Reporting Practices for Close Call (Near Miss) Reporting Systems

Abstract

This paper identifies best practices for reporting close calls (near misses) in the maritime industry. The practices were identified by reviewing approximately 44,000 actual close call reports from 27 data sources. Even though the close call data is provided in a wide variety of formats, the data demonstrates a surprising degree of uniformity in the collection of the close call data and resolution of the close calls with most organizations capturing an incident description and incident resolution. A number of organizations also have formal corporate response feedback mechanism for all incidents. The analysis demonstrates that many features of close call reporting systems discussed in the literature are being implemented in practice including avoiding blame, disseminating close callreports, and developing effective corrective measures. Based on the review of industry practices and industry feedback, a sample close call reporting form and taxonomy for close calls will be developed. 2OTC-25078-MS 2. ChallengesOne of the primary challenges of establishing a cross-industry injury and close call database results from differences in the injury/close call information that is collected and the multiple formats used by different organizations. This is particularly true with close call records. DatabaseCurrently, industry partners have access to the injury database, the close call database and a Mariner Safety Document Center that contains numerous examples of toolbox talks, ergonomic discussion papers, and safety spotlights, etc. All materials developed for the Mariner Safety Document Center are based on the data contained in the Mariner Personal Safety Database. Database revisions and improvements are based on user (industry partner) feedback. Examples of revisions and improvements include the use of stemming and synonyms (similar to a web search engine), cause, type, and location based drop down menus, and searches by vessel type. 4. Injury DataThus far, nine different industry partners have provided injury data, representing approximately 15,000 reports. Though the data varies, commonly re-occurring data fields include injury type, potential, root or cause for the incident, equipment involved, location on the vessel, vessel type, task(s) at the time of event, and demographic characteristics of the crewmembers involved. From this data, injury causes, types, locations, and their corrective actions and lessons learned have been shared with the industry partners. 5. Close Call (Near Miss) DataThus far 27 different data sources have provided close call data, representing approximately 44,000 reports. As with the injury data, the close call data reported varies amongst data sources. For close calls, commonly reoccurring data fields include close call type, potential, root or cause for the incident, equipment involved, location on the vessel, vessel type, task(s) at the time of event, and demographic characteristics of the crewmembers involved. From this data, close call causes, types, locations, and their corrective actions a...

Reporting as a Key Element of an Effective Near-Miss Management System in Shipping

“…The International Maritime Organization (IMO) defines a near-miss as a chain of events that could have resulted in negative consequences, which were prevented by a lucky interruption of a sequence of events. Unrealized negative consequences, for example, could be injury, environmental pollution, or a negative impact on a company's business [4,6,7]. Craig et al [6] indicate that near-misses may be caused by inadequate training, human error, flawed or poor design, management errors, flawed procedures or systems, unanticipated outcomes, or any combination of the above.…”

“…Reporting-a crewmember or master/safety officer reports the near-miss, and a reporting form is filled out [6,[32][33][34][35][36][37][38]; 3.…”

“…Prioritization-assessment of the degree of attention that is to be given to the event, depth of the causation analysis, assessment of the means to be used for solution finding, and the implementation of corrective measures and the proportion of dissemination [6,[32][33][34][36][37][38]; 4.…”

“…Solution identification-corrective actions which will prevent recurrence or mitigate possible consequences are identified [6,[32][33][34][35][36]38]; 7.…”

“…Dissemination-corrective actions shared with persons who are in charge of their effective implementation. They can be disseminated to a broader audience in order to increase awareness and improve safety measures [6,[32][33][34][35]37,38]; 8.…”