How to identify a knowledge "near miss"

In organisational safety management, they identify a “near miss” as evidence that safety practices need to be improved. We can do the same in knowledge management.

I have often used Safety Management as a useful analogue for KM, and here’s another good crossover idea.

In safety management they identify safety breaches (accidents, injuries, “lost time incidents”) as metrics and indicators that safety management needs to be improved.

They also track “near misses” – incidents where nobody was harmed, but only by luck, or “unplanned events that did not result in injury, illness or damage – but had the potential to do so“. A hammer dropped from height and landing a few feet away from a worker on the ground, a bolt blown past someone’s head by an escape of compressed gas, a near collision between two aircraft, all are examples of near misses indicating that safety management needs to be improved.

In KM we can track lost knowledge incidents, where time, money or effort was wasted because knowledge should have been available but “got lost” along the way. The knowledge is or was once available to the organisation, but failed to reach the person who needed to act upon it, with resulting cost to the organisation in terms of recovery cost, rework, lost sales, delay etc. If you are lucky you can quantify this cost as part of the Cost of Lost Knowledge, aka the Cost of Ignorance, and use this in your KM business case.

But we can also track Knowledge Near Misses. This is where the knowledge was not lost and no cost therefore incurred, but it was only found or transferred by lucky chance.

I heard a great example recently in a client organisation (and I paraphrase below).

The organisation was planning an activity. It seemed a little risky but quite doable, and there was management pressure to go ahead. They were discussing this activity in a meeting, and someone from another part of the business who happened to be in the meeting by chance (he was not invited to discuss this particular activity) spoke up and said “I was part of a team that tried this before. It was a complete disaster, and we are still recovering from the mess it created”.

The lessons from this previous project had not been captured, they were not in the lessons database, and the project report was not findable but buried in a mass of project files on a hard drive somewhere. Had that person not by chance been at the meeting, the “complete disaster” would most likely have been repeated with resulting costs in manpower, money and reputation.

This was a knowledge near miss. This event did not result in cost to the organisation through lost knowledge, but had the potential to do so, and was only avoided through luck. With a proper KM framework in place, and followed by all staff in a systematic way, this knowledge would not have been lost, and the planned activity could have been assessed in the full light of historic lessons.

You can find another KM near miss story here