Published
The 2013 Major Project Association conference, A Successful Project Every Time, included a presentation on the value and significance of learning from near misses. This has been something that the human factors community have focused on for many years:
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries, James Reason (2008)
Organisational Accidents Revisited, James Reason (2015)
The Field Guide to Human Error, Sidney Dekker (2014)
Just Culture: Balancing Safety and Accountability, Sidney Dekker (2012)
But outside of areas such as construction safety, I am not sure how far this culture has been adopted in project delivery.
It seems particularly relevant today, when we look back to London 2012 and remember some of the last minute panics – such as the decision to draft in members of the armed forces to help with event security.
There’s an interesting 2011 article in British Medical Journal: Learning from near misses: from quick fixes to closing off the Swiss-cheese holes which neatly references James Reason’s Swiss Cheese Model (explained in this delightful video by the author) but also points to: “three scenarios for the responses to near misses, the most common involved ‘doing a quick fix’ where clinicians recognised and corrected an error with no further action. The second scenario consisted of reporting near misses but not hearing back from management, which some participants characterised as ‘going into a black hole’. The third scenario was ‘closing off the Swiss-cheese holes’, in which a reported near miss generated corrective action at an organisational level.”
This then holds the secret of learning from near misses in project delivery. 1. Find ways of enabling near miss reporting that are easy to follow and habit forming. Some of that can be built into the project lifecycle, with regular after action reviews at key stages in the project. Other processes and systems will need to facilitate spontaneous reporting; 2. Identifying how to respond, with a ‘quick fix’; a change to working practices or just simply by ‘storyfying’ and ‘socialising’ the lesson.
Complex projects, by their very nature, involve an element of experiment, and hit and miss. We shouldn’t be afraid of the near misses, nor brush them under the carpet. They are a great way of getting better if you take the time to understand them.
Jonathan Norman, Association Knowledge Manager