Near miss reporting that reads every report as it lands and catches a rising precursor at one depot, weeks before someone is hurt
Rising near-miss trends caught by site and work type, weeks before someone is hurt.
See one case, screen by screen ↓Field crews, plant operators and contractors send hundreds of near-miss and safety-observation reports a month: a sentence typed on a phone, a voice note, a photo. A safety advisor reads each one, retypes it into the incident system, picks a category, guesses a severity and files it. Two advisors classify the same report differently, and the reporter rarely hears back — so the reports dry up.
The pattern — a run of ladder near misses at one depot in a week — shows only at the quarterly review, if at all, because a company-wide count hides a cluster at one site and one work type. And most reports are unsafe conditions: a high-energy near miss with no direct control looks the same in the inbox as a trip hazard. OSHA calls a near miss an event with no injury where a slight shift in time or position would have caused one, and does not require it to be reported; ISO 45001 clause 10.2 asks for a process to report, investigate and act on incidents, near misses included. So the company's own process is what decides whether near misses get reported at all.
Estimated split for one safety advisor handling about 50 reports a week, in hours, by hand and with the solution.
Six specialist agents read, classify, join and watch every report; a safety advisor confirms and the Head of HSE signs.
Lumina Utilities is an electricity and water utility with five sites. On Sunday 11 October 2026, during storm repairs after the wind, a pole ladder kicks out at Ashby Lane, Northgate. By Monday morning it is one of 16. Here is what happens next, screen by screen, in the working solution.
Nadia covers Network Field Services at the Northgate and Eastmoor depots. Her home screen stacks every report from the last 12 weeks — 916 — into five tiers: 490 unsafe conditions, 233 unsafe acts, 141 low-energy near misses, 38 high energy with a control held and 14 serious potential, up 40 % on the prior 12 weeks. Four reports have arrived since 07:00 and dropped into their tiers in front of her. Beside the pyramid, an alert: ladder work at Northgate Depot.
“Common factor: 11 of 16 used the new 3.8 m pole ladders, batch LD-3800, delivered on 18 Sep without the pole strap. 2 were serious potential.”
The weekly trend run counted 916 events in weeks 30–41 for 8 work types at 5 sites. Ladder work at Northgate ran 3, 5 and 8 in weeks 39–41, against a baseline of 0.9 a week — so the rule fired and opened LA-2026-031. The chart marks the day the ladders arrived: 18 Sep, 24 LD-3800 ladders issued. Chambers at Marsh Lane and chemical handling at Kellford were watched, and did not fire.
Rule: three weeks rising, the last at least twice the 8-week baseline and at least 3 events.
11 of 16 used batch LD-3800; 12 of 16 were overhead service connections; 9 were contractor crews from Brackenfield Utility Services; 6 were on wet or soft ground. Time of day and crew were not shared — seven different crews. The stores records show 14 ladders of the same batch issued to Eastmoor on 5 Oct, with no report yet, and 6 unissued at Marsh Lane.
“Eastmoor crews do the same service connections. The alert and the strap action cover both depots.”
Dan was strapping on at about four metres to transfer a service when the ladder kicked out at the base on the wet verge. Kofi was footing it and held it; the live LV service was right by his hand. The report reader transcribes the 38-second voice note, describes the 2 photos and ties each of 6 facts to the phrase or photo it came from — the missing strap is circled on photo 2, tag LD-3800-17.
“New ladder, no pole strap on it, same as the others in van NG-14. I came down slowly and we stopped the job. Nobody hurt.”
High energy present: yes — a fall from 4.1 m and a live 400 V service within reach. Released: yes, the ladder base moved. Serious injury: no. Direct control in place: no — no pole strap, top not tied, and footing a ladder is not a direct control. Serious potential, confidence 0.93. The duty manager, Owen Pritchard, is told at 15:53 and stands the crew down from ladder work at 16:02.
“High energy, released, no direct control — only chance and a colleague stopped a serious injury.”
Kofi Mensah of Brackenfield reports the same event from the same pole 25 minutes later. The duplicate finder matches pole, time and words and joins his report to Dan's, so the trend counts one event, not two. Nothing is deleted: in the inbox, NM-2026-04421 shows as “Joined to 04417”, and each man keeps his own report and gets his own reply.
Duplicates are joined, never deleted. Each reporter still gets a reply.
Serious potential has to be confirmed by a safety advisor within 24 hours. Nadia confirms at 08:24, accepts the four proposed actions and sends both replies at 08:31 — 16 h 41 m after Dan's report, inside the 24-hour clock. Every agent step on the report sits on one list, from the voice note transcribed to her confirmation.
“Thanks, Dan. Your report of the ladder at pole 47/112 has been read and confirmed as serious. You were right about the strap.” — Nadia
The action drafter proposes actions from the top of the hierarchy of controls, each with an owner and a due date. Substitution: issue stand-off pole ladders from stores until the straps are fitted. Engineering: fit pole straps to all 38 LD-3800 ladders before reuse — Northgate 24, Eastmoor 14 — Owen Pritchard, due Wed 14 Oct. Administrative: a toolbox talk on tying the ladder top before climbing, and a query to Halden Access Equipment on the order spec, owned by procurement.
Proposes only; the safety advisor accepts. Never closes an action.
Safety alert SA-2026-019 says what happened, why, and what to do from now: do not climb on an LD-3800 ladder until a pole strap is fitted — check the tag, LD-3800-01 to -44; use a stand-off ladder; tie the top every time, because footing is not enough on a round pole. It goes to 212 people: Northgate's 96 and Eastmoor's 88 overhead and service crews and 28 Brackenfield contractors, by text and the crew app.
“Report any ladder that moves, even a little. Every report is answered.”
The Head of HSE signs every safety alert. Martin signs at 09:05 with the meaning “approved for issue”, and the alert is sent the moment he signs. The screen then tracks who has read it: 168 of 212 crew members so far. The trend was caught in three weeks — before anyone fell.
“Signed by Martin Achebe · Head of HSE · Mon 12 Oct 09:05 · meaning: approved for issue”
The same ladder trend, seen by the five people it touches — what their week looked like, and what it looks like now.
Six specialist agents read, classify, join and watch every report; a safety advisor confirms and the Head of HSE signs.
Reads typed reports, voice notes and photos; pulls what happened, where, the job, the equipment and who was there, and quotes the phrase each fact came from.
Sorts each report into unsafe act or unsafe condition, names the energy sources and answers the four high-energy questions — high energy present, released, serious injury, direct control in place — to place it in a tier.
Compares each new report with the last 72 hours at the same site and joins two reports of the same event by time, place, people and words, so a trend counts events, not reports.
Every Monday at 06:00 counts each tier by work type and site, fires when a precursor rises three weeks in a row to at least twice its 8-week baseline, then finds what the reports share and checks stores records for the same equipment elsewhere.
Proposes corrective actions from the top of the hierarchy of controls — eliminate, substitute, engineer, administrative, PPE — with an owner from the site roster and a due date, and drafts the safety alert in plain words for crews.
Answers every reporter in under 80 words: thanks them, says what was found and what will change and when, inside 24 hours.
Confirms every serious one. The agents propose; a named person decides.
Ask about any report, trend or action — or say what to change. Every answer points to its records.
Why did the ladder alert fire for Northgate?
Ladder near misses at Northgate rose three weeks in a row: 3, 5, then 8, against a baseline of 0.9 a week. The rule is three rising weeks with the last at least twice the baseline. 11 of the 16 used the new 3.8 m pole ladders from batch LD-3800, delivered on 18 Sep without the pole strap, and two were serious potential, the worst at pole 47/112 on Sunday.
Which other depots have the same ladders?
Two places. Eastmoor Depot received 14 ladders from batch LD-3800 on 5 Oct: no ladder near miss there yet, and Eastmoor is already in the safety alert and the strap action. 6 more sit unissued in Marsh Lane stores. I have put those 6 on hold until straps are fitted.
Show every serious-potential report this quarter
14 serious-potential reports in 12 weeks, up from 10 in the 12 weeks before. Gravity is the energy in 8, electrical in 6, ground collapse in 2 (some have two). The two most recent ladder reports are both at Northgate.
Make a moving ladder above 1.8 m with no tie-off serious potential
Done. New rule: a ladder that moves with a person 1.8 m or more up, with no strap or top tie, is serious potential, whatever the job. It applies to new reports from now on. I re-checked the last 12 weeks: the two serious-potential ladder reports already meet it, and no other report changes tier. You can change it in Settings.
12 screens from the working solution, on its sample data. Pick one to see it large.
What counts as high energy, when a trend fires, the clocks and who signs are settings. Your team can add its own classification rules too — “Footing a ladder is never a direct control” is one of Lumina's.
| Setting | Default | Choose from |
|---|---|---|
| High energy: fall from height | 1.8 m or more | Editable, with electrical 50 V, vehicles and plant 30 km/h, stored pressure 1 bar and suspended load 500 kg |
| Weeks rising in a row | 3 weeks | Editable · the trend watcher runs every Monday at 06:00 |
| Last week against baseline | 2× or more | Editable · baseline window 8 weeks |
| Smallest count that can fire | 3 events | Editable · test the rule on the last 12 weeks before it applies |
| Serious potential confirmed by a safety advisor | 24 hours | Editable · the duty manager is told at once |
| Reply to every reporter | 24 hours | Editable · the feedback writer drafts, the safety advisor sends |
| Safety alerts signed by | Head of HSE · Martin Achebe | A named person, who signs with the meaning recorded |
| Anonymous reports and languages | Allowed · English, Arabic, Polish | Anonymous reporters are answered through the app only |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (EEI, Power to Prevent SIF: Safety Classification and Learning model — classification consistency 65 % → 95 % in its working group; BLS Census of Fatal Occupational Injuries, via BLS Industries at a Glance, Utilities (NAICS 22) — 43 work deaths in 2024). Context: OSHA near-miss definition; ISO 45001:2018 §10.2. Lumina Utilities, its depots, contractors and suppliers, and the people, reports and records named on this page are fictional — characters and sample data in the working solution.
Software that takes in near-miss and safety-observation reports — typed, spoken or photographed — classifies them, finds trends and tracks what was done about them. Near Miss Reporting adds six agents that read each report as it arrives, classify it on four high-energy questions, join duplicates, watch for rising trends by site and work type, draft actions and alerts, and answer every reporter. A safety advisor confirms; the Head of HSE signs.
The classifier decides unsafe act or unsafe condition, names the energy sources — gravity, electrical, motion, pressure, chemical and others — and answers four questions: was high energy present, was it released, was a serious injury sustained, was a direct control in place. The answers place the report in one of five tiers, from unsafe conditions up to serious potential. It can raise a tier, never lower one.
One where high energy was present and released and no direct control was in place, so only chance stopped a serious injury. In the sample case a ladder kicked out at 4 m beside a live 400 V service; footing the ladder is not a direct control, so it was serious potential. Every one is confirmed by a safety advisor within 24 hours, and the duty manager is told at once.
Every Monday at 06:00 the trend watcher counts each tier by work type and site. It fires when a count rises three weeks in a row, the last at least twice the 8-week baseline and at least 3 events, then finds what the reports share — equipment, job, crew, ground — and checks stores records for the same equipment elsewhere. The thresholds are settings you can test on the last 12 weeks.
Yes. The duplicate finder joins two reports of the same event by time, place, people and words, so the trend counts events, not reports; it never deletes or edits either one, and each reporter gets a reply. Reporters may send without their name, and names never enter classifications, trends or replies to others.
Yes. The agents read, classify and draft; they never sign, close an action or stop work. A safety advisor confirms every serious-potential report and accepts the actions, the safety advisor sends every reply, and the Head of HSE signs every safety alert and stand-down. Every change is on the activity trail with who and why.
Yes. The tiers and the four questions, the high-energy thresholds, the rising-precursor rule, the confirmation and reply clocks, who signs alerts, anonymous reporting and the languages are all settings. Your team can add rules of its own, such as “Footing a ladder is never a direct control”.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your near-miss procedure, classification model, sites and work types, and a sample of past reports — and it goes live once every quality gate has passed. We will walk you through it on your own reports first.
High-potential incidents found the hour they are reported, not at the monthly review.
1-min demoSerious Injury and Fatality PreventionEvery high-energy job checked for its critical controls before the crew leaves the yard.
1-min demoElectronic Permit to WorkNo permit goes live over a held or missing isolation, and every signature is on record.
1-min demoWe'll run Near Miss Reporting on a sample of your own near-miss and safety-observation reports.