What went right? A systems thinking-based model of near miss incidents
Creators: name: Thoroman, Brian
Publisher: name: University of the Sunshine Coast, Queensland
Year: 2020
Subjects: near miss
incident analysis
systems thinking
human factors
sociotechnical systems

description: Systems thinking is arguably the dominant contemporary paradigm in the study of safety within complex sociotechnical systems. Across several safety-critical industries, near misses (e.g., incidents with no or limited injury or damage) have been studied to provide information to support accident prevention by identifying factors that potentially lead to accidents. Despite extensive work studying near misses, little research has applied systems thinking in this context. While there exists several systems thinking–based accident causation models, there is currently no systems thinking–based model specific to near misses.
description: This thesis involves the development of a toolkit including a systems thinking–based model of near misses, a near miss reporting tool and a near miss analysis framework to support identification of the systemic factors that prevent near misses from progressing to accidents. The research itself includes the analysis of near miss incidents, the development and validity testing of a near miss reporting form and the development of a near miss incident analysis framework. Application of the toolkit leads to the development of a novel systems thinking–based model of near misses.
description: The findings show that existing near miss reporting systems do not currently capture data regarding the protective factors that prevent near miss incidents from progressing to accidents. Moreover, results indicate that a systems thinking–based model of near misses can be used to identify the systemic conditions that influence near misses. Findings from the aviation domain suggest that a systems thinking perspective applies to near misses and protective factors as well as accident causation. While similar categories of contributory and protective factors are found in near misses, the findings indicate that network interactions are a key influence on the systemic conditions that prevent near misses from becoming accidents. By combining AcciMap and network analysis, the ProtectionMap method provides a richer and more comprehensive analysis framework with which to evaluate these systemic conditions and interactions than would AcciMap alone.
description: A synthesis of the findings is used to propose a novel systems thinking–based model of near misses. The model shows how systemic influences throughout the system interact to create near misses rather than events with adverse or worse outcomes. Particularly, the model emphasises the role of protective factors such as communication, policy and procedure, organisational and individual behavioural influences, and environment and equipment in preventing incidents from progressing to accidents.
description: The research presented in this thesis provides a series of theoretical, methodological and practical contributions. A systems thinking–based toolkit is developed, comprising an accident prevention model, a near miss reporting form and a near miss analysis framework. Further, an empirical systems thinking–based model of near misses derived from near miss data from the aviation and led outdoor activity (LOA) domains is proposed. Practically, the LOA domain is provided with an analysis of the key system-wide protective factors influencing near misses.