From Wikipedia, the free encyclopedia
A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage. Although human error is commonly an initiating event, a faulty process or system invariably permits or compounds the harm, and should be the focus of improvement. Other familiar terms for these events is a “close call”, or in the case of moving objects, “near collision”. Indeed, the term “near collision” is less contradictory in nature than “near miss”, since a “near miss” would be a hit that almost missed (a glancing blow) versus a miss that almost hit.
You don’t need to be a “Monty Python” fan to see how absurd it could get if you had to submit a report every time someone got too close for comfort while underway. The “near miss” is a different animal than one might think. Although the idea is not well received by our community because it seems too broad, the point of this practice is to assist in identifying the flaws that reside within the best-laid plans. It has to be something you can put your finger on as the reason it almost failed but didn’t because that one small thing saved the day.
One of the comments I received on my article regarding using sea stories as training aids was linked to a site promoting its Root Cause Software and protocol. This site posed the question “Can tugboat accidents be prevented?” If you’re referring to procedures and professional guidelines for critical operations, I would answer that yes its possible to reduce the number of accidents but I would quickly add it’s not in our power to always address, identify, or remove one of the largest “unknowns” in our workplace, the recreational boater.
If you’re talking about rough water transits or high wind restrictions, these issues can be easily and clearly addressed. If you’re focused on keeping a proper lookout during certain evolutions putting a barge on or off a towline, yes. Avoiding the speeding pleasure boat off the port bow that just now decided to cross to starboard under your bow at a distance of 25 feet no, not without a trigger happy gun crew.
What’s the difference between a near miss and close call as described by the ISM Code? Realistically, they are one and the same . The deciding factor in documenting a true “near miss situation” is that there’s an identifiable thing that broke the chain of events that nearly led to a real disaster.
The following incident is by definition a “close call” and a “near miss”;
I was pushing a loaded oil barge northbound on the Hudson River drawing 16′ and making about 8 knots over the bottom with a fair current approaching the Port Ewen anchorage just south of Roundout Creek, Kingston NY. A few southbound units were in the Kingston reach north of Kingston Point and rather than meet them there, I’d decided to take it easy and wait as best I could below the point.
A small yawl was luffing along northbound on the western side of the river and was more or less out of the way. I warned the south bound traffic by radio of his proximity to the channel edge and figured he would stay clear until all the larger traffic had cleared. Rather than exercise that bit of good judgment he decided to tack and catch what little breeze there was to cross to the eastern side of the river RIGHT IN FRONT OF ME and my 8 knot, 400′ push tow. I nearly rattled the fillings out of my teeth as I slammed the throttles to the stops ordering full astern and sounding the danger signal until I thought I’d run out of compressed air. It was going to be an exercise in futility since I was bearing down on this yawl with little chance of stopping or having a way out.
I dispatched the deckhand forward with a radio and instructions to keep track of any survivors that may surface. I could only see the top of his mast as he reached the middle of the bow, I just knew he was going to be raked under by the chain bridles. The deckhand was yelling for him to get out of the way or jump or anything, and the guy replies “I can’t”. He then turned around, reached for and pulled the rope starter on his little 2 cylinder kicker which started on the first pull. He cranked the throttle in time to clear with moments to spare.
By now the mate and I are staring in disbelief wondering how we missed him. I asked the deckhand how in Hell did he get away and he told us how the kicker started with one pull. I had to ask if he got the name of the motor figuring I’d buy stock in the company that just saved this idiot’s life. In just 15 seconds, this guy went from being a happily oblivious sailor to a sailor nearly committed to oblivion.
[“Only a fortunate break in the chain of events prevented an injury, fatality or damage.”] The outboard motor started on the first pull.
One small factor changed the entire situation from a likely disaster to a very close call/near miss. That one small thing is what we can identify from our perspective, as the reason he escaped unharmed. We can deduce the root cause as his lack of situational awareness, either from being on the phone, or his dog jumped over the side since his leash wasn’t secured, or that he fell asleep. In hindsight that list could be endless and in any event out of our control.
Limiting Risk with Education
Towing a barge on a full sea hawser is a common practice that frequently passes unrecognized by the recreational boating public. A boating season doesn’t go by without some *P.D.B. crossing a towline or getting hit by a tow since they didn’t understand the relationship between the tug and barge. Ask any tugboatman how often he’s worried about boats nearby crossing the “wire” and the answer will likely be, “always”. Ask his opinion as to what can be done to prevent it and it’s almost certain his reply would be to insist that boater education and licensing be required for the entire boating community. A higher level of awareness comes with the proper education and an enforced responsibility for your own actions The chain of failure is broken when the small boat is aware of the relationship ahead and turns away from the towline hopefully in time. Yes I know, its the same old tune.
Years ago I was asked if I could offer some input on a Comprehensive Tug Operations Manual that could be a reference for all the operational considerations applying to the profession. My answer was “you don’t have enough paper“. It’s impossible to proscribe all of the many bad things that might happen with a “book answer” much less quantify everything that can or can’t be done.
The “book” answer for the commercial community is maintain the proper and lawful lookout conditions and safe speed while underway to avoid small recreational boat encounters. The problem with this becomes apparent when you add the recreational boater to the mix X 100. The photo of my radar screen at the top of this article shows at least 60 targets of various concern, fully half of them are a threat to my vessel. Ask “How do I avoid this?”, and the short answer is “you can’t”. If you need to move the boat from one place to another this is what you must deal with.
It doesn’t matter if it’s on a “Long Island Sound Sunday” or approaching Ambrose Entrance in a late afternoon haze, or my favorite, “deep draft” sailboats in Hell Gate or the Cape Cod Canal. We all have stories of maneuvering through a swarm of small boats on a busy summer weekend. The documentation of these events as “near misses” would be a Sisyphean task that would do little more than convince my employer that given all our exposures to peril, perhaps selling shoes might have been the better career choice after all.
We regularly pilot our vessels through crowded and congested waters giving due regard to the ignorant as well as the informed boaters we meet. The ability to do this is an art as much as a science and the fact that we must be a bit psychic to survive this exercise easily makes this one of the most stressful things that a watch officer can face. The only way you can get through it is to successfully predict where Joe Weekender is headed.
In fairness there are a few of these operators that understand where they are and what we’re dealing with, their efforts to accommodate our needs are appreciated but the vast majority are still ignorant of the limitations of commercial traffic in close quarters and the issues we face even after some very high profile accidents involving pleasure boats.
The professional community knows that when you’re talking about New York Harbor after the fireworks on the Fourth of July, no large commercial vessel will be getting underway if they can help it, at least and not until after the small boat traffic has had the chance to run for home and out of the way.
A common problem that is simple to identify is the amateur in the $50,000 boat with a $500.00 reel trying to catch a 25 cent fish while anchored in mid channel. On a nice day we can anticipate that he will be there and hope the channel allows some wiggle room or that he’s listening to his VHF radio and we can convince him in time to pick a slightly less obstructive fishing spot. It’s almost never that easy.
The State of Alabama (according to the NTSB) is the only state in the union that requires a license to operate a pleasure boat. A few other states comply with some measure of permits and education for minors. I’m not alone in thinking that their efforts are incomplete. The boating public frequently forgets their lives are on the line every time they set sail. If they were required a formal license with all the responsibility that comes with it the “blissful oblivion factor” may diminish.
There aren’t that many boating safety courses available to the general public that set any real standard for knowledge or skill. Generally, it’s show up with a pulse and you’ll get the certificate. Why do you need a license to drive a car but no such credential is necessary for a boat? You have brakes and the ability to stop in a car, boats the last time I checked are not so equipped. And unless you’re prone to driving through flood waters, cars don’t sink out from under you. Okay, I see your eyes glazing over again….
Near misses are studied as a means to mitigate the “dangerous but avoidable” situations we encounter or identify the flaw in an established plan in order to find the weakest link in the chain of failure and break it before things go wrong. I think breaking the “under-educated recreational boater link ” would easily improve the marine community for all.
Our desire to eliminate error in our day to day operations is an important practice which continues. We are well aware that we won’t get an error free environment but we can strive for the last few percentage points anyway. A more focused and complete curriculum for licensing pleasure boat owner/operators should be a primary issue for the entire country and would lead to a safer marine community all around. One more point of failure we could remove. How many pleasure boat accidents point to a poorly educated operator as the root cause? Try this one.
My skin still crawls every time I read this story as it could just as easily been me and my crew on Long Island Sound that night.