You're Missing Your Near Misses

(Originally posted at Surfing Complexity)

FAA data shows 30 near-misses at Reagan Airport – NPR, Jan 30, 2025

The amount of attention an incident gets is proportional to the severity of the incident: the greater the impact to the organization, the more attention that post-incident activities will get. It’s a natural response, because the greater the impact, the more unsettling it is to people: they worry very specifically about that incident recurring, and want to prevent that from happening again.

Here’s the problem: most of your incidents aren’t going to repeat incidents. Nobody wants an incident to recur, and so there’s a natural built-in mechanism for engineering teams to put in the effort to do preventative work. The real challenge is preventing and quickly mitigating novel future incidents, which is the overwhelming majority of your incidents.

And that brings us to near misses, those operational surprises that have no actual impact, but could have been a major incident if conditions were slightly different. Think of them as precursors to incidents. Or, if you are more poetically inclined, omens.

Because most of our incidents are novel, and because near misses are a source of insight about novel future incidents, if we are serious about wanting to improve reliability, we should be treating our near misses as first-class entities, the way we do with incidents. Yet, I’d wager that there are no tech companies out there today that would put the same level of effort into a near miss as they would to a real incident. I’d love to hear about a tech company that holds near miss reviews, but I haven’t heard any yet.

There are real challenges to treating near misses as first-class. We can generally afford to spend a lot of post-incident effort on each high-severity incident, because there generally aren’t that many of them. I’m quite confident that your org encounters many more near misses than it does high-severity incidents, and nobody has the cycles to put in the same level of effort for every near-miss as they do for every high severity incident. This means that we need to use judgment. We can’t use severity of impact to guide us here, because these near misses are, by definition, zero severity. We need to identify which near misses are worth examining further, and which ones to let go. It’s going to be a judgment call about how much we think we could potentially learn from looking further.

The other challenge is just surfacing these near misses. Because they are zero impact, it’s likely that only a handful of people in the organization are aware when a near miss happens. Treating near misses as first class events requires a cultural shift in an organization, where the people who are aware of them highlight the near miss as a potential source of insight for improving reliability. People have to see the value in sharing when these happens, it has to be rewarded or it won’t happen.

These near misses are happening in your organization right now. Some of them will eventually blossom into full-blown high-severity incidents. If you’re not looking for them, you won’t see them.

Lorin Hochstein

Surfing Complexity