Near-Miss Signals Belong to the System
Respond to a near miss by separating system learning from individual accountability.
The just-culture question Ask: what behavior are we responding to, and what system conditions shaped it? That question prevents two common failures: blaming a careful person for a bad process, or excusing a dangerous choice because no harm happened this time. Why it works People report hazards when they believe the response will be fair. Fair does not mean soft. It means the organization uses evidence to choose the response: console human error, coach risky drift, and hold reckless disregard accountable. The administrative role Administrators often own the systems around the event: staffing, throughput pressure, equipment layout, policy clarity, training,…
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