1、Designation: F3256 17 An American National StandardStandard Guide forReporting and Recording of Near-Misses for MaritimeIndustry1This standard is issued under the fixed designation F3256; the number immediately following the designation indicates the year oforiginal adoption or, in the case of revis
2、ion, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () indicates an editorial change since the last revision or reapproval.1. Scope1.1 This guide provides near-miss reporting criteria andterminology for maritime vessels.1.2 The purpose
3、of this near-miss reporting guide is tostandardize near-miss reporting, including terminology, for themaritime industry.1.3 The criteria contained within this guide should beapplied as a minimum to all near-miss reporting in themaritime industry unless otherwise specified.1.4 This guide is divided i
4、nto the following sections andappendixes:Table of ContentsSections andSubsectionsTitle1 Scope2 Terminology3 Significance and Use4 Near-Miss Standardization5 Procedure6 KeywordsAppendix X1 Probability, Severity, and Risk AssessmentAppendix X2 Sample Near-Miss Reporting Form1.5 This standard does not
5、purport to address all of thesafety concerns, if any, associated with its use. It is theresponsibility of the user of this standard to establish appro-priate safety, health, and environmental practices and deter-mine the applicability of regulatory limitations prior to use.1.6 This international sta
6、ndard was developed in accor-dance with internationally recognized principles on standard-ization established in the Decision on Principles for theDevelopment of International Standards, Guides and Recom-mendations issued by the World Trade Organization TechnicalBarriers to Trade (TBT) Committee.2.
7、Terminology2.1 Definitions of Terms Specific to This Standard:2.1.1 accident, nan incident with unexpected or undesir-able consequences that may be related to personnel injury orfatality, property loss, environmental impact, business loss,etc., or a combination of these.2.1.2 activity/task, nan acti
8、on or job that was beingperformed during the time of the near-miss, unsafe act/behavior, or hazardous/unsafe condition.2.1.3 causal factor, na structural/machinery/equipment/outfitting problem, human factors, or external factors thatcontributed to an incident, allowed an incident to occur, orallowed
9、 the consequences of the incident to be worse than theymight have been.2.1.4 consequences, nthe undesirable or unexpected out-comes that may result in negative effects for an organization.These outcomes can range from minor injuries to major eventsinvolving loss of life, extensive property loss, env
10、ironmentaldamage, and breaches related to security.2.1.5 corrective actions, nimprovements to an organiza-tions processes taken to eliminate causes of hazards, non-conformities, or other undesirable situations.2.1.6 event, na happening caused by humans, automati-cally operating equipment/components,
11、 external events or theresult of a natural phenomenon.2.1.6.1 DiscussionEvent descriptions typically include ac-tion verbs such as walked, turned, opened, said, radioed,discovered, decided, saw, etc. If negative (an error, failure orexternal factor), then the event may also be a causal factor,interm
12、ediate cause, or root cause.2.1.7 external factors, nissues outside the control of theorganization. Examples include uncharted/unknown hazards tonavigation, some sea or weather conditions, suicides orhomicides, and external events.2.1.8 hazard, na condition with the potential to causeinjury, illness
13、, or death of personnel; damage to or loss ofequipment or property; or voyage/activity/task degradation.2.1.9 hazardous/unsafe condition, nany condition thatmay adversely affect the safety of any seafarer, equipment,vessel, bridge, structure, or shore area or the environmentalquality of any port, ha
14、rbor, or navigable waterway.2.1.10 human errors, nperformance of humans that devi-ates from the desired performance.1This guide is under the jurisdiction of ASTM Committee F25 on Ships andMarine Technology and is the direct responsibility of Subcommittee F25.07 onGeneral Requirements.Current edition
15、 approved May 1, 2017. Published July 2017. DOI: 10.1520/F3256-17.Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United StatesThis international standard was developed in accordance with internationally recognized principles on standardization est
16、ablished in the Decision on Principles for theDevelopment of International Standards, Guides and Recommendations issued by the World Trade Organization Technical Barriers to Trade (TBT) Committee.12.1.11 incident, nan unplanned sequence of events orconditions, or both, that results in, or could have
17、 reasonablyresulted in, a loss event.2.1.12 incident category, nfor near-miss reporting thetypical categories are near-miss, unsafe act/behavior, orhazardous/unsafe condition.2.1.13 incident type, nfor near-miss reporting, the typicaltypes are near struck near struck by, near struck against, neartra
18、pped in, near slip, near trip, near fall (same level or differentlevel), near fire, near spill, near strain/overexertion, near caughtbetween, near contacted by, near contacted with, nearexposure, etc.2.1.14 injury, ndamage or harm caused to the structure orfunction of the human body as a result of a
19、n outside physicalagent or force.2.1.15 intermediate causes, nan underlying reason why acausal factor occurred, but it is not deep enough to be a rootcause.2.1.15.1 DiscussionIntermediate causes are underlyingcauses that link causal factors and items-of-note to root causes.2.1.16 lagging indicator,
20、nmeasure of a companys safetyperformance in the form of past incident/accident statistics.2.1.17 lessons learned, ninformation gained and sharedthrough the study of incidents that serves to help prevent thoseincidents from occurring in the future.2.1.18 leading indicator, na measure preceding or ind
21、icat-ing a future event used to drive and measure activities carriedout to prevent and control incidents/accidents.2.1.19 loss, nhuman injury, environmental damage, ornegative business impact (for example, repair or replacementcosts, schedule delays, contract violations, loss of reputation,etc.).2.1
22、.20 loss event, nundesirable consequences resultingfrom events or conditions or a combination of these.2.1.21 management system, n a methodology devisedand put in place by management to encourage desirablebehaviors and discourage undesirable behaviors.2.1.22 near-miss, na near-miss is a non-loss seq
23、uence ofevents and/or conditions/acts that could have resulted in a loss,or in an outcome with more severe consequences than actuallyoccurred. This loss was prevented only by a fortuitous orintentional break in the chain of events or conditions/acts, orboth. The potential loss could result from huma
24、n injury,environmental damage, or negative business impact (forexample, repair or replacement costs, scheduling delays, con-tract violations, loss of reputation, etc.).2.1.23 near-miss frequency (NMF), nthe total number ofnear-miss cases multiplied by 200 000 (or 1 million), dividedby the number of
25、exposure (working) hours over the past year.2.1.24 root cause, ndeficiency of a management systemcomponent that allowed the causal factors to occur or exist.Root causes must be within the control of management toaddress. For a typical causal factor, there are one to four rootcauses. Root causes are
26、usually as deep as a typical root causeanalysis will go in attempting to identify the underlying causesof an incident. Organizational culture issues, which are deeperthan root causes, could also be identified and addressed.2.1.25 root cause analysis (RCA), nan analysis by aperson(s), appropriately t
27、rained in RCA, that identifies thecausal factors, intermediate causes, and root causes of anincident and develops recommendations to address each levelof the analysis.2.1.26 safeguard, na physical, procedural or administra-tive control that prevents or mitigates consequences associatedwith an incide
28、nt.2.1.27 unsafe act/behavior, nany act/behavior of a seafar-er(s) that may adversely affect the safety of any seafarer, thevessel, the bridge, any structure, shore area, or the environ-mental quality of any port, harbor, or navigable waterway.2.2 Acronyms:2.2.1 IMOInternational Maritime Organizatio
29、n2.2.2 ISMInternational Safety Management3. Significance and Use3.1 The objective of this guide is to provide near-missreporting guidance for maritime vessels to promote standard-ization of near-miss reporting which will allow for better use ofthe data industrywide.3.2 Importance of Near-Miss Report
30、ing:3.2.1 Most accidents/incidents are preceded by a chain ofevents, circumstances, acts, or conditions. If any of theseevents, circumstances, acts, or conditions had transpired an-other way, at another time, or had been corrected, the accident/incident may have been avoided. Reporting near-misses c
31、anplay an important role in learning from mistakes, preventingaccidents, and suffering from their serious consequences.3.3 Near-miss reporting can provide information that can beused to improve most any safety system, often complementingother safety system components such as accident/incidentinvesti
32、gations, hazard analyses, safety reporting, prioritizing,root cause analysis, solution identification, communication,identifying corrective actions, sharing lessons learned, leadingsafety indicator analyses, and safety culture enhancement. Inaddition, in terms of human life and property damage, near
33、-misses are very low cost learning tools for training, preventionof re-occurrence, and a new data source on what may work tobreak the chain of events before an accident occurs. Finally,near-misses may provide key data that can prevent lowprobability-high consequence accidents by providing saferalter
34、natives.3.4 Barriers to Near-Miss Reporting:3.4.1 It is generally agreed that effective near-miss reportingcan reduce hazardous conditions and situations in theworkplace, resulting in a reduction in accidents, or at leastprovide an opportunity for hazard identification and abatement.However, there r
35、emain significant challenges and obstacles toimplementing near-miss recording/reporting systems. The bar-riers to near-miss recording/reporting can be related to theemployees and management as well as outside influences. Thebarriers to near-miss recording/reporting can lead to underre-porting in the
36、 maritime industry. Common near-miss reportingbarriers include, but are not limited to:F3256 172 Employees lack adequate near-miss training. Employ-ees must be trained to report near-misses, how to reportnear-misses, what constitutes a near-miss, and the benefits ofnear-miss reporting. Employees not
37、 being fully engaged in the developmentand operation of near-miss reporting. Employees should beinvolved in the development and implementation of near-missreporting. Employees feel their near-miss reports are not beingfollowed up on. If the reports are not actively followed up onand there is not cle
38、ar communication between ship and shore,near-miss reporting efforts will fail. Employees fear some type of reprimand or discipline.Employees must not fear any disciplinary action, peer teasing,or supervisory belittling. A means of anonymous or confiden-tial reporting should exist and a positive, no-
39、blame near-missreporting culture needs to be nurtured. Employee lack adequate motivation to report near-misses or even disincentives. Participation in near-miss report-ing cuts across all levels of an organization and managementmust fully support near-miss reporting through their words,actions, and
40、support. Management not providing unwavering support to near-miss reporting. This includes providing adequate time for theemployee to complete the near-miss report. Additionally, thisincludes any financial support or support from external experts,if necessary to correct potentially hazardous conditi
41、ons. Man-agement commitment to safety has a positive effect onreporting, while underreporting has been linked to lack ofmanagement commitment to safety. Near-miss reporting is viewed as overly time consum-ing. Near-miss reporting forms must be streamlined to be easilycompleted, easily available, eas
42、ily submitted, easily reviewed,and lessons learned easily disseminated. Management may fear legal liability or recrimination.When deciding to formalize a near-miss reporting system,organizations have both legitimate and unsubstantiated fears ofliability and recrimination. Regardless, if legislators,
43、 enforce-ment agencies, and the legal community give companieslegitimate fear of liability based on their near-miss reporting orthe fear is unfounded, the result most likely will be the same;companies will not report near-misses. Near-miss reportingmust be viewed by all stakeholders (companies, legi
44、slators,enforcement agencies, and the legal system) as one of the mosteffective ways to identify hazards and reduce accidents/incidents and not used for recrimination of any type.4. Near-Miss Standardization4.1 The maritime industry does not have a standardizeddefinition of a near-miss or near-miss
45、reporting methodology,therefore providing industry-wide lessons learned, trending,and benchmarking proves to be challenging.4.2 Near-Miss Reporting in Current Practice:4.2.1 Studies of maritime companies show a wide-range ofnear-miss reporting system maturity ranging from no system tosystems being i
46、n place for over 10 years.4.2.2 Studies of maritime companies near-miss reportingprograms and other guidance on near-miss reporting highlightthe fact that there exists varying definitions of what constitutesa near-miss and various interpretations within companies oftheir own definition.4.2.3 Based o
47、n analyses of over 100 000 maritime near-missreports, approximately 75 % of the reported near-misses arerelated to hazardous/unsafe conditions and unsafe acts andapproximately 25 % are related to a non-loss incident.Areviewof near-miss reporting practices and literature suggests that amajority of ma
48、ritime companies do capture hazardous/unsafeconditions and unsafe acts in their near-miss reports, regardlessof their near-miss definition.4.2.4 Near-miss reports across the maritime industry vary intheir data collection fields. This also creates a challenge forindustry-wide trending and benchmarkin
49、g.4.2.5 While most maritime companies that are recording/reporting near-misses use computer technology to capturenear-misses, some still use paper. One of the challenges in themaritime industry is paperwork load. The computer technologyused varies widely. Computer technology is preferred.4.2.6 Some maritime companies require near-miss quotas,while others do not. If seafarers are expected to complete aminimum number of near-miss reports in a given time,processes should be in place that prevent erroneous near-missreporting.4.2.7 Some ma
