James King

There is an old saying in process design. I think it comes from the Swiss Cheese theory of risk management.

Every near miss is a gift, you should make good use of it

Basically for every disaster there is almost always a history of

• Several near misses where an issue occurred but “luckily” something prevented it from happening;
• There was a false alarm or similar event that turned out not to be the real thing, we found gaps and then “luckily” we were relieved to find it was a false alarm; and
• There were some minor scratches and bruises that were “luckily” not worse.

So the gift is to learn from the near miss rather than waiting for the real disaster.

If we have a fire drill or fire alarm and all the fire wardens are working from home .. but “luckily” the receptionist was pro-active and called all the phone numbers in the drill then all is good. But next time there might be a real fire. All the fire wardens might be at home. The receptionist might also be at lunch.

So it is worth doing a “that was lucky but ‘what if …’” retro. Then we can beef up our resilience before the actual event.

I believe I have spoken to people about that before. I have seen some minor near misses lately. I am thankful for the gift that allows us to do a retro. It helps us improve how we work before a big event, argument, incident, or long meeting.