight backpacking trip sit in a circle around a natural rock "table" in the Mojave desert, eating dinner and reflecting on their day along with their instructors. After dinner, they clean up their dishes, strain the food particles from the dish water, and toss the water underneath the rock which they'd been seated around the past few hours. An abrupt and piercing rattle cuts through the desert air, as an enormous rattlesnake emerges from underneath the rock, covered in dishwater. Students scatter as the pit viper disappears into the Mojave dusk, and everyone realizes they'd been sitting within a few feet of the snake all evening, unbeknownst to anyone...
This snake encounter is not a hypothetical scenario, it's a dramatic example of a "near miss" from my own personal experience as an outdoor educator, where a slight difference in timing (or location) could have yielded a very different outcome. Outdoor education programs, by their inherent nature, experience many near misses -- more than may ever be quantifiable -- but what do we do with the near misses we encounter, and how do we convert those near misses into useful lessons?
How do we distinguish a near miss from an incident?
Before we distinguish between near misses and incidents, it's best to back up a step and define what constitutes a reportable near miss, and what is actually just people doing their jobs, or participating in the program as designed. Consider the following cartoon which shows some useful distinctions.
Consider the following scenarios. For all three, let's assume that the vehicle is properly maintained, the tires inflated, insurance in place, and drivers thoroughly trained to drive the vehicles.
Are these incidents, near misses, or simply risk management systems working as intended?
Scenario One: A van full of students is going down a country road, when a deer steps out into the path of the van. The driver of the van is driving at (or below) the speed limit, sees the deer, and applies the brakes in plenty of time to come to a stop. The students and staff on board are all wearing their seatbelts. The deer safely crosses the road and the van continues on its way without incident. Is this an incident, a near-miss, or systems working as intended?
Scenario Two: The same van of students continues down the road and soon hits a patch of ice going around a corner. The van turns sideways and drifts into the wrong lane for a few tense seconds, before the driver is able to correct and re-establish in the proper lane, just as a truck goes by in the oncoming lane. There is no damage to the vehicle, and no participants are injured in any way -- in fact, most of the students appear to sleep through the entire episode. Is this an incident, a near-miss, or systems working as intended?
Scenario Three: This same unfortunate group in the van carries on its way, and is now within a mile of their intended destination. However, due to a fatigued driver, the vehicle drifts onto the soft shoulder of the dirt road and gets pulled into the ditch at a high rate of speed, coming to an abrupt stop and breaking the front axle. Everyone is wearing seatbelts, and no one is badly injured, though a few students complain of stiffness and headaches after the sudden, jarring stop. Is this an incident, a near-miss, or systems working as intended?
The Occupational Safety and Health Administration (OSHA) defines a near miss as "an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred." Near misses may also be referred to as close calls, near accidents, accident precursors, injury-free events and, in the case of moving objects, near collisions. We like to focus on their potential as "accident precursors," as discussed in this 2012 article.
Why do near-misses matter?
Consider the Accident Matrix below, courtesy of Jed Williamson, which classifies the potential causes of accidents into three categories (unsafe conditions, unsafe acts, and errors in judgment):
Simply put, the factors that cause near misses are often (not always!) the same factors that can cause incidents. This is not always the case in all situations, but often can be true in the outdoor program context (as our opening scenarios illustrate). By focusing on a bigger body of information (not just the obvious, critical incidents) we are tapping into a larger set of data from which to "harvest" lessons and opportunities for improvement.
Is it possible to have a critical incident even if we focus on correcting the things causing near misses? Of course, this approach does not guarantee any specific outcome -- but it does help create a culture focused on learning.
The best we can do as risk managers is to learn from the incidents and near-misses that have occurred, and to create an environment aimed at reporting, learning, and prevention.
A word of warning from a legal perspective
It's not enough to simply report near-misses (or incidents, for that matter). As your culture of reporting increases, so does your responsibility to learn from, respond to, and document your response to any trends or incidents that arise.
If you have a documented history of near misses pertaining to equipment failure or policy violations, with no attempt to address these concerns, you may be more exposed to claims of negligence. In other words, don't just create a paper trail of incidents and near-misses -- use those incidents and near misses as genuine opportunities to learn, to modify policies, improve training, and increase awareness of any recurring or severe issues. According to attorney Charles "Reb" Gregg, "from a legal standpoint, hardly anything is more harmful to a defense than a failure to properly react (and record that reaction) to a prior similar incident."
Conclusion: Cashing in the lottery tickets
Near misses are "cheap lessons" for us - lottery tickets we've already paid for! - in which no one was injured and for which fault does not need to be assigned, but focusing on them can create vivid learning opportunities, and chances to correct problems before they recur. If we fail to act on our near misses, then they're not lessons for anyone. By creating an environment where can learn from our near misses, we are fostering a culture conducive to risk management.
For more about how outdoor programs can foster an environment in which near-misses are identified and treated as learning opportunities, listen to my recent interview with Joel Reid (from Outward Bound) on The Sharp End Podcast.