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Near Misses: Saving Ourselves One Miss at a Time……

Courtesy British Columbia Public Service

 “Near-miss : 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 have been human injury, environmental damage or negative business impact (e.g., repair or replacement costs, scheduling delays, contract violations, loss of reputation).” – International Maritime Organization

 Near-miss reporting and investigating is something that mariners have been doing for many years now.  Initially, many viewed them as a passing fad – the latest gimmick rolled out by the newest consultant.  Unfortunately, the rationale behind near-miss reporting and investigation wasn’t and probably hasn’t been explained to many.  That’s an opportunity that was certainly lost, as this is all much more than a passing fad or gimmick.

Whether it is the data gathered by Frank E. Bird, Jr. in 1969 – represented above in the graphic – or the more recent studies conducted by Conoco-Phillips Marine in 2003, there’s solid evidence that looking at and understanding the root causes of near-misses will reduce injuries and fatalities.  Why?  Because we’ve caught the situation before it produced that injury or damage and now, we have the opportunity to learn.  It doesn’t matter if it was equipment failure, personnel error or an inadequate procedure, something has been identified as a problem.  Once that root cause is identified, those lessons learned can be used to prevent further incidents of the same sort: future incidents that might not be caught and might lead to equipment damage, human injury or fatality

“The safety management system should include procedures ensuring that non-conformities, accidents and hazardous situations are reported to the Company, investigated and analysed with the objective of improving safety and pollution prevention.” – ISM Code 9.1

 So, there is a system whereby a vessel is creating a library of near-misses and lessons learned.  But, wouldn’t it something if those near-misses and lessons learned were shared across a fleet or a whole company?  Does someone within your company compile a newsletter that contains some lessons learned?  Very frequently, there will be similar near-misses from many vessels which could indicate a systemic problem.  Sometimes it is a slew of trips, slips and falls or possibly equipment that fails, such as gratings or handrails that leads to near-miss observations.  If so, a concentrated safety campaign in that area might be warranted.  At a minimum, if this information is passed around, other vessels get the opportunity to learn from the mistakes or observations of others.  Designated Persons Ashore (DPA), safety departments or loss prevention groups’ buy-in would be crucial to making this happen on a company-wide basis.

Going to the next level, what would happen if these near-misses were passed around the whole industry?  Wouldn’t it be great to stop a problem onboard your vessel before it became an issue by hearing about lessons learned from another company or possibly, another segment of the maritime industry entirely?  Oddly enough, there are already some systems set up for doing just that.  One of the most notable is the Nautical Institute’s Mariners’ Alerting and Reporting Scheme (MARS).  Drawing near-misses from across a wide swath of the maritime industry, their database goes back over 20 years.  That’s no small amount of lessons learned!  In the UK, there is CHIRP, which gathers near-misses from both the aviation and maritime industries.  The Confidential Hazardous Incident Reporting Programme (CHIRP) compiles near-misses received into a quarterly report which is quite interesting to read.  Not only do they report on information received, but they follow-up on it to see what best practices companies might have implemented in response to the near-miss.

CHIRP is definitely European-centric, whereas MARS is more international.  On the U.S. side of the Atlantic, the U.S. Coast Guard publishes lessons learned under their Incident Reports.  These lessons learned come more from inspection observations and incident investigations, rather than from within the maritime industry itself.  Perhaps, the U.S. Maritime Administration should establish its own database of near-misses – all the better for passing along lessons learned and making the industry – and mariners! – safer.

Does it take effort to pass along near-misses, especially outside the company?  Absolutely it does!  But, remember how onerous it seemed to fill out those near-misses onboard your vessel a few years ago?  And now, it’s just how you do business.   Perhaps, in a few more years, it might be just as natural to send a report into one of the national or international databases.  In the meantime, mariners, DPAs and companies should continue to look at lessons learned inside and outside their organizations to ensure best practices are used and mariners are safe!


Additional Reading and Links

U.S. Coast Guard Investigations – Investigations

MARS (Mariners’ Alerting and Reporting Scheme)

CHIRP for Maritime (Confidential Hazardous Incident Reporting Programme)

IMO MSC /Circ. 1015 “Reporting Near Misses”

IMO MSC-MEPC.7/Circ.7 “Guidance on Near-Miss Reporting”


Seamanship : Alive and Well or Dead and Gone?

What contributes more to safety?  Seamanship and common sense or the regulations and management systems that we currently use?  Captain Charis Kanellopoulos argues that seamanship onboard modern merchant vessels is almost extinct, leading to an increase in incidents across the industry.  You can read his op/ed at :

Seamanship : the Forgotten Factor

There is certainly some truth in what he says.  Does the additional administrative workload onboard contribute to fatigue?   Absolutely.  Unfortunately, the majority of regulations have been brought about by disasters or incidents where seaman have NOT used common sense and good seamanship.  Regulations are written for the lowest common denominator – the person that is not applying common sense and is prone to contributing to or causing incidents.  Is that fair to those who feel they are not that lowest common denominator?  Possibly not.  Then again, should they also feel relieved that there is some safety net that will catch an unsafe act before it becomes an incident?

So, I ask again.  What contributes more to safety?  Seamanship and common sense or the regulations and management systems that we currently use?  Perhaps, it’s a combination of all these factors…….

Lac-Megantic Derailment : Lessons Learned

The adage that you can learn something from everyone has been around for a long time.  The fact of the matter is that what you learn isn’t always what you want to do – it might be something you definitely don’t want to do.  The recent release by the Transportation Safety Board of Canada of the Lac Megantic, Quebec crude oil train derailment investigation report is most certainly the latter.

Living and working in the maritime world, many of the practices and procedures highlighted in the report are disconcerting to say the least.  Leaving a train loaded with close to 70,000 barrels of crude unattended with a locomotive running?  Can anyone imagine the outcry if you tied up a tug with a 70,000 barrel barge, left the engine running and caught a cab to a hotel for the night?  Creating a safety management system for a company in 2003 that has not physically been seen, let alone read and understood, by many employees in 2010?  Having a safety management system that requires annual internal audits that has not been audited in eleven years?

“The Company should carry out internal safety audits on board and ashore at intervals not exceeding twelve months…..” – ISM Code 12.1

Granted, mention the word “audit” and many, if not most, mariners will shudder and wonder when their relief will be onboard.  But, they are familiar with the concept, if not entirely embracing of the process.  There appears to be a world of difference between the ISM(International Safety Management) Code that was implemented in 1998 and the Safety Management Systems that became mandatory for rail carriers in Canada in 2003.  Whereas the system of internal and external checks and balances (audits) are firmly in place in the maritime world, the same cannot be said, using the Lac Megantic disaster as a snapshot, of the rail industry.

There are many similarities between the rail and maritime industries – spills, disasters and the carriage of goods aside.  One that stands out most prominently is the scaling back of crews.  In the case of the Montreal, Maine and Atlantic Railway, the crew on MMA-002 which derailed in Lac Megantic had been reduced to one.

One person to be in charge of five locomotives pulling seventy other train cars.  One person to set the hand brakes required to hold the train on a downhill grade.  One person with no one to watch his back……or check his work.

Within a very short period of time, both Canadian and U.S. authorities required trains transporting dangerous goods – in particular crude oil – to have at least two crew.  This recognition that crews had been reduced too far, contributing to a major disaster should be an eye opener.  The question is, will we see such a breaking point in the maritime industry?  What about the tugs with a crew of five moving 100,000+ barrel barges of crude?  Unfortunately, many safety regulations are “written in blood,” referring to the disasters that brought them about.

Could the maritime industry learn from the rail industry without having its own Lac Megantic?

The SOLAS(Safety Of Life At Sea) convention was brought about by the loss of more than 1,500 passengers and crew on the Titanic.  Carriage of immersion/survival suits was required after the loss of the Marine Electric.  With close to 80% of losses in the maritime industry attributed to the human element, can changes in safe manning be far off?

Fatigue is another common denominator between the rail and maritime industries.  While Transport Canada requires Fatigue Management Plans, the international maritime industry has the STCW(Standards of Training, Certification and Watchkeeping) Code and rest hour regulations.   A looming question with regard to the rail industry in light of the lack of audits required by regulation might be, “Is the same lax oversight being applied to fatigue management?”  If so, there may be future incidents.  On the maritime side, increased emphasis on STCW rest hour implementation by PSC(Port State Control) inspectors is right around the corner.

Recent reports by the International Maritime Organization (IMO) have publicized the fact that crewmember fatigue is increasingly being recognized as a major factor in maritime accidents… – American Bureau of Shipping, 2002.

The Lac Megantic disaster is certainly an example of an SMS being viewed as a “system of documents” instead of a “documented system of safety management.”  While the recriminations abound, there are some very serious lessons to be learned – both in the rail industry and outside it.

Radar – 10 Key Aspects….and more


There’s a new edition of “The Navigator” out and it’s all about radar.  Published by the Nautical Institute, the June issue addresses many of the aspects of radar use by the ship’s navigator.  Whether it is navigation or collision avoidance, radar plays a critical role on the bridge.  But, did you know that the performance criteria for marine radar hasn’t changed much since the 1940s?  Learn why and more – like 10 Key Aspects of using it – in this issue.  Don’t forget, Madden Maritime updates their links to digital magazines frequently.  Find all your favorite periodicals in one place!

Also from the Nautical Institute are the Alert! bulletins.  Addressing the many factors that play into the human element in the maritime industry, these bulletins have been published for over a decade.  If you haven’t read them, your eyes might be opened by the depth of information available.  The latest from May is available.  Titled “A design flaw that lead to a tragedy….“, issue 35 addresses some of the ship design elements that can create unforeseen hazards.  If you haven’t read these bulletins (or watched the videos accompanying many) or just want to review some of the older ones, they are all available HERE on Madden Maritime’s site.

Let’s be careful out there.