1.1 Companies should investigate near-misses as
a regulatory requirement under the “Hazardous Occurrences”
part of the ISM Code. Aside from the fact that near-miss reporting
is a requirement, it also makes good business and economic sense because
it can improve vessel and crew performance and, in many cases, reduce
costs. Investigating near-misses is an integral component of continuous
improvement in safety management systems. This benefit can only be
achieved when seafarers are assured that such reporting will not result
in punitive measures. Learning the lessons from near-misses should
help to improve safety performance since near-misses can share the
same underlying causes as losses.
1.2 For a company to realize the fullest potential
benefits of near-miss reporting, seafarers and onshore employees need
to understand the definition of a near-miss to ensure that all near-misses
are reported. The company also needs to be clear about how the person
who reports the near-miss and those persons involved will be treated.
The guidance that follows suggests that the company should encourage
near-miss reporting and investigation by adopting a “just culture”
approach.
1.3 A “just culture” features an atmosphere
of responsible behaviour and trust whereby people are encouraged to
provide essential safety-related information without fear of retribution.
However, a distinction is drawn between acceptable and unacceptable
behaviour. Unacceptable behaviour will not necessarily receive a guarantee
that a person will not face consequences.
1.4 It is a crucial requirement that the company
clearly defines the circumstances in which it will guarantee a non-punitive
outcome and confidentiality. The company should provide training and
information about its approach to “just culture” near-miss
reporting and investigation for all persons involved.