Near-Misses – Lessons from WW2, and a danger highlighted

I’m returning once again to the issue of the need for “near-miss” reporting in the EOD community.  My previous post on the subject is here.

I’ve been digging further and found an interesting study done by a famous Cambridge University psychologist, J T MacCurdy in the 1940s.  MacCurdy studied “The Structure of Morale” as it affected the British population and military during the first part of WW2. One subset he looked at were those who experienced the “Blitz” in London in 1940 and 1941.

MacCurdy theorized that people affected by the blitz fell into three categories:

• Those who were killed.
• Those who experienced very closely a bomb explosion. They are in the immediate vicinity – they feel the blast, see the destruction, are horrified by the carnage, perhaps they are wounded, but they survive. They are deeply “impressed” in the sense that there is a powerful reinforcement of the natural fear reaction. The psychological experience is of being faced by death, and the fear is reinforced.
• The next category, who MacCurdy describes as the “remote-miss” group are one step further removed.  They hear the sirens, they hear the enemy planes, they hear the explosion. But they are unharmed. Psychologically the remote miss is different – the fact that they escaped injury and escaped the devastation lessens fear – the catastrophe was physically remote and so fear is put to one side. In many there builds a feeling of invulnerability and indeed excitement.

Now, while such feelings experienced by the “remote-miss” category were probably instrumental in reducing the effects of the Blitz on the population in Britain at the time, my position is that if you took those three categories and applied them to EOD operators on modern day EOD operations, then the same categories might present themselves.

• Those operators who are killed. There will, inevitably, be some form of reporting and investigation.
• Those operators who are injured or actually witness an unintended explosion. Usually there will be some form of investigation.
• Those operators who experience a near miss, make a mistake but no explosive event occurs. I think this is analogous to MacCurdy’s “remote-miss” group.  Such events are usually not reported or investigated.  Not only does the mistake remain unaddressed, but the operator, perhaps begins to feel invulnerable and that can lead to tragedy, of course.

Instinct and a little experience tells me that that this psychological phenomena of an EOD operator feeling invulnerable after a series of “near misses” may be true.  I believe that an appropriate near miss reporting system could mitigate against this danger.

Some other broader points about near-miss reporting:

• In terms of human lives, near misses are cheap, sometimes  almost zero-cost learning tools that can be used to prevent injury and death.
• The number of near misses, compared to fatalities is significant. Typically the aviation industry finds about 600 near-miss incidents to one fatal incident. That’s a hugely useful data set that is currently being ignored in the EOD community and not even collected.

I accept the issue of non-punitive reporting is the nub of the challenge as it faces the EOD community but:

• The aviation community has confidential near miss reporting systems.
• The US fire and rescue community has an anonymous near-miss reporting system.
• There are near-miss reporting systems for nurses and doctors in the healthcare community
• The British railways system has had a near miss reporting system since 2006.

If these industries and professions can manage such systems, why can’t we?  Are our egos too big?