A Novel Near-Miss Event Model with a Quantitative Assessment Methodology

Abstract

A new near-miss event model and quantitative assessment methodology are presented, which support the identification and understanding of the near-miss phenomenon. Current approaches to near-miss assessment are a re-application of hazard analysis types, which were not developed for near-miss assessment. Such analysis fundamentally assumes an understanding of the hazard’s existence. A near-miss is an event where all the elements of a mishap congregated, but — without deliberate mitigation — did not produce harm. It signals a system weakness that was not previously identified and mitigated. In complex, procedurally driven, tightly coupled or strongly self-deterministic systems, near-miss events may be the only indication of such a system weakness. Hazard analysis is dependent on statistical analysis and identification of hazards. No safety analysis can produce a perfect understanding of all risk. This imperfect understanding of risk carries questions regarding the nature of such imperfectly defined risk. Near-miss events provide an untapped source of information about defined and unidentified risk. This new near-miss event model and quantitatively driven assessment methodology allow the system safety professional to identify and assess the nature and complexity of risk flowing from a near-miss event.