CONTENTS

1 Introduction
1.1 Learning objectives
1.2 Training other crew members
1.3 How near-miss reporting can save lives

2 Definitions
2.1 What is a ‘near-miss’?
2.2 Attitudes towards near-miss reporting
2.3 Company responsibility

3 When to report
3.1 Share the knowledge
3.2 Reporting method

4 How to report
4.1 What to include

5 Analysing reports
5.1 The ‘Five Whys’

6 What happens after initial analysis

6.1 The role of the shore office in analysing near-miss reports

7 Overcoming the barriers to reporting

7.1 The barriers
7.2 Establishing a safety culture

8 CHIRP
8.1 When to use CHIRP
8.2 The CHIRP reporting process

9 Lessons learned

10 Conclusions

11 Further resources

12 Appendices

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1 INTRODUCTION
1.1 Learning objectives
After completing this training package, you will understand:
 what a near-miss is
 the value of reporting near-misses
 what, when and how to report
 how near-miss reports can help to identify causal factors and
weaknesses in operational procedures
 common causal factors and how to identify them
 that for near-miss reporting to be effective, there must be a safety
culture
 where reports go; how they are reviewed, collated and analysed in the
shore office before being fed back to the ship
 why people do not report near-misses and how this can be overcome
 the role of the Confidential Hazardous Incident Reporting Programme
(CHIRP) in near-miss reporting

1.2 Training other crew members

If you are responsible for training others then you should aim to follow the instructions
in this section as closely as possible. It will help you to learn how to run effective
training sessions with the crew.

Preparation for group sessions

Think about the group

How familiar is everyone with near-miss reporting? What do you want this session to
achieve? What questions might they ask you? You should find out the company’s
definition of a near-miss, and the procedure for near-miss reporting.

Watch the video

It is important to familiarise yourself with the video in advance, so that you can
anticipate possible questions from the group and research your answers.

Read the Reference

The Reference reinforces the key points from the video and contains reference
material that expands on the learning. It also suggests discussion topics and group
activities that you may find useful.

Bring relevant materials to the session

Ask the shore office for some sample near-miss reports (with names blocked out if
necessary) that you can use during the training.

Tips for running an effective training session

Begin with an overview

Explain to the group the objectives of the session, what you are going to cover, what
they will know by the end of the session, and how long it will take.

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Make the best use of the video and Reference
Show the video (either from beginning to end, or section by section) and open up the
session to general questions and discussion, using the topics suggested in the
workbook. If anyone was unclear about a particular point, or you would like to
reinforce a message, you can re-play the relevant section(s) of the video and/or refer
them to the material in the corresponding section of the Reference .

Ask questions throughout

Ask your trainees questions from the start, and encourage them to take an active part
in the session. You can use the questions and discussion points in this Reference to
test understanding and raise awareness of the issues in trainees’ minds.

Start discussions
Encouraging discussions in small groups will help each individual to make a
contribution to the session. But remember that some people are reluctant to speak up,
so try and involve them.

Sum up what the session has achieved

At the end, briefly bring together everything you have covered. Make sure that you
have asked for any other questions, and answered them. Ask the group what they
found most useful. Summarise and highlight the key learning points and draw
conclusions.

Afterwards
Spend a few minutes thinking about how the session went, and how you might want to
change it next time. Write down any lessons that you have learned.

GLOSSARY

Note: Your company may have its own definitions of these safety-related terms.

Accident
An unforeseen event or chain of events which has caused injury or damage to
people, property, the environment, or all of these.

Hazard
A source of potential injury or damage to people, property or the environment under
certain conditions.

Incident
An unforeseen event or chain of events which could have caused injury or damage
to people, property, the environment, or all of these, but did not, i.e. a near-miss.

Near-miss
(Also known as ‘hazardous occurrence’, ‘latent failure’, ‘near hit’, ‘near loss’,
‘undesired circumstance’, ‘close shave’, ‘close call’.) See Section 2 Definitions.

Risk
The likelihood that people, property, equipment or the environment could be injured
or damaged if exposed to a hazard.

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 Unsafe act
Carrying out a task or other activity in a way that could harm people, property, or the
environment.

Unsafe condition
A condition in the workplace that could cause damage to property or harm to people
or the environment.

1.3 How near-miss reporting can save lives

Effective near-miss reporting is an essential feature of a successful safety culture
because it provides an opportunity to learn from past experiences and to share the
lessons learned in order to help prevent accidents. It is vital that everyone, on board
ship and ashore, understands the importance of effective near-miss reporting, and is
able and willing to carry out their role in this critical task.

The historical record shows that for every major accident involving a fatality or a
serious injury there are 29 minor accidents and 300 near-misses (H W Heinrich,
Industrial accident prevention: a scientific approach, 1931).

Incidents can have a terrible impact not only on the victims but also on their family
members, colleagues and those who witness the incidents – they may be mentally
and permanently scarred for life.

Collating and effective analysis of near-miss reports enables valuable lessons to be

learned. Implementing this learning throughout the fleet can lead to a reduction of
serious incidents and to shrinking the accident and near-miss pyramid.

Near-miss reporting can also identify weaknesses in operational procedures.

It is the responsibility of everyone on the ship to alert other crew members, take
appropriate action and report if they see any unsafe act, unsafe condition, hazard or
near-miss. (“If you see it, you own it.”)

Unsafe acts
Unsafe acts are usually connected to lack of understanding, knowledge and skills, or
to attitudes such as complacency. The results are degraded behaviour including
failure to follow correct procedures.

Some examples of unsafe acts:

 violations and shortcuts
 incorrect use of equipment
 ineffective maintenance
 unauthorised operation or use of equipment
 using defective tools or equipment, or using them incorrectly
 operating tools or equipment at an unsafe speed
 poor housekeeping – failure to put things away when not using them; not
disposing of rubbish properly
 removing or bypassing safety devices
 riding hazardous moving equipment

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  failure to warn or signal as required
 standing in an unsafe place
 lifting heavy objects using incorrect technique
 indulging in horseplay
 distracting other crew members
 distraction due to multitasking
 failure to wear personal protective equipment (PPE)
 inadequate passage planning
 incorrect use of ECDIS (Electronic Chart Display and Information System)

Unsafe conditions
Some examples of unsafe conditions:
 lack of effective guards or safety devices
 lack of effective warning system
 fire and explosion hazards
 incorrect or ineffective personal protection clothing or equipment
 ineffective ventilation
 protruding object hazards
 close clearance and congestion hazards
 hazardous arrangement of workstations and storage
 ineffective illumination
 intense noise
 defective tools and equipment

Why do accidents happen?

Analysis shows that almost all accidents on ships are the result of human behaviour
and actions rather than purely technical failures.

Single cause accidents are rare. Accidents usually stem from the relationship
between human understanding (and its associated behaviour) and a variety of latent
defects (also known as systemic issues) in the organisation.

Human understanding and behavioural issues include:

 training and knowledge
 situational awareness
 local practices/culture
 personal goals, attitudes, beliefs, self-discipline
 physical and mental capabilities including fitness for duty
 language and communication skills

For a list of latent defects, see Section 12 Appendices.

Research in safety-critical industries has shown that it is frequently an

unpredictable, complex and often unusual combination of these factors (including
sometimes sheer bad luck) that turns a near-miss into an accident.

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 This helps to explain why, despite the many safety regulations that are introduced to
address specific errors, accidents keep happening.

However, some organisations have far fewer incidents and accidents than others,
and one characteristic they have in common is that they pay close attention to risk.
They use the data that they collect on near-misses and accidents to identify and put
right the problems in a number of interfaces, for example, between training practices
and actual working practices, between officers’ and ratings’ relationships, and
between the drive for efficiency and the need for thoroughness.

Why report near-misses?

All near-misses are accidents waiting to happen. They could happen to you or to one
of your workmates. If you regularly report near-misses, then it is more likely that you
will avoid accidents.

If the problem is not reported, it will not go away.

If you see a near-miss, report it.

If you have caused or been involved in a near-miss, report it.

2 DEFINITIONS

2.1 What is a ‘near-miss’?

In its guidance on near-miss reporting (MSC-MEPC.7/Circ.7), the IMO defines a near-
miss as “A sequence of events and/or conditions that could have resulted in loss. This
loss was prevented only by a fortuitous break in the chain of events and/or conditions.
The potential loss could be human injury, environmental damage, or negative
business impact (e.g. repair or replacement costs, scheduling delays, contract
violations, loss of reputation).” In other words, it is an accident waiting to happen.

The Oil Companies International Marine Forum (OCIMF) definition is “An event or
sequence of events which did not result in an injury but which, under slightly different
conditions, could have done so.” (Source: Marine Injury Reporting Guidelines.)

Your company may have its own definition but it will be similar to these. Near-misses
are sometimes called ‘hazardous occurrences’.

Note: This training package demonstrates good practice and is intended to support
your company’s training and procedures, so all definitions and procedures in your
ship’s documentation will take precedence over the content of the Report a Near-Miss
– Save a Life training package. You must always follow your company’s procedures
as set out in the ship’s Safety Management System (SMS).

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Legal obligations
Near-miss reporting is a requirement of many ships’ Safety Management Systems, as
the International Safety Management (ISM) Code includes it as an obligation.

Extract from ISM Code, Part A – Implementation

9 Reports and analysis of non-conformities, accidents and hazardous

occurrences

9.1 The safety management system should include procedures ensuring that non-
conformities, accidents and hazardous occurrences are reported to the company,
investigated and analysed with the objective of improving safety and pollution
prevention.

9.2 The company should establish procedures for the implementation of corrective
action, including measures intended to prevent recurrence.

Another legal requirement is the Maritime Labour Convention (MLC, 2006, as

amended), which stipulates that near-miss statistics must be used to support risk
assessment.

Extracts from MLC, 2006

Standard A4.3 – Health and safety protection and accident prevention

 The competent authority shall require that shipowners conducting risk evaluation
in relation to management of occupational safety and health refer to appropriate
statistical information from their ships and from general statistics provided by the
competent authority.

Guideline B4.3.5 – Reporting and collection of statistics

1. All occupational accidents and occupational injuries and diseases should be
reported so that they can be investigated and comprehensive statistics can be
kept, analysed and published, taking account of protection of the personal data
of the seafarers concerned. Reports should not be limited to fatalities or to
accidents involving the ship.

Corrective actions

Where possible, a near-miss should be corrected immediately as well as reported. A

corrective action could be:

 removing the hazard altogether

 finding out why the problem arose (e.g. why the equipment broke) and
minimising the chances of it happening again
 training the personnel how to carry out the task correctly

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 When a corrective action has been taken, the likelihood of an accident taking place
is much reduced.

2.2 Attitudes towards near-miss reporting

Near-miss reporting means being honest about your errors and omissions and is only
likely to be effective in a safety culture which provides confidentiality and where you
are not punished for making a mistake.

Remember: near-miss reporting is not a weakness, it is a strength. By reporting a

near-miss, a crew member may prevent a serious accident to someone they know.
Companies should thank and praise their crew for any reports they submit.

The IMO Guidelines on Near-Miss Reporting (MSC-MEPC.7/Circ.7) set out the need
for a ‘just culture’ which differentiates between inappropriate behaviour that requires
disciplinary action and that which can be described as an honest mistake (a genuine
error).

‘Just culture’ definition

(From MSC-MEPC.7/Circ.7)

“A ‘just culture’ features an atmosphere of responsible behaviour and trust whereby

people are encouraged to provide essential safety-related information without fear of
retribution.

However, a distinction is drawn between acceptable and unacceptable behaviour.

Unacceptable behaviour will not necessarily receive a guarantee that a person will
not face consequences.”

Acceptable or unacceptable?
Your company should define the circumstances in which it will guarantee an outcome
of confidentiality and where no punishment will be imposed, and the circumstances
when disciplinary action will be taken. Ideally, management and workforce should
work together on this.

An acceptable behaviour or action could be:

 a ‘situational violation’ – an action taken to get things done (depending on the
context, the risks involved and the way the action was carried out)
 a ‘routine violation’ – This may be a common practice, but the company should
still review their procedures to see why they are being routinely violated
 a ‘system induced violation’ – where there was no workable or correct
procedure, or where the person was insufficiently trained or experienced
 an error of judgment
 a genuine error – slip, lapse, mistake
 a genuine attempt to deal with an unusual situation

An action or behaviour that is unacceptable and therefore requires disciplinary action

could be:
 deliberate, wilful action where harm is intended

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  a breach of the company drugs and alcohol policy
 an exceptional violation or gross negligence or recklessness

2.3 Company responsibility

The company has a duty to acknowledge and reply to every near-miss report. The
company office staff should also look at their own practices to identify if there are
causal factors attributed to management that may also have contributed to the near-
miss. (See the list of ‘Human understanding and behavioural issues’ under Why do
accidents happen? in Section 1 Introduction.)

If in doubt, report it

In summary, there are several definitions of what is and what is not a near-miss. If
there is actual loss or injury, it is an incident and must be reported as such. However,
on the ship there is no need to be concerned about precise definitions. When in any
doubt about reporting a near-miss – report it. If the shore office does not consider it to
be a near-miss then they can always reclassify it.

TRAINER - GROUP DISCUSSION

Ask the group:

 How does the company define a ‘near-miss’?
 How would you define a near-miss? Or ‘acceptable’ and
‘unacceptable’ actions or behaviour?

3 WHEN TO REPORT
3.1 Share the knowledge
Near-miss reports should be circulated widely so that they can raise awareness of
hazards.

Often it is thought that if a defect has been found and fixed, there is no need to report
it or to make a near-miss report, but this stops the sharing of the knowledge of the
potential hazard.

Everyone on board should report as a near-miss any hazardous situation that they
see. Your ship’s SMS procedures will provide you with a template for near-miss
reporting and you can find a sample form in Section 12 Appendices.

What to report
The IMO gives (in MSC-MEPC.7/Circ.7) several examples of what should be
reported:
 any event that leads to the implementation of an emergency procedure, plan
or response and thus prevents a loss, e.g. a collision narrowly avoided; a
crew member double-checking a valve and discovering a wrong pressure

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 reading on the supply side

 any event where an unexpected condition could lead to an adverse

consequence which does not occur, e.g. a person moving from a location
immediately before a crane unexpectedly drops a load of cargo there; a ship
finding itself off-course in normally shallow waters but does not ground
because of an unusual high-spring tide

 any dangerous or hazardous situation or condition that is not discovered until

after the danger has passed, e.g. a vessel safely departing a port of call and
discovering several hours into the voyage that the ship’s radio was not tuned
to the Harbour Master’s radio frequency; the discovery that the ECDIS
display scale does not match the scale, projection or orientation of the chart
and radar images

What not to report

The following are not suitable for reporting as near-misses:
 incidents or events with no safety content
 issues involving conflicts of personalities
 industrial relations and/or terms and conditions of employment problems

Who should report

Anyone should be able to report a near-miss. Depending on your company’s
system, the actual written report may be completed either by the person who
noticed the near-miss or by their head of department.

It may be possible to submit a report anonymously (i.e. without including your name)
but again this will depend on company rules.

Examples – safety lessons learned from reports

1. Galley personnel were cleaning the galley without having properly isolated
the power supply.

Lesson learned
 Risk assessment reports aim to improve the safety on board and protect the
crew from hazards involved in the onboard activities. It is therefore a safety
need for (a) the risk assessment reports to be communicated effectively to all
personnel involved, and (b) the corrective measures to be implemented
during the on board activities. Ensure that the appropriate risk assessment is
made available to galley personnel.
2. During operation of a ship’s incinerator, the 3 rd engineer supervised by the
2nd engineer bypassed the safety lock device and opened the door to add
more garbage. They were not injured or burned from the flames.

Lessons learned
 During your next Safety Committee Meeting, discuss with the crew the

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 causes of this incident, underlining the fact that the alarms and safety devices
are fitted to protect the crew from harm and also the equipment and
machinery from potential damage. Bypassing a safety device may lead to a
serious personal accident or serious loss.
 A senior officer teaching a junior officer to bypass safety devices is a very
serious breach of duty. The engineers were taking short cuts and through this
rule-breaking behaviour they created a potential risk of severe injury to
themselves.

3. A seafarer was working aloft marking the lifeboat’s name without wearing a
safety harness. The bosun was in attendance and the company’s ‘working
aloft’ procedures were not being implemented.

Lesson learned
 It is important that the supervisor always includes safety instructions when
issuing work instructions.

4. A duty engineer went into the engine room to check an alarm during an
Unmanned Machinery Space (UMS) duty period. He was not correctly
dressed, wearing T-shirt, shorts and slippers. He justified his action stating
that it was a job that would only take a few minutes.

Lessons learned
 The causal factors were complacency and rule breaking behaviour through
the personnel taking short cuts.
 The ship’s personnel were reminded that personal protective equipment
(PPE) is provided for their own safety. Use of the correct PPE is not only a
requirement but also a safety need.

TRAINER - GROUP ACTIVITY

Ask the group to give examples of near-misses in:

 procedures (e.g. not carrying out a risk assessment before
working at height, not complying with or renewing a ‘Permit to
Work’)
 maintenance (e.g. not putting a guard back in place on a
machine after a routine maintenance task)
 housekeeping (e.g. not disposing of an oily rag correctly)
 communication (e.g. not testing radios when entering an
enclosed space)
 training (e.g. not being proficient in using the ECDIS)

3.2 Reporting method

Whether you have paper or electronic (spreadsheet, email) reporting forms will
depend on your company. Whatever the type available, the company should ensure
that the process for reporting is easy and does not create excessive administration
either on the ship or in the shore office. However, it is worth putting some extra work
into reporting near-misses because this means fewer accidents.

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 TRAINER - GROUP DISCUSSION
Ask the group:
 What experience do you have of a near-miss on your ship?
Was it reported? If not, why not? Who should have reported
it? Was corrective action taken? What could or should have
been done?
 What is the company’s system for reporting? How could it be
made easier?

4 HOW TO REPORT

4.1 What to include

It is important to make clear in the report what was the actual near-miss. The IMO (in
MSC-MEPC.7/Circ.7) indicates that the following minimum information should be
included:
 Who and what was involved?
 What happened, where, when, and in what sequence?
 What were the potential losses and their potential severity?
 What was the likelihood of a loss being realised?
 What is the likelihood of a recurrence of the chain of events and/or conditions
that led to the near-miss?

If in doubt, it is better at first to give too little information rather than too much. If further
information is required by the person analysing the incident, they can ask the reporter
for further details.

Why you should report good quality data

Good quality data is valuable because the analysis does not just help to correct the
near-miss itself but also indicates wider trends that give a clear idea of what is
happening in the whole fleet.

The reporting process

For near-miss incidents involving the ship, the SMS procedure will probably be to pass
the report to the Master, then the Safety Committee and finally always to the head
office where the report will be thoroughly analysed and reviewed.

TRAINER - GROUP ACTIVITY

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 Hand out print-outs of the company’s near-miss report form (or print
off the sample form in Section 12 Appendices) and ask the group
to write a near-miss report using case study no.4 from Section 9
Lessons Learned.

Classification of near-misses
Some shipping companies classify near-misses into different categories, according to
the seriousness of the consequences as if the potential injuries or damage had
actually occurred.

Industry example of near-miss categories

Risk level Type of near-miss Follow-up action

High risk (severe) Where an emergency response Investigate further and
would have been required. A circulate to the fleet
Lost Time Injury* (LTI), damage vessels through a
from a collision or to important ‘lessons learned’ report.
equipment, and/or
environmental pollution are all
avoided.

* Also known as a Lost Time

Incident or Lost Time Accident
(LTA).

Medium risk A Medical Treatment Case List in the monthly

(moderate) (MTC), damage to non-
important equipment or ship’s
structure, and pollution damage
on the ship are all avoided.
summary of the near-
misses circulated to the
fleet vessels by the
company’s Safety
Officer.

Low risk (minor) A First Aid Case (FAC) injury is Discussion on board
avoided and there would be no during the next safety
damage to any equipment and meeting.
no pollution of any kind.

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5 ANALYSING REPORTS
Causal factors
Analysis is essential to identify the causal factors – the essential reasons or
determining elements that led to the near-miss. The most obvious explanation may not
always be the fundamental reason for the incident, and there are generally several
causal factors that work in combination, and often in rare combinations. It is often easy
to identify ‘what’ happened, or ‘how it happened’ but not always ‘why’.

Initial analysis will start on the ship, and the report should include a preliminary
assessment of the causal factors.

Frequent causal factors can be seen in this illustration.

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5.1 The ‘Five Whys’
A useful tool to help identify the causal factors is to ask the question ‘why?’
repeatedly. This question may need to be asked five or even more times in order to
peel away the layers of symptoms which can lead to the problem’s causal factors, and
this is why the technique is sometimes called the ‘Five Whys’.

The technique can be applied in a series of steps:

1. Write down the specific problem.

2. Next, ask why the problem happens and write the answer below the problem.

3. If the answer you just provided doesn’t identify the basic cause of the problem
that you wrote down in Step 1, ask why again and write that answer down.

4. Loop back to step 3 until the problem’s basic cause is identified. This may take
fewer or more times than Five Whys.

Taking the example from Part 5 of the video:

Why did the filter leak?

Because it wasn’t replaced properly.

→ Why wasn’t it replaced properly?

Because it was difficult to fit.

→ Why was it difficult to fit?

Because the design allowed it to be assembled incorrectly without being
noticed.

→ Why wasn’t it noticed?

Because it wasn’t checked.

→ Why wasn’t it checked?

Because not enough time was available for the job.

→ Why wasn’t enough time available for the job?

(And so on.)

Bear in mind that some ‘Becauses’ can generate more than one ‘Why’, for example:

→ Why was it difficult to fit?

Because the design allowed it to be assembled incorrectly without being
noticed, AND because the maintenance manual is inadequate.

→ Why wasn’t it noticed?

AND
→ Why is the maintenance manual inadequate?

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The final ‘why’ should lead to a statement that you can take action on. In the video
example, the time allotted to maintenance procedures may need to be increased.
Note that The Five Whys is only one technique and may be too basic for more
complicated situations.

TRAINER - GROUP ACTIVITY

Ask the group to:
(a) describe a near-miss or unsafe condition that they have
witnessed or heard about on the ship (or on a previous ship)
(b) identify possible causal factors by using the ‘Five Whys’
technique
(c) analyse a sample near-miss report that you have obtained
from the company, using this ‘Five Whys’ worksheet

Five Whys worksheet

From the report, analyse the problem:

Why is it happening?

Why is it happening?

1. You do not need

Why is that? to list all causal
factors. Go as
far as you can
2. with one factor
Why is that?
to find the
fundamental
cause.
3.
Why is that?
If your last
answer is
4. something you
Why is that?
cannot control,
go back up to
the previous
5. answer.

Action:

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6 WHAT HAPPENS AFTER INITIAL ANALYSIS

6.1 The role of the shore office in analysing near-miss reports

Once the ship personnel has done an initial analysis, the report is sent to the shore
office. It is not always possible for those on the ship to see which near-misses are
important and occur frequently, but in the shore office where all the near-miss reports
from the fleet are collated, the situation becomes much clearer and patterns and
weaknesses are revealed. This information can lead to improvements both in
equipment and procedures.

Each company has its own process but generally once the near-miss report has
reached the shore office, it goes to the Designated Person Ashore (DPA) and to the
superintendent who discuss and analyse it. This may involve a review process of
gathering data by interviewing key personnel and by collecting physical and location-
related information: photos, Voyage Data Recorder (VDR) recordings, charts, logs and
damaged components. A report is then generated, collated and stored.

The lessons learned are passed on to the senior management of the company who
then feed them back to the ship and other vessels in the fleet. (Ideally, feedback
should be given to the person who reported the near-miss so that they will feel
encouraged to report again in the future. Even if nothing is to be done about the near-
miss, it is still important to give them the reason.) The precise distribution of the
lessons learned will follow the company’s SMS.

The company will produce statistics to see how many near-miss reports they are
receiving from the fleet, and this will be followed by setting targets and measuring the
progress to these reporting targets.

Analysing near-misses requires trained and experienced staff, with persistence and
skill.

Example of a near-miss reporting, analysis and feedback process

1. Targets may be set for a minimum number of near-miss reports to be submitted

by each vessel in the fleet every month (though it should be made clear that all
near-misses should be reported).

2. There is continual review and statistical analysis of the near-misses reported by

the vessels in the fleet with a view to establishing trends and setting priorities for
corrective actions.

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 3. Every near-miss incident reported to the office is evaluated by the company and
a feedback report on the necessary corrective actions is forwarded to the
reporting vessel.

4. A ‘lessons learned’ report is issued and circulated to the vessels in the fleet on a
regular basis.

Back on the ship: discussing near-miss reports in safety meetings

On the ship, all the relevant near-miss reports sent by the shore office should be made
ready for safety meetings. It is good practice to discuss relevant near-miss reports
openly in the meetings and all personnel should be given a chance to comment.

Safety alerts can also be posted on board.

TRAINER - GROUP ACTIVITY

Hand out a sample near-miss report from the ship and ask for
comments from each member of the group about:

 what the consequence(s) of the near-miss could have been

 what could be done to stop the near-miss turning into an
accident

7 OVERCOMING THE BARRIERS TO REPORTING

7.1 The barriers

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Research from the Swedish Department of Shipping and Marine Technology,
Chalmers University of Technology (Best Practice in Near-Miss Reporting, Ilknur
Erdogan, Göteborg, Sweden, 2011) indicates that too few reports come in from ratings
and that there are a number of reasons for this.

Barriers to near-miss reporting include:

 fear of punishment and penalties
 complacency
 distrust of the company personnel dealing with near-miss reporting
 disappointment resulting from the company not acknowledging or acting on the
information in reports
 worry that a third party inspector/auditor may report the near-miss as a
deficiency
 concern about loss of face and appearing incompetent or stupid, either
embarrassing yourself or others
 anxiety about the extra work of writing a report
 worry about being asked to solve the problem
 time pressure

A further barrier may be apathy, where crew members do not believe there is any
point in reporting, especially where management is not seen to take effective action as
a result of reports.

There may also be other factors such as:

 lack of situational awareness
 lack of teamwork
 lack of competence or experience
 lack of confidence
 not being sure what to report (i.e. there is no clear company definition)
 a complicated reporting system
 age – older seafarers may see reporting as extra work while younger crew
members may be more sensitive to safety issues
 discouragement – the person to whom the report is given shows little interest

7.2 Establishing a safety culture

Near-miss reports should be easy to make. Importantly, seagoing personnel need to
feel secure that their reports will be treated fairly and that their courage in raising
safety issues will be recognised. One essential element for near-miss reporting is
therefore establishing a safety culture where no blame is attached to those who make
mistakes.

This approach recognises that things can go wrong unintentionally for many reasons.
Stress, fatigue, new technology, lack of effective training, and unexpected conditions
can all contribute to genuine mistakes. A hard culture where someone is always found
responsible and then punished is counterproductive. The unintended consequences of
this approach will be cover-ups, secrecy and lies.

© Videotel MMXVII
 What is a safety culture?
A culture is a community in which the members have shared attitudes, beliefs and
values which cause them to behave in similar ways. In a safety culture, people
support one another and look out for each other. It is the way that safety is managed
effectively in an organisation and reflects the attitudes, beliefs and values of the
workforce in relation to safety. “It is the way we do safety here”.
Safety culture starts at the top. People base their behaviour on what they can see is
important to their bosses, so it is important for the Master to attend safety meetings,
for example, and for the shore office to spend money on safety even when there is
no obvious commercial benefit to them. Management’s commitment to safety is
paramount.
A safety culture means:
 Safety is not seen as just a matter of compliance with minimum regulatory
requirements but as an integral part of every activity on the ship, whether it is
unloading cargo, maintaining equipment, rigging an accommodation ladder or
welcoming a visitor on board. People think about their own safety and that of
their fellow seafarers all the time.
 All near-misses are reported. Analysis of the causes of near-misses helps to
improve systems and procedures, and to minimise incidents and accidents.
 A ‘no blame’ attitude. The management team encourage good relationships
and communication between ranks, between engine and deck, and between
different nationalities. Crew members should feel they can speak out if they
have concerns over a safety issue, without fear of put-down, blame or
recrimination. (Note, however, that blame may be attributed in appropriate
circumstances – see Section 2 Definitions.)
Ships with a well-developed safety culture have the fewest accidents.

TRAINER - GROUP DISCUSSION

Ask the group:
 Do you feel happy about reporting near-misses? If not, what
can we do about this?

Ask the group to write down their thoughts and suggestions

about how near-miss reporting could become a more central
part of the ship’s safety procedures. These ideas could then
be passed in confidence to management.

How management can encourage the crew to think proactively about safety
Management can promote near-miss reporting by inviting crew members and officers
to question their own and others’ safety. They may also wish to provide incentives to
encourage reporting. The research in Best Practice in Near-Miss Reporting showed
that although a system of bonus rewards may help to raise awareness, many
participants felt that it was not the right approach (as it could generate an unnecessary

© Videotel MMXVII
number of reports) and that near-miss reporting should come naturally, as it is in
everyone’s interests to stay safe.

Each incident which may affect safety and each accident which results in injury
represents an opportunity for constructive action. This is because any given case may
reveal an error or practice which can then be made safer.

Accidents should therefore be reported as a matter of routine, and each near-miss

regarded as an opportunity to strengthen the SMS.

The role of experience

The more experience that crew members gain, the more likely they are to detect vital
safety-related information or recognise its importance.

On the job training helps to improve competence, and task rotation is an excellent way
of giving crew members experience and insight into other people’s work. If they know
how a task is done, they are more likely to recognise when something is not being
done correctly and will feel confident in reporting it.

Creating a healthy and supportive onboard environment

When there is an atmosphere of openness on board, accidents are far less common.
This is because crew members feel they can speak up at any time and give their
opinion about any operational matter that they are concerned about, without fear that
they will be criticised or that action will be taken against them. From their side, senior
officers feel they can consult crew members without losing their authority.

Tips for how officers can encourage near-miss reporting

1. Explain that near-miss reporting is not exposing a crew member’s failure –

rather it is a demonstration of their cleverness at noticing a problem so that it
can be resolved and prevented from happening again.

2. Make each crew member feel valued. This is done by taking seriously their
reports, listening to what they have to say and asking for their ideas and
thoughts.

3. Follow up. When someone has completed a near-miss report, look into it and
where appropriate put their suggested corrective action into practice.

4. Foster team spirit. Explain how you are working together towards a common
safety goal and encourage an attitude of co-operation.

5. Be approachable and implement an ‘open door’ policy. Crew members will

keep their safety concerns to themselves if they are anxious about speaking
to you.

© Videotel MMXVII
 TRAINER - GROUP DISCUSSION AND ACTIVITY
Ask the group:
 How open do you feel the atmosphere is on the ship?
 Discuss and write down some suggestions for how openness
could be increased.

Training for assertiveness

Assertiveness training – which is now required for all seafarers by STCW
(International Convention on Standards of Training, Certification and Watchkeeping for
Seafarers, as amended) – will help to make an unconfident person feel more able to
report near-misses.

TRAINER - GROUP DISCUSSION

Ask the group:

 How could crew members be encouraged to write more near-
miss reports?

The bottom line

Reporting near-misses is mandatory but it is also in everyone’s interests to identify
potential hazards so that corrective action can be taken, the information shared
throughout the fleet, and everyone can stay safe.

8 CHIRP

© Videotel MMXVII
8.1 When to use CHIRP
An important option for near-miss reporting is the independent charitable trust
Confidential Hazardous Incident Reporting Programme (CHIRP). This is suitable
when:
 the near-misses involve third parties – personnel and/or facilities outside your
ship and company
 your company’s SMS does not offer a way to deal with a near-miss (because of
significant factors beyond the ship’s or company’s control), or you have
exhausted company/regulatory reporting procedures without the issue having
been resolved
 you are concerned and wish to protect your identity
 other reporting procedures are not appropriate or are not available

8.2 The CHIRP reporting process

1. Write the report, giving your name and contact details. (These will not be
passed on but identification is important for the validation of the report. You can
be totally confident that your name will be kept confidential.)
2. You will receive a report receipt.
3. Your report will then be analysed.
4. A sympathetic investigator will probably contact you to confirm details and ask
for more information and photographs.
5. Your name and the ship’s name will be removed from the report.
6. Where appropriate, CHIRP may contact the third party organisation responsible
for the near-miss, without using your data.
7. Lessons learned and remedial actions will be identified.
8. The result will go through a quality check.
9. The independent Maritime Advisory Board will review the report, confirming
lessons learned and deciding whether it is worthy of publication.
10. The data will be entered and processed.
11. When approved, the summary report with the safety lessons learned is
published on the CHIRP website and in the quarterly newsletter Maritime
FEEDBACK.
12. The original report and all its details, including the identity of the reporter, are
then destroyed.

The quarterly CHIRP newsletter Maritime FEEDBACK is distributed worldwide

through:
 Nautilus International – Telegraph
 The Mission to Seafarers – The Sea
 IHS – Safety at Sea
 National Federation of Fishermen's Organisations – NFFO News
 The Marine Society – Libraries to Ships

The CHIRP system provides a practical way of helping identify procedural failures and
problems and minimising potential accidents. It is there for the benefit of all seafarers
and they should use it.

A CHIRP reporting form is reproduced in Section 12 Appendices.

© Videotel MMXVII
 The difference between CHIRP and MARS (Mariners’ Alerting and Reporting
Scheme)

CHIRP Maritime is an independent, confidential reporting system that allows

proactive follow-up and investigation of individual safety issues which otherwise
have not been reported to the ship manager or the authorities.

The primary purpose of the Nautical Institute’s MARS is to identify lessons learned
from near-miss and recent incident reports and relay these to seafarers through the
Seaways magazine and the searchable MARS website. As with CHIRP, the reports
are confidential. MARS does not provide follow-up to individual reports through
investigation.

TRAINER - GROUP DISCUSSION

Ask the group:

 Have you come across any instances involving third party
near-misses during your time at sea? What happened? How
was it reported?

9 LESSONS LEARNED

The point of near-miss reporting is to learn from unsafe acts, hazardous occurrences,
omissions or mistakes. The reports need to be analysed and the lessons learned must
be distributed.

This section describes incidents shown in the video, and other case studies, to
demonstrate lessons that can be shared.

TRAINER - GROUP DISCUSSION

Discussion
Use the incidents in this section (the first three of which are from the
video) as the focus of group analysis and discussion. You could use
these questions as probes:

 What do you think about the conclusions that have been put
forward about lessons learned?

 Do you think there were other causal factors? If so, what

were they?

 How could the chain of events been broken?

© Videotel MMXVII
 CASE STUDY 1: Defective snap hook

What happened
A pilot ladder was prepared. Afterward, the crew member noticed
that the snap hook on the chain was defective and realised this
was a potential hazard, but he neither fixed it nor reported it. He started to write a
report but had to return to work and forgot about it.

A few days later a different crew member was walking past carrying paint. He
slipped. The chain gave way and he fell into the water. He was picked up by the
rescue boat. His injuries led to him being kept in hospital for several days.

Analysis
Following this incident no report was made. The crew member involved considered
the defective snap hook a minor issue. He realised the danger of leaning against it
but he knew never to do that. He was unharmed, but his colleague was not so lucky.

The main lesson learned is ‘Always report a near-miss’.

Other questions were left unanswered:

 Why was the snap hook defective?
 What further unsafe situations existed on deck?

CASE STUDY 2: Distractions on the bridge

What happened
The ship was heading for its berth to discharge, but at the last
minute, because of unexpected problems there, the Master had to
turn the vessel away from the breakwater. He told the watchkeeping officer (the 3rd
Officer) that they were going to the anchorage.

On the bridge were the superintendent, the Master, the Chief Officer and the 3rd
Officer. The senior officers were angry and very concerned about the delayed
discharge. No voyage plan was made and no anchorage position was identified.

The 3rd Officer was newly promoted. He had joined the ship the week before. It was
his watch, but he thought that the Master had the con.

In the heat of the moment nobody was paying much attention to the ship’s progress,
but the ship was being set by the conditions towards a chemical tanker at anchor.

At the last minute the Master realised the situation. He put the ship full ahead and
hard to starboard. As there was no collision, there were no injuries and no damage
and the Master filed a near-miss report.

Analysis
Any confusion or distraction while navigating in confined waters is dangerous and
could be considered a near-miss. Distraction is frequently mentioned as a causal

© Videotel MMXVII
 factor in collisions. Loud speech and the use of mobile phones can distract
navigating personnel.

The lack of a voyage passage plan with no agreed final position in the anchorage
and the confusion over who had the con all contributed to the near-miss. The
watchkeeping officer could have sought clear instructions from the Master and
clarified who had the con.

The Master should have prioritised navigation over the delayed discharge
discussion.

The watchkeeping officer could have politely asked the senior officers to make less
noise.

Early intervention can often prevent a hazardous situation from developing into a
near-miss or even an actual accident.

CASE STUDY 3: Oil leak

What happened
Routine maintenance was carried out on an oil filter. It was cleaned
and checked. However, it was not properly reassembled and this
resulted in a small oil leak. Fortunately this did not find a source of ignition.

The oil leak was spotted by the duty engineer who took appropriate action. The
machinery was stopped and the filter was re-assembled correctly. The duty engineer
realised that the filter could easily be re-assembled incorrectly. But he did not make
a near-miss report.

Three months later on a different ship the same thing happened on re-assembling a
similar oil filter after maintenance. Again there was a leak, but this time it did find a
source of ignition and fire broke out.

The result was three crew members were killed and the ship’s engine room was
destroyed. Had a near-miss report been made of the first incident, this accident
might have been avoided.

Analysis
This incident showed how inadequate procedure and lack of checking can lead to
serious consequences.

A key lesson is that ‘proper maintenance procedures must always be followed’ and
that ‘machinery must always be checked after completion of maintenance by a
responsible person’.

The officer who found the filter leaking did not file a near-miss report. He kept this
information to himself. Later, on another ship, after a similar leak a serious accident
occurred and three people died.

© Videotel MMXVII
 As there was no report, other casual factors were not identified and further lessons
were not learned:
 Was there a toolbox talk before the work was carried out?
 Was re-assembly mentioned?
 Was there a problem with the design of the filter?
 Why was the work not properly checked when it was finished?

CASE STUDY 4: Engine room flooding following a valve cast

body failure

What happened
The incident occurred alongside the berth. The vessel was due to
depart after completion of its loading operation when the Chief Engineer notified the
Master that there was a serious water ingress in the engine room due to a damaged
valve of the main engine sea water cooling system. A large part of the valve cast
body had parted.

The valve failure caused flooding of the engine room which in turn resulted in the
vessel becoming inoperable. The vessel was fully laden with 137,000 tonnes of coal.

Water ingress in the engine room damaged adjacent electric motors driving main
and auxiliary pumps at the lower engine room platform. In total, 20 pumps/motors
were damaged. There were no injuries to ship’s personnel, no damage to the
environment or ship’s cargo.

Analysis
From the investigation on the cause of the valve damage, it became apparent that it
was a typical cast iron material failure which could not be easily discovered by
routine maintenance and inspections.

Lessons learned were about:

 Situational awareness. Although the material failure could not have been
predicted or easily identified by the crew at its early stage, the crew needs to
be aware that piping systems under pressure are susceptible to frequent
failure either in way of valves or in way of flanges.

 Communication. Effective communication between the ship and terminal is

essential and must be maintained at all times to ensure that both are capable
of responding in the event of an emergency.

 Attention to early warning signs. Onboard self-inspections by Masters, officers

and crew should be performed regularly. During these inspections no
tolerance should be shown to minor leakages and/or other maintenance
issues.

© Videotel MMXVII
  Emergency response capability. Senior officers and crew upon their
embarkation should also become familiar with the ship’s piping systems in
order to become aware of potentially dangerous situations and how they can
be handled in an emergency.

 Sharing with industry and stakeholders. Lessons learned should be disclosed

to valve manufacturers and industry bodies in order to share experience and
minimise the risk of recurrence. The design and manufacture of equipment is
often a contributory factor in accidents and incidents, and the manufacturers
need to know about it.

CASE STUDY 5: Grounding on sandbank

What happened
On a calm and clear night a modern, well equipped tanker was
heading through a busy coastal traffic separation scheme. To the
Officer of the Watch (OOW) and lookout, everything on the bridge seemed normal.
The OOW was sitting in the bridge chair, where he could see the radar display and
the ship’s ECDIS. He was following the route shown on the ECDIS display and he
adjusted the ship’s heading whenever necessary to keep on track.

Unexpectedly, the ship’s speed reduced to zero and soon afterwards an engineering
alarm sounded. Assessing that there was a problem with propulsion, the OOW
phoned the second engineer and asked him to check the engines.

The second engineer called the bridge back and confirmed that power was available
on the starboard engine, so the OOW applied power using the starboard control
lever. But the ship still did not move. The OOW also called the Master to explain that
propulsion had failed in the traffic separation scheme.

Ashore in the local coastguard station, a watchkeeper noticed that the ship’s position
was directly over a well charted sandbank, and called the ship on VHF radio to ask
about the situation. Only when prompted by the coastguard did the OOW realise that
the ship was hard aground on the sandbank.

Analysis
1. Checking the passage plan is vital. ECDIS was the ship’s primary means of
navigation and the deck officers had all been trained and certified in its use.
However, the passage plan, which passed directly over the sandbank, had not been
properly checked using the ECDIS ‘check route’ function. The Master was also
unable to use the ECDIS system and had not properly checked the plan before
departure.

2. Avoid over-reliance on ECDIS for monitoring the route. Correlation of visual,

radar, echo sounder and electronic navigation information is critical to maintaining
good situational awareness, especially on a coastal passage in a traffic separation
scheme.

© Videotel MMXVII
 3. Good bridge team management means making sure the lookout is encouraged to
contribute to the safe navigation of the ship. In this case, despite the lookout seeing
flashing lights from the buoys marking the sandbank ahead of the ship, this
information was not reported to the OOW or acted upon.

4. There was no ECDIS alarm because the safety settings in the system were
inappropriate; the safety contour value was wrong and the audible alarm was not
working. If ECDIS is the primary method of navigating the ship, it is crucial that the
system is properly set up for the passage. Alarm management is also important to
ensure the bridge team are warned of navigational hazards or system failures.

5. If navigational equipment is defective, it should be fixed, not ignored.

CASE STUDY 6: A hundred tonne flood

What happened
Due to the scheduled programme at a large cargo ship’s next port, a
routine inspection of a fresh water storage tank was conducted
on passage. The Chief Officer was responsible for the management of the fresh
water and he delegated the task to the seafarer ‘waterman’. The ‘waterman’ was told
which tank to inspect and that the tank had been emptied. The ‘waterman’, who was
familiar with the tank inspections on other ships, arranged for another crew member
to assist. Neither crew member had inspected the water tanks on board.

The two crew members went to a compartment in the accommodation block where
they thought that the tank lid was located. They then removed the lid’s securing nuts
and one of the crew members levered it out of position. As he did so, the tank lid
was projected across the compartment by the force of water coming from the tank
below, narrowly missing one of the crew members as it did so – it was the wrong
tank.

Water quickly flooded into the compartment and one of the crew members quickly
escaped through the open door. However, the door was soon forced shut by the
flood water, trapping the second crew member inside. As the water depth increased
to about two metres, he was forced to climb on to a bench sink. The trapped crew
member was subsequently rescued by the ship’s emergency response team.

The water spread rapidly into all compartments on two decks, including the high
voltage converter space. Quick action by the ship’s crew to isolate the power
supplies to the high voltage equipment prevented serious damage to the propulsion
system. Nonetheless, the ship drifted not under command for several hours until
temporary repairs were completed.

Analysis
1. Any tank, regardless of its contents, is a dangerous enclosed space. The safety of
crew engaged in tank work, including fresh water tank inspections, relies on a proper
risk assessment being undertaken and access controlled by a permit to work
system. Anything less has the potential to be very costly.
2. Assuming that a crew member is familiar with a task due to his or her routine

© Videotel MMXVII
 duties during their previous contracts on other vessels, is a frequently repeated
mistake. All ships vary and people are different. It pays to double check that any
person assigned to do a safety-critical job has been properly briefed, fully
understands how to complete the job in a safe manner and is supervised
appropriately.

3. The clear, consistent and unambiguous marking of all tank lids, sounding tubes,
vent pipes, etc. is a simple and inexpensive way of identifying what a tank is and
what it contains, and should always be done.

CASE STUDY 7: Hot Work in No Weld Zone

What happened
Crew were found conducting welding operations in an area of a
vessel where hot work was forbidden. The incident occurred when
arrangements were being made for the installation of steel shelves in a storage cage
on the upper tween deck. This area ‘upper tween deck’ is below the main deck,
amidships.

A Permit to Work was raised for this operation and was signed by the rigging
supervisor as Area Authority. The welder set up the required equipment at the
worksite and was in the initial stages of the task when the Chief Engineer walked by
on a routine inspection and stopped the job. The Chief Engineer explained to the
welder that he was about to weld onto a fuel tank which is located on the other side
of the deck, and called an ALL STOP.

Analysis
The series of failures which brought about this event:
 Inadequate task plan
 Inadequate communication of task plan
 Lack of awareness/perception of risk
 Inadequate attention to detail
 Unclear/conflicting lines of responsibility
 Insufficient warning signage
 Following usual task

Actions taken:
 Identified all no weld areas on vessels and ensured they were suitably
marked/highlighted and ‘No Welding’ signage was clear from all directions.
 Ensured that vessel GA (General Arrangement) drawings were used to show
location of open permits and to assist in de-conflicting permits and hot work,
with all the no weld zones/areas clearly marked to assist in the approval of
hot work permits and to prevent approval being given for hot work on no weld
areas.

© Videotel MMXVII
  Ensured that persons responsible for issuing Permits to Work were suitably
trained and fully understood their roles and responsibilities.
 Ensured that those who were ‘Area Authorities’ fully understood the hazards
and restrictions associated with those areas.

10 CONCLUSIONS

Safety must be at the heart of all operations on ships. The objective is to return all
crew members back to shore in good health at the end of their contracts.

One good way of reducing the number of accidents is to learn from other people’s
errors and mistakes. Near-miss reporting is one part of that effort.

 Responsibility: It is the responsibility of every member of the ship’s personnel

to identify, report and take appropriate and timely action if they see an unsafe
condition or are involved in a near-miss.

 Procedures: Always follow your company’s SMS procedures in near-miss

reporting.

 Third parties: If the near-miss involves outside organisations or third parties,

seafarers can report to CHIRP.

 Benefits to seafarers: An effective near-miss reporting scheme will reduce

accidents, which means improved safety for the personnel on board.

 Benefits to the company: Improved safety records lead to a better reputation,

more clients, lower insurance cost, reduced profit leakage and more jobs.

 Save a life: Reporting near-misses is about sharing information on hazards.

Always remember, if you report a near-miss you could save a life.

11 FURTHER RESOURCES
Regulations and guidance
The latest versions of regulations and publications should always be consulted.

International Convention for the Safety of Life at Sea (SOLAS)

International Convention on Standards of Training, Certification and Watchkeeping for
Seafarers (STCW)
International Safety Management (ISM) Code
Maritime Labour Convention, MLC, 2006
MSC.-MEPC.7/Circ.7 Guidance on Near-Miss Reporting, IMO
UK Marine Guidance Notice (MGN) 458 Accident reporting and investigation (MAIB)

Publications

© Videotel MMXVII
Best Practice in Near-Miss Reporting, Ilknur Erdogan, Swedish Department of
Shipping and Marine Technology, Chalmers University of Technology, Göteborg,
Sweden, 2011

The Human Element – A guide to human behaviour in the shipping industry, MCA

Alert! Improving awareness of the human element in the maritime industry

www.nautinst.org/en/Publications/alert/

Websites of useful organisations

Australian Maritime Safety Authority www.amsa.gov.au
Australian Transport Safety Bureau www.atsb.gov.au
Bahamas Maritime Authority www.bahamasmaritime.com
BEAmer, Marine Accident Investigation Office (France)
www.bea-mer.developpement-durable.gouv.fr
Confidential Hazardous Incident Reporting Programme
https://www.chirp.co.uk/newsletters/maritime
Danish Maritime Accident Investigation Board www.dmaib.com
Dutch Safety Board www.onderzoeksraad.nl
European Maritime Safety Agency (EMSA) www.emsa.europa.eu
Hellenic Bureau for Marine Casualties Investigation (HBMCI) www.hbmci.gov.gr
International Chamber of Shipping www.ics-shipping.org
International Labour Organization (ILO) www.ilo.org
International Maritime Organization www.imo.org
Japanese Transport Safety Board www.mlit.go.jp
Marine Accident Investigation Branch (MAIB - UK)
www.gov.uk/government/organisations/marine-accident-investigation-branch
Marine Accident Investigators’ International Forum (MAIIF) www.maiif.org
Maritime Accident Casebook http://maritimeaccident.org
Maritime & Coastguard Agency www.dft.gov.uk/mca
Maritime New Zealand www.maritimenz.govt.nz
National Transportation Safety Board (USA) www.ntsb.gov
Nautical Institute: The Mariners' Alerting and Reporting Scheme (MARS)
www.nautinst.org
Norwegian Maritime Authority www.sjofartsdir.no
SEAHEALTH Denmark www.seahealth.dk
South African Maritime Safety Authority (SAMSA) www.samsa.org.za
Swedish Accident Investigation Authority www.havkom.se
Swedish Transport Agency www.transportstyrelsen.se/en/shipping
Transport Accident Investigation Commission (New Zealand) www.taic.org.nz
Transport Canada www.tc.gc.ca
United States Coast Guard www.uscg.mil

Related Videotel programmes

Incident Investigation, Analysis and Reporting Training Course (Code 1237)

Intervention – Do the Right Thing (Code 1196)
Making the ISM Code Work for You (Edition 2) (Code 1262)
The Mariners Role in Collecting Evidence (Edition 2) (Code 1173)
Unsafe Act Awareness (Code 710)

© Videotel MMXVII
Vessel Resource Management Series, Part 8 - Five Case Studies (Edition 2)
(Code 1282)
Working with Multinational Crews – It’s a Cultural Thing! (Code 1228)

Videotel™, the market-leading provider of training films, computer-based training, and e-Learning
courses, is part of KVH Industries, Inc., a premier manufacturer of solutions that provide global high-
speed Internet, television, and voice services via satellite to mobile users at sea, on land, and in the air.
KVH is also a global news, music, and entertainment content provider to many industries including
maritime, retail, and leisure.

12 APPENDICES
12.1 Sample Near-Miss Report Form

Vessel……………………………….Vessel’s position/port…………………….

Time and date of incident…………………………………

Time and date of report…………………………………..

Name of person reporting (optional)……………………………………

___________________________________________________________________

Description of incident
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………
___________________________________________________________________

Risk level: High  Medium  Low 

___________________________________________________________________

Type of accident avoided:

Injury  Damage to machinery/equipment  Damage to property 

Illness  Pollution 
___________________________________________________________________

© Videotel MMXVII
12.2 Sample Near-Miss Investigation Report

Description of incident
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………

Causal factors
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………

Comments on causal factors (if any)

……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………

Actions taken
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………

Recommendations for corrective actions/measures

…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………

Name/signature (Safety Officer/Chief Engineer)……………………………………

Name/signature (Master) …………………………………………………………………

© Videotel MMXVII
 12.3 CHIRP Reporting Form

© Videotel MMXVII
12.4 Latent defects list

Source: James Reason

Basic risk factors Causal factors

Hardware Bad condition (circumstances)

Bad condition (wear/corrosion)
Not suitable for purpose
Procurement and stock management
Insufficiently delivered
Unavailable due to theft
Design No standardisation
Not ergonomic
No indication of condition
Badly accessible
Illogic lay-out
Practical use unknown to designer
Maintenance management Insufficient supervision on maintenance

No feedback of condition
No specialised maintenance staff
No relevant documentation
Insufficient planning of maintenance
Procedures Author insufficient knowledge
Lack of feedback on usability
Rules difficult to find
Insufficient inventories
“Political” reason
Important rules missing
Area of scope unclear
Design of rules unstructured
Error enforcing conditions Human physical constraints
External influences
Socially determined circumstances
Personality circumstances
Abuse or addiction
Housekeeping Insufficient means
Lack of management commitment
Wrong image to management
No field visits by management
Difficult due to environmental circumstances

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 Unclear responsibility
Bad planning of housekeeping
Incompatible goals Progress of production
Financial constraints
Discrepancy between social and individual
factors
Time pressure
Discrepancy between formal and informal
practices
Discrepancy between short and long term goals
Indistinctness with management
Communication Language problems
Inadequate structure of communication
Erroneously transferred messages
Low ratio of signal versus rustle
Incorrect or ambiguous information
Inconsistently provided information
Loss of information
Overflow of information
Physically or mentally inaccessible
Organisation Badly defined departments
Unclear delegation of responsibilities
Discrepancy between policy and execution
Bad planning or co-ordination
Much bureaucracy / low flexibility
Corrupted management of business
Frequent reorganisations
Safety a goal instead a medium
Curing instead of reforming
No or unclear tasks, authorities and
responsibilities
Training Insufficient management commitment
Inadequate management training
Education inconsistent with requirements
Human resource selection inadequate
No structured training plan
No assessment of training
Training not provided or ineffective
Discrepancy between training requirements and
rules
Varying quality requirements
Not tuned to targeted population
No test of acquaintance and skill
Targeted population not identified

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 Defences Insufficiently ready for emergencies
Inadequate personal protective equipment
Unsuitable detection systems
No emergency procedures or instructions
Insufficient trained on emergency procedures
Detection difficult to recognise
Insufficient awareness of risks
Incapable to restrict consequence
Irreversible situation

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