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Heed Every Near-Miss
Table of Contents
A close call means the system nearly failed, not that we got proof the activity was safe because nobody died.
Key Concept
- When nobody gets injured, organizations often relax.
- Level 1: A close call means something almost went wrong - treat it like a warning, not proof everything is safe.
- Level 2: When nobody gets injured, organizations often relax - near misses are signals, like smoke before a fire, not lucky free passes.
- Level 3: Ignoring near misses trains the system to wait for blood before it changes - the hazard was already present when luck blocked injury.
- Level 4: Log every near miss and act before injury proves you should have listened.
- Level 5: Incident Investigation stays blameless; Hierarchy of Controls asks what hazard to eliminate after the near miss, not who to blame.
- The opposite read is usually right: the system failed, and luck blocked the worst outcome.
- A rescue, a panic incident, or a loss of control should trigger investigation and redesign before anyone runs the same activity again.
- Luck covering a near-miss is not proof the system works.
Examples
- A swimmer needed rescue during the same open-water drill last month - that is a warning to stop, not proof the safety boat can handle it forever.
- The toddler almost fell off the same chair twice - survival does not prove the setup is safe; fix the hazard before the third time.
Note Relationships
| Relationship | Wikilink | Reason |
|---|---|---|
| contradicts | Normalization of Deviance | when “we have done this before without dying” becomes permission to repeat |
| extends | Anti-Fragile Systems | Near misses are stress signals - learn before the system breaks for real |
| extends | Blameless After-Action Review | Close call deserves after-action review before the third repeat |
| extends | Eliminate Before Managing | Investigation should ask whether the hazard can be removed, not only managed better |
| extends | Failure as Feedback | Close calls are feedback before harm |
| extends | Incident Investigation | Every close call deserves a root-cause pass, not a shrug |
| extends | Learning Organizations | Organizations that learn treat near misses as data, not luck to forget |
| implements | Active Knowledge Curation | Capture the close call, redesign the activity, do not let the lesson rot in memory |
