Reporting non-conformities, accidents and near misses
1The lesson in plain words
The SMS learns only from what is reported. Report non-conformities, accidents and near misses, find the root cause and fix it.
What must be reported
The SMS must have procedures to report non-conformities, accidents and hazardous occurrences to the company. Hazardous occurrences are events that could have caused harm. Reports must be investigated and analysed, so that safety and pollution prevention improve. The company sets procedures to put corrective action in place, including measures to stop it happening again.
Three findings
An observation is a statement of fact made during an audit and supported by objective evidence. It is not automatically a non-conformity: evidence must show a specified requirement is unmet. A non-conformity (NC) means that evidence exists. A major non-conformity is a serious threat needing immediate corrective action, or a lack of effective, systematic implementation of an ISM requirement. External audit handling is in Ship business.
Near misses
A near miss is a sequence of events or conditions that could have caused a loss, such as injury, pollution or damage, but did not, only because the chain was broken by chance. The IMO guidance on near-miss reporting, MSC-MEPC.7/Circ.7, asks companies to encourage these reports. They are free lessons: the same causes, next time, may not be stopped by luck.
Just culture
People report only when they trust the system. A just culture means honest errors are not punished, while reckless acts and deliberate violations are not tolerated. Reports should be easy to make, may be anonymous, and should be answered. Feedback is essential: tell the crew what changed because of their report.
Root cause and corrective action
Corrective action removes the cause of an NC that has happened. Preventive action removes the cause of a possible one. Ask why several times until you reach the root cause, such as an unclear procedure, a missing tool or workload, not just the person who made the error. Agree who acts and by when, then check later that the fix worked.
2Step by step
Handling a near miss on board
- 1
Make the situation safe and stop the work if needed.
The hazard that nearly caused harm may still be there.
- 2
Notify the officer in charge and company through the SMS; record the initial facts.
Unrecorded events cannot be analysed or shared.
- 3
Collect facts: time, place, people, conditions, photos.
Memories fade fast; evidence supports a fair analysis.
- 4
Find the root cause with the people involved.
Blaming one person rarely fixes an unclear procedure or design.
- 5
Agree corrective and preventive actions with owners and dates.
An action without an owner and a deadline is seldom done.
- 6
Share findings and feedback with the crew and company; check that actions work.
Other ships learn from it, and you confirm the fix works.
3Key data
- Near-miss guidance
- MSC-MEPC.7/Circ.7 (IMO, 2008)
- Non-conformity
- Objective evidence that a specified requirement is not met
- Major NC
- Serious threat needing action now, or ISM not systematically applied
- Observation
- Evidence-backed statement of fact recorded during an SMS audit
4Key points
- 1
Report non-conformities, accidents and hazardous occurrences to the company.
- 2
A near miss is a loss avoided only by chance; report it.
- 3
A major NC is a serious threat needing immediate action.
- 4
Just culture: honest errors are not punished; reckless acts are not tolerated.
- 5
Fix the root cause, then check that the action worked.
5Frequent mistakes
Wrong: Nobody was hurt, so there is nothing to report.
Right: No injury does not mean no loss. Report any damage or pollution too. A near miss could have caused harm but did not; report it so the causes can be addressed.
Wrong: The corrective action is to warn the person who made the error.
Right: Look for the root cause, such as an unclear procedure, a missing tool or a design fault, and fix that.
6Practice case & exam keys
During mooring, a rope parts under load. The snap-back hits the bulwark where an AB had been standing seconds earlier. Nobody is hurt. The bosun says to splice a new eye and carry on. What do you do?
Show the answer
Stop the operation and make the station safe. Report the rope failure and narrowly avoided injury through the SMS. Keep the parted rope and record the facts: load, rope age, lead and positions of the crew. Check rope condition, leads and crew positions, then establish why inspection, replacement or mooring-planning safeguards failed. Agree actions, inform the company and brief all mooring teams.
Exam keys
- ISM section 9: report and analyse non-conformities, accidents and hazardous occurrences.
- Observation, non-conformity and major non-conformity defined.
- Near miss: loss prevented only by chance; MSC-MEPC.7/Circ.7.
- Corrective action removes the cause; preventive action removes a potential cause.
Finish this unit
When you've read it, answer three questions. Get all three right to finish the unit; opening the page alone doesn't count.
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