Having Trouble Explaining the Difference Between Near Misses and Unsafe Acts?

Professional Mariner Forum
1

[SIZE=2]Is it a near miss? Or was it an unsafe act? Maybe just an unsafe condition. What’s the difference and how do you explain it to your crew when introducing them to your safety management system?

Check out nearmiss.dk for more cartoons like the one below. It’s a good visual explanation of the differences between some of the terms used in our safety management systems. As the safety culture of a vessel and/or company evolves, many are moving away from the simple reporting of near misses. By identifying (and resolving!) unsafe acts and unsafe conditions, the goal is to break the error chain before a near miss even occurs.

So, where is YOUR safety culture on the evolution chain?[/SIZE]

2

a near miss was a clear unsafe incident where no particular damage or injury occurred but which was witnessed and can documented. It is hard to use the above cartoon’s example as a near miss since the load was damaged although people unhurt. A better near miss example would be the sling leg breaking but the load not falling. In the examples they use, the near miss would be an accident and the accident would be a serious marine casualty or incident

most good SMS manuals define the difference and provide methodology for reporting both near misses and accidents

of course, the problem with reporting near misses is that people are afraid that if they do report, they will be punished if somehow implicated by management

3

I would agree. Depending on which incident at which you are looking - the potential injury or the potential cargo gear failure - it could be viewed as an incident from the get-go. I believe the intent was to show the near injury, however.

While most SMS manuals will define the terms and provide methods of reporting, it is sometimes difficult to get the understanding and buy-in from the whole crew. I’ve found that posting something like the above cartoon adjacent to the menu outside the galley will sometimes get people thinking about it. There are many ways to address safety - this is but one that I have found to be effective.

Quoting from IMO MSP-MEPC.7/Circ. 7 ““Guidance On Near-Miss Reporting””,

"3 Overcoming barriers to reporting near-misses

3.1 There are many barriers related to the reporting of near-misses. In many cases,
near-misses are only known by the individual(s) involved who chose to report or not report the
incident. Some of the main barriers to the reporting of near-misses include the fear of being
blamed, disciplined, embarrassed, or found legally liable. These are more prevalent in an
organization that has a blame-oriented culture. Amongst other barriers are unsupportive
company management attitudes such as complacency about known deficiencies; insincerity about
addressing safety issues and discouragement of the reporting of near-misses by demanding that
seafarers conduct investigations in their own time.

3.2 These barriers can be overcome by management initiatives such as:
.1 Encouraging a “just-culture” in the company which covers near-miss reporting.
.2 Assuring confidentiality for reporting near-misses, both through company policy
and by “sanitizing” analyses and reports so that personal information (information
identifying an individual) of persons associated with a near-miss is removed and
remain confidential. Personal information should not be retained once the
investigation and reporting processes are complete.
.3 Ensuring that investigations are adequately resourced.
.4 Following through on the near-miss report suggestions and recommendations.

Once a decision has been made to implement, or not implement, the reports’
recommendations should be disseminated widely."

Of course, this is in an ideal world, in which we do not necessarily work. However, if a company is serious about implementing an effective safety program and improving their safety culture, there should not be repercussions. Points to ponder.

4

Personally I have always hated the term “Near Miss.” Wasn’t it actually a “Complete Miss” and more of a “Near Hit?”

5

I was just gonna say that. The term “near miss” is ridiculous. A near-miss should mean it almost missed but didn’t.

6

In port one fine day last spring they had us walk around with our phones and photograph anything and everything that could be a potential hazard. Then we projected them onto the screen and discussed them. Seemed silly at first but it was a real eye opener because the hazards identified were all things we took for granted every day. I thought it was a good exercise and beat sitting there listening to a boring lecture.

I don’t like the term near miss either, a near mishap is just that, a near or narrowly averted mishap. What we were photographing were potential hazards.

7

My Old Company preached Safety but there were Captains that would do almost anything to stop a crew member from reporting anything. I sailed as CE for a long time and always told my AE’s to come to me if and when they saw anything that was not safe. I also impressed on them the policy that Stated that ANYONE could Stop Anything if they thought it was Unsafe.

In my years of working for several Companies, I saw more Lip Service from upper Management, rather then supporting the Sea Going Supervisors and Crews that were doing their best to work safely but also follow the rules and report Near-Misses (I hate that term also). While they did not OPENLY come down on those doing the reporting they definitely kept track of who was reporting the most.

When all is said and done it is up to those that sail to do the job as safely as possible. But we all have to realize that sometimes no matter how safe and careful we are “Shit Happens”. I was injured during a ME repair and believe it or not they could not find and thing that was dome wrong, (unless you count me ending up with three blown discs as wrong).

8

I think that the most trenchant comment made so far was from Capt. Madden’s quote from the IMO pub:

.2 Assuring confidentiality for reporting near-misses, both through company policy
and by “sanitizing” analyses and reports so that personal information (information
identifying an individual) of persons associated with a near-miss is removed and
remain confidential. Personal information should not be retained once the
investigation and reporting processes are complete.

I would go further to delete any record: written or electronic identifying personnel involved. This may be impossible if injury is involved. The initial reporting is typically verbal and therefore kept on the ship. The goal is to identify the problem not the blame. You cannot develop a safety culture if personnel feel that their job is in jeopardy if they respond honestly. I also would highly recommend that shipboard operational personnel at the management level who are responsible for reporting “near misses” to the company office carefully analyze the report and underlying causes and supply a solid and practical solution for the incident before submitting the report and thereby circumvent any “Monday morning quarterbacking” by office personnel safely ashore. A cogent and rational answer by competent mariners on the scene in possession of both the facts and the experience to parse the same, will prevent the office from shoving an unworkable, impracticable shore side solution up your back side.

9

It is kinda my experience that if near misses are reported, and something positive happens out of the reporting process… like stuff gets fixed or bought or a procedure is updated in reasonable manner…then the system is working. That is, let’s take a look and make it better. You’re right, no one should feel they are going to get the axe in reporting a near miss. We would rather that near misses be reported so we understand what is really happening, and WHY.

Sometimes people screw up, sometimes wrong judgements are made. Sometimes the gear isn’t suited for purpose. Why not get that out in the open?

Punishing people for reporting honest errors and near misses, is a sign of a “little” and scared person. Our guys report stuff, and well - sometimes there are errors made that aren’t fully disclosed and because the port engineers know the ships and how they work, so we see it in the investigation. So you help them work it out and find a solution anyway. Are we going to fire someone honestly trying to make it better or busting their ass to deal with the screwup? Naw. Not really my first thought.

But don’t lie, falsify or erase or delete, because that ain’t gonna make the grade and chances are we will find out. We’ve done some fantastic investigations using data, CCTV recordings, automation data and photos available, and coupled with witness statements, it comes pretty clear what actually happened. I’ve listened to captains spout absolute BS not supported by any facts / data loggers / CCTV / etc., and contradict themselves in the same interview … Ahhh they don’t deserve or get benefit of the doubt.

And cmakin, I know you know this better than me …

10

some industries are better at having a real safety culture than others. When I was in the union we watched safety videos once a week and everyone was very safety conscious, especially the officers.
in recent days I have seen the opposite effect and it seems many people dont have the basics of safety 101. i think companies need to spend more time/money on safety training. maybe they need to get with the shipping companies and ask them how they do it, and/or hire third parties to come in and teach. i saw a lot of better safety practices in deep sea shipping. it seems that most places that are not deep sea shipping and non union, the old school mentality is resistant to change and dont like to be made enlightened to safety issues, no matter what the shore side might preach.

[QUOTE=RichMadden;151656]I would agree. Depending on which incident at which you are looking - the potential injury or the potential cargo gear failure - it could be viewed as an incident from the get-go. I believe the intent was to show the near injury, however.

While most SMS manuals will define the terms and provide methods of reporting, it is sometimes difficult to get the understanding and buy-in from the whole crew. I’ve found that posting something like the above cartoon adjacent to the menu outside the galley will sometimes get people thinking about it. There are many ways to address safety - this is but one that I have found to be effective.

Quoting from IMO MSP-MEPC.7/Circ. 7 ““Guidance On Near-Miss Reporting””,

"3 Overcoming barriers to reporting near-misses

3.1 There are many barriers related to the reporting of near-misses. In many cases,
near-misses are only known by the individual(s) involved who chose to report or not report the
incident. Some of the main barriers to the reporting of near-misses include the fear of being
blamed, disciplined, embarrassed, or found legally liable. These are more prevalent in an
organization that has a blame-oriented culture. Amongst other barriers are unsupportive
company management attitudes such as complacency about known deficiencies; insincerity about
addressing safety issues and discouragement of the reporting of near-misses by demanding that
seafarers conduct investigations in their own time.

3.2 These barriers can be overcome by management initiatives such as:
.1 Encouraging a “just-culture” in the company which covers near-miss reporting.
.2 Assuring confidentiality for reporting near-misses, both through company policy
and by “sanitizing” analyses and reports so that personal information (information
identifying an individual) of persons associated with a near-miss is removed and
remain confidential. Personal information should not be retained once the
investigation and reporting processes are complete.
.3 Ensuring that investigations are adequately resourced.
.4 Following through on the near-miss report suggestions and recommendations.

Once a decision has been made to implement, or not implement, the reports’
recommendations should be disseminated widely."

Of course, this is in an ideal world, in which we do not necessarily work. However, if a company is serious about implementing an effective safety program and improving their safety culture, there should not be repercussions. Points to ponder.[/QUOTE]

11

http://profoundlydisconnected.com/the-only-one-responsible-for-my-own-safety-is-me/

12

true, it can be like that in some places but on most deep sea shipping ships, the crew work bell to bell (or close to it) and still find time for safety. other places, they might put in a good 4 hours and still complain about the extra three minutes to takes to do something more safely

I guess if the union was good for anything at all, they were good about backing the crew up about safety concerns -most of the time

[QUOTE=Flyer69;151794]http://profoundlydisconnected.com/the-only-one-responsible-for-my-own-safety-is-me/[/QUOTE]

13

[QUOTE=cajaya;151796]true, it can be like that in some places but on most deep sea shipping ships, the crew work bell to bell (or close to it) and still find time for safety. other places, they might put in a good 4 hours and still complain about the extra three minutes to takes to do something more safely

I guess if the union was good for anything at all, they were good about backing the crew up about safety concerns -most of the time[/QUOTE]

Hey you…since the other thread got locked know this

I served us Navy and made my first MED cruise in the mid 80’s sailing across the Atlantic on a 30,000 HP steam ship while you were still layin around in daddy’s fun bag…

And NOAA isn’t my only job at the moment.

Any time honey…I may be old but I can take you.

Maybe when you sober up…wouldn’t wanna take advantage of a hopeless drunk

14

A near miss is when the relief valves don’t lift after you do something stupid.

15

and what were you then? a cook. seriously go fuck your self. its still the government and the government’s protective bubble. i never had a problem with anyone on here untill i posted about the discrimination that happened at hornbeck. I got shit from people, including YOU a WOMAN of all people, you jumped right on the bandwagon. you wanna fit in with the boys?

Well let me tell you something about what i know about the government and NOAA. I knew a bosun that sailed with them, he said it was run by all women and they were a bunch of bitches.
He said it was to the point where he quit because of the reverse discrimination he had to put up with. You think I’m gonna take shit about my behavior or the way I handle things from cunt the works at NOAA of ALL places?HA! GO FUCK YOURSELF

I would like to see you come out here and play with the REAL salty dogs, or should I say salty BITCHES, and see how well you fair out.
When it turns out that you can’t hang, and you aren’t interested in giving gum jobs either, they’ll be calling the office first thing to try to get rid of you.

stupid bitch

[QUOTE=catherder;151892]Hey you…since the other thread got locked know this

I served us Navy and made my first MED cruise in the mid 80’s sailing across the Atlantic on a 30,000 HP steam ship while you were still layin around in daddy’s fun bag…

And NOAA isn’t my only job at the moment.

Any time honey…I may be old but I can take you.

Maybe when you sober up…wouldn’t wanna take advantage of a hopeless drunk[/QUOTE]

16

Getting good now!

17

Shit yeah it is!!

18

$5 bucks on Catherder!