Everybody knows near misses because you’ve lived them – the sharp intake of breath, the spike in adrenalin, and the feelings of relief and residual fear about ‘what if?’. Whether it was getting cut-off in traffic, stepping back just in time as a bus pulls up to the kerb, or a narrowly avoided accident in your work place. Sometimes it seems that it’s not just about asking why accidents happen, but rather why don’t MORE accidents happen? Critically, asking why more accidents don’t happen will give us clues about how to keep our systems safe.
When an accident or near miss occurs, analysis methods look back at all the things that went wrong, where something had zigged rather than zagged, and what could be done differently next time? From these analyses, recommendations are developed and implemented, historically focused on the people at the ‘sharp end’ but, as the understanding of accident causation matures, increasingly considering systemic factors which contribute to accidents. While this ‘systems thinking approach’ addresses broader factors of accident and near miss causation, the focus is still primarily on what has gone wrong rather than attempting to identify what went right.
My PhD research is addressing this gap. The project, What went right? A systems thinking-based model of near miss incidents for the led outdoor activity context, is developing a model of near misses which identifies the factors which differentiate near misses from fully blown incidents. These ‘what went right’ factors, called Protective Factors in the research, will identify how decisions and actions throughout work systems act to prevent incidents.
While the systems approach is arguably the dominant paradigm in accident causation research, no specific systems thinking-based model of near misses has emerged. This project will identify a series of tenets, extended from Rasmussen’s tenets of accident causation, which apply to near misses. These extended tenets describe how a system turns potential accidents into near miss incidents. Through applying these tenets in the Led Outdoor Activity (LOA) domain, an empirical model near misses will be developed. A method is also being developed to support validation of the new model as well as collection and analysis of ‘what went right’ data in practice.
The AcciMap approach has been successfully used to analyse accidents in several domains, including the LOA. In this project, AcciMap is being adapted to identify the factors related to the identification, assessment, and resolution of a potential accident which results in a near miss. This adapted method, called ProtectionMaps, will be used throughout the project to represent the interaction between contributing factors to the potential accident and the protective factors which create the near miss.
What you look for is what you find and reporting systems have found a lot about what goes wrong. As the idea of understanding ‘what went right’ in near misses is uncommon, existing reporting systems do not yet capture this information. To capture this information, a tool is being developed which will allow LOA practitioners to voluntarily and anonymously report their near misses online and provide the data on systemic factors which have provided for near misses in their daily work. The new tenets, analysis method, and data capture tool will provide the LOA domain with a systems approach to understanding what went right in near misses. Whilst developed in the LOA context, the method will be generic and usable in any safety critical domain.
A systems approach to understanding what went right begins to offer some explanation to why don’t more accidents happen, and in turn gives indications of how future accidents can be prevented. Safety science has done so much to eliminate and control hazards, giving us the level of safety we currently enjoy. However, to continue to increase our level of safety, we must expand our view beyond limiting what went wrong towards increasing and exploiting what went right. This project makes a significant first step to that goal by focusing on identifying the systemic factors associated with what goes right in near miss incidents. Stay informed and up-to-date on this project as it progresses via ResearchGate.
Brian Thoroman is a PhD candidate in the Centre for Human Factors and Sociotechnical Systems
You can read Brian’s recently accepted article analysing the protective factors in aviation incidents here.
See also our conversation article discussing the Hudson river landing
Centre for Human Factors and Sociotechnical Systems 