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What counts as an incident or a near miss?
An incident is an event that caused harm, loss or a broken promise: an injury, a data breach, a missed delivery to a key customer. A near miss is an event that could have done so but did not, often by luck or a late catch. Near misses are the cheapest lessons you will ever get, which is why they deserve the same attention. Whether a situation needs calm handling or immediate action is the distinction I describe in abnormal versus emergency procedures.
How do you encourage people to report?
- Make it quick — a short form or message, not a long investigation template.
- Respond visibly — acknowledge every report and say what happened as a result.
- Protect honest reporters — be explicit that reporting a mistake is not, in itself, a disciplinary matter.
What should happen in the first minutes and hours?
Safety first, always. Contain the situation so it does not get worse, follow any approved procedure that applies, and escalate to the named person on your escalation list. Preserve evidence: records, messages, photos, system logs. If no procedure covers the situation, a structured method such as D.O.D.A.R. helps the team decide calmly — see when the checklist ends. Legal, regulatory and insurer notification obligations in your sector come first and may have strict deadlines; take specialist advice.
How do you establish the facts?
Talk to the people involved as soon as practical, separately, and ask what they saw and did rather than why they got it wrong. Build a simple timeline. Compare what happened with what the approved procedure says should have happened. Often the gap points to the procedure, the training or the conditions, not just the individual.
How do you find the root cause?
Keep asking why until you reach something the organisation can change. "The operator skipped a step" is a finding, not a cause. Why was it skipped? Perhaps the step was buried on page six, the shift was short-staffed, or two procedures contradicted each other. Aviation investigations look for contributing factors across people, procedures, equipment and organisation; that is an analogy for business, not a regulatory method you are bound by, but it is a useful discipline.
Who approves corrective actions?
Each corrective action needs a named owner, a deadline and approval from a leader with authority over the risk. Where an action changes a procedure, the normal SOP approval route applies, as set out in who should create, approve and manage SOPs. The procedure is updated, the version and revision history are recorded, and the people affected are told promptly — not at the next refresher.
Is blameless learning the same as no accountability?
No. A just approach distinguishes honest error, which deserves support and learning, from at-risk shortcuts, which deserve coaching, and from recklessness or deliberate violation, which may warrant disciplinary action under your own policies. Being clear about that line is what makes people trust the reporting process. Your business sets and applies the policy; I help make the procedures around it clear.
Where does AI fit?
Within your Company Operations Hub, the AI SOP Captain can help people find the approved procedure that applies. It does not decide whether something is an incident, assign blame or approve corrective actions. Accountable people do. I explain its role in what an AI SOP Captain is.
How do you close the loop?
- Check after an agreed period that corrective actions were completed and worked.
- Share the lesson more widely, without names, where other teams could face the same risk.
- Track near-miss reporting and repeat incidents as part of how you measure operational excellence.
- Use incidents as scenarios in six-monthly training and refreshers.
Frequently asked questions
Should every near miss be investigated?
- Every near miss should be recorded and acknowledged. Investigation effort should be proportionate to the potential consequence.
Who should lead an incident review?
- Someone with authority and enough distance to be fair, supported by people who understand the work. Approval of actions sits with an accountable leader.
Does a blameless approach mean nobody is ever disciplined?
- No. Honest error is treated as learning; recklessness or deliberate violation is handled under your own policies.
Do we still need specialist advice?
- Yes. Legal, regulatory, health and safety or insurance obligations may apply, and specialist advice comes first.
Read the crisis management and D.O.D.A.R. pillar, or book a discovery call to discuss how your organisation learns from incidents.
