System thinking applied to near misses: a review of industry-wide near miss reporting systems

Abstract

Learning from near misses is an important component of maintaining safe work systems. Within safety science it is widely accepted that a systems approach is the most appropriate for analysing incidents in sociotechnical systems. The aim of this article is to determine whether industry-level near miss reporting systems are consistent with systems thinking. Twenty systems were identified, from a range of work domains, and were evaluated against systems thinking-based criteria. While none of the reporting systems fulfilled the full set of criteria, all are able to identify actors and contributing factors proximal to events in sociotechnical systems and many capture information on how accidents were prevented. It is concluded that the explanatory power of near miss reporting systems is limited by the systems currently used to gather data. The article closes by outlining a research agenda designed to ensure that near miss reporting systems can fully align with the systems approach.

Keywords:

• Near miss
• incident reporting
• reporting systems
• accident causation
• systems thinking

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This project was supported by funding from the Australian Research Council (ARC; LP150100287) in partnership with Australian Camps Association, Outdoor Council of Australia, The Outdoor Education Group, Sport and Recreation Victoria, Victorian YMCA Accommodation Services Pty Ltd, Outdoors Victoria, Outdoor Recreation Industry Council (Outdoors NSW), Outdoors WA, Outdoors South Australia, Queensland Outdoor Recreation Federation, Wilderness Escape Outdoor Adventures, Venture Corporate Recharge, and Christian Venues Association. Paul Salmon’s contribution was funded through his current Australian Research Council Future Fellowship (FT140100681). Natassia Goode’s contribution was funded through the University of the Sunshine Coast and the State of Queensland through the Department of Science, Information Technology and Information, Advance Queensland Research Fellowship.

Notes on contributors

Brian Thoroman

Brian Thoroman M.S. is a researcher within the Centre for Human Factors and Sociotechnical Systems at the University of the Sunshine Coast. His research focuses on the application of systems thinking to the analysis of near miss incidents.

Natassia Goode

Dr. Natassia Goode is a senior research fellow and theme leader for Organisational Safety at the Centre for Human Factors and Sociotechnical Systems at the University of the Sunshine Coast.

Paul Salmon

Professor Paul M. Salmon is an Australian research council future fellow and holds a chair in Human Factors at the University of the Sunshine Coast (USC). He is the inaugural director of the Centre for Human Factors and Sociotechnical Systems at USC.