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Near Miss

A sequence of events or conditions that could have resulted in a loss, the potential loss could be human injury, environmental damage, or negative business impact. 

Near miss may define the primary condition which may lead to an accident. or its a warning of an accident so to avoid an accident the primary conditions(near miss) to be eliminated by corrective actions.

Examples of near miss:
  1. Any event that leads to the implementation of an emergency procedure, plan or response and thus prevents a loss Eg.:- a collision is narrowly avoided; or a crew member double checks a valve and discovers a wrong pressure reading on the supply side
  2. Any event where an unexpected condition could lead to an adverse consequence, but which does not occur. Eg.:- a person moves from a location immediately before a crane unexpectedly drops a load of cargo there, or a ship finds itself off-course in normally shallow waters but does not ground because of an unusually high spring tide
  3. Any dangerous or hazardous situation or condition that is not discovered until after the danger has passed. Eg.:- a vessel safely departs a port of call and discovers several hours into the voyage that the ship's radio was not tuned to the Harbor Master's radio frequency; or it is discovered that ECDIS display's scale does not match the scale, projection, or orientation of the chart and radar images.

Barriers of reporting near miss:
  1. In most of the cases near misses are known to individual only who decides it reported or not.
  2. Another factor is the fear of being blamed, disciplined, embarrassed, or found legally liable.
  3. Unsupported company management attitude
  4. Insincerity about addressing safety issues
  5. All these barriers can overcome by:
  • Encouraging a “just culture” in the company which covers near-miss reporting
  • Assuring confidentiality for reporting near-misses, through company policy
  • Ensuring that investigations are adequately resourced.
  • Following through on the near-miss report suggestions and recommendations.

Near miss investigation process:
1. Minimum information gathered about near miss
  • Who and what was involved?
  • What happened, where, when, and in what sequence?
  • What were the potential losses and their potential severity?
  • What was the likelihood of a loss being realized?
  • What is the likelihood of a recurrence of the chain of events and/or conditions that led to the near-miss?
2.Date, time, location, cause, weather condition
3.Gathering near miss information
4.Analyzing information
5.Identifying casual factors
6.Developing and implementing the recommendation
7.Completing the investigation

Completing the investigation:
  1. Completion of the investigation process requires the generation of a report, either brief or extensive, depending on the depth of analysis performed and the extent of risk.
  2. The ultimate objective of near-miss reporting and investigating is to identify areas of concern and implement appropriate corrective actions to avoid future losses. To do so requires that reports are to be generated, shared, read, and acted upon. Companies are encouraged to consider whether their report should be disseminated to a wider audience.
  3. It may take years for safety trends to be discerned, and so reporting must be archived and revisited on a timely basis. Near-miss reports should be considered along with actual casualty or incident reports to determine trends. There should be consistency in the identification and nomenclature of causal factors across near-miss and casualty/incident reports


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