ASTM F3256-25

4.1.1 The maritime industry has not consistently applied a harmonized definition of a near-miss or a structured near-miss reporting methodology. This makes providing industry wide safety related lessons learned, trending, and benchmarking challenging.

4.1.2 A functioning comprehensive near-miss reporting, follow-up investigation, and corrective action system supports compliance with the IMOs requirement for near-miss reporting as outlined within the ISM Code. The ISM Code mandates that shipping companies establish procedures to report “hazardous occurrences,” including near-misses, to enable investigation and analysis to prevent future incidents; essentially, all near-misses should be reported and investigated as appropriate to the level of risk of the near-miss event to improve safety on board ships. This guide supports those companies.

4.1.3 For maritime operating companies that are not required to comply with the ISM Code, the direction and assistance in this guide is provided for the voluntary establishment, implementation, and administration of near-miss reporting and analysis programs for continual safety improvement, which will reduce the number of incidents and operating costs onboard their vessels.

4.2.1 Most accidents/incidents are preceded by a chain of events, circumstances, acts, or conditions. If any of these events, circumstances, acts, or conditions had transpired another way, at another time, or had been corrected, the accident/incident may have been avoided. Reporting near-misses can play an important role in learning and procedural improvement with the intent to prevent accidents and their potential serious consequences or the reoccurrence of the event.

4.2.2 Near-miss recording and reporting provides information that can be used to improve any safety system, often complementing other safety system components such as accident/incident investigations, hazard analyses, safety reporting, prioritizing, root cause analysis, solution identification, communication, identifying corrective actions, sharing lessons learned, leading safety indicator analyses, or safety culture enhancement. In addition, in terms of human life and property damage, near-miss recording, reporting, and analyses are low-cost learning tools to support training and prevention of reoccurrence as well as to provide a new data source on what may work to break the chain of events before an accident occurs. Finally, near-miss analyses may provide key data that can prevent low-probability, high-consequence accidents by supporting safety barrier improvements or providing safer alternatives.

4.3.1 Management should provide unwavering support for near-miss recording and reporting. This includes providing adequate time for the employee to complete the near-miss report. Additionally, this includes any financial support or support from external experts, if necessary, to correct potentially hazardous conditions. Management commitment to safety has a positive effect on reporting, while under-reporting has been linked to lack of management commitment to safety.

4.3.2 Management should not be overly fearful of legal liability as to damper the near-miss recording and reporting process. When deciding to formalize a near-miss reporting system, organizations have both legitimate and unsubstantiated fears of liability and recrimination. Near-miss recording and reporting should be viewed by all stakeholders (companies, legislators, enforcement agencies, and the legal system) as one of the most effective ways to identify hazards and reduce accidents/incidents and not used for recrimination of any type. As noted in 4.1.2, the IMO requires shipping companies to include near-miss recording and reporting within their SMS.

4.3.3 Employees should not fear any disciplinary action, peer teasing, or supervisory belittling. A means of anonymous, confidential, and secure reporting should exist, and a positive, no-blame near-miss recording and reporting culture needs to be nurtured. This includes security and cybersecurity for data systems that support the organization’s near-miss process.

4.3.4 Employees should be fully engaged in the development, implementation, and operation of the company’s near-miss recording and reporting system.

4.3.5 Employees should believe that their near-miss reports are being followed up. If the reports are not actively followed up and there is not clear communication between ship and shore, near-miss reporting efforts will fail.

4.3.6 Employees should be adequately trained in the near-miss recording and reporting process and familiar with its goals and objectives. Employees should be trained how to report near-misses, what constitutes a near-miss, and the benefits of near-miss recording and reporting. Training employees properly will ensure that reports on near-miss events are as comprehensive and complete as possible.

4.3.7 Employees should be motivated to report near-misses. This could include productive incentives for reporting. Participation in near-miss recording and reporting cuts across all levels of an organization, and management should fully support and encourage near-miss reporting through their words and actions.

4.3.8 The near-miss recording and reporting process should be efficient and not overly time consuming. Near-miss reporting forms and tools should be automated and as comprehensive, as possible, to be easily completed, easily available, easily submitted, easily reviewed, and lessons learned easily disseminated.