Over the past decade, Tinsley and a team of experts in organizational behavior and intelligence analysis have studied near-misses in dozens of companies. The research shows trends of multiple near-misses preceding every disaster or crisis studied, most of which, the team says, were ignored or misread by business managers and leaders.
“Theoretically, near-misses could be interpreted two ways,” Tinsley says. “1) The system is vulnerable (because a disaster almost happened) or 2) the system is resilient (since a disaster did not happen). Although these two interpretations are possible, it turns out the many near-miss events are interpreted as disasters that did not happen.”
Some near-miss events are categorized as successes, she continues, while others are seen as “less than successful,” but are far from being classified as a negative event, resulting in no follow up action.
This can be an issue for obvious reasons, she continues. “Presumably people want to prevent crises before they occur rather than just investigate them post-hoc for what went wrong. Understanding how organizational disasters often are a complex interaction of quite mundane events can help organizational actors, such as safety and health professionals, be on the lookout for early warning signals, which may presage looming catastrophes,” Tinsley says.
In correlation with NASA, Tinsley and her team have developed seven strategies to help SH&E professionals and business leaders detect and learn from near misses and ward off loss events:
2) Learn from deviations. Often, when some aspect of operations deviate from the norm, managers will recalibrate what they consider acceptable risk, despite understanding the statistical risk represented by the deviation. Managers should examine their reasons for tolerating the associated risk from operational deviations.
3) Uncover Root Causes. Often when managers identify errors they respond to the symptom rather than the cause of the deviation.
4) Demand accountability. Even when people are aware of near-misses, they tend to diminish their importance. Requiring managers to justify their assessment of near misses is one way to limit this issue.
5) Consider worst-case scenarios. Many people will not consider the possible negative consequences of near misses unless advised to do so. Examining events closely helps people distinguish between near misses and successes.
6) Evaluate projects at every stage. When things go badly, manager will analyze the situation to prevent recurrences, but rarely will they review successful operations, allowing some near-misses to escape scrutiny. Critically examining projects while they’re under way will help teams avoid outcome bias and see near misses for what they are.
7) Reward owning up. Organizational alertness will help prevent errors, but if people aren’t motivated or discouraged from exposing near-misses, no amount of attention will prevent incidents. Leaders should reward staff for uncovering near misses, including their own.
For more examples, look for Tinsley’s keynote at ASSE’s Avoiding the Worst: Fatality and Severe Loss Prevention Symposium.
