Four Reasons, Eight Lessons Reluctance to Report May Not Be Caused By Fear BY PHIL LA DUKE Conventional wisdom holds that people won’t report near misses because they fear repercussions associated with admitting that they screwed up, but in most cases, conventional wisdom is wrong. Near misses — incidents where no one was seriously injured but COULD have been — provide us with an opportunity to learn about system failures and correct the hazards before a catastrophic incident happens. But people are reticent to report these mishaps, and organizations lose this opportunity. Why? Many, if not most safety professionals land on “people are afraid they’ll get in trouble,” and while this is sometimes the case, more often it’s not. In the past two weeks, I’ve been involved with three near misses that I did not report. Why? Was I afraid? What was it about these incidents that made me balk at reporting them? In each case I did nothing wrong. In the first case, I was trying to turn off a light in a cubicle and as I felt along the bottom of the light to locate the power switch, I instead crammed my palm into the plastic light cover; it hurt, but it didn’t injure me. Had I been hurrying or had the plastic been jagged I could have been injured—from a safety standpoint I could have been cut, burned or received an electrical shock. The second near miss was a slip on the snow walking down concrete steps into a traffic area. I slipped but managed to grab the handrail and while I was off-balance I didn’t fall; so, another near miss. I did a quick analysis and again, I was blameless. I wasn’t walking too fast, I was wearing appropriate footwear, and I was walking in an area intended for pedestrians. The steps were sloped down and forward and being concrete and smooth, the slightest moisture (never mind ice and snow) can easily cause a loss of traction. To further complicate things, there are no sidewalks from this parking lot to the entrance forcing people to walk on the snow-covered grass or in traffic. Not only is an injury probable, but if an injury does occur, the incident promises to be severe or even fatal. The third near miss involved me catching the heel of my shoe on a step and falling forward. In this case, I was also able to catch myself using the rail and felt only mild discomfort in my knee and ankle. Things most certainly could have been much worse but I was lucky. In this case, as with the others, I was not distracted, I was following procedures, and I was not behaving unsafely. But, I didn’t report any of these near misses and here’s why: 1. After the first incident, I asked a colleague if the organization had a near miss reporting process. She asked me what that was. Clearly, my safety jargon was getting in the way so I asked her differently, “how do we report injuries?” She explained that there was a system, but she didn’t know what it was and that I should ask the department head. Reason number 1: reporting a near miss is hard. 2.When I asked the head of the department about near miss reporting I got the same general response: I don’t know. When she asked me why I was inquiring, not in an accusatory tone, but in more of a concerned, “Did you want to report something?” sort of way, I found myself dismissing the near miss as too trivial to report (when was the last time somebody died looking for a light switch?) Reason number 2: Because there wasn’t any serious, consequence resulting from the near miss, it wasn’t worth reporting. 3. After my near slip on the ice, I noticed a group of people talking about the fact that the lack of side walks meant that they had to walk into traffic and that the few sidewalks that did exist were slick with ice. I shared my experience with the icy steps, and one person responded, if you call facilities they tell you that you have to fill out a work order and even when you do, they don’t do anything. Reason number 3: Because people believe, the organization does not value the information. 4. By the time I caught my heel on the step and almost fell, I was fully indoctrinated into a culture that did not report near misses, but I desperately wanted to avoid being one of those people that ignored the problem. I mentally resolved to find the process and report these near misses. Then I mentally walked myself through the scenario of me reporting these three near misses and decided that I would look like: a) an accident-prone klutz, b) I would be seen as Chicken Little and c) nothing would be done with the information anyway. Reason 4: The risk to reward ratio is stacked against anyone who reports a near miss. For the record, this organization has an amazingly nurturing and employee centric culture. Employee development is encouraged and training is a key priority. And yet I was clearly and quickly “told” that near miss reporting was not a priority, not valued, and the organization was not concerned with my safety, despite none of these things being true. So what did I take away? Several things: 1. People feel foolish when they do something that results in a near miss even if they did nothing wrong, and people who feel foolish are unlikely to advertise it. 2. People will only report a near miss if it is easy to do so, and ideally, if doing so is anonymous. Advertising the process is key. 3. If an organization solicits people to report, hazards or near misses it had better be ready to respond quickly and effectively to the hazard. 4. Even a veteran safety professional is not immune to peer pressure. 5. The fear of being made to look like a whiner or a wimp is greater than the desire to improve the safety of the workplace. 6. You absolutely must have a blame-free reporting process. If I was reluctant to report something that happened for which I was in no way responsible, how much more reluctant will I be for an incident where my behavior played a role in causing the incident? 7. My guess is that near miss reporting will most likely only happen in cases where it is virtually impossible not to report it. This needs to change but unless near miss reporting is given the same priority as reporting a serious injury, we are doomed to a world of ignorance. 8.We get what we measure. Nobody seemed very interested in collecting my information so I was certainly not going to push it. Sadly, while we preach a good fight when it comes to near miss reporting, we don’t do a good job in executing because many of us start with the assumption that people won’t report near misses because they are afraid. Until we move beyond that mindset, our organizations will be at risk and we will continue to underestimate our risk of serious injuries and fatalities. FSM Phil La Duke, a safety consultant, can be reached at philipladuke@comcast.net.