Chapter 7

Near Miss and Potential
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.

7-1 Near Miss and Potential Accident Reports
Behind one major accident or disaster is said to lie
29 minor accidents or disasters, and a further 300
potential accidents.

Heinrich's law

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.

1 major accident

Heinrich’s law
Simulation such as risk prediction training, andproviding simulated risk experience in training
facilities etc. is considered as an effective methodof accident prevention.
Summarized as follows.

！

Important

29 minor accidents
300 potential accidents

Disasters are eliminatedif accidents are prevented
Elimination of unsafe behavior
and unsafe situations eliminates
accidents and disasters.
(safety checks and maintenance in the workplace environment, in particular in reference to appropriate employment, training, and monitoring of personnel, and therelated responsibility of managers)− 52 −

* 7-2 Potential Accident Reports in Practice
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.

123The basic data for the potential accident report is a report from the site(the vessel and the navigation management division). The report is therefore prepared by personnel on-site, and it is those personnel in which
improved awareness is required. The captain and chief engineer, and thecompany, 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 haveto be done periodically. The presented potential accident reports must
be classified every 3 - 6 months, and the time zones for occurrence andpreventative measures to be summarized.

If measures to prevent reoccurrence, and improvement measures, areproposed 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.

4 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 tomaintain anonymity.
Feedback to the person reporting, and to the vessel in question, must be provided with thanks for the submission of thereport, 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 managementdivision) 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 reporthas 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.
− 53 −

Chapter 8Conclusion

The author is confident that readers have understood thatmanagement 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, isconsiderable. The question of how to cultivate inexperienced
navigators and engineers to the levels expected of captains andchief engineers is a topic for future discussion.
Furthermore, modern vessels are manned by a combination ofdifferent nationalities, and BRM and ERM management must also apply to non-Japanese navigators, engineers, andcrews. 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 approximately 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 regulations have led to an increase in the volume of reports and document management work which is, without 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 introduction 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 andreduce the load on site personnel.

− 54 −

Reference materials
Provided by Maritime Human Resource Institute:* Engine Room Resource Management* Above on DVDࠉࠉࠉࠉ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 −

03:40

-1.7

Brothers Lt Ho

ESE

00:17

0:03

W/L 3.0(Tr.3/O, 2/O)

□ VTIS Report

06:54

09:36
1.0

<120>

10:57

<200>

10:57

2.8

-0.5

0:23

▶▶▶
0:33

▶▶▶

21:27

<066>4.9⑥ Buﬀalo Rk

-1.5

15:29

<245>

02:45

+1.0

06:47

Baﬀalo Rock
<065>

16.5

0:24

(72 RPM)<049>4.9
23:34

0:17

22:17

06:54

<238>

12:34

15:34

-0.9

+4.8

Batu Berhanti
<058>

-0.7

17:27
-1.7

-0.7

19:07

Master of S.S. XXXX
Capt. Takuzo OKADA<236>

14:2511:00<056>

Horsburgh□ Steering Single

0050hrs 〜 Level - 1

0:10

Watch same way, crossing vessels and ﬁshing boats.

0:18＊ Watch departing/arriving vessels, check VTis
information

1.0<049>523:51□ VTIS Report

Level-1.5

R/up eng. and Start increasing rpm

1:42

Horsburgh L't H▶▶▶ ⑨ Horsburgh L't H ▶▶▶ ⑩ Clear Out SPR St

16.5 72 RPM PlanCaution
Same way andCrossing Vsls

Pu Mungging

Horsburgh LH
R/Up Eng.

□ Passing Singapore Report to ECR, CCR

21:51

<082>

<066>28.1▶▶▶ ⑧ Pu Mungging@sp'd

23:34 HoursPu Mungging
Watch Level 2Caution
OPL Vsls▶▶▶ ⑦ B.Berhanti@sp'd★ Pirates Counter 1800hrs/26th Aug. - 0700 hrs/27th Aug.
Measure Disch. Sea Water.

＊ Check ship's position Caution other vessels＊ Passing Deep Draft Channel

20:54

<056>

<040>6.6⑤ Takong Kecil(48 RPM)age

Phillip Channel

14:30

21:07

<060>4.6
20:31<026> 07:43

18:32

12.0

1.2

Brothers Lt Ho

<300>

0712

20:54 Hours
Takong Kechil(Phillip Channel)

1938▶▶▶ ④ Racon "D"@sp'dSun Set

Sun RiseReduce RPM depend on situation

20:28<090>0.6③ Racon "D"

Racon "D"P.M. 25th Aug 〜 AM. 28th Aug
1930 ｈ rs 〜 2300hrs 27th Aug.
Depending on Traﬃc

W/L 2.0

Takong Kechil★ Lock Entrance/ light up on poopdeck / water injection★ A.B. Double Watch★ Call Capt. 30' to TSS Ent.

One Fathom Bank

WNWStart Reduce□ VTIS Report

1:08

19:30

S/B Eng.

<121>18.8

19:20

▶▶▶

CautionDep./Arr. Vsls
B.Berhanti

C/E

C/E

21:51 Hours

Buﬀalo Rk

T3/O

T3/O

Passing Day Time

3/O

3/O

Batu Berhanti L't H
Oﬀ Singapore
Start increasing RPMWatch leaving/entering vessels for anchorage

1:49▶▶▶ ② Brothers L't H

2/O

2/O

21:27 Hours

Caution Small Vsls
Sameway Vsls

16.5 (70 RPM)

11.95

10.95

1/O

1/O

Buﬀalo RockPasir Panjang

C/O

C/O

Singapore

Capt

De-brief ing
28th Aug 081140 〜□ Check Navigational equipment□ Report to VTiS

19:05 〜 W/L 1.5

17:30<131>30① Call Capt.

Tidal Current Information

Remarks

Watch Level

Eng. Motion

Actual Time

ETPassTime Req.

Co./Dist.

Point

@sp'd

dF

(72 RPM)dA@sp'd 16.5

27th Aug 08

20:31 Hours
Racon "D"
Reduce RPMCaution
Crossing Ships

Voy. No. 98 Laden

Brothers L't H

Tg Pelepas

19:20 HoursBrothers L't H
S/B Eng. .
19:30 Watch Level 2.0
Start Reduce

17:30 Hours
Call Capt.
17:30 Hours
Watch Level 1.5

Capt

Brief ing Capt
26th Aug 08
1300 〜

00:10 Hours

1 day before at Bridge

S.S. "XXXX" Passage Plan for Malacca & Singapore Strait （East Bound)

Singapore Straits Passage Plan = BRM Brieﬁng =Appendix ① Singapore Straits Passage Plan - BRM Brieﬁng Materials (Sample)

Appendix ②−１

Standing Order and Night Order Log（Sample）
xxth XXXXXX, 20XX

MASTER'S STANDING ORDER
This is master's standing order during the time I command the vessel M.V. "ABC'' and I do expect all OOW tomaintain safe navigation.

1. Be proud of Your Duty
There are many lives on board M.V. "ABC'' and the vessel carries an enormous sum of cargoes from manycustomers.
Value of cargoes are too high and the inﬂuences of damage to cargoes or late arrival of cargoes caused by accident
are too much to estimate.
This means you have so much important responsibilities with safe lives and cargoes on board the vessel on behalfof Master during you are on navigational watch and you can be proud of your important duty.

2. Avoid Any Navigational Accident
Study International COLREG well and other rules of navigation and consult SMS Manual and so on continuously
to make use of avoiding any navigational accident.
1

When in Ocean, give all other vessels ample room;
More than 2.0 miles of CPA and 5 miles clearance in front.

2

When in Coastal cruising, give all other vessels ample room;
At least 1 mile of CPA and 2 miles clearance in front.

3

It is highly recommended to alter her course before the distance between the ship becomes lessthan 6- 8 miles.

3. Do Call Me at Anytime and Well Ahead of Time
Call me at anytime and well ahead of time when you encounter situations Mentioned below and instructed by
SMS Manual or Master's night order.
＊ Visibility less than 3 miles.
＊ Heavy traﬃc or group of ﬁshing boats.
＊ Ship's position in doubt.
＊ Remarkable change of weather and sea condition.
＊ Diﬃculties in maneuvering the vessel.
In addition to the above, Call me when you ﬁnd anything unusual or any sign of Trouble.

4. Pay Keen attention to All Aspects to catch any sign of trouble all the time.
5. Keep a Sharp Lookout All the Time when on Watch.
Keep good, Sharp and Continuous look out using all available means regardless of weather and other situation.
Secure at least one person always who gives exclusive attention to look-out.

6. Read this Master's Standing Order before your duty in every time.
C/Oﬀ.

2/Oﬀ.

3/Oﬀ.

M/V "ABC"− 57 −

Capt. Takuzo OKADA

Appendix ②− 2Standing Order and Night Order Log（Sample）

Date : xxth XXXXX, 20XX

From Yokohama
G.Co <220>

to Singapore
Mg. Co<225>

1. Keep a Sharp Lookout continuously with all available means

2. Give a wide room to all passing vessels and other boats

3. Keep a following CPA and Distance to all passing vessels
CPAMor than 2.0 miles

Distance in front

More than 5.0 miles

4. Call me at any time Visibility less than 3 miles
Observe fishing group in front
Remarkable change of weather and sea condition

5. Do not hesitate;
Use a whistle
Use a Main Engine
Call Captain

6. Follow the Master's Standing Order and SMS manual strictly (Signiture)
Have a good watch
C/Off

2/Off

3/Off

AB-A

AB-B

AB-C

Master of M/V"ABC" Capt. Takuzo OKADA− 58 −