Horseshoes and hand grenades? Don’t forget about projects!

It is a common practice in many organizations to do a thorough post-mortem once a major project issue has occurred to understand why it happened, how effectively the team responded to it, and what might be learned from it to avoid or reduce impacts from similar causes in the future.

But what about near misses?

Addressing those would require us to shift our thinking from a simplistic binary view of “no problem” and “issue” to the continuum where near misses might justify some response.

As with all project management activities, the level of effort consumed needs to be commensurate with the expected benefits. On low complexity or low value projects it might be of little benefit to have the team do a post-mortem on “almost issues” as the magnitude of their impact would likely have been accepted. But on more critical projects or those possessing a higher level of complexity, there might be some value while high severity risks are being analyzed to add the dimension of a threshold that should trigger some degree of investigation and corrective action.

But when should this investigation take place?

Let’s consider the analogy of a driver who narrowly misses losing control of their car on an icy road. The ideal time for this self-reflection is within a few minutes of the near miss. If the driver waits till the end of that day the close call will seem less compelling and two days later they would have entirely forgotten about it. This is a perfectly normal reaction of our brains as if we go through life having perfect recall of every dire situation which almost transpired we’d be paralyzed by fear.

This further supports the rationale for regular team reflection on what has been learned.

If a project manager asks team members to think back over the last week or two about what almost went wrong, valuable learnings won’t be lost and could be incorporated into the team’s standard practices. This requires that the team feels psychologically safe so that individuals are willing to share situations which they were responsible for.

We should learn something from the airline industry. There is tremendous effort expended after an airline disaster in identifying the root cause and building safeguards to prevent repeat occurrences but a reasonable amount of investigation occurs whenever an accident which might have occurred is narrowly avoided. Reporting and investigation of near misses is also a very common practice at construction sites. The rationale for this is clear as people’s lives are at stake. With most of our projects we don’t face such extreme situations but scaling such practices would seem reasonable.

Maybe we need to add projects to the old cliché “Close only counts in horseshoes and hand grenades“!