PodcastUsing near misses as powerful learning tools: Turning incidents and near-miss reports into meaningful learning experiences.
Duration: 9m32s
AUSMASA Intro: Welcome to the Train-the-Trainer Podcast, proudly brought to you by the Australian Mining and Automotive Skills Alliance. Empowering industry to develop essential workforce capabilities for today and tomorrow.
Marc: Howdy folks, Marc Ratcliffe here on another Train-the-Trainer Podcast. In this episode, we're talking about near misses and how trainers and assessors can use them as powerful learning tools rather than letting them become something lost in the paperwork. Today, I welcome Mike West back to the chair. How are you today, Mike?
Mike: I am thrilled to be back in the hot seat, Marc, and looking forward to chatting about how we can use those near misses more powerfully as teaching moments.
Marc: Sounds good, Mike. Let's strap ourselves in!
Marc: A near miss is often described as an incident that didn't result in injury, damage, or loss, but easily could have.
Mike: In other words, it's a warning shot. It shows us where the system, the task, the behaviour, or the conditions nearly failed.
Marc: That's right. And that makes it incredibly valuable for learning.
Mike: The problem is, near misses are not always used well. Sometimes they're reported, logged, and closed out administratively, but never really discussed in a way that influences future behaviour.
Marc: Yeah. Sometimes people are hesitant to speak openly because they fear blame. Other times, the learning stays at a surface level, where people say things like 'hey, just be more careful', or 'follow that procedure'. But that's not enough.
Mike: So, if we want near misses to strengthen competence, they need to be turned into learning conversations.
Marc: But where do we start, Mike?
Mike: First, you have to start with culture. People need to believe that reporting a near miss leads to improvement, not punishment. If workers think the report will only be used to find fault in them, they'll stop reporting or start filtering what they say.
Marc: So, what you're saying is that for learning to happen, the environment needs to support honesty.
Mike: Yeah, but that doesn't mean there's no accountability. It means we focus first on understanding what happened, what conditions made it possible, and what needs to change.
Marc: Okay, I totally see the need for that. So, what's next?
Mike: Next, we should use the near miss while it's still fresh and still real.
Marc: Yeah, the learning is definitely stronger when the situation is real and relevant. And we can get them thinking about not wanting this to happen to them or happen again to them.
Mike: Correct. And that recent event on site or in the workshop can have immediate meaning. Workers can picture the task, the location, the equipment, and all the pressure involved.
Marc: And I think the learners become more connected because it's something that has just happened.
Mike: That's right. We want it front of mind, not lurking in the background.
Marc: Do you have any final thoughts on how we get the best value from focusing on a near miss?
Mike: Well, we really should move beyond the headline. If a report says, 'The operator nearly struck a hand while changing tooling, that's just the starting point. The learning comes from exploring the details.
Marc: So, how could we draw that learning out, Mike?
Mike: Well, the devil is in the debrief, Marc. A good debrief isn't about asking, 'Who messed up?' It is about asking, "What was happening here, and what can we learn from it?'
Marc: Okay, so let's imagine a trainer is facilitating a discussion around that near miss. How could that go?
Mike: The trainer could begin with a neutral question like 'let's walk through what was happening at the time. What was the task, and what was going on around the operator?'
Marc: Okay
Mike: That helps people reconstruct the situation. Maybe production was under pressure. Maybe the operator had done the tooling change many times before and got a little complacent. Perhaps access was awkward, visibility was poor, or the machine was not fully isolated.
Marc: Or any number of things. And then I guess the trainer could ask: 'What assumptions might have been made?' to open up the conversation.
Mike: Right. Someone might say, 'The operator assumed the machine would stay still. Another might add, 'they may have assumed a quick adjustment didn't require the full lockout process'. These are important because near misses often sit on top of normalised shortcuts or routine thinking.
Marc: That's an important point, Mike.
Mike: Next, the trainer could shift to controls. Such as, 'what controls should've protected the person here? Were any missing, bypassed, or ineffective?'
Marc: Yeah, that could bring out issues like missing guards, a poor tooling-change procedure, or like you said before, that reliance on habit instead of a formal check.
Mike: Spot on, Marc. And the trainer should capture these without judgement, because the aim here is to show how systems succeed or fail and the impact that could have on the worker, plant and equipment.
Marc: I'm thinking another strong question could be: 'What signals were present but missed?'
Mike: Yeah. Sometimes these things are hidden in plain sight. Maybe there was movement in the machine that suggested stored energy. Or the operator was rushing. Perhaps another worker noticed an awkward hand position but didn't say anything.
Marc: And many sites I've been to over the years have had procedures that lacked detail or clarity (or sometimes both), but nobody challenged it because 'that's how it's always been done.
Mike: That's where the real learning starts to emerge, Marc. And the trainer can summarise: this was not just about one person's hand placement. It was about the conditions, assumptions made, and weak controls all lining up.
Marc: So, in the end, how would you close the debrief, Mike?
Mike: A solid close from the trainer could be something like 'so, what do we need to do differently next time?' To this question, the group might identify clearer isolation steps, a tooling-change checklist, refresher training, supervisor verification, or simply encouraging workers to stop and speak up when something feels off.
Marc: Thanks, Mike, that kind of debrief builds awareness, not defensiveness. And that's the real value.
Mike: For sure, and this means a near miss becomes a chance to strengthen thinking, improve controls, and prevent the next event from becoming an injury.
Marc: Okay, Mike. How else could you discuss a near miss in a practical way?
Mike: I think a perfect place would be presenting the situation in a toolbox talk, a team meeting, or even build it into existing training sessions.
Marc: That makes a lot of sense. Through those forums, you can invite learners to outline the risks in their own words, drill down on what led to the decisions made, and what controls should have been in place.
Mike: Yeah. These can become real 'lessons learned' moments. I think you can also connect the near misses directly to workplace procedures and required competencies to make the lessons even more meaningful.
Marc: Yeah, I totally agree. If the near miss involved something like isolation, working at heights, or even simple housekeeping, you could use it to reinforce the exact standard linked to that area.
Mike: That would help learners to see that procedures are not abstract rules. Rather, they are responses to real risks.
Marc: 'Hashtag truth, Mike. We want to be sending our staff home safely to their families every night, and a near miss gives us vital intel on how successful we are at following through on that promise.
Mike: I like that, Marc. The human factor can be so powerful. Another key point I want to make is that we have to avoid turning the near miss into a story about one person.
Marc: I hear that, Mike. If the discussion becomes too focused on who made the mistake, people stop listening for the wider system lessons and fall into 'protecting their backsides' mode.
Mike: Correct. So, we have to keep the conversation focused on conditions, decisions, controls, and, of course, the learning. That said, realism matters. Workers know that human choices are part of the picture. We shouldn't pretend otherwise. But the trick is putting the focus on trying to understand why a choice made sense at the time, even if it led towards risk.
Marc: Like production pressure? Fatigue? Poor communication?
Mike: Yeah, these are the things that make the discussion meaningful. Near misses are especially useful because they don't carry the same emotional weight as serious incidents, but they still contain real evidence.
Marc: I guess this would make them easier to discuss openly and allow trainers to intervene before someone gets hurt.
Mike: Yes, Marc. It's kind of one step removed from a tragedy. A place we can get perspective, but also stay calm as we dissect what happened.
Marc: Are there implications here for assessment, too?
Mike: Totally! The use of near misses can support the assessment process very effectively. Asking a learner to analyse a near miss, identify controls, or explain what should happen differently can reveal a lot about their practical understanding.
Marc: And finally, how would you close the loop?
Mike: If you use near misses in learning, show what changed as a result. Maybe a process was clarified. Perhaps a guard was improved. Maybe a communication step was added. That follow-through shows that reporting matters.
Marc: Thanks again for all your insights, Mike
Mike: My pleasure.
Marc: So don't let near misses become just another form in the system. They are some of the best real-world teaching tools we have. When used well, they can sharpen awareness, deepen understanding, and help prevent future harm. So, next time you're preparing for training, consider integrating near miss information, not as a throw-away anecdote but as something that can bring about thoughtful discussion and meaningful connections to workplace practice. This will not only help you to add impact to your training, but it'll also increase authenticity to the overall learning experience, and give learners something relevant and tangible to draw upon back on the job.
All the best in putting near misses to work in your next training session.
AUSMASA Outro: Search AUSMASA Resources for more videos, guides, templates and checklists to support your role and help progress your Vet career. Check these out at: ausmasa.org.au/resources.
END.
Training clip