NEAR MISSES - CAN THEY BE LEVERAGED TO PREVENT SEVERE ACCIDENTS?

NEAR MISSES - CAN THEY BE LEVERAGED TO PREVENT SEVERE ACCIDENTS?

Amit Shah, Shruti Singh and Arash Azadegan, PhD

If learning from mistakes is too costly, could learning from near-misses be a more reasonable alternative in mitigating the effect of accidents? A near-miss is an event, observation, or situation that possesses the potential for improving a system’s performance and flexibility in the face of a disruptive force. On the upside, recognizing near misses helps in making future decision making by not only identifying the root cause of the issue, but by also helping take more educated actions. However, for near misses to work effectively, recognition, disclosure and classification of near misses is very important. For instance, how far the performance by members of a supply network can be stretched (before it breaks) is one potential benefit of near-misses.

One way for this recognition to happen is through near-miss mockups or experiments. Closely related to emergency fire alarm drills, near miss experiments can help identify weak links and prepare the system to cope up with future accidents. By introducing small and deliberate near-misses, we identify its weaknesses and hope to make it more resilient in coping with more serious circumstances. Small-scope experiments help find out further shortcomings and loopholes that can be filled so as to minimize future high impact occurring from accidents. This will not only allow us to leverage near misses to prevent future disruptions in the supply chain but, but can also provide the supply chain with more flexibility and adaptability. Thus, it will prepare the industry for similar disruptions in the future and will also give it a chance to figure out what else they could change to be better prepared if any of our proposed experiments were to actually occur. Since these experiments will be in controlled conditions, it will not impact the supply chain, but they will certainly give us an idea of what needs to be changed in order to handle a similar or a larger crisis.

Another aspect of near miss that be looked at is the extent of the impact it has on the operational structure. Near misses which have a smaller impact are easier to reproduce and control, whereas, larger near misses are more practical, more extensive and more insightful but at the same time are more complex to reproduce. The larger near misses are the ones that will test the limitations of the supply chain and may provide for a steeper learning curve. Higher sloped learning curve provides the basis to help more easily identify, prevent or mitigate major accidents.

A third aspect of near misses importance is their probability of occurrence. The ones with the most probability provide the most visibility of what could go wrong. But the ones with the least probability could be the one to cause most number of hidden problems. These are the ones for which a supply chain may not be prepared and hence, the ones which may lead to potential accidents. Testing with these scenarios is of immense importance to manage the risk associated with them and also to expose the system’s limitations during these scenarios.

        Fire drills and war games are common learning tools in fire departments and the military. Indeed, running exercises are frequent means for testing military preparedness. As supply chains become more competitively fierce, it may be necessary to seriously consider the need for near-miss “mockups”. After all, how did each of us learn how to ride a bike without training wheels if mom or dad let go of the handle, knowing that they would catch us before falling over?  Some parents run this particular near-miss exercise in a soft, grass-laden backyard to curtail any possible bruises. Such is the spirit behind running near-miss experiments. Toughening through learning with minimal possible damage.