Near misses are normal because safety hazards are normal, especially when performance is at its maximum (e.g., moving through a highly congested waterway such as the Dover Strait). This profile is apparent because current maritime assists are so complex that design errors are frequent, and procedures are often underspecified. Also, the operational environment changes constantly (technology ages, undergoes upgrades, people come and go, the market transforms and requires adjustment), adequate procedures can become inadequate, and investigation recommendations can become irrelevant.
Hence, near misses should mean that hazardous conditions were detected in time and effectively responded to, which makes near misses priceless for learning about accident prevention. There are many learning opportunities since near misses are typically considerably greater than the number of incidents and accidents.
Reclassifying near misses as successes of prevention will make it easy to encourage their reporting, which will change the current situation where near misses reporting has been seen as an unnecessary burden, and investigation recommendations as costly and introducing yet another set of procedures. Blaming human
error as a root cause, which has aggravated the situation and led to cover-ups, will also become pointless.
However, mere reporting of near misses is not enough. The way near misses are described has to change, for the utility of current near misses descriptions is not conducive to learning from them. Descriptions focus on what happened and when and have little information on how hazards were detected, responded to, and the resources (time, skills, technology, communication, etc.) that proved vital.
A related question is what event should be considered a near miss in the first place. Many hazardous events are so frequent that they are considered normal and expected, and it is difficult to say if an event would have led to an accident if it had not been resolved. Hence, reporting near misses is inherently subjective, at least for now.
Turning the near-miss information into knowledge is the ultimate aim. That definitely should not be just another set of dos and don’ts. Instead, or in addition, the analysis should reveal the role of the overall safety management system (SMS) in accident prevention, highlighting good and bad features within the system so that the performance of the SMS as a whole can be better understood.
In summary, a few research questions still need to be addressed to learn from near misses about safety at high performance:
- What events should be considered as near misses? Should they be all events that would lead to accidents if inadequately attended to or only those events that could be referred to as close calls?
- How can one effectively report near misses to become conducive to learning? That is, how does one maximise the utility of near-miss analysis and uptake? Does it require developing a new taxonomy (to capture how hazards were detected, responded to, and what resources proved vital) or perhaps using a myriad of sensors and AI?
- How to map near-miss information to SMS, where people are just one part? This may sound complex, but it does not need to be. There are examples in the research literature of how seemingly complex safety management systems are represented as simple hierarchical structures that are easy to understand and communicate. Thus, technology’s contribution (or lack thereof), management and responsibility structures, communication with other vessels, and used regulations and rules need to be highlighted.
The Report • June 2022 • Issue 100 | 111
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