June 22, 2011 | Ken Reed

Root Cause Analysis Tip: Why Investigate Near Misses?


Boy, that was close.
Luckily, no one was hurt.
It’s a good thing no one was standing there.
It’s a wonder no one was killed.

How many times have you heard phrases like that?  Whenever I hear things like that, it sends chills down my spine.  Some companies would categorize these types of problems as Near Misses.  George Carlin had a great definition for a “near miss”:

George Carlin

Watch this video from an earlier post.  Determine if you would consider this to be an incident or a near miss.  Believe it or not, companies would classify this both ways, depending on their trip points.

Crane Drop

So what do you do with one of these near misses?  Do you investigate them, just track them, or are they just ignored?  Many companies have policies in place that cover these situations.  For example, your policy might state that you would be required to perform a TapRooT® investigation if an incident caused one of the following:

– Lost Time Injury
– Damage to equipment in excess of $5,000
– Lost production totaling more than $30,000
– Any motor vehicle accident
– Any problem that had the potential to cause one of the above

This is a good start, but it can be just too overwhelming to consider all the possible problems we see as fitting our definition.  We don’t want to be too broad with our definition; otherwise, we’ll end up investigating everything.  We just don’t have time for that, right?

So where is the dividing line?  When do I investigate a near miss, and when do I just document and trend the problem?  One great way to figure out what needs to be investigated is to look at it from a resource perspective.  The ideal would be that we investigate all of our problems.  However, I’m a realist enough to know this just isn’t possible.

Instead, follow your policy as closely as you can.  Investigate those problems that cause $5,000 damage, or $30,000 in lost production.  Then conduct a periodic evaluation to determine how we’re doing.  Do I have the time and resources to investigate more problems?  If so, maybe you can lower your trip point to $2,000 damage and $15,000 in lost production.

The ideal is that your investigators are exactly maxed out with the number of investigations, but not so overburdened that they can’t keep up.  This is good resource allocation.  Keep performing these periodic evaluations and see if your trip points need to be adjusted.  You should find, over time, that you are able to lower your trip points gradually, conducting more (and smaller) investigations.  You’ll find a higher percentage start going toward near misses and audits, because you’ll be having fewer actual incidents as your investigation results provide effective corrective actions.

Another item to consider is, “How do I convince my boss that I need to spend money on problems that have not yet occurred?” In other words, nobody got hurt, you didn’t break anything, and you didn’t break any laws.  Why should you be given money to implement corrective actions when there were no actual consequences?

The answer to this is obvious to most of us, and yet the allocation of funds is still a common problem.  The issue isn’t that we don’t think the near miss is important.  The problem is that we need to convince those with the funds that the problem is worth dedicating resources to fix.  Often, the disconnect occurs because we as safety experts haven’t done a good job proving the return on investment.  You might try looking back at history and showing that, although the near miss didn’t cost us anything this time, you can show how much similar problems cost you in the past.  Add to that how much this near miss could have cost if it had occurred just slightly differently, and you might be able to prove how cheap your corrective actions really are.

Investigating  near misses is one of the most basic forms of Proactive Improvement.  Take a look at how you handle near misses, and see if you can leverage even more effectiveness from TapRooT® and your improvement programs.

Learn more about proactive improvement by registering for TapRooT® training or contact us for more information.

Root Cause Analysis
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