Port safety: Near-Miss Incidents as a Wake-up Call

Navigating Port Safety Challenges

Container ports are harsh environments. Working at a terminal often requires physically demanding tasks. Many employees spend much time outdoors and are at the mercy of the weather. When container handling equipment (CHE) is involved, it is almost always a steel colossus.

The digital maritime platform RightShip, focused on Environmental, Social, and Governance (ESG) issues, reports 2,400 incidents for 2022 with a recorded location. About half of them occurred within port and terminal boundaries.

Common hazards and risks in ports

• Heavy Machinery: Collisions, falls, and crushing injuries can occur when operating cranes, reach stackers and other heavy machinery.
• Falling Objects: Containers, cargo and equipment stored at height can fall and injure personnel working below.
• Slips, Trips, and Falls: These hazards arise from uneven or slippery surfaces and obstacles on the floor.
• Manual Handling: Manual lifting, carrying and moving can cause injuries to the musculoskeletal system.
• Crushing Hazards: Workers risk becoming trapped between containers or vehicles when loading, unloading or stacking containers.
• Structural Integrity of Containers: A damaged container or those with improperly stowed cargo can collapse or tip over, posing a hazard to personnel working nearby.
• Traffic accidents: Collisions and pedestrian accidents can occur when trucks and other vehicles move onsite.
• Equipment malfunction: When machines malfunction, this can result in container drops or collisions.
• Confined Spaces: In confined spaces, such as within containers or storage facilities, suffocation, entanglement, or entrapment can occur.
• Exposure to Hazardous Materials: Containers can contain hazardous materials, and chemical exposure and contamination can happen.
• Fire and Explosion Risks: Containers may contain flammable or combustible cargo, increasing the risk of fire or explosion, especially if stored incorrectly or handled improperly.
• Electrical Hazards: Contact with electrical devices or power lines (for example, when connecting reefers) poses a risk of electric shock.
• Noise and Vibrations: Some machines produce high levels of noise and vibration, which can cause hearing loss and other health problems.
• Fatigue and Long Hours, Stress: Working long and irregular hours under pressure can cause fatigue and impair judgment, increasing the risk of accidents.
• Weather Conditions: Working outdoors exposes personnel to weather-related hazards such as extreme temperatures, high winds and lightning strikes.
• Security Risks: Container terminals are occasionally the target of theft or vandalism, posing a risk to the crew's safety.

This list clearly shows that ports are challenging settings full of dangers that can quickly become the source of an accident if mishandled. Fortunately, not every hazard results in an accident with severe consequences; some result in unsafe behaviour or incidents without injury.

Now, let's take a closer look at how hazards, near-misses and incidents correlate. As early as 1966, Frank Bird connected fatalities, accidents and near-misses based on his analysis of more than 1.5 million accidents.



What exactly is a near-miss?

To make it easier to understand, we will briefly differentiate between the individual terms:

• What is a hazard? (Also called risk, danger, threat, or peril.) Hazards are potential sources of harm to a person, property or equipment. They can be physical, chemical, biological, ergonomic or psychosocial in nature.
• What is an unsafe act? (Also called risky behaviour, dangerous action, or reckless conduct.)
  Unsafe acts are actions or behaviours that directly contribute to dangerous conditions or situations, such as not wearing personal protective equipment (PPE), disregarding safety protocols, operating equipment recklessly, or engaging in distracted behaviour while working.
• What is a near-miss? (Also called close call, almost-incident, or narrow avoidance.) A near-miss is an unplanned event that did not result in injury or damage but had the potential to do so. The point is that something happened.
• What is an incident? (Also called accident, injury, or case.) Incidents are any unforeseen events that result in injury, health damage, property damage or other loss.

Common near-misses in ports

Here are two examples to help us better imagine near-misses. Often, it's only a matter of seconds for something or nothing to happen.

Clerk almost run over: A container handler moves containers to a waiting area near the quay. The view to the front is limited by the vehicle's mast and hydraulic systems. An inspector runs from the containers in front of the handler towards a crane. At the last moment, the vehicle driver brakes, alerted by the inspector's scream.

Reefer not turned off: A reefer should be unplugged and picked up. Due to a misunderstanding, a successful unplugging was communicated. Luckily, the driver noticed that the plug had not been removed.

Port safety: Why focus on near-misses when nothing happened?

In near-misses, no one is injured, and no damage is caused. So why keep thinking about them? All good, move on, nothing to see here?

Well, the fact that the near-accident went off lightly was purely a matter of luck. And if just one parameter had been slightly different, a great misfortune might have occurred.

In principle, they are lessons—an accident that did not happen but turns out to be possible. These incidents act as a silent alarm, warning of potential dangers and providing invaluable opportunities for preventative measures. They highlight risks and vulnerabilities in the workplace that can be pointed out and often be defused.

Imagine you almost fell into an unsecured opening in broad daylight; luckily, you recognised the danger at the last moment and could hold on. You didn't fall. The following person may not be so lucky and pass the spot in lower-light conditions. They could actually fall and seriously injure themselves. When the incident is reported, it becomes clear that there is an error (unsecured opening), and remedial action can be taken. In this case, the risk no longer exists.

Port Safety: Near-miss reporting

The first step in learning from near-misses is identifying and recording them. For this purpose, staff must be trained and sensitised accordingly. In some companies, this even goes so far that employees are encouraged to report near-accidents from their private lives to raise awareness and make the topic universal.

The participation of all employees is therefore crucial. Therefore, you need to educate them about why reporting near-misses is necessary.

Unfortunately, there are barriers to reporting near-misses. These must be identified and eliminated:

Barriers to Near-Miss Reporting

Some people may be ashamed that "something so stupid" almost happened to them, but you have to disclose exactly what happened in a report like this. This applies to newcomers and old hands alike. Admitting mistakes is not easy, but it should be encouraged in the company culture.

Time restrictions. If you constantly work under time pressure, you are already demanding enough in your everyday work. It is not always laziness when immediate measures are taken but not officially recorded.

Ignorance of the contact persons. If no attention is paid to what employees report or changes are made, people will stop reporting.

"There's nothing wrong at our terminal" approach. Nobody is perfect, and there is room for improvement everywhere. If the definitions and rules are unclear, assessing what should and should not be reported is difficult. Citing real-life examples can help here. In addition to removing barriers, there are, of course, also various measures to support the reporting culture:

How to Encourage Near-Miss Reporting?

Implement a blame-free culture. Don't get tired of reinforcing that it's about learning and improving. And not about blaming or punishing anyone. You may also consider anonymous reporting to increase submissions. At least ensure that the reports are treated confidentially and that the reporter's identity is not disclosed.

Train employees to recognise and report hazards at their discretion. Employees often hesitate if they are unsure whether a report is their responsibility. So, identify responsibilities and encourage participation.

Communication is key. Maintain interest by regularly addressing the topic and presenting developments and results. Also, a good example should be set by having everyone report, including the top boss and middle management.

Near-misses are not an issue that will ever be resolved. There will always be new cases to learn from. Therefore, continuous training should be relied on for both, the existing workforce and new employees when onboarding.

How to handle a near-miss

• Report any near-miss, no matter how small or who was involved.
• Secure the scene as quickly as possible.
• Share the near-miss event with supervisors and the safety department.
• Create a near-miss report with all the details.
• Follow the investigation process and take an active part in it.
• Make your colleagues aware of the danger.

Port Safety: Analysing near-misses

Once the incidents and their details have been collected, it is time to analyse them. It's about identifying the root causes and contributing factors. Involve all relevant stakeholders in this process: employees, supervisors, safety personnel and management.

Various techniques can be used for root cause analyses, such as the "5 Whys" or fishbone diagrams. Determine systemic issues, human factors, equipment failures, procedural deficiencies, or other factors contributing to the near-misses.

The next step is to prioritise near-misses based on their significance, likelihood of recurrence, and potential safety impact. Focus on addressing the root causes and factors that pose the highest risk or have the most significant potential to prevent future incidents.

The analysis must now be used to develop specific, actionable corrective actions to address the identified threats, mitigate risks and prevent similar incidents from occurring in the future. The measures must be practical, feasible and effectively target the root causes.

In addition to setting up the measures, the responsibilities must also be clarified. Implementation must be assigned to the appropriate people and teams within the organisation. Clearly define the roles, responsibilities and timelines for implementing the measures.

Once all of this is done, the measures can be implemented. As is often the case here, communication is the key.

Applying insights from near-misses to port safety

Communicate findings from incident analysis to the entire organisation. Share lessons learned through safety meetings, toolbox talks, training, newsletters, or other communication channels, such as posters posted in strategic locations to raise awareness and promote learning.

Provide employees with ongoing training on safe work practices, including sessions to promote hazard awareness and the importance of reporting. Safety is a continuous process; use new insights to improve and sharpen existing measures. Monitor trends, analyse patterns, and identify recurring issues or areas for improvement to address potential risks proactively.

Also set up feedback loops to evaluate and measure the effectiveness of the measures implemented. Rely on qualitative feedback from your employees and quantitative feedback based on safety metrics.

Track the performance indicators, milestones, and deadlines identified for the actions. Periodically review and evaluate whether the hazards have been effectively remedied and similar incidents prevented.

The insights gained, the measures derived from them and their review must be documented and kept up to date.

Pre-Operational Safety Checks (POSC)

A POSC is an inspection of equipment, machines or vehicles, usually carried out by the operator, before they are put into operation (learn more about operator login, operator access and operator safety solutions). Its purpose is to ensure that the equipment is in safe operating condition, free of defects and ready for use. The goal is to reduce the risk of accidents, injuries and equipment failure.

During POSC, the operator follows a predefined checklist or procedure to inspect the equipment's critical components, systems, or safety features. Possible points are:

• Signs of damage and wear
• Loose and missing parts
• Fluid levels and leaks
• Proper functioning of safety mechanisms such as brakes, lights, alarms and emergency shutdown systems

Expanding the checklist with new insights gained from the near-miss analysis is a measure that can usually be carried out quickly and easily. Existing queries can also be sharpened by upgrading previously non-critical questions to critical questions. The latter means that the vehicle may not or cannot be put into operation.

The easiest way to do all of this is through an automated system. The operator is presented with the questions on a screen and carries out the inspection. Not only does this make recording and later retrieval easier, but the data is also available in real-time. This means you can react quickly and correct any deviation from the target state. In addition, automation can also prevent the vehicle from being started at all after a critical problem has been reported.

Control the vehicle's twist-lock

Incorrectly placed containers pose several risks, for example, overloading or uneven weight distribution, which can lead to structural damage to the container. This can result in bent frames and twisted corners, but also in the entire container collapsing or tipping over, which poses a danger to personnel and the vehicle.

Containers placed incorrectly or too close together can obstruct the route or visibility. Drivers sometimes have to perform dangerous driving manoeuvres or overlook obstacles and personnel on the site.

If repeated problems with incorrectly placed containers occur, a solution that controls the twist-lock device can be installed. This ensures that the container handling equipment (CHE) can only park the container at the location that the TOS has assigned to it.

Since the attempt to place the container in the wrong location is tracked, a responsible person can contact the driver to find out how the attempt came about. Was it an oversight or sloppiness that could result in another near-miss?

No more missed collisions

Container ports are complex working environments, and collisions can sometimes occur in the heat of the moment. They are often critical near-miss events. A container or other vehicle is damaged just enough that it does not currently pose a threat. However, the danger may develop at a later time, in a different location or under different conditions. For example, it is dry right now, but it starts to rain later, and water can get into a hole in the damaged container.

A shock sensor can play a crucial role in identifying and addressing near-misses by detecting sudden impacts or vibrations that could indicate potential hazards or unsafe conditions (learn more about shock management solutions).

The sensor can act as an early warning system by detecting shocks and vibrations as warning signs that can precede a near miss. In this way, worse things can be prevented in real-time.

Modern automated solutions can provide precise information about the course of events. They also have a "historical map" with which near-miss events can be played repeatedly on a monitor—on the one hand for processing and analysis, but also in safety training.

Port Safety: Understand safety as a cycle

Safety is a loop, not a one-way street. Understanding safety as an ongoing process is essential for maintaining a proactive approach to risk management.

Safety isn't a one-time task but a continuous assessment, action, and improvement loop. It involves identifying hazards, implementing controls, monitoring effectiveness, and adjusting strategies as needed. An effective security concept is a dynamic system of prevention and response.

Understanding security as a cycle also highlights the importance of continuous learning and adaptation. It is recognised that no measure is foolproof, and new threats may emerge over time. Therefore, regular assessments and refinements of practices are critical to staying ahead of evolving threats.

Embracing this mindset empowers individuals and organisations to create safer environments and reduce the likelihood of accidents or near-misses.

FAQs

Content of a Near-Miss Report

• Date and Time: The date and time when the near-miss incident occurred or was discovered.
• Location: The specific place where the near-miss occurred, including all relevant details, such as areas or zones.
• Description of near-miss: A detailed description of the event: what happened, how it happened, and the contributing factors or circumstances.
• Personnel Involved: List all people involved in the near-miss, including their roles or positions. Also, record contact details if external individuals are implicated.
• Reporting Personnel: The name and contact information of the person responsible for the reporting.
• Witnesses:  If there were any witnesses, their names and contact information should be recorded.
• Documentation: All additional documentation or evidence, e.g. photos, sketches, or equipment logs.
• Approval Signatures: Signatures of supervisor or safety officer reviewing and approving the near-miss report.

Optionally, you can also append the following points:

• Potential Consequences: An assessment of the potential consequences if the near-miss had resulted in an actual incident or accident. This could include injury to personnel, damage to property, environmental impact, etc.
• Root Causes: Analysing root causes and contributing factors helps to identify the underlying issues that need to be addressed to prevent similar events in the future.
• Recommendations for Prevention: Based on the analysis, recommendations can be provided that may include changes to processes, training, equipment, or other measures that improve port safety.

Why People Ignore Safety Rules

• They don't know about the rule
• They don't understand the rule
• They don't know why they need the rule
• They think the rule doesn't apply to them
• They disagree with the rule
• There are too many rules
• The rule takes too much time
• No one follows the rules
• You don't enforce the rule

Takeaway

Rapid growth presents port safety with constantly new challenges; Near-misses can serve as critical wake-up calls. Near-misses often occur in environments involving heavy machinery, manual handling, high traffic volumes, and exposure to hazardous materials. These near-harm incidents are valuable learning opportunities to help prevent future accidents.

Identifying and reporting near-misses is critical to improving safety measures. Therefore, hurdles such as shame, lack of time or irritating ambiguities must be overcome, and an appealing reporting culture must be developed.

The near-miss analysis identifies root causes, prioritizes risks, and establishes actionable corrective actions. The knowledge gained in this process can, for example, be used to tighten up pre-operational safety checks.

A twist-lock control system can be installed to prevent misplaced containers if there are corresponding near-miss cases. A solution to undocumented collisions is a shock sensor that records precisely when and where a crash occurred and how severe it was.

Continuous communication, training and re-evaluation of measures are essential to ensure a high port safety standard.

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