The near miss is often celebrated.
There are sighs of relief, smiles across the group, and a line of people willing to take credit for what seems like a success.
But more time should be spent dissecting the near miss. Could it be a signal that there are gaps in our current way of working?
Why did it happen? What caused it? What would’ve happened had things gone truly wrong? How does our system need to change so we reduce the probability that things go wrong in the future?