One on One with … LEO Near Miss

At the 2014 annual meeting of the International Association of Chiefs of Police (IACP), the Police Foundation launched LEO Near Miss, an online error reporting system designed to help officers and agencies learn from the real-life experiences of their peers across the country.

Similar systems are common in other industries with proven track records of reducing injuries and errors, but non-punitive peer review has never been common in the law enforcement field. Because it is a new and different concept in law enforcement, many people have lots of questions when they first hear about it.

To help Dispatch readers out with answers to some common questions, Deborah Spence of the COPS Office spoke with three other panelists at the launch presentation. In addition to interviewing Jim Bueermann and Karen Amendola of the Police Foundation and Dr. Alexander Eastman, Deputy Medical Director for the Dallas (Texas) Police Department, she spoke with Chief David Flory of the Hot Springs (Arkansas) Police Department, who first learned about LEO Near Miss while in the audience at the IACP conference session.

CP Dispatch: This new program is called LEO Near Miss. What exactly is a near miss?

K. AMENDOLA: The concept of near miss is known across many industries including aviation, medicine, nuclear power, and others. What is typically meant by a near miss is narrowly avoiding a serious incident or accident in which significant injury, property damage, or other problems could have arisen. Personally, I think of them as defining moments, where individuals come face to face with their mortality and lack of control over what can happen. These defining moments are often embedded in one's memory for the rest of one’s life.

J. BUEERMANN: A near miss is a close call or unsafe occurrence that could have resulted in a serious injury, fatality, significant property damage, or a crisis if not for a fortunate break in the chain of events. Leonearmiss.org highlights near miss events in which other policing personnel could benefit and learn from the experience.

I would like to make the point that the concept of near misses also extends to, among other things, crime control strategies, disciplinary actions, and organizational efforts of all types. For example, an agency about to initiate a street crime strategy that is well-intended but would infuriate a particular community was saved from doing so by a supportive community member who pointed out the negative public perception of such a strategy. This could be categorized as a near miss for the agency’s police legitimacy.

Similarly, a case in which an officer was about to be disciplined but was saved by some fortuitous event that exonerated him or her would certainly have experienced a near miss as it relates to his or her career and the organization’s sense of internal legitimacy.

The idea of near miss reporting systems is not new. They have been used extensively in aviation, medicine, and firefighting for years. They have proven invaluable in reducing preventable errors in those fields and have undoubtedly saved thousands of pilot, patient, and firefighter lives. It just makes sense that policing engage in the same kind of reporting and inquiry to reduce injuries and deaths. Every cop I know can relate multiple near misses they personally experienced. And they willingly tell their colleagues about them in a variety of informal settings.

What's missing is a national discussion about policing’s near misses and an organized way to capture these incidents and disseminate them in a manner that translates lessons learned into lessons applied. Leonearmiss.org does just that.

CP Dispatch: How does LEO Near Miss work? Is it going to let agencies and officers learn from each other? Will we have to wait years for a report?

BUEERMANN: Leonearmiss.org is a very user friendly reporting system. It is intended to be completely anonymous (although users can add their contact information if they want). Its capacity for anonymity is completely consistent with the principle of non-blaming inquiry, which is fundamental to identifying and correcting preventable errors.

The system uses a variety of techniques to anonymize the IP addresses of the computers used to submit the reports. The only way a submitter can be identified is if they voluntarily add their contact information. This protects the person submitting, their agency, and the leonearmiss.org system from subpoenas and potential litigation. Users simply go to leonearmiss.org, scroll down to “submit a report,” and start entering the incident information.

The reports are then forwarded to at least two subject matter experts who come from all rank levels of policing. These SMEs review the reports and make a judgment about their plausibility or authenticity and also ensure the reports don't identify the agency or personnel involved. If the agency contact information is included, the SMEs contact the appropriate agency representative to confirm authenticity and accuracy and obtain permission to include it in the report. This may prove quite valuable for agencies trying to prevent the type of incident being reported.

The system is intended to operate in a timely manner. When a report is deemed a relevant near miss, it will be posted on the leonearmiss.org site within 10 days of submission. We want each incident and its attendant lesson to be applied as soon as possible in the hope that it saves some cop’s life.

Similar to how they are used in the fire service, these reports can be used by individual officers to improve their own personal safety, in briefing trainings and discussions, and to create or modify formal training protocols and inform agency policy. Ultimately, we will be using a machine thinking system to automate the identification and translation of lessons learned from real-life experiences.

AMENDOLA: LEO Near Miss only works if individuals are willing to share their near misses to help fellow officers avoid getting into similar situations and thereby prevent tragedies. The records, once posted to the system, are quickly made available to others to review, and as more and more incidents are entered, law enforcement personnel can search on various terms to find information relevant to their interests (robberies, vehicle pursuits, etc.).

In addition, as a significant number of incidents are entered into the system, Police Foundation researchers will conduct analysis to examine patterns of risk that may threaten officer safety. For example, certain types of equipment failures may be responsible for some near miss incidents or accidents, and that information will be conveyed as it is uncovered.

CP Dispatch: This sounds a little bit like something raised in the book American Policing in 2022, which featured an essay that discussed non-punitive peer review. Is there a connection between that essay and this program?

A. EASTMAN: Indeed, there is a connection. The idea for LEO Near Miss really came to fruition at the 2013 IACP Conference in Philadelphia, during a great discussion in a COPS Office session featuring some of the contributors to American Policing in 2022. The energy in the room that day around the need for a non-punitive peer review system that would allow for practical, scenario-based learning was palpable. It was from that discussion that the foundations of LEO Near Miss were laid.

BUEERMANN: Leonearmiss.org is certainly consistent with that theme. The concepts of preventable error and officer safety and wellness are connected to the book’s theme and purpose. In the future, policing will have to focus incessantly on eliminating preventable error. Whether the topic is wrongful arrest or conviction, sympathetic fire, tactical mistakes, or wrongful discipline, the profession’s public and internal perception of legitimacy is inextricably tied to the prevention of errors that we have some control over.

In addition, officer safety research clearly shows that preventable error is the cause of many officer deaths and serious injuries each year. Meaningful reductions will only come when we get away from the notion of blame and accurately focus on the processes by which error occurs and then craft our policies, practices, and mindsets in ways that reduce error.

CP Dispatch: So we know this practice of review works in medicine, but isn’t policing a totally different profession?

EASTMAN: Clearly medicine and law enforcement are different professions. But the principles of peer review and performance improvement have been proven to work not only in medicine but also across the board in industries that implement these sorts of practices. As law enforcement agencies work to become more transparent generally, having our near misses looked at and translated into lessons learned for agencies across the country has great life-saving potential for officers and civilians alike.

CP Dispatch: As someone who was introduced to LEO Near Miss during our IACP Conference panel presentation, what was it about the program that prompted you to talk afterwards?

D. FLORY: As one of the 15 U.S. agencies that were part of an IACP injury database study in 2010–2011, I was hopeful that the end result would be a large-scale reporting mechanism such as this. I am glad to see that something may finally exist that law enforcement can use to better track event dynamics that could have resulted—or did result—in officer injuries, as well as the dynamics that reduce injury such as self-aid/buddy-aid.

CP Dispatch: How do you see this system being used by officers and agencies?

FLORY: I am confident that the LEO Near Miss database can and will be used by agencies across the United States as a tool to learn from the potential and actual mistakes made by their own and other law enforcement agencies. By examining this information, officers can learn how to avoid similar mistakes and therefore reduce the risk for injury or death to officers.

CP Dispatch: What can a chief do to promote use of the system by their officers at all levels?

FLORY: Expose members of police agencies to the program and stress its value in reducing the risk to officers. Most agencies’ training divisions or individual LE trainers already use anecdotal stories of near misses as examples of what can or could happen. Now we will have empirical data and real-life stories that can be referenced in order to reinforce this type of training. Most agencies will be best served when the police chief makes the reporting of near misses mandatory to the LEO Near Miss database.

BUEERMANN: To help decrease officer deaths and injuries via leonearmiss.org, policing leaders can 1) make an effort to understand the nature of preventable error and blameless after-action reviews; 2) do an internal assessment of their agency’s deaths, injuries, disciplinary actions, and crime control strategies to determine the extent to which preventable error played a part in less-than-optimal outcomes; 3) promote and encourage the use of leonearmiss.org internally and among their peers; 4) officially enter their near misses into the system (they do not have to identify their agency to do so), as many fire departments have now done with firefighternearmiss.org; and 5) incorporate the lessons learned from leonearmiss.org into their training programs, policies and practices.

CP Dispatch: Five years from now, what do you hope LEO Near Miss will look like? What might it have accomplished?

AMENDOLA: In five years, or sooner, I would like to see hundreds or thousands of incidents in the system so that we can examine ways to keep officers safe and prevent community tragedies. With every new incident and lesson learned that is shared, lives can be saved. The idea that the power to prevent tragedy is in the hands of those who have the courage to share their mistakes or experiences is exciting. It empowers the policing profession with the composite knowledge to protect each other and help others go home safely every day.

BUEERMAN: In five years, I hope that leonearmiss.org is a widely used, central entry point for cops nationwide to tell their near miss stories. I envision building it into an artificial intelligence-like capability that will constantly analyze the thousands of submitted reports to detect patterns in the incidents, giving us the ability to avoid error and dramatically increase the benefits of critical decision making. The resultant changes in training, policy, and practices will save cops’ lives, dramatically reduce injuries, reduce police use of force, and increase the perceptions of policing’s internal and external legitimacy.

EASTMAN: I hope that it becomes a powerful tool that uses data from many different sources to generate lessons that can be applied across a wide swath of law enforcement. Improving transparency and review within agencies is important. But in five years, I want us to have a system that can truly integrate data from thousands of agencies and translate it into real and meaningful lessons learned for officer safety.

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