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Learning from Near Misses

The Close Calls Might Teach Us Valuable Lessons

by Gene Benson

Much has been written about learning from our mistakes. Accident analysis is all about learning from the mistakes of others. But we can kick that up a notch by also learning from the accident or incident that was narrowly avoided.

Aviation has been a leader in looking at the near misses. That would be studying the circumstances leading up to the narrowly avoided accident. Collection and analysis of this data has led to changes in procedures and practices that have undoubtedly prevented accidents. The key is to identify items that more frequently are cited as being a precursor to something more serious.

We are many years into a successful program administered by NASA called the Aviation Safety Reporting System. Pilots and other aviation professionals are provided with a means of reporting things, including their errors, that could have led to an accident. By reporting the event and providing information on how any errors might have been avoided, the person submitting the report is exempt from most enforcement actions by the FAA. Reports are de-identified by NASA before being sent to the FAA or being made public. The individuals submitting the reports are provided with a receipt bearing an identification number.

In the error-reduction field for other high-stakes industries, we modify the aviation systems to suit the specific operation. There are hurdles to be overcome but they can be managed. A key element is the consistent reporting of the near misses. People must not fear repercussions of reporting their close calls. This is handled by establishing an anonymous reporting procedure operated by a third party. Some operations in highly regulated industries are fearful of the reports finding their way to regulators. This is handled by working directly with the regulatory agency. Having the FAA and NTSB already onboard for this in aviation is a great help.

We can all be better by applying these same principles to our personal lives. A less formal, but also effective method for personal use is to simply make a mental note of each time you become aware of a near miss. For example, I once changed a light switch in the kitchen without incident. I was sure that I had turned the circuit breaker off before beginning. But, after connecting the wires, I flipped the switch and the light came on. I had turned off the wrong circuit breaker and I had worked on a live circuit with pliers and a screwdriver. Nothing bad happened, but one slip of the pliers or screwdriver could have really gotten my attention. It was a near miss. I made note to always verify that the circuit is dead and not just rely on the breaker box labeling.

For another example, I narrowly avoided getting rear ended on a busy highway in rush hour traffic. I wrote it off to some distracted driver. A few more miles up the road, another driver almost drove into the back of my car. (This was before the days of all the collision mitigation technology on cars.) A few more miles up the road, a driver in the lane next to me signaled for me to put down my window. She informed me that my brake lights were not working. Since that day, I learned to never assume that my brake lights are working. Each day before I move the car. I step on the brake pedal and watch in the mirror to see the brake lights reflect off something.

So, we can learn from our mistakes but we can also learn more from our near misses. If something almost ended badly but did not, that can also be a valuable learning opportunity. To make sure the event and the lesson enter our long-term memory. we must take time to think consciously about and verbally state what almost happened was and how we can avoid it in the future. It really does work.

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