4.1 As a minimum, the following information should
be gathered about any near-miss:
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.1 Who and what was involved?
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.2 What happened, where, when, and in what sequence?
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.3 What were the potential losses and their potential
severity?
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.4 What was the likelihood of a loss being realized?
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.5 What is the likelihood of a recurrence of the
chain of events and/or conditions that led to the near-miss?
4.2 The answer to these questions will determine
if an in-depth investigation is needed, or if a cursory report will
suffice. An in-depth investigation is required of those near-misses
which are likely to recur and/or which could have had severe consequences.
4.3 Once a decision has been taken to proceed
with a full investigation, further decisions are taken about levels
of staffing required, who should be responsible, and what resources
are required for the investigation to be completed successfully. The
main steps in the investigation are: