It is a rare thing to meet someone in the working at heights sector, who doesn’t have a story around a near miss, human error, or of a failure of a system. What is important to acknowledge from such stories is that human error is as important as mechanical or rigging failure. There are numerous causes of human error has led to a fall or an incident at height, including complacency, poor communication, lack of knowledge and over confidence.
Whilst we can readily admit that within the heights industry many have had ‘moments of stupidity’; it is when these moments occur without a witness, ‘a near miss’, incidents that may have resulted in a consequence greater than an increased heart rate and a sudden realisation of your own mortality.
Learning from failure is a vital part of the safety system; and human error is one that is neglected. Whether it’s forgetting part of the safety system, threading devices incorrectly, having more that the prescribed number of persons attached to a system, a karabiner misconnection, dropping tools or equipment, not connecting to safety systems. All of these occurrences are considered to be a near miss.
We use the term neglected, because it is rare that workers ‘own up to small mistakes’, or that there is a workplace culture that mocks such occurrences instead of supporting the worker, and seeking action(s) to prevent them from happening again. It is vital that such incidents are reported. Without such reporting, these occurrences don’t become a learning experience for others.
Ultimately, unreported near misses may at some point result in an injury or fatality. For example, a small fall from height where no injury occurred may result in the same situation recurring where injury or fatality may occur.
One theory1 tells us that for a large number of ‘No damage, Near miss’ events there will be a smaller number of ‘damage accidents’ and – ultimately – a ‘serious or disabling’ event, e.g. a fatality.
Accordingly, one way to help prevent the more serious incidents is to report the near misses. By reporting all the smaller, seemingly ‘insignificant’ incidents, it may be possible to identify a pattern in the types of incidences, which could lead to a way to prevent them.
Even though it may seem like nobody wants to own up to, or report a foolish mistake, it is important to recognise that near miss information can be used to make changes, prevent accidents and save lives.
There is a multitude of reasons why things can go wrong:
- There may be a ‘blame culture’.
- A technician may lack experience or knowledge.
- There may be poor supervision.
- There may be a lapse of judgment.
- Someone may decide to cut a corner.
- There may be a false sense of safety.
- A near miss may not be reported.
- Procedures may be ineffective or inefficient.
- Someone may be overconfident.
- Communication may be poor.
You and those you work with can take steps to ensure near misses do not occur, and if they do, have the workplace culture in place to support the reporting process.
You can take time to assess what is going on. You’re less likely to have a lapse in judgement when tasks are though through properly.
Allow adequate time to complete tasks. Don’t encourage rushing.
Encourage near miss reporting (if necessary, reporting can be anonymous). You can ‘learn from failure’.
Ensure good standards of supervision. There should be enough manager(s) and/or supervisor(s).
Use the correct people for the task. Protect and teach those who are inexperienced.
Make sure that technicians are aware of the risks and the potential severity of an incident. Training and information is vital.
Ensure that communication is suitable and sufficient. Assess each task separately and ask yourself, “What’s different today?”
Ensure that procedures are kept under review. Work methods evolve and improve; make use of the most efficient and effective methods available.
Encourage a “no blame culture”. Where possible, ensure that technicians learn from their mistakes (rather than being punished for them).
It is also important to consider how you can encourage or incentivise workers to report and discuss near misses and experiences that they have encountered or heard about.
You can utilise toolbox talks or task assessment briefings; have a variety of topics around near misses, and encourage participation – it’s quite amazing to see the knock on effect once one person shares a near miss they experienced or heard about. These completed documents can also aid a business in demonstrating a commitment to safety.
It is also possible for businesses to review the management system’s procedures around ‘near misses’ and incident reporting to ensure that all workers can feel comfortable about reporting without fear of reprisal, or detriment to their position at work.
Human factors: Behavioural safety approaches – an introduction (also known as behaviour modification)
SafeWork Australia – Incident Reportin
IRATA International Topic Sheet No. 2: Near Misses: Learning from Failure
1 Frank E. Bird, Jr (1921 – 2007)