What's a Near Miss / Near Hit?

Usually a near miss or hit is defined as an accident that almost happened.

For example, the situation where someone trips and almost falls down the stairs but manages to grab the hand rail just in time, or when someone is almost hit by a reversing fork lift. In these two examples no injury resulted but this was the result of good luck rather than good management.

When near misses occur they can be regarded as early warnings that something is wrong somewhere in the system. We therefore need to develop a system which allows us to take action before an injury occurs.

When a Hazard and Near Miss report is received by a supervisor, the supervisor should discuss it with the person making the report, investigate, and decide what corrective action should be taken and implement the change as soon as possible if it is within the supervisor's authority. If not, the matter should be referred to a member of management for review and correction.

All Near Misses should be reported, reviewed and recommended corrective actions implemented as soon as possible after the event. These items should also be discussed in daily tailgates and monthly safety committee meetings to ensure affected employees are apprised of the changes. The idea is to take immediate corrective action to prevent recurrence with a more serious outcome.

Below is summary of an actual near miss (not one of ours) that is quite common:
Incident Date: 1/09/2009
Task Description: Working on elevated platforms using hand tools.
Summary: A hand tool fell through a small gap in the work area and dropped and deflected from other equipment causing the hand tool to fall outside the exclusion zone identified for the process.
Cause of incident: Moving, flying or falling object
Root cause: Lack of risk assessment
Activity Type: Maintenance
Specific Equipment: Hand Tools and the lack of securing devices to ensure they are unable to fall from aloft.

Lessons Learned:

Risk assessments must be thorough…there was a gap here was the exclusion zone underneath the work area large enough?

There was no plan for the safe and controlled use of working with tools at height.

It appears there was at least one gap in the protective matting which had not been managed effectively.



Near-misses are often less obvious than accidents and are defined as having little if any immediate impact on individuals or processes. Despite their limited impact, near-misses provide insight into potential accidents that could happen. As numerous catastrophes illustrate, management failure to capture and remedy near-misses may foreshadow disaster. Notable examples where near-miss precursors have been observed but not effectively managed include:

1. The 1986 Space-Shuttle Challenger explosion. Engineers had identified and reported degraded O-ring seals on previous missions dating back to 1982 with degradation increasing as ambient liftoff temperature decreased. The night before the disaster, management had been warned of the potential for catastrophic failure when lifting off at ambient temperatures of 53 °F or below (the liftoff temperature was 36 °F) (Vaughan, 1996).

2. The 1997 Hindustan refinery explosion in India. Sixty people died and over 10,000 metric tons of petroleum based products were released to the atmosphere or burned. Written complaints of corroded and leaking transfer lines where the explosion originated went unheeded (Khan and Abbasi, 1999).

3. The 1999 Paddington train crash catastrophe in which 31 people died. From 1993-1999 eight near-misses, or ‘signals passed at danger’ (SPADS), had occurred at the location (Signal 109) where the eventual collision and explosion occurred. At the time of the crash, the signal was one of the 22 signals with the greatest number of
SPADS (Cullen, 2001).

4. The 1998 Morton explosion and fire resulting from a reactor temperature excursion. Nine people were injured, two seriously. In an accident investigation, the Chemical Safety Board concluded, “Management did not investigate evidence in numerous completed batch sheets and temperature charts of high temperature excursions beyond the normal operating range.” A disproportionate number of excursions resulted after the process was scaled-up (Chemical Safety Board, 2000).

Many accidents can be prevented by taking prompt action to prevent a hazardous situation from continuing or developing into something worse. Near Miss reporting is a key element in an Accident Prevention Program. Experiences shared and information gathered at one facility can be used at other facilities to mitigate risk and control losses. Therefore, we must continue to encourage employees to report all near misses, immediately. We need to use Near Miss reports as ‘our early warning system’ and do all we can to minimize the potential for loss.

Waiting for an injury to happen before acting just doesn't make sense! The best answer is prevention…and that takes timely, effective communication.