Near‐Miss Incident Management in the Chemical Process Industry

Abstract

This article provides a systematic framework for the analysis and improvement of near-miss programs in the chemical process industries. Near-miss programs improve corporate environmental, health, and safety (EHS) performance through the identification and management of near misses. Based on more than 100 interviews at 20 chemical and pharmaceutical facilities, a seven-stage framework has been developed and is presented herein. The framework enables sites to analyze their own near-miss programs, identify weak management links, and implement systemwide improvements.

A near-miss management system architecture for the forensic investigation of software failures

“…Recognising an observed event or condition as a near miss requires a clear definition of what constitutes a near miss with various supporting examples. Organisations therefore spend considerable effort to formulate a simple and all-encompassing definition of near misses that is relevant for their respective business operations (Ritwik, 2002;Phimister et al, 2003). This definition can differ significantly from one industry to the next.…”

“…Root-cause analysis of near misses can be performed with investigation techniques taken from engineering disciplines, such as fishbone diagrams, event and causal factor diagrams, and failure mode and effects analysis (Phimister et al, 2003;Jucan, 2005;Hecht, 2007 Identifying near misses through observed physical events and conditions, as is done in many industries, is especially challenging in the software industry. Indeed, in the case of software applications, near misses might not even be visible as no system failure occurs and the events are virtual rather than physical.…”

How Bad is it? – A Branching Activity Model to Estimate the Impact of Information Security Breaches

“…A classic example of this are are near-miss events (Clement 1989, Muermann and Oktem 2002, Phimister et al 2003, Thomas 2009a, Vanderschaaf 1992, Wright and van der Schaaf 2004, which except for some small twist of fate could have turned into a major loss episode. It is vital that people and organizations recognize and learn from near-miss events.…”

Justification shift and uncertainty: why are low-probability near misses underrated against organizational routines?

“…Although this benefit is true only in retrospect, researchers argue that it is a good strategy to record and study near misses for organizations and industries. In the field of safety and risk management, the nearmiss management system has been an emerging tool that managers and engineers rely on to improve processes, standards, and procedures (e.g., Tamuz 1987;Phimister et al 2003;Macrae 2010;Oktem et al 2010). In the field of organizational management, near misses, once they occur, are not a curse that managers should never touch again but a blessing to embrace for a better future.…”

“…1 raises an important question on how the justification shift occurs. The lack of requirements and data is a reason why near misses are precious learning opportunities (Tamuz 1987;March et al 1996;Weick et al 1999;Phimister et al 2003;Oktem et al 2010). It is a contradiction if near misses are necessary to fill the "void" but the "void" makes near misses ineffective for experts and professionals to overcome burden of proof.…”