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Many, if not most, man-made disasters are preceded by near-misses, where something goes awry but lucky circumstances prevent things from going truly and irreparably wrong. Organizations can learn from these near-misses and make changes necessary to prevent future disasters, but often they do not. This can sometimes be the fault of dysfunctional leadership, but there are also more basic psychological factors at work.

Lessons learned in blood: Why we fail to use near-misses to prevent man-made disasters