Learning Lab · Near-miss review · 6–8 minutes

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.

Fictional composite scenarioHumanitarian field movementLearning + accountability
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Part 1 of 3 · What happened?33%
Part 1 of 3

The route change

Three passengers and a driver are travelling from a provincial office to support a partner-run mobile clinic. Heavy rain has damaged the approved route. A delay could disrupt the clinic’s vaccination session. The programme is already under time pressure, and the team is conscious of expectations from country management, HQ and the donor to keep activities on schedule.
07:10

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.

08:25

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.

08:40

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.

08:52

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.

Near misses are evidence.
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

01Programme and donor pressure
02Fragmented information
03Ambiguous authority
04Communications failure
05Workload and time pressure
Part 2 of 3

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.

Knew about the reported armed presence on secondary roads, but did not pass the information to the field coordinator or the local security field officer. Was also conscious of the pressure to avoid further delay to the programme.
Knew the approved route was blocked and knew an alternative route from previous travel. Did not know about the new armed-presence warning.
Knew the team was working to a deadline and that further delay could disrupt the vaccination activity. After entering the secondary road and noticing the lack of traffic, one of them raised a concern and suggested contacting the field coordinator or local security field officer. They did not know about the earlier armed-presence warning.
Knew the approved route was blocked and authorised the deviation following a poor HF exchange. Did not know about the armed-presence warning and did not inform the local security field officer.
Was not informed about either the warning or the route deviation and therefore had no opportunity to assess the changed movement.
Operational pressure matters too.
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.
Was this primarily one bad decision — or a failure of information to reach the people who needed it?

2. Where could the chain have been interrupted?

Select the points where the situation could have changed.

A near miss usually reflects more than one weakness.
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.

Would everyone actually have felt able to use that authority?

4. What should the review ask first?

Part 3 of 3

What changes before the next movement?

A good review does not end with an explanation. It ends with changed practice.

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.

Job security over physical security?

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.

Named actionsEvery agreed change has an owner.
DeadlinesActions do not remain indefinitely on a review document.
Follow-upSomeone checks whether the change was actually implemented.
Feedback to staffThe people who reported or participated in the review are told what changed.
If staff report a near miss and nothing visibly changes, the organisation teaches them that reporting is not worth the effort.
What prevented harm?

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.

The real test: Did the organisation learn something that makes the next movement safer?
Read the companion article →
Discussion

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?