I recently read the book, Managing the Unexpected, by Weick and Sutcliffe. The book is a collection of case studies of organizations and people dealing with emergencies; disastrous emergencies. It tries to get to the bottom of what caused them and if they could have been avoided. Were there any signals way before the disaster struck? The book then goes on to show what organizations can do to become resilient and be better prepared to manage the unexpected.
One thing that I have picked up from this book is to treat a near miss as a failure. Not to heave a sigh of relief that we got lucky and then move on, but treat it as a disaster and understand how we got so close to it. Worth a read.