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 CodeNear Misssafety culturereporting

Operational Explanation

A near miss is a sequence of events or conditions that could have produced a loss, avoided by a break in that sequence. It may affect people, the environment or ship operations. ISM section 9 requires reporting and analysis of hazardous occurrences; MSC-MEPC.7/Circ.7 guides its application to near misses. Analysing them alongside incidents helps identify causes and recurrence.

A just culture encourages good-faith reporting, safeguards confidentiality and distinguishes error, working conditions and unacceptable conduct. ‘No blame’ does not mean blanket immunity or absence of accountability.

Regulatory Reference

ISM Code section 9 provides the mandatory basis for hazardous occurrences. MSC-MEPC.7/Circ.7 is the specific guidance on reporting and just culture. A.1188(33) concerns implementation of the Code by Administrations.

Specific guidance on reporting, investigation and follow-up: MSC-MEPC.7/Circ.7.

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

Make people and activities safe where necessary; report promptly with observed facts and conditions.
Preserve evidence and distinguish hypotheses from established causes.
Assess potential severity, unmet requirements and external reporting duties. Open an NC where there is evidence of an unmet requirement, including an isolated event.
Assign investigation and action proportionate to risk, with owner, deadline and verification.
Provide feedback and share lessons with appropriate confidentiality; review trends, quality and follow-up.

Practical Example

Learning example: a line slips from a winch and narrowly misses a seafarer. The operation is made safe and evidence on tension, line, brake and arrangement is preserved. A brake defect is a hypothesis, not an established cause. Competent personnel determine conditions and necessary action before resuming. The report assigns an owner, deadline and outcome verification.

What Typically Goes Wrong

Collecting reports without investigation or follow-up leaves risk factors unresolved. Use potential severity and recurrence likelihood to determine investigation depth; also communicate reasoned decisions not to implement a recommendation.

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

What the PSCO Checks

Report counts and rates need context: exposure, quality, interviews and follow-up. Few reports do not automatically prove a weak culture; many do not prove safety. PSC assesses SMS functioning within its own remit; certification audits are distinct.

Operational Tips

Explain protections for good-faith reporting and confidentiality limits under Company procedures.
Make reporting simple and quick, even just verbal at first.
Periodically review aggregated Near Misses to identify patterns, not just single episodes.

Preparation checklist

Educational checklist. This summary supports learning and preparation only. It does not replace the vessel’s approved procedures, manuals, statutory documents, company SMS, or applicable official requirements. Completing it demonstrates neither compliance nor readiness for an inspection: it shows that a list has been read, not that the ship is in order. Always verify the current documents carried on board.

Immediate condition made safe where necessary
Facts and evidence recorded; hypotheses distinguished from causes
Unmet requirements, potential severity and notifications assessed
Actions with owner, deadline and verification
Feedback and lessons shared with appropriate confidentiality
Trends reviewed without quotas or automatic diagnoses

FAQ

Is every Near Miss an NC?

No. It is an NC where objective evidence shows an unmet requirement, even in an isolated event. Otherwise it remains an event to analyse and address according to risk.

Who manages follow-up?

Personnel designated by the SMS, with appropriate competence and ship–shore coordination. Actions need an owner, deadline, verification and feedback.

Is external notification required?

Check duties applicable to the event and jurisdiction. An internal record does not replace mandatory notification.

Reporting a Near Miss

Operational Explanation

Regulatory Reference

Scope of Application

Procedure / How to Complete It

Practical Example

What Typically Goes Wrong

Common Mistakes Mistake Library

What the PSCO Checks

Operational Tips

Preparation checklist

FAQ

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