I am trying to formulate decision rules for capturing and segregating near miss catastrophic events in a risk management system. I would like suggestions on how to segregate near miss into robust system or intervention driven .
How can one design a mechanism to analyse this? Is there any research work on this?
Thank you
Much has been published on this subject. There are many examples of reporting systems and incorporation into risk avoidance on the internet.
The biggest problem is the reporting of near misses. Most go unreported. People learn from their own mistakes, but fail to pass on their knowledge.
This is an interesting question that touches on an aspect of risk systems that has not received much attention, namely, the detection (and capturing) of near miss events. Near miss events need to be documented so that remedial measures can be found. This means that the detection of near miss events would be coupled with factors associated with such events and the formulation of remedial measures to reduce the incidence of near misses.
The following M.Sc. thesis contains 47 occurrences of "near miss" along with many examples and probable causes:
N. Jayashree, Risk management in obstetrics and gynaecology, M.Sc. thesis, Rajiv Gandhi University of Health Sciences, 2013:
http://14.139.159.4:8080/jspui/bitstream/123456789/8918/1/Jayashree%20N%20OBG%20Comm%20Hosp%202013.pdf
For the detail study of near-miss reporting, framework and analysis one can follow the research work of given researchers: T. W. van der. Schaaf, Phimister , M. G. Gnoni and U Oktem.
Dear Raveendran,
we have developed a RM system enabling linking up near misses (and losses / success stories) to a risk scenario in order to use this information to improve safety, quality, environmental, and economic performance over time. Please read more in our user manual: http://www.swissnor.com/Products/UserManual/
"Many accidents, disasters and lost business opportunities have occurred because enterprises have ignored the warning signs of precursor incidents or have failed to learn from the lessons of the past. We define an incident as an unexpected or unwanted change from normal enterprise operation which causes a loss (CLAIM) or a gain (SUCCESS) or has the potential to cause a loss (NEAR MISS).
Note that several incidents can be linked to the same risk scenario in order to track the loss history of a given risk exposure / scenario. This enables the organization to extract useful information from incidents of all kinds (severity, frequency and annual loss distribution) and to use this information to improve safety, quality, environmental, and economic performance over time."
Best regards
Eivind
A broader issue is how to interpret near-miss events.
If you know (or think you know) what percentage of potentially dangerous behaviors end in a near-miss and what percentage end in a serious accident, then an an increase in the number of near-misses is a warning: the more near-misses, the higher the probability of a serious accident. "We almost exploded the tank!"
But if you don't know that, then a near-miss can be seen as evidence that a serious accident is unlikely. "We've 'almost exploded the tank' hundreds of times and yet the tank has never exploded. Defense-in-depth must be working. Those 'near-misses' aren't so near after all!"
This is a fundamental problem in talking to people about near-misses. What is intended by the communicator as a warning can easily be seen as reassuring by the audience.
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