Nothing Happened.
That Was the Warning.
A short interactive exercise on reconstructing a near miss, looking beyond the final decision and turning learning into changed practice.
Begin the exercise →The route change
A warning lands elsewhere
A partner messages the programme officer about a new armed presence on secondary roads. The information is not passed to the field coordinator or the local security field officer.
The approved route is blocked
The driver proposes a known alternative route.
The team contacts the field coordinator by HF radio. Reception is poor, but the field coordinator hears enough to respond: “If the driver knows it, proceed carefully.”
Treating the change as a minor deviation and assuming the driver knows the area, the field coordinator does not alert the local security field officer. No route-specific security check is made.
Something feels wrong
A few minutes after turning onto the secondary road, the team notices that there is almost no traffic.
One team member suggests contacting the field coordinator or local security field officer to check whether anything has changed in the area.
They try to establish contact by HF radio, but the vehicle is in a dead zone and no reliable connection can be made. The team has no second independent long-range communications option available and continues along the route.
The team meets an informal checkpoint
Armed men signal the vehicle to stop and direct it off the road. The driver stops, keeps both hands visible and follows their instructions.
The team is held and questioned for 25 minutes. An experienced local colleague explains the purpose of the movement and the group eventually allows the vehicle to leave.
The vehicle tracker also has no coverage from the location.
Nobody is harmed.
The absence of harm does not mean the controls worked. Sometimes the difference between a near miss and a serious incident is simply circumstance.
Conditions in play
Reconstruct before judging
Start with what people knew, what they expected and what they were trying to achieve. Accountability comes later.
1. Who knew what — and when?
Open each role.
Decisions are rarely made in a vacuum. Deadlines, programme commitments, donor expectations and perceived pressure from HQ can all influence how readily staff challenge a movement or recommend delay.
2. Where could the chain have been interrupted?
Select the points where the situation could have changed.
If a review ends with “the driver should have…” or “the field coordinator should have…”, it risks focusing only on the last decision made rather than the wider conditions that shaped it — such as information flow, procedures, communications, authority and operational pressure.
3. Could anyone have stopped the movement?
The organisation’s movement procedure states clearly that any member of the team can stop a movement if they believe it should not proceed.
A member of staff who believes that challenging a decision could affect their job, contract, reputation or future employment may stay silent even when they feel unsafe.
A genuine speak-up culture means making sure staff do not have to choose between the two.
4. What should the review ask first?
Understanding what people saw, knew, expected and tried to achieve does not remove accountability. It gives the organisation the information needed to apply accountability fairly.
What changes before the next movement?
The team returned safely. The organisation now has an opportunity to act before the same weaknesses contribute to a more serious event.
Threat or access information relevant to field movements must be shared promptly with the people responsible for operational and security decisions.
In this case, the warning about armed presence should have reached both the field coordinator and the local security field officer.
Learning point: Information that remains inside one programme or department cannot inform decisions elsewhere.
A blocked road may make a change seem routine, especially when the driver knows an alternative. But changing the route can also change the risk.
The local security field officer should have been consulted before the route deviation was authorised.
The revised movement should then have been checked against current information before the team continued.
Learning point: Familiarity with a road is not the same as knowing its current security conditions.
The team had HF radio, but when the lack of traffic raised concern they were in a dead zone and could not establish reliable contact. The tracker also failed to provide useful coverage.
For movements where loss of contact could significantly affect operational decisions or the response to an incident, the team should have access to at least two independent long-range communications options.
Example: HF radio + satellite phone.
A second independent system might have allowed the team to obtain updated information and reassess the movement when concerns emerged. It would not guarantee a different outcome, but it would have given the team another option.
Learning point: Communications redundancy creates options when the primary system stops working.
The organisation already has a procedure stating that any member of the team can stop a movement if they believe it should not proceed.
That authority must exist in practice as well as on paper.
Staff need to be able to raise concerns, challenge assumptions and recommend that a movement stop without fearing consequences for their contract, reputation or future employment.
A genuine speak-up culture means people should never feel they have to choose between the two.
A review should produce visible action.
Not one control. Not one procedure. Not one person.
The team benefited from the judgement of an experienced local colleague, the restraint of the armed group and, ultimately, circumstance.
The fact that nobody was harmed does not prove that the system worked.
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What would you change?
Near-miss reviews are most useful when practitioners compare how different organisations would respond. What stands out to you in this scenario? What would your organisation change before the next movement?