Near Miss? Can We Learn From Others’ Mistakes?
Growing up, many of us heard cautionary tales from our parents that included lines such as, “If you do that, you’re going to break your neck.” Hearing these tales, many of us altered our plans, possibly avoiding serious injury. Others of us didn’t, but regardless, we were offered potential outcomes of risky behavior based on previous experience. Somewhere along the way, empowered with the invincibility of youth and possibly a new degree or license, a lot of us stopped listening to such advice. The result? We proceeded to make our own mistakes, from which we subsequently learned.
On a personal level, making our own mistakes comes at the cost of professional reputation, financial penalties and criminal or civil liability. Obviously, the potential consequences noted are at the most severe end, yet professional reputation is oft overlooked. We live and work in a relatively small community of mariners in which word of mouth or hearing news over the “grapevine” is common. Being known as a maverick, cowboy or risk-taker may not help you to find the next job or contract.
On a corporate level, many individuals insisting on making their own mistakes from which to learn is a costly endeavor. In an era where replacement materials and repairs are becoming ever more costly and profit margins ever thinner, any additional costs must be mitigated. While a single repair may not be exorbitant, multiplying said repair by ten, a hundred or in the extreme, a thousand, a common error or design flaw may wind up costing a company millions of dollars.
Thus far, the emphasis has been on the financial or legal repercussions, but the health and safety of our mariners is the primary reason why we need to learn from others’ mistakes. As supervisors and senior officers onboard ships, if we allow even one crew member’s health or safety to jeopardized by a situation that could have been avoided, we have failed miserably. Finances are certainly a concern, but are no match for the long-lasting effects of a serious injury or death.
So, we have tools such as near misses. Near misses are required under section 9 of the ISM (International Safety Management) Code issued by the IMO (International Maritime Organization) reporting of hazardous conditions. Further guidance was given by the IMO in MSC-MEPC.7/Circ. 7 “Guidance on Near Miss Reporting.” Most companies have an in-house system that they may or may not make available to all vessels. More often, the designated person ashore or HSSEQ (Health, Safety, Security, Environment and Quality) department will cull the more pertinent ones and forward to all vessels. The wider the dissemination of near misses, however, the greater the chance is that they will prevent similar incidents in the future.
One way to get an even greater effect is to have a centralized database of near misses. The Nautical Institute has a mature database of near misses under their MARS (Mariners’ Alerting and Reporting Scheme) program. This database reaches back to the early 1990s and contains a wide range of situations and incidents. Recently, the SOCP (Ship Operations Cooperative Program) and the U.S. Maritime Administration investigated establishing their own database. Such databases offer an industry wide and confidential method of reporting near misses without fear of repercussions. This premise of a “just culture” is what makes reporting a near miss palatable as it isn’t “putting yourself on report.”
So, can we learn from others? Or, must we make our own mistakes? Remember your parents’ advice…….