Learning from near-miss events

Near miss, close call and near escape are a few of the terms used to describe a scenario where, if conditions were just slightly different, an outcome could have been catastrophic. No matter what you call these events they create amazing learning opportunities. The more we understand about how a near-miss event occurs and how our decisions and actions may have contributed to the outcome, the better prepared we can be to ensure if similar circumstances were to happen again it would not result in tragedy.

As noted, I consider a near-miss as a series of events that, if any of the circumstances were altered slightly, it could result in a tragedy. The benefactor of a near-miss will sometimes look at their outcome as resulting from luck. And sometimes it is. There’s nothing wrong with having a little luck on your side.

However, when performing high-risk work that has a high-consequence potential it is always better to program out some of the luck and replace it with knowledge and a skillset. Lessons learned from near-miss events can build knowledge to prevent – or at least significantly reduce – the potential for tragic outcomes.

Here are six points to consider to help you learn and share from near-miss events.

1

Understand what a near-miss event is

Near-miss events are not always so obvious. While teaching on the topic of situational awareness and high-risk decision making I often poll my audience as to how many have experienced a near-miss event. It is amazing how few realize they’ve had a near-miss event because, as they explain it, they’ve never had an incident where they suffered a significant injury.

Casualties are not a prerequisite to defining a near-miss event. Some of the most amazing near-miss stories shared with me on the SAMatters Show involve individuals who, quite literally, walked away from an incident without a scratch. Some suffered only minor injuries or burns. Others sustained significant injuries or burns. Some of the near-miss survivors I’ve interviewed were, sadly, working alongside comrades who were killed in the incident.

If you can honestly say to yourself that you’ve had occasions where you’ve been lucky, chances are you’ve experienced a near-miss.

2

Become a student of near-miss events

The best way to learn about how near-miss events occur and how to prevent them is to immerse yourself in the lessons shared from others who have had incidents where they survived and now they have a story to tell. Of course, “I was lucky” is only the beginning of the story. There are always deeper explanations and often complex contributing factors related to thermodynamics, physics, engineering, physiology, psychology, organizational culture and more.

For example, one of the contributing factors to near-miss and casualty events is flawed situational awareness. But flawed awareness is never a root cause. It is a symptom. There is a deeper explanation as to what caused the awareness to be flawed. Over the past 15 years I have focused my research on the barriers that impact and erode situational awareness and I have uncovered more than 100 barriers (i.e., explanations). Understanding how awareness is flawed is powerful knowledge that can be applied to preventing issues with awareness, improve high-risk decision making, and reduce the potential for a near-miss event.

3

Adopt an inquisitive mindset

Following a near-miss event, ask questions of yourself and others. These questions should not be motivated toward finding fault or placing blame. Rather, they are questions to gain a deeper understanding than what appears as the surface explanation. 

For example, after learning about a near-miss event where the initial assessment was those involved were someplace they should not have been, doing something they should not have been doing, the natural inclination might be to adopt a judgmental mindset and ask: “What in the world were they thinking?”

Inverting the question allows responders to look at the situation from a different perspective by asking: “Why did what they were doing, at the moment things went bad, make sense to them?” This question removed the judgement and allows responders to contemplate and understand, on a deeper level, the sense making surrounding the near-miss event. 

It also allows for one to contemplate the possibility the responders were not thinking at all. I have been blessed that my research has afforded me the opportunity to interview hundreds of near-miss survivors. Stunningly, many near-miss survivors have admitted to me they were not thinking. Rather, they were simply acting on auto-pilot – performing tasks based on training and habits. They had not done any form of conscious assessment nor had they given consideration to potential consequences prior to engaging in a high-risk activity.

The more responders can learn about complex root causes, like automaticity, mind drift, and auditory exclusion, the better equipped they will be to understand why near-miss events occur and their vulnerabilities as a responder. For example, for a variety of reasons, a responder under stress may not see and hear as well as when they are not under stress. In fact, a responder can, literally, become blind and deaf to critical clues that are right in front of them.

Failing to understand human vulnerabilities can quickly lead to judgment of actions. The judging mind is not a learning mind. Set judgement aside and be inquisitive. That’s when the real learning begins.

4

Share the gift of your experience

Sadly, many responders are reluctant to share the lessons from their near-miss events. There are a variety of explanations for the hesitation. None of us like to be judged or ridiculed and there is the potential for both to occur if one exposes themselves to enquiry following a near-miss event. There is no shortage of self-proclaimed “experts” in the fire service who are quick to point out errors in decision making and actions.

While social media has made it possible for us to share lessons quickly with others, it also makes it way too easy for pundits with little first-hand knowledge about an incident to quickly pass judgment and to make hateful comments about the actions of fellow responders. This is unfortunate as it can prevent the sharing of valuable near-miss lessons that could save a life.

A near-miss event can be embarrassing. The “I wasn’t thinking” admission of a seasoned responder can subject them to criticism and their status among their peers may be damaged. If given the opportunity to share the full accounting of the events leading up to the near miss, issues with incident scene communications, common operating picture, shared goals, past training practices, flawed, conflicting, poorly communicated or non-existent standard operating procedures, tactical priorities, under-developed critical thinking and resilient problem solving skills, automaticity, pressure to complete a task with haste, and a host of other factors might shed important light on how the near-miss occurred and the role other factors played in contributing to event.

Organizations that have adopted a learning mindset expend great effort to understand near-miss events because they know that near-miss events are the precursors (i.e., early warning signs) for catastrophic losses.

For more information, go to www.SAMatters.com

References

1 The SAMatters Show is a free weekly podcast and videocast show hosted by Dr. Gasaway where he shares lessons on situational awareness, high risk decision making and he conducts interviews with near-miss survivors. You can subscribe to the podcast by searching for SAMatters radio on iTunes, Google Play or Stitcher Radio and the videocast by subscribing to SAMattersTV on YouTube.