Loss-Prevention-Bulletin-Vol.35-Light_3 (1)

Near Miss and Potential
Chapter 7
Accident Reports
In terms of prevention, near miss and potential accident reports are an effective means of understanding the root
causes of accidents before they occur.
Behind one major accident or disaster is said to lie

29 minor accidents or disasters, and a further 300
potential accidents.
In order to prevent a major accident or disaster it

is necessary to deal with problems in the potential
accident stage at which they can be predicted.
Heinrich’s law
Simulation such as risk prediction training, and
providing simulated risk experience in training
facilities etc. is considered as an effective method
of accident prevention.
Summarized as follows.
Disasters are eliminated

Important if accidents are prevented
Elimination of unsafe behavior
and unsafe situations eliminates
accidents and disasters.
(safety checks and maintenance in the workplace en-
vironment, in particular in reference to appropriate em-
ployment, training, and monitoring of personnel, and the
related responsibility of managers)
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A large number of companies have introduced the potential accident report system, however the frequent complaint
from managers in the shore-based management division is that ‘we can’t get the reports’. The following must be
considered in order to use potential accident reports effectively.
The basic data for the potential accident report is a report from the site
(the vessel and the navigation management division). The report is there-
fore prepared by personnel on-site, and it is those personnel in which
improved awareness is required. The captain and chief engineer, and the
company, must take the lead in the awareness program.
It is also important that not only ‘potential accident items’, but also
improvement measures etc., are reported.
Making a tabulation and analysis of the potential accident report have

to be done periodically. The presented potential accident reports must
be classified every 3 - 6 months, and the time zones for occurrence and
preventative measures to be summarized.
If measures to prevent reoccurrence, and improvement measures, are

proposed for each report and summarized monthly in table format, they
can be used as attachments to the analysis results described above. It is
important to use the preliminary figures as feedback for the vessel.
It is important that tabulation and analysis results are taken up as topics

by the safety conference etc.
The name of the vessel and the name of the person preparing the report must not be disclosed, and care is required to
maintain anonymity.
Feedback to the person reporting, and to the vessel in question, must be provided with thanks for the submission of the
report, and measures to prevent reoccurrence, and handled confidentially. These measures increase the motivation of
the person reporting, and are linked to submission of the next report.
Furthermore, one proposal is to award each person reporting and each site (the vessel and the navigation management
division) in accordance with details and number of reports at safety conferences etc.
Conversely, unless these measures are taken, the person reporting is unsure as to how his/her potential accident report
has been taken up by the company, and the number of reports will diminish.
In addition to potential accident reports, introduction of an improvement submissions system etc. is linked to raising
motivation on-site.
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Chapter 8 Conclusion
The author is confident that readers have understood that

management with BRM and ERM are effective in achieving
safety in operation.
However, in comparison with the difference in technical level

between aircraft pilots and co-pilots, that of between captains
and navigators, or between chief engineers and engineers, is
considerable. The question of how to cultivate inexperienced
navigators and engineers to the levels expected of captains and
chief engineers is a topic for future discussion.
Furthermore, modern vessels are manned by a combination of

different nationalities, and BRM and ERM management must also apply to non-Japanese navigators, engineers, and
crews. In other words, BRM and ERM management must also be considered with diversity in characteristics, culture,
and customs.
In the case of aircraft, landing and takeoff are associated with the most tension being concentrated into a period of ap-
proximately 11 minutes, referred to as the ‘critical eleven’. For shipping, coastal voyages and passage through narrow
channels, arriving and departing the pier, loading and unloading, various vessel inspections, looking after customers,
and repairs, makes for continued tension within the context of the increasingly diverse crews employed. This work
may justifiably be termed critical week (month).
Under these conditions, using OJT as the means for education of inexperienced navigators and engineers may place
too greater burden on the captain and chief engineer.
In this context, the large number of frameworks in the SMS manual and safety management regula-
tions have led to an increase in the volume of reports and document management work which is, with-
out exaggeration, by a factor of anything from a few to a few tens over the former level. Furthermore,
such regulations as ballast water management and the use of low sulfur fuel, and vessel inspections
such as PSC, have increased.
Approximately 20 years have passed since introduction of the SMS manual. Almost ten years has passed since intro-
duction of safety management regulations for coastal vessels. These may be essential tools for safe operation, however
if the same accident occurs again, and we consider that they have not served to eliminate the accident, it may be time
to consider revising SMS and safety management regulations documentation control and preparation of reports and
reduce the load on site personnel.
54
Reference materials
Provided by Maritime Human Resource Institute:

* Engine Room Resource Management
* Above on DVD
ࠉࠉࠉࠉ㸦http://www.maritime-forum.jp/en/index.php㸧
Japan Captains Association:

* Educational lectures
No.75 Human Error from the Point of View of Psychology
No.77 BRM
No.80 Safety in a Proud Occupation – Why is BRM necessary?
No.81 Eliminating Accidents Caused by Human Factors
Skills of Individuals Supporting BRM – Improving the Skills of Inexperienced Navigators (DVD)
Nihon VM Centre : Anzen no Komado

(http://www.maroon.dti.ne.jp/nvmc/komadobkNo.html)
P&P Network: Meaning and Objectives of OJT

(http://www.d1.dion.ne.jp/~ppnet/prod06150.htm)
Seizando Shoten: Bridge Resource Management
Maritime Accident Inquiry Tribunal:

(http://www.mlit.go.jp/jmat/saiketsu/saiketsu_kako/04saiketsu.htm)
Transport Safety Board Report

(http://jtsb.mlit.go.jp/jtsb/ship/)
55
56
57
CPA Mor than 2.0 miles
Distance in front More than 5.0 miles
Observe fishing group in front

Remarkable change of weather and sea condition
Use a whistle
Use a Main Engine
Call Captain
Have a good watch

C/Off 2/Off 3/Off
AB-A AB-B AB-C
58

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Near Miss and Potential

Behind one major accident or disaster is said to lie

In order to prevent a major accident or disaster it

Disasters are eliminated

Making a tabulation and analysis of the potential accident report have

If measures to prevent reoccurrence, and improvement measures, are

It is important that tabulation and analysis results are taken up as topics

The author is confident that readers have understood that

However, in comparison with the difference in technical level

Furthermore, modern vessels are manned by a combination of

Provided by Maritime Human Resource Institute:

Japan Captains Association:

Nihon VM Centre : Anzen no Komado

P&P Network: Meaning and Objectives of OJT

Seizando Shoten: Bridge Resource Management

Maritime Accident Inquiry Tribunal:

Transport Safety Board Report

Observe fishing group in front

Have a good watch

AB-A AB-B AB-C

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