2.1 Near-miss: A sequence of events and/or conditions
that could have resulted in loss. This loss was prevented only by
a fortuitous break in the chain of events and/or conditions. The potential
loss could be human injury, environmental damage, or negative business
impact (e.g., repair or replacement costs, scheduling delays, contract
violations, loss of reputation).
2.2 Some general examples of a near-miss help
to illustrate this definition:
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.1 Any event that leads to the implementation
of an emergency procedure, plan or response and thus prevents a loss.
For example, a collision is narrowly avoided; or a crew member double
checks a valve and discovers a wrong pressure reading on the supply
side.
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.2 Any event where an unexpected condition could
lead to an adverse consequence, but which does not occur. For example,
a person moves from a location immediately before a crane unexpectedly
drops a load of cargo there; or a ship finds itself off-course in
normally shallow waters but does not ground because of an unusual
high-spring tide.
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.3 Any dangerous or hazardous situation or condition
that is not discovered until after the danger has passed. For example,
a vessel safely departs a port of call and discovers several hours
into the voyage that the ship's radio was not tuned to the Harbour
Master's radio frequency; or it is discovered that ECDIS display's
scale does not match the scale, projection, or orientation of the
chart and radar images.