Date of Award


Document Type


Degree Name

Doctor of Education (Ed.D.)


Learning, Leadership and Change

First Advisor

Rod P. Githens

First Committee Member

Ronald E. Hallett

Second Committee Member

Brett Taylor


The practice of reporting workplace incident events is adopted as best practice by organizations and complies with Occupational Safety and Health Administration (OSHA) mandates. Reporting the near miss incident type in which no injury or damage to equipment or the environment occurs is buttressed by the assumption that both the worker and the organization ascribe to the same goal to identify workplace hazards and prevent incident recurrence. The goal of incident reporting is not apparent, and the path to achieving the goal is obstructed by internal and external hazards that act to oppose the reporting process, such that the goals are obscured by competing priorities. The general qualitative method was applied to a nonrandom snowball sampling technique to recruit eight participants. Over 176 years of combined experience across aircraft maintenance and petrochemical operations are represented. Participants were removed from either industry within the last five years. Each participant experienced multiple near miss incident events in the past. At the time an incident occurs, the compelling individual need that exists is explained in terms of Abraham Maslow’s (1943) theory of motivation. The Process- Practice-Purpose principle is developed and used to demonstrate the association between activities (the “what”) that occur within workspaces and customary practices (the “how”) that develop in the course of realizing the incident reporting goal. Three recurring themes support the findings: (a) The motivation to report, (b) Beliefs about reporting, and (c) The purpose of 7 reporting over time. Together, the themes form the three-legged stool of the incident reporting perception. Any leg missing renders the stool out of balance. Hazards are identified in terms of personal safety. The near miss definition is expressed in terms of individual perspective and is guided by experience, personality, knowledge, and personal agency to take action. The goal of reporting is explained in terms of benefit to people, the process, and practice. Alignment with the OHSA goal is evaluated by examining the motivation to report, beliefs about reporting, and the purpose of reporting over time. The Principle of Understanding partnership model is developed to engage the worker and the organization in active learning from near miss incidents through awareness and knowledge about the cumulative utility of near miss data, perceptions of incident severity, and optimizing communication.





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