What Near Misses Are Trying to Tell Us
By Donna Pollander
I recently had the opportunity to sit in on a webinar titled Equipment System Failure Investigation, presented by Vinod Sharma, and I came away thinking less about catastrophic failures and more about the quieter warnings that come before them. If you would like to view a recording of Vidod's presentation, it's in our Members Only
One of Vinod’s most memorable lines captured his philosophy perfectly: “I spend time in two places, the delivery room and the morgue. I much prefer the delivery room.” It is a striking way to describe the difference between designing safety into systems from the start and trying to understand disaster after the fact. That quote stayed with me because it speaks to the heart of good engineering, good maintenance, and good leadership: prevention is always better than explanation.
A central theme of Vinod’s presentation was that serious failures rarely come out of nowhere. In fluid power and process systems, there are usually warning signs: abnormal operation, worn parts, unexpected volumes, unusual sounds, odd smells, or procedures that seem “good enough” until they are not. Too often, these moments are dismissed as minor anomalies or operator error. Vinod challenged that thinking directly. Near misses, he argued, are not bad luck. They are the system talking to us.
That idea is especially important in industries where energy is stored and transmitted in compact, powerful ways. Hydraulic, pneumatic, and fluid handling systems can operate safely for years, but they are never risk-free. When they fail, the cause is usually not one dramatic mistake. It is a combination of small issues: design assumptions that have eroded, safeguards that were bypassed, maintenance patterns that went unquestioned, or communication gaps between teams.
What I appreciated most about this webinar was its systems-level view. Vinod made the point that component blame is rarely enough. A failed valve, ruptured pipe, worn hinge pin, or open drain valve does not exist in isolation. Equipment operates within a system shaped by design choices, operating conditions, maintenance practices, procedures, and organizational culture. If we stop at the direct cause, we miss the deeper lesson.
His case studies reinforced that point clearly. Whether the incident involved a gas leak, a compressor fire, a confined space fatality, or diesel escaping containment, the pattern was the same: there were early signals, and there were opportunities to intervene. The question is whether organizations recognize those signals and act on them before a close call becomes a tragedy.
I also appreciated Vinod’s emphasis on simplicity. A near-miss process does not need to be complicated to be effective. It needs to be trusted. Capture the abnormal condition. Preserve evidence. Ask better questions. Look beyond the failed part. Share what was learned. That kind of discipline strengthens safety, improves reliability, and supports the transfer of knowledge to the next generation of professionals.
My biggest takeaway is this: near misses are not noise. They are data. They are free lessons, if we are willing to listen. And in every plant, shop, facility, or field operation, listening early may be the difference between the delivery room and the morgue. To watch Vinod Sharma’s full presentation, IFPS members can view the recently uploaded webseminar recording on the IFPS website; the recording is available only to members who are logged into their IFPS account.