Near misses: warning signs of emerging risk

The Health and Safety Executive (HSE) estimates that, for every workplace accident recorded, there are approximately 90 near misses - each a warning of a risk that may cause serious harm if left unaddressed. The recent prosecution of St James Group Limited and Lindner Prater Limited is a stark reminder of the consequences of failing to act on such warnings.

St James was the developer, Principal Contractor and Principal Designer of the Corniche development on London’s Albert Embankment, while Lindner Prater designed the penthouse windows. The companies were fined a combined £1.3 million after a 130kg window fell 300 feet from the 26th floor, killing a passer-by in 2018. This case is particularly notable because in 2017, just one year prior to the fatal incident, a window from the same penthouses had fallen in windy conditions and narrowly missed two workers.

What are near misses and why are they important?

A near miss is an event that causes no harm but had the potential to cause harm in the form of death, injury or ill-health. In near miss cases, the hazard and exposure were present, but injury was avoided - often through chance rather than effective control.

In the Corniche case, the 2017 incident was a clear warning that a window could detach and fall onto the area below. The fact that no one was injured on this occasion did not reduce the risk - it created an opportunity to address the underlying design and control failures before they ultimately proved fatal.

It is crucial for an effective health and safety management system to do more than respond after an accident. Properly recorded, analysed, investigated and acted-upon near misses provide valuable safety intelligence. They expose emerging risks, test the effectiveness of existing controls and help prevent future incidents.

The absence of injury does not mean the absence of risk

In the Corniche case, the windows were changed during the design process from opening inwards to outwards, exposing the pedestrian area below if one detached. Their safety depended on a single restrictor secured by one screw, and the manufacturers had not confirmed that the fittings were suitable for the bespoke curved windows. The 2017 incident should therefore have prompted reconsideration of the design change, the fittings and the effect of leaving a window open in windy conditions. Although St James carried out an internal review following the 2017 incident, the HSE found that key concerns were not followed up effectively. The windows were redesigned to open inwards only after the fatal incident.

Acting on near miss reports

Near miss reporting will happen regularly within a business, but is effective only if it leads to action. Reports should be used by organisations to identify warning signs, test existing controls and address risks before harm occurs.

Although a near miss may appear minor in isolation, considering it alongside relevant design, maintenance and operational information can reveal serious weaknesses that accident data alone may not. That assessment should identify patterns, challenge assumptions and uncover failures in systems and controls. Any weaknesses identified should then be addressed promptly, with the effectiveness of the corrective action kept under review.

The Corniche case demonstrates that simply carrying out a review is not enough. Significant concerns must be followed up and result in corrective action. If concerns are identified but not followed up, the organisation and those affected by its undertaking remain exposed to a known risk. In this case, the HSE found that insufficient attention had been given to the risk of windows detaching when left open in windy conditions, while too much reliance had been placed on a small sign reminding residents to close them. Such administrative measures, whilst easy to implement, cannot substitute for properly addressing an underlying design risk.

Failing to properly investigate near miss data is a missed opportunity to improve safety before there is actual harm. For advice on near-miss reporting, incident investigations or wider health and safety compliance, please contact a member of the Brodies Health and Safety team.