Operational Guide · Registers & Logbooks

# 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.

ISM Code Near Miss safety culture reporting

## 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

1. Report the event as soon as possible, using the Near Miss form provided by the SMS (paper or electronic).
2. Describe objective facts (what happened, where, when, surrounding conditions), avoiding attribution of individual blame at the reporting stage.
3. 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.
4. Share lessons learned with the crew, anonymised if necessary, through briefings or safety meetings.
5. 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

Historical analyses of serious maritime incidents (and in other high-risk sectors) repeatedly show that the serious event had been preceded by one or more similar Near Misses, never reported or reported but not systematically analysed — the failure to "close the loop" between reporting and action is often the real risk factor.

## 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

PSC inspectors and certification auditors assess the Near Miss reporting rate as an indicator of safety culture health: an anomalously low number of reports, especially if linked to a recent incident, is often a red flag rather than a good sign.

## 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

## FAQ

Must a Near Miss always be converted into a Non-Conformity?
No: it becomes an NC when it reveals a systemic gap in the SMS. If it remains an isolated episode with no systemic cause, it can remain recorded as a Near Miss with lessons learned shared, without formally opening an NC.
Who is responsible for collecting Near Misses on board?
Typically the Master or the designated Safety Officer, who collects, analyses and forwards reports to the DPA and the Company under the SMS procedure.
Must Near Misses also be reported to the authorities?
Generally no, unless the event also constitutes an incident/near-incident with an external reporting obligation (e.g. a near-collision) under applicable rules (SOLAS, flag State regulations).
🎬 Additional photos, videos and interactive diagrams for this topic will be available in a future version of the platform.

## Related Topics

Non Conformity (NC) Management Corrective and Preventive Action (CAPA)Designated Person Ashore (DPA)

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