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Near Miss Reporting Lacking in the U.S.

Costa Concordia
Costa Concordia

By Captain Richard Madden 2018-04-21 19:20:07

Let’s talk about near miss reporting. If there is a subject sure to get eyes rolling and profanities muttered under people’s breath in the maritime industry, it’s the topic of near misses and their reporting.  

Near misses, near miss reporting systems and accident investigations are of great interest to me and, in my humble opinion, should be of great interest to mariners as a group. As the readers start rolling their eyes and muttering under their breath, the prevailing thought is likely, “Why?” The answer is something I say quite often, “I’d much rather learn from someone else’s mistakes or near misses than make them myself.”

Then again, as colleague of mine will often say, “Sometimes you have to realize that your purpose in life is to be a cautionary tale for others.” It’s up to you to decide which path you might follow.  

Credit:  NearMiss.dk

The Theory

The theoretical advantage to near miss reporting is pretty clear. Whether you are referring to Heinrich, Petersen & Roos (1980) or Bird and Loftus (1976), the correlation of around 600 near miss accidents to a single serious or fatal accident might encourage us to look for some of those near misses. Those near misses, unsafe conditions or unsafe practices, if identified, are leading indicators that some type of incident or accident might occur if left unchecked. Frequently, the error chain or causal chain that would bring about that incident is broken before it occurs. It is in these instances that the identification, investigation and dissemination of near misses may help others in a company, organization or industry avoid their own similar near misses or incidents.

Regardless of whether or not the exact ratios of Heinrich, Petersen, Roos, Bird and Loftus are correct (and there are a number of scholarly articles purporting to debunk Heinrich), the effectiveness of near miss reporting as a leading indicator of safety remains. Stopping the error chain at the unsafe condition, unsafe act or near miss is far preferable to dealing with an accident, the ensuing investigation and report that may be detrimental to the individual or organization.

Studies of near miss reporting are almost universally in agreement that the reporting, analysis of causal factors and dissemination of near miss data can help prevent accidents from occurring. Under the International Safety Management (ISM) Code from the IMO, shipping companies should encourage the reporting of near misses to maintain and improve safety awareness. Therefore, near miss reporting on a company or organization level within the maritime industry is widespread. But, is this helping the maritime industry as a whole?

Maritime Near Miss Reporting Schemes – International

Near miss reporting schemes for the maritime industry are relatively widespread on the international level. Not only do you have the company or organization-level schemes mandated by the ISM Code, but there are a variety of national and international schemes available.

On the national level, NearMiss.dk is a joint cooperation between the Danish Shipowners’ Association and SEAHEALTH. It is set up both as a common database to which shipping companies contribute and such that companies can manage their company near miss reporting, including corrective actions, preventive measures and follow up, separately. 

Foresea.org, a collaboration between Sweden and Finland, is based on the Swedish Insjo.org, which is now defunct. With over 3,000 reports (as of 2014) in English, this is a good resource for the industry as a whole.

On the international level, there are two near miss reporting schemes to discuss. The first is run by The Nautical Institute, an international representative body for maritime professionals involved in the control of sea-going ships. The Mariners’ Alerting and Reporting Scheme (MARS) has been accepting reports since 1992 and has a significant database built up. As many near miss reports as possible are published in their monthly Seaways magazine. 

The second international scheme to discuss is the U.K.’s Confidential Hazardous Incident Reporting Scheme (CHIRP). Building from the successful implementation of CHIRP in the aviation industry, it’s scope was widened to the maritime industry in 2003. Designed to be complementary to other government and organizational reporting systems, this scheme has become known internationally and accepts near miss submissions from all.  

CHIRP is run as a charitable trust, thus maintaining autonomy from other industry organizations. The reports are de-identified and then passed along to organizations that can follow up on them. Frequently this will include dialogue with the reporter to gather additional information. Additionally, other parties to the near miss will be contacted to obtain their point of view, as well as to alert them to the near miss. At all times, great effort is taken by CHIRP to avoid identifying the reporter.

CHIRP publishes their findings and near miss reports on a quarterly basis in their Feedback magazine. They have also started to produce videos highlighting many of their near miss reports, as well as identifying some industry best practices.

Having had the opportunity to report near misses to both The Nautical Institute MARS and CHIRP, I found the submission of the reports quite easy over email. The follow up by both organizations was excellent, with CHIRP contacting the third party for comment and attempted resolution of unsafe work practices.  

While the third party in my report did not respond to CHIRP with comment (continued communication with CHIRP allowed this feedback to the reporter), the unsafe work practice appeared to have been mitigated in future interactions. In both cases, the near miss reports were published by MARS and CHIRP, allowing other mariners to learn from my near miss.

Near Miss Reporting in Other Industries

The maritime industry is certainly not the only high-risk, high-consequence industry. High Reliability Organizations (HRO) are those that have succeeded in avoiding catastrophes in environments where normal accidents can be expected due to risk factors and complexity. Aviation, nuclear power, health care and military operations such as aircraft carrier operations are examples of these HRO. Although these organizations routinely avoid serious incidents, they are not without them; and occasionally, they are catastrophic. One of the characteristics that define these HRO, though, is that they continually strive to learn from these incidents, as well as near-incidents or near-misses. In fact, they actively seek near miss reporting so as to head off bad things before they happen.

The Aviation Safety Reporting System (ASRS) has enjoyed success to a large part due to its use of the National Aeronautics and Space Agency’s (NASA) Ames Research Center as an independent third party. As a third party organization, NASA is outside the regulatory, administrative or enforcement processes of the Federal Aviation Administration (FAA). NASA collects, analyzes and collates the near miss reports. This safety information is then disseminated to the aviation industry.  

Since 2010, these processes have been conducted under contract by Booz Allen Hamilton of Sunnydale, California. Over the course of its 42-year history, the ASRS has collected over 1.3 million near miss reports, issued over 6,200 safety alerts, authored or supported 60 research products and continues to put out a monthly safety newsletter that is distributed to over 30,000 subscribers.

The U.S. aviation industry embraced the ASRS based on the tenets of being confidential, voluntary and non-punitive. It is confidential, not anonymous. This allows investigators to follow up with the reporter to gain more information and verify the veracity of the report. Being voluntary, making an ASRS report is not mandatory. It is widely recognized within the aviation community, however, that reporting a near miss allows one to self-identify a fault in a system or process so that others may learn from it. Lastly, being non-punitive, the FAA under federal regulation may not use a report to the ASRS for enforcement action unless it concerns an accident or criminal offense.

NASA has gone on to act as the third-party organization for the U.S. medical and railroad industries near miss reporting schemes. The Confidential Close Call Reporting System (C3RS) for the railroad industry and Patient Safety Reporting System (PSRS) for the medical industry are both based on the system in place for the ASRS. They, too, are currently administered under contract by Booz Allen Hamilton. 

Other near miss reporting schemes within the U.S. exist for firefighters and the oil and gas industry operating on the Outer Continental Shelf (OCS). The near miss scheme for firefighters is administered by the International Association of Fire Chiefs (IAFC) and, although relatively young (launched in 2005) has a robust following of 9,000 subscribers for their weekly report. 

SafeOCS for the oil and gas industry was developed jointly by two government agencies. These were the Department of the Interior’s Bureau of Safety and Environmental Enforcement (BSEE) and the Department of Transportation’s Bureau of Transportation Statistics (BTS). In place since 2013 for the collection of near miss information, SafeOCS now collects required reports on equipment malfunctions, as well.

Maritime Near Miss Reporting Schemes – U.S.

Predating the introduction of the ISM Code, the U.S. National Research Council in their 1994 publication, Minding the Helm, discussed the fact that the underlying causes of maritime accidents were not being addressed. Additionally, it noted that the marine safety data available at the time was not adequate to identify the causal factors and any preventative measures that could be applied. Sounds like a system of near miss reporting could be of use…

By 1998, when much of the shipping industry was required to be in compliance with the ISM Code, the U.S. attempted to develop a near miss reporting system of their own. Called the International Maritime Information Safety System (IMISS), it was created when a memorandum of agreement was signed between the U.S. Maritime Administration (MARAD) and the U.S. Coast Guard (USCG). It was intended that the system would allow both agencies to receive, analyze and disseminate information about unsafe occurrences.

Development of IMISS moved forward, with NASA’s ASRS working with the USCG to develop the reporting form. This prototype form was then used by 87 mariners to report a simulated incident. Analysts, including human factors and maritime representatives, then reviewed the submissions and assessed how completely the incident had been described.

Despite receiving widespread support from the maritime industry, shipping companies and regulatory agencies, IMISS stumbled on one of the three tenets that had helped ensure the success of the ASRS. Those three tenets were that the reports were confidential, voluntary and non-punitive. While the confidentiality was problematic in the maritime industry, as there are fewer mariners working in a geographic area, thus allowing deduction of a reporter’s identity, it was the non-punitive nature on which IMISS eventually failed.

Unlike the ASRS where statute ensures that reports will not be used in enforcement action, the U.S. Department of Justice (DOJ) had a different view of the maritime industry. “The DOJ found it unreasonable to provide protection from civil fines and certificate action for inadvertent incidents.” Due to these objections, IMISS stalled and the USCG withdrew funding. Industry and Department of Defense(DOD) support remained strong, but there failed to be a way forward for the program.  

2012 rolled around and the Ship Operations Cooperative Program (SOCP), a non-profit organization of commercial ship operators and maritime stakeholders in the U.S., commissioned a study for MARAD to the determine the needs for a centralized marine safety data network. Ironically, the author of this report was Mr. Alexander C. Landsburg, a former MARAD representative to IMISS.  

The SOCP/Landsburg study was comprehensive, covering all aspects of near miss reporting from the theory, to potential sources of maritime operational safety data and barriers to effective implementation of a near miss reporting scheme. Various conclusions were drawn from this in-depth analysis, including the value of such a network. Certainly, shipowners would benefit due to their financial and reputation risk in the event of incident. Government agencies would benefit as well – specifically, USCG being responsible for regulation of the recreation and commercial maritime industries, USCG and NTSB in investigating maritime accidents and, lastly, the U.S. Navy with concerns about the safety of their vessels. That last benefactor, the U.S. Navy, would revisit their vessels’ safety issues in unhappy circumstances just five years later.

The outcome of this study in 2012 was an influx of funding from SOCP and MARAD for the American Bureau of Shipping’s (ABS) Maritime Safety Research Initiative (MSRI) and Mariner Personal Safety (MPS) project. The MSRI/MPS is a collaborative program between ABS and Lamar University to develop a large international database and online repository of maritime injury and close call (near miss) reports. Their website currently claims over 100,000 reports from 31 data sources. A variety of best practices and reports have been published by the MSRI, but do not appear to have been updated past 2016.  

In 2016, the U.S. Coast Guard’s Navigation Safety Advisory Council (NAVSAC) was tasked with discussing and developing a near miss reporting program that includes criteria for reporting and cataloging near miss data. Specifically, the requirements for reporting navigational near misses – collisions, allisions and groundings – were to be discussed. It’s interesting, in retrospect, that the previously attempted program, IMISS, might have been fulfilling the needs of the USCG for close to 15 years by this point, had it not been defunded.

The U.S. Navy, five years after it was noted by SOCP/Landsburg that they (the U.S. Navy) could benefit from a near miss reporting system, experienced two fatal collisions in June and August of 2017. In total, 17 U.S. Navy sailors lost their lives. These incidents, along with others, sparked a “Comprehensive Review of Recent Surface Force Incidents,” which was published in October 2017.

Once again causal factors and near miss events are referenced. How many near collisions had the U.S. Navy experienced since IMISS was defunded? Might they have identified some causal factors or best practices that could have avoided the eventual loss of life?

Barriers to Near Miss Reporting

In the early 2000s when IMISS was defunded, communication obstacles to reporting from remote areas of the world was considered an impediment to implementation. In the years since, with the introduction of internet access to most crew on vessels, reporting via email or web form is easily done. Like everything else, there could simply be “an app for that.”

Technology is no longer the issue. The biggest barrier to near miss reporting remains that elusive element that we are partially trying to address with near miss reporting; namely, that which makes us human – the human element.

The fact remains that the real obstacles to near miss reporting are built into the human psyche. Raising issues with a company or organization’s processes, personnel or equipment potentially risks one’s livelihood, promotions and reputation. These risks, on a personal level, are not insignificant as they threaten the ability to put food on the table and a roof over the head.  

Abraham Maslow, in his Hierarchy of Human Needs (1943), opined that for one to move to a higher level on the pyramid, the needs on the lower levels must be...

The opinions expressed herein are the author's and not necessarily those of The Maritime Executive.