1、Designation: F3256 17Standard 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 revision, the year of last revision
2、. 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 of this near-miss reporting gu
3、ide 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 into the following sections and
4、appendixes: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 purport to address all of thes
5、afety concerns, if any, associated with its use. It is theresponsibility of the user of this standard to establish appro-priate safety and health practices and determine the applica-bility of regulatory limitations prior to use.1.6 This international standard was developed in accor-dance with intern
6、ationally 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. Terminology2.1 Definitions of Terms Specific t
7、o 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 action or job that was beingperformed during the t
8、ime 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 the consequences of the incident to be worse
9、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, environmentaldamage, and breaches related to secu
10、rity.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, external events or theresult of a natural phe
11、nomenon.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,intermediate cause, or root cause.2.1.7 external fac
12、tors, 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, or death of personnel; damage to or loss ofe
13、quipment 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, harbor, or navigable waterway.2.1.10 human error
14、s, 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 approved May 1, 2017. Published July 2017. DO
15、I: 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 established in the Decision on Principles for the
16、Development 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 reasonablyresulted in, a loss event.2.1.12 in
17、cident 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, neartrapped in, near slip, near trip, near fall (same
18、 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 an outside physicalagent or force.2.1.15 interm
19、ediate 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, nmeasure of a companys safetyperformance in th
20、e 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 indicat-ing a future event used to drive and meas
21、ure 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.).2.1.20 loss event, nundesirable consequences resu
22、ltingfrom 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 sequence ofevents and/or conditions/acts that cou
23、ld 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 human injury,environmental damage, or negative bus
24、iness 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 exposure (working) hours over the past year.2.
25、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 usually as deep as a typical root causeanalysi
26、s 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 trained in RCA, that identifies thecausal facto
27、rs, 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 incident.2.1.27 unsafe act/behavior, nany act/behavi
28、or 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 Organization2.2.2 ISMInternational Safety Management3. Si
29、gnificance 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 Reporting:3.2.1 Most accidents/incidents are precede
30、d 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 canplay an important role in learning from mist
31、akes, 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/incidentinvestigations, hazard analyses, safety reporting, pr
32、ioritizing,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-misses are very low cost learning tools for t
33、raining, 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 saferalternatives.3.4 Barriers to Near-Miss Reporting:3.
34、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 remain significant challenges and obstacles toi
35、mplementing 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 maritime industry. Common near-miss reporting
36、barriers 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 being fully engaged in the developmentand ope
37、ration 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 clear communication between ship and shore,near-m
38、iss 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-blame near-missreporting culture needs to be n
39、urtured. 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 support. Management not providing unwavering s
40、upport 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 conditions. Man-agement commitment to safety has a po
41、sitive 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, easily submitted, easily reviewed,and lessons lea
42、rned 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, enforce-ment agencies, and the legal communit
43、y 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, legislators,enforcement agencies, and the legal sy
44、stem) 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 reporting methodology,therefore providing indu
45、stry-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 in place for over 10 years.4.2.2 Studies of mar
46、itime 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 on analyses of over 100 000 maritime near-missr
47、eports, 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 maritime companies do capture hazardous/unsafeco
48、nditions 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 benchmarking.4.2.5 While most maritime companies that are
49、 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 maritime companies normalize their near-missdata based on
