What are the best practices for investigating near-misses in a manufacturing facility?

1 Define near-misses

When investigating near-misses, it is essential to define what constitutes a near-miss in your facility. While there is no universal definition, a common one is any unplanned event that did not cause harm, but had the potential to do so. Examples of near-misses include slipping on a wet floor and catching oneself before falling, a machine malfunctioning and shutting down automatically before anyone gets hurt, a forklift driver narrowly avoiding hitting a pedestrian or another vehicle, and a fire breaking out but quickly being extinguished by the sprinkler system. To ensure that all employees and contractors recognize and report near-misses when they occur, you should establish clear criteria and examples of near-misses for your facility and communicate them to everyone.

2 Encourage reporting

In order to investigate near-misses, it is essential to encourage reporting. However, many workers may be hesitant to report near-misses due to fear of blame or punishment, lack of awareness or understanding, belief that near-misses are not important or relevant, and difficulty or inconvenience of reporting. To create a positive and supportive culture, it is important to ensure workers can report near-misses without fear of reprisal. This could be done through online forms or apps, suggestion boxes or feedback cards, verbal or written reports to supervisors or safety representatives, and anonymous or confidential reporting options. Additionally, it is important to acknowledge and reward workers who report near-misses and provide feedback on the actions taken as a result of their reports.

3 Investigate root causes

Investigating root causes is the third step in near-miss investigations. Root causes are the underlying factors that contributed to the occurrence of the near-miss, and can lead to more serious incidents if not addressed. Common root causes include human errors or behaviors, equipment failures or defects, environmental conditions or changes, organizational policies or procedures, and communication or coordination issues. To identify root causes, you should use a systematic and objective method such as the 5 Whys technique, Fishbone diagram, or Fault Tree analysis. Involve those who were involved or witnessed the near-miss, as well as other relevant stakeholders in the investigation process. Additionally, collect and analyze any evidence such as photos, videos, documents, records, or data that can help you identify the root causes.

4 Implement corrective actions

The fourth step in investigating near-misses is to implement corrective actions. These measures are taken to eliminate or reduce the root causes of the near-miss, and to prevent recurrence or escalation. Examples of corrective actions include training or coaching workers on safe work practices, repairing or replacing faulty equipment, improving the work environment, updating organizational policies, and enhancing communication systems. You should prioritize and assign the corrective actions based on the severity and likelihood of potential consequences, set realistic and measurable goals with deadlines for completion, monitor progress and effectiveness, and make adjustments if needed.

5 Share lessons learned

The fifth step in investigating near-misses is to share lessons learned. These key findings and recommendations derived from the investigation and corrective actions can help to improve the safety knowledge and awareness of the workers and the organization. Examples of lessons learned may include the causes and consequences of the near-miss, best practices or tips for preventing or handling similar situations, gaps or weaknesses in safety systems or processes, successes or challenges in implementing corrective actions, and how these were addressed, overcome, or resolved. It is important to share the lessons learned with all affected workers and stakeholders, document them in a central location such as a safety bulletin board, newsletter, database or library, safety meeting or training session, or safety audit/review. Additionally, the lessons learned should be used to update/refine safety policies/procedures/standards and inform future safety planning/decision making.

6 Promote continuous improvement

The sixth and final step in investigating near-misses is to promote continuous improvement. This ongoing process involves seeking feedback from workers and stakeholders, measuring and analyzing safety indicators, identifying new ways to prevent or reduce near-misses, and celebrating the achievements of workers and teams in improving safety. It is important to foster a proactive and collaborative attitude towards continuous improvement, and encourage workers to participate and contribute. Additionally, you should review and update your near-miss investigation process regularly to ensure it is aligned with your safety goals and objectives.