Reporting a Near Miss
A near miss is the most valuable and hardest-to-collect piece of information: how to build a reporting culture that does not punish the person who reports.
Operational Explanation
A Near Miss is an event that, under slightly different circumstances, could have caused an injury, damage or an environmental incident, but in fact did not. The ISM Code requires the Company to establish procedures for reporting and analysing these events, treating them as a leading indicator that is far more useful than actual incidents, which by definition have already happened.
The critical factor is not the procedure itself but the culture that underpins it: a "no-blame" system, which treats reporting as a contribution to collective safety rather than self-incrimination, is what distinguishes a genuinely living SMS from a merely formal one.
Regulatory Reference
ISM Code, Section 9 (Reports and Analysis of Non-Conformities, Accidents and Hazardous Occurrences) — "hazardous occurrences" include Near Misses. The 2023 Guidelines on Implementation of the ISM Code by Administrations (Resolution A.1188(33)) reaffirm the importance of a safety culture that encourages spontaneous reporting.
Scope of Application
Applies to the entire crew and the Company's shore-based staff: anyone who observes a near miss, in any department (deck, engine, cargo management, shore office).
Procedure / How to Complete It
- Report the event as soon as possible, using the Near Miss form provided by the SMS (paper or electronic).
- Describe objective facts (what happened, where, when, surrounding conditions), avoiding attribution of individual blame at the reporting stage.
- The person in charge on board (often the Master or the Safety Officer) analyses the event and, if relevant, escalates it to a Non-Conformity with an associated CAPA.
- Share lessons learned with the crew, anonymised if necessary, through briefings or safety meetings.
- Aggregate Near Misses over time to identify recurring patterns to bring to the Management Review.
Practical Example
Example report: "Near Miss 22.02.2026 — during mooring, a cable under tension suddenly released from the winch, brushing past a seaman without striking him. Cause: undetected wear of the winch brake. Action: extraordinary inspection of all mooring winches and revision of the maintenance checklist."
Real Cases
Common Mistakes Mistake Library
| Mistake | Consequence | How to avoid it |
|---|---|---|
| Punitive culture towards those who report | The reporting rate collapses and useful information is lost | Adopt and clearly communicate a 'no-blame' policy for good-faith reports |
| Near Misses collected but never analysed in aggregate | Recurring patterns are never identified before the incident | Systematically include Near Miss review in the Management Review |
| Reporting form complex or perceived as punitive | Very low rate of spontaneous reporting | Simplify the form and allow quick reports, even verbal ones initially, later formalised |
PSC Observations
Operational Tips
- Communicate clearly to the crew that Near Misses are welcome, not punished.
- Make reporting simple and quick, even just verbal at first.
- Periodically review aggregated Near Misses to identify patterns, not just single episodes.
Checklist
- Event described with objective facts, not judgements
- Report made as soon as possible after the event
- Cause and contributing factors analysed
- Lessons learned shared with the crew
- Event included in the periodic aggregation for the Management Review