It is all a matter of sharing knowledge.
www.nearmiss.dk is the sector's own database where companies can report near miss events from which others can learn. All reports are anonymised. We circulate some of these reports anonymously as "Safety Alerts".
Currently there is focus on the safety work and attitudinal on board and our work with near miss is a part of this. The key word for our effort in this part of the safety work is learning, knowledge-sharing and experiences.
- What is near miss?
- Why have near miss reporting?
- Nobody makes mistakes on purpose
- Be at the forefront!
- A case study
- Rated on the safety culture
- Be appreciative of people
- Find your own form
- Learning events
In brief, a near miss is an accident that was just about to happen.
For two main reasons:
- It makes us better at "spotting" unsafe actions and conditions. This boosts our safety awareness, which in turn affects the way we act.
- It enables us to share the lessons we learn from a near miss so we can prevent an 'event' from happening again.
One condition for preventing and cutting accident rates at sea is that we know of the kind of events that actually occur. Then we can get better at learning from each other's technical and human errors. Read more about human factors
Nobody makes mistakes on purpose. They are always the result of bad leadership, lack of training and education, lack of experience, poor technical solutions, assumptions, habits, attitudes, culture, silent acceptance, shortcuts, etc. All things that are reflected in the safety culture.
Human error is a sign of deep-rooted problems in the system. In order to explain events, rather than trying to find out where people have made mistakes, we should instead identify the significance of people’s reactions in the light of the circumstances at the time.
This is what we need to know to take a constructive approach to preventing accidents. Otherwise we have no way of repairing and building up systems anew.
Think proactively. Speak openly and without prejudice about safety issues and human factors so that lessons are not just learnt when accidents have happened. Take action on the near-misses that occur - because you will simply not accept accidents aboard because you know that ACCIDENTS ARE PREVENTABLE. The better we are at sharing our knowledge about how things go wrong, the fewer industrial accidents - and accidents at sea - will happen.
Imagine that you are on the foredeck when docking. A hawser breaks and slices through the air just 30 cms from the head of a deckhand who is busy paying out cable through a hawse pipe. If the deckhand had been standing 30 cm closer, he could have been killed or very seriously injured. In a near-miss situation like this, you could wipe the sweat from your brow and say "thank goodness nothing happened" and continue working.
Then ask yourself if someone has to die or be seriously injured before we learn anything. Why did the wire actually break? Is the winch too powerful for the breaking strain of the wire? Is there a heavy swell running? What manoeuvres are being carried out while docking? Are there crew who are generally in the danger zone when docking? Is the Chief Officer recently qualified and does he lack the training to direct docking operations? Are docking procedures good enough? Are we pressed for time and how should we cope with that, etc?
Many ship-owners have learned the near-miss reporting method and now use near-miss systems as an active tool for boosting their safety culture aboard. This is primarily to avoid personal injury and damage to the vessel and cargo but also because more and more companies are being rated on their safety culture by their customers. Near-miss registration has become a tool for enhancing safety awareness amongst individual seamen which will in time boost the safety culture aboard - for the benefit of your colleagues and workmates, the ship and the company.
A near-miss event needs to be out in the open for others to learn from it. Otherwise the event goes no further and in the worst case, could lead to a serious accident later on. By focusing and working systematically on near-miss reporting, we not only learn a lot that can prevent the situation from happening again, but experience has shown that the whole safety culture gets a boost. It does so because we become better trained in spotting and observing unintended events and conditions. This way, we can be better at analyzing the circumstances and situations underlying unintended events which in turn enables us to eliminate the precursors to a near-miss event.
In some circumstances, it can be difficult to report mistakes. Especially in the maritime sector where stories of mistakes are not what we boast about aboard. At Seahealth Denmark, we believe that all of us throughout the sector need to change our approach. We need to get away from finger pointing and a blame culture and move towards the question of "Why it happened" and "What can we learn from that." We need to get to a point where crew are actually appreciated and acknowledged for reporting errors to a near-miss system. Every man aboard needs to feel good about reporting a near-miss event to the company. Because we can see that safety gets better and better and because people start to talk about safety issues in a very different way. It suddenly all makes sense.
If seafarers think that it will affect their job or rank, nothing will happen and no one will be any wiser from what they have to say.
So how should the practical knowledge gained from a near-miss be used? How can it be implemented in the organisation and how should it be used by others? These are important questions that need to be discussed by the ship and the company. Here you need to find your own way ahead. Which near-misses should be reported to the company and which can be dealt with by the crew in the safety committee? As a general rule, every organisation can ask itself: Could other vessels or ship-owners learn something from this? Could this event change procedures, behaviour, communication, etc., so that safety will improve throughout the company? If yes, the event should be reported back to the company as a near-miss.
Be careful in the terminology you use when describing near-misses. Even though we all agree that the industry needs to have a no-blame culture, we should avoid the words "blame" in our endeavours and focus more on learning and changing behaviour. In other sectors that up at the forefront in safety, the term "near-miss" has been replaced by "Learning Events" or something similar, since expressions like near-miss are thought to be negative.
Senior Occupational Health Consultant
Søren Bøge Pedersen
+45 3311 1833
+45 5364 1609
I can help you with:
- The 8 Safety Links
- Accident prevention in general
- Guidance on mooring
- Welfare-enhancing projects
- The program Health and Safety at Sea