Near misses: what the absence of harm does not prove
When an anomaly is caught before it causes harm, closing the case often seems reasonable. Yet the managerial question is precise: how can we determine whether that outcome reflects a reliable safeguard or a fortunate intervention that would be difficult to reproduce?
What the literature establishes
Amy Edmondson (1999, Administrative Science Quarterly) identifies an association between psychological safety and learning behavior in work teams. Being able to report an error, ask for help or discuss a difficulty without fearing interpersonal penalties supports discussion of how work actually happens. A sparsely populated incident log therefore does not establish operational reliability: the conditions under which people can speak about anomalies also need examination.
Learning from an event that does not recur
James G. March, Lee S. Sproull and Michal Tamuz (1991, Organization Science) examine opportunities for learning when available experience consists of very rare events. Their work highlights, among other possibilities, enriching the interpretation of an event and considering plausible alternative outcomes. For a near miss, this means asking what would have changed had the person who spotted the anomaly been absent, rather than focusing solely on the absence of harm.
The premature conclusion
It would be tempting to conclude that every anomaly requires a new procedure and that more reports prove deteriorating safety. Neither conclusion follows directly from this research: an increase in reporting may also reflect a lower perceived risk in speaking up. The task is to distinguish a safeguard that actually operated from a recovery dependent on exceptional availability. (our executive and employee training programmes)
What the evidence cannot settle
The psychological safety study does not demonstrate that increasing reporting automatically reduces harm, while the work on rare experiences offers a theoretical analysis rather than a validated incident-review protocol. Reconstructing an alternative outcome is itself vulnerable to hindsight bias. A useful review must therefore separate documented facts, interpretations and hypotheses to be tested.
A practical check in Sion
Within SHR’s “Management complexe” programme, an exercise in Sion could examine anomalies caught in hydropower operations, clinical handovers, grape-harvest preparations or Alpine tourism services, without treating their safety requirements as equivalent. During a six-week pilot, chosen for practical reasons rather than as a scientific threshold, each incident reviewed would have a record specifying the observed recovery, the expected safeguard and a test of that safeguard compatible with sector-specific constraints. The measure would be the proportion of records with a completed test and a documented result by the deadline, reporting both numerator and denominator. This indicator checks whether the proposed learning activity took place, not whether risk has demonstrably decreased. To go further: explore the Complex Management training in Sion in the canton of Valais, or browse our executive and employee training programmes in Switzerland.
In pictures: Complex Management in Sion
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