Transcription of Gains from Getting Near Misses Reported
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Gains from Getting Near Misses Reported
_____ 1 Gains from Getting Near Misses Reported Mr. William G. Bridges, President Process Improvement Institute, Inc. (PII) 1321 Waterside Lane Knoxville, TN 37922 Phone: (865) 675-3458 Fax: (865) 622-6800 e-mail: 2012 Copyright reserved by Process Improvement Institute, Inc. Prepared for Presentation at 8th Global Congress on Process Safety Houston, TX April 1-4, 2012 Keywords: investigation, near miss, accident, incident, root cause, RCA ABSTRACT The need for effective root cause analysis is finally gaining the spotlight in the chemical process industry. If we do not find out about an incident, we cannot investigate the root causes. We find out about accidents (harm done) because they are difficult to hide. However, there is only one accident for about 10,000 errors and failures (sometimes called unsafe acts and unsafe conditions). The definition of a near miss (a potentially damaging sequence of events and conditions, but without harm) can be vague and varies from site to site.
3 a total population of roughly 10,000 errors for every accident. Figure 1 illustrates the relationships between accidents, near misses and non-incidents.
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