Near-miss Management Research Articles

Enabling Effective Implementation of Occupational Safety and Health Interventions

BackgroundThe design, implementation, and evaluation are three important stages of occupational safety and health (OSH) interventions. Historically, there has been a tendency to prioritize implementation, often neglecting detailed design and rigorous outcome evaluation. Currently, much has changed, and contemporary approaches recognize the interdependence of these stages, considering them integral to the success of any intervention. This work presents a comprehensive procedure for implementing interventions, not only to ensure short-term effectiveness but also their long-term sustainability through continuous monitoring. The focus is on a national OSH project introducing a near-miss management system (NMS) in Italy. MethodsInitial meetings were convened among project partners, complemented by interviews with diverse stakeholders, to plan implementation steps and test the NMS. Tailored questionnaires were designed for diverse stakeholder groups – initial promoters, company managers and employers, and employees – facilitating targeted implementation, and three case studies were started in Italian regions to assess the structured implementation, involving intervention promoters and collaborating companies. ResultsThe primary outcome is the development of practical tools, specifically three questionnaires, which are considered valuable for establishing an effective human-centered implementation strategy, meticulously designed to facilitate ongoing monitoring of processes and continual enhancement of instruments intended for NMS integration within companies. ConclusionsThis work lays the foundation for successful NMS implementation in Italy and, although the outlined procedure had specific objectives, it also provides valuable insights applicable in enhancing the effectiveness and sustainability of interventions across diverse contexts. It underscores the importance of comprehensive planning, stakeholder engagement, and continuous evaluation in achieving lasting OSH interventions.

Relationship Between Companies' Responses to Near-Miss Reports and Turnover Intentions of Workers: A Nationwide Cross-Sectional Study

BackgroundEffective near-miss management is important in preventing workplace accidents. A company's inadequate response to near-miss reports can lead workers to feel insecure and dissatisfied with the company. We investigated the relationship between companies' responses to near-miss reports and turnover intentions of workers. MethodsWe conducted a cross-sectional study using online self-administered questionnaire survey to workers aged ≥20 years in Japan in March 2022. The analysis included 5,071 participants who had near-miss experiences and reported them to their companies. The independent variable was companies' responses to near-miss reports, classified into three categories: adequate response group, inadequate response group, and no response group. The dependent variable was turnover intentions. We calculated the odds ratio and 95% confidential interval (CI) using multilevel logistic regression analyses nested for industries and adjusted for covariates. ResultsOf the 5,071 participants, 3,058 (60.3%) were adequate response group, 1,484 (29.3%) were inadequate response group, and 529 (10.4%) were no response group. In multivariable adjusted model, compared with adequate response group, the odds ratio of inadequate response group and no response group were 1.80 (95% CI: 1.56–2.08) and 2.63 (95% CI: 2.15–3.22), respectively. ConclusionOur results suggested that there was a relationship between companies' responses to the near-miss reports and turnover intentions of workers. It is important not only to collect near-misses but also to respond appropriately to the reports and provide feedback to workers.

Application of Near-Miss Management Systems: An Exploratory Field Analysis in the Italian Industrial Sector

Near-miss events are usually identified as adverse events that could have turned into incidents/injuries but, due to an intervention of a safety system or by chance, developed into harmless situations instead. Past and present studies have also outlined the importance of collecting and analyzing near-miss events, as they have same causes of more serious events, thereby allowing for more effective preventative measures at the workplace. Although their importance has been outlined for several years, standard models for designing near-miss management systems (NMMSs) are still lacking and cannot yet support companies in their full-scale application. Despite this condition, NMMSs are applied in several industrial sectors, such as in the construction, mining, chemical, and nuclear industries. The aim of this study is to analyze how companies are developing their own NMMSs. An exploratory analysis was developed through survey analysis; it was provided to a sample of Italian companies in order to evaluate the adoption level of NMMSs as well as current practices applied by companies. The sample included companies of different sizes in the industrial sector. The results extracted from the field analysis outline interesting issues that point out current procedures adopted for the identification, collection, and analysis of near-miss events as well as real benefits and criticalities related to the application of NMMSs.

Sustainable occupational safety and health interventions: A study on the factors for an effective design

Effective interventions are a priority in continuously changing occupational environments, particularly in companies struggling to manage health and safety in the workplace. Practitioners may consider practical solutions for Occupational Safety and Health (OSH) improvement as a panacea for all major problems. However, they may overlook a range of other factors that affect the success of such solutions. The way in which a solution is developed, designed, implemented, and evaluated determines its impact. Participatory interventions are one way of ensuring better results. Consequently, this study proposes a way of establishing sustainable, effective, and efficient interventions by defining the required processes and actively involving responsible actors (i.e., who, when, and how).A national OSH intervention for introducing a near-miss management system, funded by the Italian National Institute for Insurance against Accidents at Work (INAIL), is used as a reference because its development process includes an accurate design stage. Based on this intervention, a multistep design process is built to answer how (how the intervention will persist by defining the context, processes, and scenarios), who (who will be the responsible actors actively participating), and when (when actors will be involved) questions.The design process established for the intervention, although within a specific context, provides clues to discriminant factors that would enable effectiveness in general interventions, and the proposed system for near-miss management generates insights that may be generalizable to other OSH interventions developed in different environments.

Ship Safety Officers' Perceptions and Attitudes Toward Near-Miss Management Systems

Unlike learning from accidents, learning from near misses is based on events that caused no injuries or damage. Therefore, reporting and investigating near-miss events in shipping could be considered a more convenient means of reducing accidents and safety improvements than accident investigations. However, to facilitate learning from near misses, an adequate and efficient Near-Miss Management System must be implemented on board ship. Since ship Masters and Safety Officers are responsible for the efficiency of the Near-Miss Management System (NMMS) on the shipboard side, their attitudes and opinions on implemented systems might be considered indicators of its quality. Therefore, the questionnaire was developed and distributed among Masters and Safety Officers to collect their perceptions of and attitudes toward Near-Miss Management Systems. Furthermore, the paper aims to examine the relationship between the respondents' ranks (Masters and Safety Officers), the type of ship they are serving on, and their attitudes toward Near-Miss Management. The data analysis showed that most respondents are satisfied with the Near-Miss Management Systems implemented on their ships but consider near-misses underreported. Moreover, analysis results showed that there are no significant differences in attitudes towards NMMS between ranks and types of ships.

Integrating Safety-I and Safety-II Approaches in Near Miss Management: A Critical Analysis

Safety-II is a recently theorized approach, considering safety as the ability of a system to reach a positive outcome under variable conditions: analyzing “what goes right” can help to understand the dynamics of the analyzed system and improve its inherent safety level. On the contrary, a more traditional perspective, defined as Safety-I, aims at analyzing “what goes wrong”, thereby relating the safety level of a system to the number of adverse events that occurred. This study explores the potentialities of integrating these two approaches in near-miss management. Through a Safety-I approach, near-miss events are analyzed to identify the root causes generating the event chain, in order to delete them and prevent future accidents. Applying a Safety-II approach, the analysis can include elements that contributed to limiting the consequences and blocking the event chain, revealing the resilience level of the systems. This study presents a critical analysis of the two approaches and proposes a practical framework to integrate them into near-miss management systems. A test case shows the potential benefits of this integration. This work provides a tool to support the implementation of Safety-II on the operative level while suggesting a new perspective for near-miss management.

A Blockchain-Enabled Conceptual Framework for Near-Miss Management in the Construction Industry

The safety problem is still a concern in the construction industry, and near-miss management has become one of the most important practices to improve construction safety. Despite good intentions, problems with near-miss management emerged. These included: a limited reporting rate of near misses, information fraud, the risk of being distorted or lost, and insufficient information sharing among construction stakeholders. These issues have an adverse impact on the effectiveness of near-miss management. Blockchain has the potential to be a reliable platform for near-miss management due to its decentralization, immutability, transparency, and autonomous enforcement of agreements with smart contracts. However, there has been limited investigation into the blockchain’s possibilities in near-miss management. To bridge this gap, this paper proposed a blockchain-enabled conceptual framework for near-miss management. The challenges of near-miss management and the potential of blockchain were discussed. An overall conceptual framework was created, which could help to record near-miss information in an immutable, transparent, traceable, and secure way.

A science mapping approach-based review of near-miss research in construction

PurposeNear misses are important references for the construction industry to move toward zero injuries, and are of great significance in reducing accidents and improving safety education. To fully improve the construction industry's understanding and standardize the management process of near-miss events, this paper describes a systematic review of the research front and intellectual basis of near-miss events based on scientometric technique and CiteSpace.Design/methodology/approachThe authors reviewed and summarized the research wave and definitions of near-miss events in construction. The science mapping approach is used to conduct quantitative analyses of 120 relevant articles published between 2009 and 2019. Three research themes are identified via author analysis, keyword analysis and co-citation analysis: the construction of near-miss management systems, near-miss events research and characteristic research.FindingsIt is found that improving the data collection method to maximize the quality of near-miss reports, optimizing and verifying the event analysis model considering the characteristics of near-miss events in construction, establishing a more comprehensive framework for the analysis of near-miss events and building a highly inclusive technology integration platform are the four main development directions for the future.Originality/valueAccording to Heinrich's law, incidents are mainly blamed on near-miss events such as workers' unsafe behaviors. Due to the complexity and variability of the construction site, near-miss events in construction may have different features. This article helps promote the understanding of near misses in academia, standardizing the management process of near-miss events, which is conducive to mining the potential value of such events in practice. Some insights into the research front and the intellectual base of near-miss research in construction are proposed.

Improving Safety Management through Analysis of Near-Miss Reports—A Tanker Ship Case Study

A near-miss management system (NMMS) is a tool used for improving safety at sea if adequately implemented. Valuable knowledge to improve safety management might be gained by investigating and analysing reported events. Therefore, it is of the utmost importance to report each observed near-miss event. Because tankers are generally considered dangerous, but at the same time safe due to stringent requirements, near-miss reports and NMMS policy were collected from one oil tanker ship. Data were pre-processed and analysed. Variables used during analysis were near-miss type, risk level, ship position, and onboard location of near-miss occurrence. Analysis of policy and reports revealed that most near misses occurred on the deck area, but higher-risk-level events were reported in the engine room and navigating bridge. Housekeeping, equipment failure, use of personal protective equipment (PPE), and process-/procedure-related events were most common and generally related to lower risk levels. The most frequent corrective actions recorded were implementing safe working practices and PPE. In addition, higher-risk-level events were related to less effective corrective actions. Based on the findings, suggestions for improvements include promoting safe behaviour and adequate PPE usage through additional training, ensuring proper housekeeping, regular maintenance of shipboard equipment and spare parts management, and toolbox meetings and risk assessments that include conclusions of near-miss investigations and analysis.

The effect of patient safety culture on nurses' near-miss reporting intention: the moderating role of perceived severity of near misses.

Reporting near misses is a practical approach to improve the confounding challenge of patient safety. Evidence suggests that patient safety culture and the characteristics of errors might have important impacts on reporting. No studies, however, have examined the relationships among patient safety culture, perceived severity of near misses and near-miss reporting. To explore the relationship between patient safety culture and nurses' near-miss reporting intention, and examine the potential moderating effect the perceived severity of near misses might have on this relationship. Using a cross-sectional survey, data were collected with three validated survey instruments completed by 920 Registered Nurses in eight tertiary hospitals in China. Multiple regression analysis tested relationships among the variables. Nurses reported a moderate-high level of near-miss reporting intention. Patient safety culture was positively associated with nurses' near-miss reporting intention. Perceived severity of near misses did not significantly moderate the relationship between patient safety culture and reporting intention. Nurses generally showed a positive willingness to report near misses. A specific near-miss management and education system within a learning, supportive working environment are key components to improve reporting intention among nurses which could significantly improve patient safety.

Reporting as a Key Element of an Effective Near-Miss Management System in Shipping

Shipping is a high-risk industry and prone to accidents. A near-miss management system is an important aspect of the safety performance in shipping because the causes are the same for near-misses and accidents. Reporting, analyzing, and learning from near-misses can prevent the recurrence of accidents and thus improve safety on ships. This paper addresses near-miss management systems in shipping and provides insights into the quality of the implementation of these systems, with an emphasis on the importance of reporting. Research data were derived from two surveys and supported by data gained from near-miss reports and existing literature reviews. Professional seafarers of various ranks, ages, nationalities, and experiences, serving on tankers, cruise ships, bulk carriers, and container ships, voluntarily participated in these surveys. The first survey comprised 223 participants, and the second survey involved 22 participants. The research results indicate that near-miss reporting is inadequate, and several barriers limit appropriate near-miss reporting. The difficulty of seafarers in identifying near-miss events was found to be one of the major barriers to near-miss reporting at sea. Based on this research, a conceptual model of a near-miss management system was developed, and measures that can be applied to overcome barriers and increase reporting are proposed.

Exploring the Potential Use of Near-Miss Information to Improve Construction Safety Performance

Construction project management usually has a high risk of safety-related accidents. An opportunity to proactively improve safety performance is with near-miss information, which is regarded as free lessons for safety management. The research status and practice; however, presents a lack of comprehensive understanding on what near-miss information means within the context of construction safety management. The objective of this study is to fill in this gap. The main findings enrich the comprehensive understanding of the near-miss definition, the near-miss causation model, and the process of near-miss management. Considering that near-misses are more tacit and obscure than accidents, the process for near-miss management involves eight stages: discovery, reporting, identification, prioritization, causal analysis, solution, dissemination, and evaluation. The first three stages aim to make near-misses explicit. The other five are adopted to better manage near-miss information, compiled in a well-designed near-miss database (NMDB). Finally, a case study was conducted to show how near-miss information can be utilized to assist in construction safety management. The main potential contributions here are twofold. Firstly, corresponding findings provide a knowledge framework of near-miss information for construction safety researchers who can go on to further study near-miss management. Secondly, the proposed framework contributes to the guidance and encouragement of near-miss practices on construction sites.

Systematic approach to crane-related near-miss analysis in the construction industry

ABSTRACTThe use of near-miss management systems in construction is relatively new and has not been fully explored or understood. Near misses have not been investigated in a systematic perspective that will enable an analysis from a given set of reported incidents. This research effort suggests a systematic approach to near-miss analysis and concentrates on tower-crane-related near-miss events due to the centrality of tower cranes in nowadays construction and their potential as hazard generators on construction sites. The study began with an extensive effort to collect stories of safety events, including near misses and accidents. An exploratory research method was then implemented in developing a comprehensive database of crane-related accidents and near-miss events. The database classifies each event using a set of encoded variables that disclose event definition, crane status, activity, main incident factor and more. The applicability of the database is demonstrated by providing support to the notion of cause commonality between accidents and near misses, an issue that has been studied in the context of other industries. Further investigation into the causal factors preventing near misses from developing into full-scale accidents provided an important insight on the benefit of near-miss investigations.

Analyzing risk factors in crane-related near-miss and accident reports

Learning lessons from near-miss reports is a well-known procedure in various high-hazard industries. The construction industry tends to adopt near-miss management systems, but the procedure is relatively new and has not yet been fully explored or understood. Although the management of near-miss reporting systems in construction has been investigated, no effort appears to have been made to suggest a methodology for technically investigating the content of near-miss reported events. This paper reports a study that implemented both qualitative and quantitative analysis methods for a structured investigation of tower-crane-related incident stories (near misses and accidents). The study began by collecting a large number of incident stories (51 accidents and 161 near misses) that were qualitatively analyzed to form an incident database that served as raw material for further quantitative analyses. The database structure definitions contained categories, which in turn contained variables, such as defining the event severity outcomes on a six-point scale from ‘1’ – near miss to ‘6’ – fatality. Further quantitative analysis suggests comparing groups of similar or identical incidents. The groups (clusters) were established by implementing k-means clustering based on the database definitions as variables. The relative risk potential of each cluster was then quantified by comparing each cluster’s severity outcome occurrences to those of the other clusters and to the entire database as well. Findings from the analyses suggest that technical failures are the most hazardous risk factors within the tower crane domain.

A near-miss management system architecture for the forensic investigation of software failures

Digital forensics has been proposed as a methodology for doing root-cause analysis of major software failures for quite a while. Despite this, similar software failures still occur repeatedly. A reason for this is the difficulty of obtaining detailed evidence of software failures. Acquiring such evidence can be challenging, as the relevant data may be lost or corrupt following a software system's crash. This paper proposes the use of near-miss analysis to improve on the collection of evidence for software failures. Near-miss analysis is an incident investigation technique that detects and subsequently analyses indicators of failures. The results of a near-miss analysis investigation are then used to detect an upcoming failure before the failure unfolds. The detection of these indicators – known as near misses – therefore provides an opportunity to proactively collect relevant data that can be used as digital evidence, pertaining to software failures. A Near Miss Management System (NMS) architecture for the forensic investigation of software failures is proposed. The viability of the proposed architecture is demonstrated through a prototype.

Gydytojų ir slaugytojų požiūris į nepageidaujamų įvykių ir neatitikčių valdymą lietuvos bendrojo pobūdžio ligoninėse

Adverse events and near-miss management in Lithuanian general hospitals is analyzed in this article. The aim of the paper is to evaluate the attitudes of physicians and nurses towards adverse events and near-miss management. 1020 general hospitals health care professionals took part in the anonymous survey, which was performed during the period of June - December, 2014. The results suggested that 9.9% of the respondents did not know what adverse event is, and 10.7% did not know the meaning of near-miss. Nurses compared to physicians knew much more about the process of what and where to register the adverse event or near-miss. Most of the respondents declared that it is useful to register adverse events and near-misses. Older health care professionals with longer work experience were considerably more active in this process. Most of the respondents declared that after the near-miss happens, the efforts are put to examine causes of the event, but only half of them knew further near-miss investigation steps and were instructed about the adjustment and preventive actions.

Using digital forensics to improve software reliability

IT systems are ubiquitous in today's interconnected society and play a vital role in a number of industries such as banking, telecommunications and aviation. Software, in particular, is embedded in most technical and electronic products, ranging from massive machines such as airplanes to lightweight devices such as mobile phones. Software applications are essential to the proper functioning of these products and their associated service offerings. The use of digital forensics to analyse software failures has been almost exclusively limited to examining problems after they occur. The IT industry would do well to adopt the near-miss management system (NMS) approach used by many other industries. An NMS that combines near-miss analysis and digital forensics can contribute significantly to the improvement of the accuracy of the failure analysis. However, as Madeleine Bihina Bella and Jan Eloff of the University of Pretoria/SAP Innovation Centre, Pretoria explain, there are challenges to implementing an NMS for software.

Measuring the effectiveness of a near-miss management system: An application in an automotive firm supplier

Accidents and near-miss events are usually characterized by common causes and different consequences; a near-miss event is a potential hazardous condition where the accident sequence was interrupted; these events have common causes with accidents (or injuries), but, differently from the latters near miss consequences are null (or reduced).Thus, near-miss events are accident precursors; furthermore, they provide “weak signals” to safety managers for preventing more effectively injuries at workplace. The study proposes a methodological framework to verify the global effectiveness of a near-miss management system (NMS): the model is based on lean safety and learning loops strategies. The proposed framework uses data collected by the firm NMS crossed with information extracted from occurred accidents/injuries. A case study in an automotive firm supplier is proposed aiming to validate the proposed framework. The analysis has revealed effective to outline overall potentialities of the proposed approach together with improvement points for the firm NMS application.

Are Mariner near Misses Influencing Design?

In an ongoing research effort by the American Bureau of Shipping, Lamar University, and vessel operators, more than 18,000 reports of maritime near misses have been collected. The focus of this paper is on near-miss reports that included a recommended design change on or to the vessel and any related quality or safety management system. Limited consistency was found in the definition of a near miss and the type of near-miss data being collected. Most of the near-miss reports for this study contained some form of recommendation or corrective action. This review also found apparent differences in vessel operator safety program maturity among the companies providing near-miss data. As a result, this investigation focused on the recommended corrective actions and associated hazard-control processes. Additionally, based on the findings of limited consistency, this paper discusses core components for near-miss reporting and for an effective near-miss management system.

“Lean occupational” safety: An application for a Near-miss Management System design

A critical component of a safety management system is the Near-miss Management System (NMS). An effective NMS aims to recognize signals from the operational field in order to apply more effective prevention strategies. These systems are widespread in industrial contexts characterized by a high risk level, such as major hazard and hospital sectors. Few examples occur in manufacturing processes which are characterized by different operational conditions at workplace and, consequently, different risk types. The Lean Thinking (or Management) strategy currently represents a worldwide competitive tool for improving productivity in the manufacturing sector all over the world. Thus, the application of these principles forces firms to define new approaches to design and manage the whole organization and consequently the safety management system. The paper proposes innovative design of a NMS based on the integration of principles of Lean Management in occupational safety for a worldwide automotive supplier firm. As no reference model has been previously defined, several factors have been assessed aiming to efficiently integrate occupational safety in the current Lean Management system. Innovative features characterizing the proposed model have been also discussed together with first results obtained by the full scale application.