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background and no training in workplace health and safety, and not much more from the service providers. The competitive nature of the industry and in some countries litigious nature of the population, tends to discourage sharing of information which legal advisors may consider risky, and resource constraints contributes to the underreporting of near misses in recreational diving. Safety requirements are generally imposed by certification agencies and to a lesser extent by commercial level occupational health and safety authorities. The service provider is mostly uninvolved beyond basic compliance with rules. Changing these attitudes would require either a cultural shift towards prioritizing safety and collaboration the major stakeholders in the diving community, or a clear threat to profits. There are a few non-profit organisations involved in recreational diver safety, such as
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enlightened to report these close calls as there has been no disruption or loss in the form of injuries or property damage. Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and reporting near miss incidents can make a major difference to the safety of workers within organizations. In the heavy construction industry, near miss reporting software allows crews to find and document opportunities that help reduce safety risks as the software tracks, analyzes and calls attention to near misses on the job site to help prevent future incidents. History has shown repeatedly that most loss producing events (accidents) were preceded by warnings or near accidents, sometimes also called close calls, narrow escapes or near hits.
362:, and some of the member oriented technical diving organisations, which do the majority of research into recreational dive safety, and analyse what information on near misses is available. Part of the problem in getting divers to report near misses is the stigma attached to what are perceived by some as violations of safety rules, without due analysis of why the rules were violated, or even whether they were strictly applicable, as there is a tendency among training agencies to prescribe behaviour as appropriate, correct, and necessary without going into the reasons for the rules, and as a consequence most divers are not in a position to make a fair and informed judgement, or even to know that there may be an alternative or specific scope to the received rules.
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injury or death of participants, with associated risk of liability for the operator and participants. Certifying and safety agencies gather risk data reported in the recreational scuba diving industry, but there is no published research specifically regarding recreational divers and dive centres attitudes and perceptions of safety. Avoidable accidents continue to occur in recreational diving in spite of long established education by the training agencies, which is mainly focused on essential skills specified by training standards. More awareness of risk, and a changed attitude toward safety would help to reduce the number of such incidents.
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one fatal accident in about 4.5 million departures, from one in nearly 2 million in 1997. Furthermore, according to a report in The New York Times on
Wednesday, November 15, 2023 in response to a series of near collisions, the Federal Aviation Administration sought the input of external experts. The experts recommended addressing the shortage of air traffic controllers and upgrading outdated technology.
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A book was published in 2021 providing personal recollections of near misses by a number of well known and influential technical divers to counteract this attitude and show that even the most respected divers are occasionally inattentive, unlucky, or make mistakes, and have survived by luck, skill or
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One of the primary workplace problems near miss incident reporting attempts to solve directly or indirectly is to try to create an open culture whereby everyone shares and contributes in a responsible manner. Near miss reporting has been shown to increase employee relationships and encourage teamwork
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An ideal near miss event reporting system includes both mandatory (for incidents with high loss potential) and voluntary, non-punitive reporting by witnesses. A key to any near miss report is the "lesson learned". Near miss reporters can describe what they observed of the beginning of the event, and
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Solutions
Foundation. Law enforcement members are to submit voluntary reports when involved in or having witnessed or become aware of a near-miss event. Near miss reports take minutes to submit, can be submitted anonymously and are not forwarded to regulatory or investigative agencies, but are used
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A total of 1,439 U.S. law enforcement officers died in the line of duty during the past 10 years, an average of one death every 61 hours or 144 per year. There were 123 law enforcement officers killed in the line of duty in 2015. In 2014, the Law
Enforcement Officer (LEO) Near Miss Reporting System
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was established, funded by grants from the U.S. Fire
Administration and Fireman’s Fund Insurance Company, and endorsed by the International Associations of Fire Chiefs and Fire Fighters. Any member of the fire service community is encouraged to submit a report when he/she is involved in, witnesses,
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There is a combination of a factors hindering the reporting of near misses in the recreational diving industry. There is a lack of structured reporting mechanisms, a lack of clarity of what would constitute a near miss, or reportable incident, as most recreational divers have very little personal
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without regulatory action. Some familiar safety rules, such as turning off electronic devices that can interfere with navigation equipment, are a result of this program. Due to near miss observations and other technological improvements, the rate of fatal accidents has dropped about 65 percent, to
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defines a near miss as an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near misses also may be referred to as near accidents, accident precursors, injury-free events
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There are factors for a near miss related to the operator, and factors related to the context. Fatigue is an example for the former. The risk of a car crash after a more than 24h shift for physicians has been observed to increase by 168%, and the risk of near miss by 460%. Factors relating to the
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Recreational divers are personally responsible for their own actions and are largely unregulated. Risk awareness and personal and peer group attitudes are determining factors in triggering dive accidents. Recreational scuba diving operations are exposed to risks which can develop into incidents,
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Most safety activities are reactive and not proactive. Many organizations wait for losses to occur before taking steps to prevent a recurrence. Near miss incidents often precede loss producing events but are largely ignored because nothing (no injury, damage or loss) happened. Employees are not
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Getting a very high number of near misses reported is the goal as long as that number is within the organization's ability to respond and investigate - otherwise it is merely a paperwork exercise and a waste of time; it is possible to achieve a ratio of 100 near misses reported per loss event.
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There is a significant difference between professional and recreational diving. Professional diving has long established systems for risk assessment, incident mitigation, codes of practice and industry regulation, which have made it an acceptably safe occupation, but at considerable cost. The
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In a near miss, all the involved parties are alive to provide detailed information. In fatal incidents much of the critical information may be lost. In some cases the survivors may provide useful information on how a fatality was avoided.
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was established, with funding support from the U.S. Department of
Justice's Office of Community Oriented Policing Services (COPS Office). Since its launch, the LEO Near Miss system has established endorsements and partnerships with the
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covering medication or transfusion reactions, communication or consent issues, wrong patient or procedures, communication breakdown or technology malfunctions. An analysis of incidents allows safety alerts to be issued to AORN members.
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The rate of fire fighter fatalities and injuries in the United States is unchanged for the last 15 years despite improvements in personal protective equipment, apparatus and a decrease in structure fires. In 2005, the
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Provides immense opportunity for "employee participation," a basic requirement for a successful workplace health and safety program. This embodies principles of behavior shift, responsibility sharing, awareness, and
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Near misses are smaller in scale, relatively simpler to analyze and easier to resolve. Thus, capturing near misses not only provides an inexpensive means of learning, but also has some equally beneficial spin offs:
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is a prerequisite for free reporting. An environment in which the organisation is quick to apportion blame without first analysing what went wrong, and why it went wrong will discourage full and accurate
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To prevent the near miss from happening again, the organization must institute teamwork training, feedback on performance and a commitment to continued data collection and analysis, a process called
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Achieving and investigating a high ratio of near miss reports will find the causal factors and root causes of potential future accidents, resulting in about 95% reduction in actual losses.
185:, and that earlier another airline had told its pilots, but not other airlines, about a similar near miss. The ASRS identifies deficiencies and provides data for planning improvements to
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near
Washington, D.C., killing all 85 passengers and seven crew in 1974. The investigation that followed found that the pilot misunderstood an ambiguous response from the Dulles
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In terms of human lives and property damage, near misses are cheaper, zero-cost learning opportunities (compared to learning from actual death, injury or property loss events)
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is an unplanned event that has the potential to cause, but does not actually result in human injury, environmental or equipment damage, or an interruption to normal operation.
173:(ASRS) has been collecting confidential voluntary reports of close calls from pilots, flight attendants, air traffic controllers since 1976. The system was established after
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1031:
Lucrezi, Serena; Egi, Salih; Pieri, Massimo; Burman, Francois; Ozyigit, Tamer; Danilo, Cialoni; Thomas, G.; Marroni, Alessandro; Saayman, Melville (23 March 2018).
1033:"Safety Priorities and Underestimations in Recreational Scuba Diving Operations: A European Study Supporting the Implementation of New Risk Management Programmes"
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and, in the case of moving objects, near collisions. A near miss is often an error, with harm prevented by other considerations and circumstances.
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context include time pressures, unfamiliar settings, and in the case of health care, diverse patients, and high patient-to-nurse staffing ratios.
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287:(the Confidential Incident Reporting and Analysis System) is a confidential reporting system modelled upon ASRS and originally developed by the
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252:, a US-based professional organization of perioperative registered nurses, has put in effect a voluntary near miss reporting system called
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In the United
Kingdom, an aviation near miss report is known as an "airmiss" or an "airprox", an air proximity hazard, by the
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mandated its use throughout the whole UK rail industry. Since 2006 CIRAS has been run by an autonomous
Charitable trust.
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Reporting of near misses by observers is an established error reduction technique in many industries and organizations:
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236:, a national, independent non-profit organization, operates the system and has received additional support from the
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or is told of a near-miss event. The report may be anonymous, and is not forwarded to any regulatory agency.
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228:(IACP), the International Association of Directors of Law Enforcement Standards and Training (IADLEST), the
330:, which are anonymised reports of accidents and near misses from the offshore diving industry published by
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473: – Engineering discipline which assures that engineered systems provide acceptable levels of safety
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Researchers recognise that more information on near misses would facilitate analysis of diving safety.
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152:: People are discouraged from reporting near misses if there is never any feedback provided.
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to provide analysis, policy and training recommendations to the law enforcement community.
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919:"Police Foundation Receives Public Safety Grant Award from Motorola Solutions Foundation"
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550:"Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction"
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Lenert, L.A.; Burstin, H.; Connell, L.; Gosbee, J.; Phillips, G. (1 January 2002).
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which inform the industry and encourage independent evaluation of the incidents.
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National Fire
Fighter Near-Miss Reporting System (www.firefighternearmiss.com):
425: – State in which risks associated with aviation are at an acceptable level
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Safety
Management: Near Miss Identification, Recognition, and Investigation.
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467: – Method of identifying the fundamental causes of faults or problems
416: – Incident which nearly precipitated nuclear warfare, example of a
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868:"National Law Enforcement Officers Memorial Fund: Law Enforcement Facts"
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455: – Prevention, reduction, reporting, and analysis of medical error
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714:"Staffing and Technology Woes Threaten Aviation Safety, Report Says"
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Aiken, LH; Clarke, SP; Sloane, DM; Sochalski, J; Silber, JH (2002).
431: – System to allow safety problems to be reported in confidence
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Captures sufficient data for statistical analysis; trending studies.
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197:. Since reporting began, aircraft near misses continue to decline.
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538:, Talk of the Nation, National Public Radio, 13 December 2006.
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and factors that may either amplify or ameliorate the result.
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modeled upon the Aviation Safety Reporting System to monitor
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for use in the Scottish rail industry. However, after the
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to identify the defect in the system that resulted in the
479: – Concept for keeping aircraft safe distances apart
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professional diving industry delivers materials such as
1112:"Does The Sport Diving Community Learn from Accidents?"
663:"Surely if we blame and punish, things will be safer?"
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The events that caused the near miss are subjected to
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387: with: need for a just culture,. You can help by
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964:"Federal Patient Safety Initiatives Panel Summary"
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222:National Law Enforcement Officers' Memorial Fund
208:National Fire Fighter Near-Miss Reporting System
92:the factors that prevented loss from occurring.
648:Near-Miss Incident Reporting – It's About Trust
30:"Close call" redirects here. For the film, see
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266:National Aeronautics and Space Administration
226:International Association of Chiefs of Police
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844:"Database seeks to lower firefighter deaths"
332:International Marine Contractors Association
262:United States Department of Veterans Affairs
352:Rebreather Education and Safety Association
232:(ODMP) and the Below 100 organization. The
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276:through voluntary, confidential reports.
140:Fear of blame and other repercussions: A
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636:(Report). Process Improvement Institute.
499:"Everybody gets to go home in one piece"
414:1983 Soviet nuclear false alarm incident
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631:Gains from Getting Near Misses Reported
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1158:Columbia Journalism Review:‘Near Miss’
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749:(first ed.). Osprey. p. 26.
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437: – Incorrect or inaccurate action
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126:in creating a safer work environment.
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687:Wald, Matthew L. (October 1, 2007).
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842:Mandak, Joe (September 18, 2005).
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689:"Fatal Airplane Crashes Drop 65%"
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356:National Speleological Society
313:Human factors in diving safety
157:Safety improvements by reports
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1110:Lock, Gareth (5 April 2023).
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661:Lock, Gareth (2 July 2022).
179:Dulles International Airport
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712:Walker, Mark (2023-11-15).
526:DANIELLE OFRI, MAY 28, 2013
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321:Underwater diving emergency
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952:Retrieved on July 16, 2006
801:Civil Aviation Authority:
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230:Officer Down Memorial Page
169:In the United States, the
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812:, Retrieved July 16, 2006
505:. National Safety Council
293:Ladbroke Grove rail crash
289:University of Strathclyde
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1050:10.3389/fpsyg.2018.00383
923:www.policefoundation.org
747:A Dictionary of Aviation
745:Wragg, David W. (1973).
568:10.1001/jama.288.16.1987
536:When Doctors Don't Sleep
477:Separation (aeronautics)
195:Civil Aviation Authority
1037:Frontiers in Psychology
1010:CIRAS Charitable Trust
832:Retrieved July 16, 2006
369:a combination of both.
317:Scuba diving fatalities
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183:air traffic controllers
177:crashed on approach to
771:"Air Proximity Hazard"
108:continuous improvement
1129:Kas, Stratis (2021).
974:(6 Suppl 1): s8–s10.
968:J Am Med Inform Assoc
667:www.thehumandiver.com
348:British Sub-Aqua Club
268:(NASA) developed the
135:Barriers to reporting
344:Divers Alert Network
201:Fire-rescue services
980:10.1197/jamia.M1217
899:www.leonearmiss.org
465:Root cause analysis
459:Road traffic safety
328:IMCA Safety flashes
97:root cause analysis
948:2006-07-17 at the
828:2006-07-18 at the
808:2006-08-13 at the
718:The New York Times
693:The New York Times
596:. 15 December 2021
471:Safety engineering
447:Maternal near miss
418:nuclear close call
148:Failure to report
1140:978-1-5272-6679-7
783:on August 1, 2014
614:McKinnon, Ron C.
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1167:Categories
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904:2016-11-14
877:2016-11-14
853:2006-07-08
787:August 29,
731:2023-11-19
698:2007-10-01
484:References
307:See also:
245:Healthcare
145:reporting.
51:close call
43:near death
32:Close Call
18:Close call
1092:10 August
943:SafetyNet
848:USA Today
726:0362-4331
254:SafetyNet
39:near miss
1069:29628904
998:12386172
946:Archived
826:Archived
806:Archived
576:12387650
408:See also
238:Motorola
165:Aviation
150:feedback
47:near hit
1116:InDepth
1060:5876297
1043:: 383.
600:14 June
509:28 June
1173:Safety
1137:
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672:3 July
574:
350:, the
319:, and
64:Causes
1178:Error
781:(PDF)
774:(PDF)
634:(PDF)
435:Error
285:CIRAS
101:error
1135:ISBN
1094:2024
1065:PMID
994:PMID
789:2014
751:ISBN
722:ISSN
674:2022
602:2022
594:HCSS
572:PMID
555:JAMA
511:2021
280:Rail
260:The
250:AORN
57:OSHA
1055:PMC
1045:doi
984:PMC
976:doi
823:FAQ
564:doi
560:288
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