By Brie DeLisi and Josh Williams
Does your organization promote a culture of reporting or a fear of punishment surrounding close call events? Recently an air traffic controller in Switzerland was actually convicted in Swiss court for reporting a near miss...
On March 15, 2011 an air traffic controller in Zurich, Switzerland reported a close call. Two pilots, on intersecting runways, were given takeoff clearance in rapid succession. As a result, two airplanes were on a potential collision course at high speed. Fortunately, one of the pilots diverted his path in time to avoid a possible collision. Rather than applaud the controller for bringing awareness to the situation and potentially preventing a future disaster, criminal proceedings were initiated against him by the Swiss Courts and he was convicted and fined fine of 18 900 francs in December 2018.1
What message did this handling of the close call report send to the controller and other airline personnel?
The Air Traffic Controllers European Union Coordination2
and The Netherlands Guild of Air Traffic Controllers have both issued statements that this conviction is harmful to the safety of the aviation industry: “Aviation safety benefits greatly from an atmosphere of trust in which professionals are encouraged to report and provide essential safety-related information, without fear of being punished for actions, omissions or decisions which are commensurate with their experience and training.”3
Issuing punitive measures with close call reporting is harmful to a company’s safety culture and will drive near hit reporting underground. Employees will avoid reporting close calls and minor injuries if they believe they are going to be punished for doing so. The purpose of reporting near misses and minor injuries is to avoid serious injuries in the future.
Improving close call (i.e., near hit, near miss) reporting helps prevent future serious injuries in organizational settings. OSHA and the National Safety Council define a near miss as “An unplanned event that did not result in injury, illness or damage – but had the potential to do so.”4
For instance, skidding off the side of the road in icy conditions is a close call. Slamming into a tree after doing so is an incident.
Organizations with a strong safety culture avidly support reporting near misses to prevent future and more serious reoccurrences. Some even incentivize reporting with company-wide recognition, raffles, and rewards to support a culture of reporting. Company leaders should follow these guidelines with close call processes:
- Keep the reporting process as simple as possible.
- Create a learning environment to openly discuss the details of near hits.
- Share close call information with all employees to raise situational awareness.
- Prioritize and address close calls depending on the severity and likelihood of incidents occurring.5
- Use close call information to identify system weaknesses and failures.6
- Identify solutions (e.g., facility improvements, training) for close calls with input from employees when appropriate.
- Advertise these improvements with all employees to demonstrate organizational commitment to safety and boost morale.
- Consider using near miss data in predictive models to prevent future incidents.7
As an example, an employee at a Virginia soft drink bottling company reported that a large stack of empty pallets nearly fell on her as she walked through the warehouse. After meeting with employees in the area, the safety director chose to set height limits on stacked pallets in the facility and decided that all empty pallets would be stored in a covered outdoor area. By filling out a near hit form, this employee helped ensure that she and other employees wouldn’t be injured by falling pallets in the future.
Bottom Line: Close calls and minor injuries will be swept under the rug if employees believe they’ll be punished for reporting them. Near hits are teachable moments that help keep people safe because a) employees are made aware of and learn from potential hazards and b) organizational leaders receive information they need to make system improvements. Close call reporting, when done correctly, is a powerful tool to improve safety culture and prevent serious injuries and fatalities.
At Propulo, we partner with organizational leaders to improve close call reporting and other key safety systems to achieve a culture of Safe Production. If your organization is actively striving to improve cultural maturity, we’d love to discuss our innovative ‘People Meet Process’ approach and how we might be able to help you.
1. von Ledebur, Michael (2018). Nine dramatic seconds in the tower and a start-off order that came too late. Neue Zürcher Zeitung. https://www.nzz.ch/zuerich/9-dramatische-sekunden-im-tower-und-ein-startabbruchbefehl-der-zu-spaet-kam-ld.1444357
2. ATCEUC (2018). Swiss Prosecutors are endangering the safety of European Aviation. http://www.atceuc.org/uploads/docs/20181216-press-release-on-switzerland-issue.pdf.
3. VNLG (2018). Statement on the conviction of a Swiss air traffic controller. https://vnlg.nl/wp-content/uploads/2018/12/VNLG-Statement-on-Swiss-conviction-14-12-2018.pdf.
4. Morrison, K. W. (2014). Reporting near misses: Why are they important, and how can safety pros get employees involved? Safety and Health Magazine online.
5. Howard, K. (2012). Everybody gets to go home in one piece: How reporting close calls can prevent future incidents. Safety and Health Magazine online.
6. United States Federal Railroad Commission (2002). Improving railroad safety through understanding close calls. https://www.hsdl.org/?view&did=15786.
7. Pettinger, C. (2013). Are near misses leading or lagging indicators? Safety and Health Magazine online.