Building Support for Near-Miss Reporting

The last time you were at the airport, you almost surely heard the expression, “Have a good flight.” As I see it, there are three fundamental requirements for a “good flight”: 1) safe take-off, 2) safe landing, and 3) no unexpected activities in between those two events.  

What I know about flying a commercial aircraft could fit neatly on the head of a pin with room to spare, but I understand the gravity of the situation when a 737 leaves the ground (no pun intended). And yet, traveling by air is incredibly safe in the United States, in no small part thanks to a group of NASA employees who developed and continue to run the Aviation Safety Reporting System (ASRS).

You Call That an “Incident”?
The ASRS is a voluntary near-miss self-reporting system set up nearly 40 years ago to allow pilots, flight crews, ground support crews and others associated with the aviation industry to report events that occur in the process of moving millions of passengers annually throughout the friendly skies.

This program was borne out of the fundamental idea that human beings in high-stress situations have the potential to make mistakes–regardless of their level of competency, training, professionalism, years of experience, etc. This is not conjecture but fact: Consider the number of fatal aviation crashes that have occurred in our lifetime, coupled with the statistic that 99% of all aviation crashes are the result of human error.

Given the fact that there’s simply no way to engineer all human error out of the equation of defying gravity, the ASRS was designed to capture incidents that didn’t result in a fatality. Reporting an incident to the ASRS is basically a way of saying, “I/we made a mistake that could have killed someone, but since it did not, let’s learn from it and share it with everyone in the hopes of avoiding a similar or more tragic outcome.” Good stuff.

A cornerstone of the program is that the reporter, acting in good faith and without the attempt to avoid criminal responsibility, is shielded from sanction. It’s an excellent program that has had unbelievable success–the ASRS recently received its one-millionth report. Trust has been built among the stakeholders and there is a fundamental belief among those who use the systems that it works–lives have been saved as a direct result of their participation.

During a recent presentation, a member of the ASRS team reported that a “gear-up” landing that doesn’t result in any injuries is classified as an incident, not an accident–meaning that in order to learn from it, someone would have to report it to the ASRS. That’s right–you can land a turbo-prop plane on its belly and in the process destroy both propellers, but because no one gets hurt, it’s just an “incident.” While it may be true that any landing you walk away from is a good one, I don’t know too many individuals outside the aviation industry that would classify such an event as just an “incident.” The point is that even such serious events as the one described qualify for the ASRS reporting system. Interestingly, a single report can result in an industry-wide alert, the functional equivalent of a Nationwide Safety Stand Down or Safety Alert as result of the willingness of one individual to recognize that sharing their story can save lives.

The Capacity to Learn
In the past five years, the fire service has established a similar voluntary, anonymous, non-punitive program known as the National Fire Fighter Near-Miss Reporting System (www.firefighternearmiss.com). The system is designed to capture any event that has not resulted in a firefighter fatality. Although still in its infancy, the program has received nearly 5,000 reports.

This is an outstanding start to an incredibly important program, but we can do better. There are more than 24 million fire calls in the United States every year. Conservatively, 10% of these calls (or 2.4 million incidents annually) result in near-misses. And yet, the number of reports received by this system is comparatively small.

This does not mean that the program is a failure–to the contrary, it’s making a tremendous difference. But it does point to the genuine need to increase both awareness of and participation in the program. The folks at Near-Miss are outstanding, but they cannot do it alone. This is a program specifically designed for the fire service, by the fire service, to save firefighter lives. So many conversations in the fire service today center on the loss of experience as senior members continue to retire (career and volunteer). The near-miss program is the perfect venue for senior members to “download” their experiences so that their lifetime of service can be captured before they hang up their gear for the last time.

Sometimes saving a fellow firefighter occurs away from the emergency incident scene. If you’ve ever walked away from a “crash landing,” share your story at www.firefighternearmiss.com.