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Near miss incident

  • 1.  Near miss incident

    Posted 05-03-2020 12:30
    The CCPS define to term:

    Accident: An incident that results in significant human loss (either injury of death), sometimes accompanied by significant property damage and/or a significant environmental impact.

    Incident: An unplanned sequence of events with the potential for undesirable consequences.

    Near miss incident: An unplanned sequence of events that could have caused harm or loss if conditions were different or if the events were allowed to progress, but actually did not.

    ¿What is the diferent between "Incident" & "near miss incident"? ¿What is the adequate translation "near miss incident" in spanish? for example?

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    Victor Palacios Chuy
    Enginnering Supervisor
    Procesadora De Gas Parinas
    Perú
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  • 2.  RE: Near miss incident

    Posted 05-05-2020 02:09
    Following examples may be suitable :

    Near miss incident : An object has fallen from top and a person just narrowly escaped (or) there was a sudden flange leak, but nobody injured.

    In both cases,  there was a possibility of injury.

    Incident: Flash over 
    occurred or MCB tripped.

    Others may add their opinions.

    Regards,

    Rama

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    KOTTI KUMAR Commission,Revampof
    Ex. Head Plant Operations
    INDO GERMAN PETROCHEMICALS LIMITED
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  • 3.  RE: Near miss incident

    Posted 05-05-2020 08:21
    In English language, most organizations use the term "incident" as the single term for both actual and potential loss events.  An accident is an incident with actual losses.  A near miss is an incident with potential losses.  So the sentences "We investigate all incidents" is equivalent to "We investigate all accidents and near misses."  It is not really necessary to use the word "incident" after "near miss," but if someone does, what they are really saying is the "near miss type of incident."

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    Donald Lorenzo PE
    Director, Training Solutions
    ABS Group
    Knoxville TN
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  • 4.  RE: Near miss incident

    Posted 05-05-2020 14:13
    Edited by Steve Cutchen 05-05-2020 14:14
    I can certainly see the confusion with a term such as "near miss incident." If someone were to throw a rock at me and "nearly miss," it would hurt!

    A more correct description would be a "near hit incident." But we are stuck with it.

    That said, the term "near miss incident" is used for an incident that is judged to have not turned out as bad as it could have.

    There are personal injury near misses and process safety near misses. My background focuses on process safety.

    Process safety near-misses are gifts. The initiating event took place, but the consequence was not as bad as was envisioned. The lessons have been exposed without the worst consequence. And there are reasons for this that investigation can reveal.

    Investigating a near-miss provides the understanding necessary to learn from it.

    A non-resilient organization often simply applies Outcome Bias---nothing too bad happened so it's all good, or it's unimportant---and fails to incorporate lessons from the event. When the initiating event recurs, perhaps this time the details or the response is different, and a significant process safety event occurs.

    A resilient organization investigates near-misses as if they were incidents. They broaden the analysis beyond just the specifics of the incident and develop general findings. Incorporating the explanation of near-misses often allows improvement of
    1) Safety-I systems, e.g., additional or improved operating procedures, and more complete process hazard reviews with better estimates for event frequency, and
    2) Safety-II systems, e.g., revised response framework and more complete safety envelope understanding.


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    Steve Cutchen
    Investigator, retired
    US Chemical Safety Board
    Houston TX
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  • 5.  RE: Near miss incident

    Posted 05-06-2020 02:31
    ​Near miss : it is an unplanned event that is not result injury , illness or damage but it had a potential to do so, e.g. worker drops a spanner from a height- scaffold and some one is passing through that area but no injury or harm.

    Incident : it is an unplanned event that is not result injury  but it has a property damage not  an injury. e.g. worker operating machine and it get damage due to over load but not injured worker.

    Accident : it is an unplanned, unwanted event which leads to injury, damage or loss of property or fatality. e.g. sudden gas leaks from flange joint and get fire and loss of life due to fire and damage property .

    in all above scenario reporting is required for investigation and to avoid replicates scenario.

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    Hiteshkumar Patel PE,CSP
    SR. ENGINEER
    Toyo Engineering India Ltd
    Surat City
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  • 6.  RE: Near miss incident

    Posted 05-06-2020 03:38
    Using Google Translate, since my Spanish is rudimentary, “near miss incident” returns “casi accidente”. Switching it back to English, the tool shows the literal translation, “almost accident”.

    That seems to be a valid alternate term to use in English but like others have noted the “near miss” words are etched in our Safety vocabulary. As you learn and teach people in Spanish, does a “casi accidente” cause you to investigate, find ways to prevent an actual accident and save lives, limbs or property? I hope it does as almost dead is too close.

    In safety and process safety, a near miss is a gift to be used for positive change.


    ZERO Is the Objective,
    Gary Koehler
    Houston




  • 7.  RE: Near miss incident

    Posted 23 days ago
      |   view attached
    I'd like to expand on a great point that Steve made:

    "A non-resilient organization often simply applies Outcome Bias---nothing too bad happened so it's all good, or it's unimportant---and fails to incorporate lessons from the event. When the initiating event recurs, perhaps this time the details or the response is different, and a significant process safety event occurs."

    A similar concept, called "Normalization of Deviance," is one of the factors that led to the Challenger space shuttle disaster.  The term "Normalization of Deviance" was coined by a sociologist evaluating the event.  She described it as follows:

    "Social normalization of deviance means that people within the organization become so much accustomed to a deviation that they don't consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety."  -Diane Vaughan, 1996


    In my organization, we have used this example as part of our training regarding both safety issues and process/product quality issues.  The same tendency to slowly accept greater and greater deviation from the original design and/or specifications can apply in a variety of areas, and can - at worst - lead to catastrophic consequences.  This is why a "near miss" ( or Steve's alternate "near hit") incidents should be used as critical opportunities to learn new information, to reinforce the standards and culture in regards to safety, process operation, product quality, etc.

    There is an interesting brief presentation available from NASA about this concept, attached as PDF and found at the link below.

    https://sma.nasa.gov/docs/default-source/safety-messages/safetymessage-normalizationofdeviance-2014-11-03b.pdf?sfvrsn=c5421ef8_4



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    Andrew Riederer
    Quality Operations Manager
    Boehringer Ingelheim
    Columbus OH // Athens, Greece
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  • 8.  RE: Near miss incident

    Posted 21 days ago
    Good catch, Steven, on the language of "near miss".  We have a lot of language terms that are blatantly incorrect and probably have consequences.  

    Here's another one, very recent:  social distancing.   We should say "physical distancing".

    Bill Stuble
    Design20FIRST  LLC
    Cora, WY





  • 9.  RE: Near miss incident

    Posted 21 days ago
    "Here's another one, very recent:  social distancing.   We should say "physical distancing"."

    Hah! I agree!
    We need to use what we can to try to maintain social connections as intimate as possible while our physical connections have to remain separated.  


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    Steve Cutchen
    Investigator, retired
    US Chemical Safety Board
    Houston TX
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  • 10.  RE: Near miss incident

    Posted 21 days ago
    Though topic is different, agree with Mr.Bill. Proper word is physical distancing not social distancing.

    Regards,

    Rama





  • 11.  RE: Near Misses

    Posted 20 days ago
    Terminologies are in place as assists. So long as personnel know the value behind reporting and analysing events which act like alarms before actual accidents, we can live with them.

    Being associated with Process Safety, I see Near misses as events where the trajectory of event progression is stopped by one of the barriers that we have built around the hazards. Refer James Reason's Swiss Cheese Model. This can be due to the way the barrier was built or maintained or just pure luck.

    But the fact is a barrier (Risk Control System) actually worked as intended and stopped the event becoming an accident (i.e. the maximum possible consequences were not realized).

    An example to see this is the Exxon Mobil FCCU Explosion that the US CSB put in as a near miss as the HF Tank in the nearby Alkylation unit was not damaged by the debris. It fell nearby. The Explosion event would be termed an incident normally, and the additional event of the debris falling near the HF Tank as the near miss.

    It just means the event missed becoming a catastrophe, and gave us another opportunity to learn to avoid the real danger. You can translate accordingly. I have not found literal translations of the terms helpful in the local languages here. They lack the depth, an explanation provides.

    Cheers
    Kaushik Jayaraman

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    Kaushik Jayaraman
    Senior Manager (Lead) - Process Safety
    Nayara Energy Limited
    Jamnagar
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