Sharing Learning Across the Organization: The Power of Near-Misses

Source: Moody Air Force Base

I'm working on a new case study about the Boeing 737 MAX crisis right now, and I've come across a very interesting incident that arose before the first crash.  I think there is a key lesson from that incident that applies to all organizations as we cope with the COVID-19 crisis today.  

On the day before the crash of Lion Air Flight 610 in Indonesia, pilots flying the same plane nearly experienced tragedy.   Fortunately, a third pilot happened to be in the cockpit that day.   He observed the captain and co-pilot struggling to understand and react to the fact that the stall-prevention system was pushing the nose of the plane down repeatedly.   Finally, the observer recognized what was happening and identified how to rectify the situation.  He intervened and saved the day.  Unfortunately, the lessons from this "near-miss" never flowed to other crews at Lion Air.   On the very next day, flying the very same plane, tragedy ensued.   Pilots experienced a mis-fire of the stall-prevention system, brought on by a faulty sensor reading.  They did not know how to address the sitaution, and the plane crashed into the sea, killing everyone on board.

What's the lesson for us today?   We have to make sure that teams are reflecting on what they have learned, particularly after failures, and sharing their lessons learned with others throughout the organization.   Of course, failures often get a lot of attention, and people do hear about what went wrong and what the lessons learned are from those situations.  However, people often do not hear about the near-misses, yet they are some of the most valuable learning opportunities.   Near-misses are those situations when a failure almost occurred, but thankfully, someone intervened to take action, avoiding a major negative consequence.   

Why don't we hear about the near-misses?   Often, people's natural reaction is to simply say, "Phew! Thank goodness!"   Then they don't share the news of the situation with others.  In part, they do it to avoid scutiny or perhaps the assignment of blame.  Sometimes, they simply don't think about how the lessons from that incident can be helpful to others in the organization. 

Years ago, Amy Edmondson, Anita Tucker and I wrote a case study about Children's Hospital and Clinics in Minneapolis/St. Paul.   They wanted to surface near-misses, rather than sweep them under the rug, so as to learn from them and avoid future medical accidents.  Someone there came up with the brilliant idea to rename the near-misses!   They started calling them "Good Catches."   Clinicians were asked to record these "good catches" in logs, and then a team studied the lessons from those situations.  The term "good catch" emphasized the heroic action to intervene and avoid tragedy, rather than focusing on the bad things that happened leading up to the problem.   I since have encountered another organization, in a manufacturing environment, that actually borrowed the phrase "good catch" and actually created an award for plant employees who initiated a "good catch."  As a result, they learned about many more near-misses than ever before, studied them closely, and over time, they reduced quality defects in the factory considerably!