You lost your near misses – surfing complex

FAA data shows 30 MISSE at Reagan Airport – NPR, Jan 30, 2025

The amount of attention to an incident has proportion to TERRIBLY In the incident: The organization has the more effect, more attention to get post-inslood activities. It is a natural response, because the effect is greater, the more they can’t stop them: they are worried that the incident is more aware, and wants to prevent it from happening again.

Here’s the problem: Most of your incidents don’t change incidents. No one wants to be an incident to be recur, and therefore there is a natural built-in mechanism for engineering teams to put in an effort to do the proventative job. The real challenge is to control and can easily mitigate novel In the future incidents, which are most of your incidents.

And that brings us near the misses, those surprises of surgery without a real impact, but can be a significant event if conditions are minor different. Think of them as those who are primarily in incidents. Or, if you are more likely to place a poem Tomens.

Because most of our incidents are novel, and because bad missins are a source of sight of future incidents, if we are serious about the development of reliable, we need to treat our Miss in the first class, how we did incidents. However, I have been quiet without tech companies there today to place the same level of effort with a Near Miss as they want a real incident. I want to hear about a tech holding company holding Near to Review MissS, but I haven’t heard yet.

There are real challenges to treat misses in the first class. We can usually spend a lot of effort into the event-incident with every noble event, because there are not many of them. I am confident that your org meets many more miscases than high-gravity incidents, and no cycles will be placed in each near event. This means we should use JUDGES. We cannot use the severity of the effect of leading us here, because these close misses are, by definition, zero weight. We need to know where those nearly misses are worth checking out, and who will let go. It’s a call to decide what we think we can learn from seeing more.

Another challenge is just to surfe those close to misses. Because they are the zero effect, most likely that only some people in the organization knows when a nearby miss occurred. Treatment near Missina as first-class events require a cultural transition to an organization, where people know they promote reliable understanding of trustworthiness. People need to see the value of sharing as soon as it happens, it must be rewarded or does not occur.

These nearly misses are happening in your organization today. Some of them finally bloom in perfect high-gravity incidents. If you don’t seek them, they don’t see you.