Near Miss Incidents in Maritime Operations
Near-Miss Case 1 – Unsafe Conditions During Boat Transfer
Near-Miss Description
During a boat transfer from a cargo vessel to shore, a small boat that was not suitable for the size of the vessel was used despite rough and windy weather conditions. At the final step of the pilot ladder, the individual’s foot level was aligned with the upper structure of the boat; nevertheless, an instruction was given to jump into the boat from an approximate height of 2 meters. At that moment, an incoming wave created a risk of being crushed between the vessel and the boat. The individual refused the unsafe instruction, returned to the vessel, and the situation was narrowly avoided without turning into an accident.
Evaluation
This near-miss incident demonstrates how risks in marine personnel transfers can rapidly escalate to a critical level when environmental conditions, equipment suitability, and human factors are not evaluated together. Conducting a transfer from a large-tonnage vessel to a small boat with insufficient stability in rough seas significantly increases the risk of falling and crushing injuries. The approximately 2-meter height difference clearly indicates that safe transfer limits were exceeded.
The instruction to jump into the boat was incompatible with safe working principles and posed a serious risk of severe injury or fatality. Sudden distance changes between the vessel and the boat due to wave action further amplified this risk. The incident highlights that weather and sea conditions were not adequately assessed prior to the transfer and that appropriate equipment selection was not made. The individual’s decision to refuse the unsafe instruction was a vital safety behavior that prevented an accident. This case clearly demonstrates that proper boat selection, careful consideration of environmental conditions, and near-miss reporting are essential learning tools for preventing similar incidents in the future.
Near-Miss Case 2 – Uncontrolled Collapse of a Scaffolding Component
Near-Miss Description
During a renewal survey conducted at a shipyard, a loud metallic sound was heard as a field inspection was ongoing. Upon observation, it was noted that a vertical component of a scaffold—believed to have been installed for welding reinforcement works—rotated around its horizontal connection point and fell to the ground in an uncontrolled manner. As the inspection team was positioned at a safe distance, no contact or injury occurred, and the incident was classified as a near-miss.
Evaluation
This near-miss highlights the critical importance of stability in temporary scaffolding and structures used in shipyard environments. The fallen scaffold component was not secured to the ground and was supported only by a single connection point, leaving it vulnerable to external impacts and vibrations. In areas where multiple activities are carried out simultaneously, particularly those involving mobile equipment, risks can easily interact and escalate.
Although personnel were observed to be using appropriate personal protective equipment and had received safety training, such measures alone cannot eliminate the risk of serious injury or fatality resulting from the collapse of a structural component. This case demonstrates that temporary scaffolding must be evaluated not only based on its intended use, but also considering all surrounding activities and interactions within the work area. Proper fixation of scaffolding, holistic risk assessment in multi-activity environments, and the early identification of hidden hazards through near-miss reporting play a vital role in preventing accidents.
Near-Miss Case 3 – Excessive Deflection and Dynamic Load Risk on Gangway
Near-Miss Description
During a survey access operation to a vessel in service at a shipyard, a significant safety risk was identified on the gangway used for boarding. During normal passage, the gangway was observed to exhibit noticeable deflection due to its long span. Although the Safe Working Load (SWL) was indicated as 450 kg / 6 persons, this capacity was assessed as unsafe when considering the actual span length and operating conditions. When multiple persons crossed simultaneously, noticeable vibration and resonance occurred, increasing the level of deflection. The combination of dynamic loads generated by walking and the relative movement between the vessel and the quay created a serious accident potential, and the situation was classified as a near-miss.
Evaluation
This near-miss incident demonstrates that temporary access equipment such as gangways cannot be considered safe based solely on static load ratings. In long-span configurations, dynamic loads caused by pedestrian movement and relative vessel–quay motion can render theoretically adequate SWL values unsafe in practice. Simultaneous passage by multiple persons further amplifies vibration and resonance effects, weakening structural stability.
The incident highlights the need for gangway capacity information to be reassessed for each installation, taking into account span length, connection points, and expected dynamic effects. The absence of limits on the number of persons using the gangway and insufficient site control can allow risks to escalate unnoticed. Pre-use visual and structural inspections of gangways, consideration of dynamic loading effects, and early identification of such vulnerabilities through near-miss reporting play a critical role in preventing serious accidents.
Near-Miss Case 4 – Multiple Risks Arising from Temporary Arrangements in a Shipyard
Near-Miss Description
During newbuilding survey activities at a shipyard, several unsafe conditions were identified during field inspections. It was observed that the occupational health and safety officer was present on site and that corrective actions were implemented promptly following the reporting of the risks. The unsafe conditions included a manhole gasket placed over an open pit, a broken temporary wooden cover used to protect cables in front of an electrical panel, and a cleaning trolley left at the top of a stairway. These conditions created risks of tripping and falling; once identified, the relevant items were removed and the area was made safe. The situations were collectively evaluated as a near-miss.
Evaluation
This near-miss demonstrates how temporary arrangements and poorly organized equipment in shipyard environments can quickly develop into serious hazards. Covering high-risk areas with temporary materials can create a misleading perception of safety, posing significant danger to workers and visitors. Likewise, temporary protections with insufficient strength may introduce new risks instead of reducing existing ones.
The presence of unsecured equipment in stairways and access routes is particularly misleading for personnel unfamiliar with the site and significantly increases the risk of falls. This case shows that conditions which may appear minor when considered individually can substantially increase injury potential when combined. On a positive note, the rapid identification and correction of the risks highlight the critical role of effective site communication and feedback in accident prevention. This near-miss clearly demonstrates that even temporary solutions in shipyard environments must be planned, robust, and controlled to support a strong safety culture.
Near-Miss Case 5 – Disabling of Wheel Locks on a Mobile Ladder
Near-Miss Description
During a condition assessment survey conducted at a shipyard, a serious safety risk was encountered involving a mobile (wheeled) ladder used for boarding a vessel. While the survey was ongoing, the ladder was accessed without noticing that its wheel locks had been disengaged. As soon as weight was applied, the ladder moved, creating a risk of falling. The situation was narrowly avoided without injury and was reported to site management.
Evaluation
This near-miss illustrates how disabling basic safety features on mobile access equipment can quickly lead to serious accidents. Wheel locks are critical components that ensure ladder stability, and when disengaged, the ladder becomes uncontrolled and hazardous.
The fact that the ladder’s locks were released during an ongoing survey indicates insufficient coordination between equipment use and site activities. Equipment that may be considered temporarily safe by one person can pose a serious hazard to another user. This case demonstrates that even “short-term” or seemingly minor interventions can carry significant risk. In shipyard and industrial environments, mobile ladders must be checked for lock engagement and stability before every use, and disabling locking mechanisms constitutes an unacceptable safety risk. Near-miss reporting plays an essential role in identifying such seemingly simple hazards before they result in serious injuries.
Near-Miss Case 6 – Structural Failure on a Scaffolding Platform
Near-Miss Description
During an inspection activity, a sudden structural failure occurred on a scaffolding platform in use. As a result of the support arm carrying the steel plates at the platform base breaking at its welded connection, an abrupt collapse of approximately 40 cm occurred on one side of the platform. The person on the platform was able to maintain balance and leave the area safely, and the incident was narrowly avoided without injury.
Evaluation
This near-miss clearly demonstrates the critical importance of the integrity of load-bearing elements and welded connections in scaffolding systems. Failure of a structural component significantly reduced the load-carrying capacity of the platform and created a risk with the potential for severe consequences such as full collapse, falls, or crushing injuries. The sudden deflection of approximately 40 cm highlights how close the situation was to a serious accident.
Such damage suggests that the scaffolding may not have been adequately inspected, that welded connections were not subject to periodic examination, or that the system was subjected to loads or usage conditions beyond its design limits. Particularly during inspection and survey activities, assuming that scaffolding is safe simply because it is erected can lead to a false sense of security. This case demonstrates that scaffolding must be regularly checked for structural integrity, welded joints, and load-bearing components both before and during use. The early identification of such structural weaknesses through near-miss reporting is critical for preventing serious accidents and strengthening a proactive safety culture.
Near-Miss Case 7 – Personnel Transfer During Unsafe Boat Maneuvering
Near-Miss Description
As part of a planned Bottom In Water inspection at a port area, a personnel transfer from the vessel to a diver support boat was scheduled. Prior to the transfer, preparations for a safe transfer were requested. The boat master proposed using the vessel’s crane and a basket for the transfer; however, this method was deemed unsafe and rejected. It was then clearly stated that the boat should approach safely beneath the pilot ladder. Despite this, the boat approached using a rope maneuver without engine power, and while surveyor was on the accommodation ladder, the boat made contact with the ladder. Following the incident, the transfer was stopped, and it was clearly stated that no transfer would take place unless safe conditions were ensured. After repeated warnings, the boat approached correctly beneath the ladder and a safe transfer was completed. The incident was classified as a near-miss.
Evaluation
This near-miss incident highlights the high level of risk associated with personnel transfers during marine operations and demonstrates how unsafe boat maneuvers can lead to serious accidents. Uncontrolled approaches make vessel–boat interaction unpredictable and elevate crushing and falling risks to a critical level. The contact between the boat and the ladder while a person was positioned on it indicates that the situation had the potential for fatal consequences.
The key factor preventing this incident from escalating into an accident was the firm decision to refuse work under unsafe conditions and to stop the operation. This case demonstrates that personnel transfers must only be carried out using clearly defined and safe methods, and that near-miss reporting plays a vital role in making safety-compromising practices visible and preventing future accidents.
Near-Miss Case 8 – Personnel Transfer Using Inadequate Boats in Open Sea Conditions
Near-Miss Description
Personnel transfers were carried out to a vessel anchored approximately 10 nautical miles offshore as part of classification transfer surveys, using boats dispatched at different times. Observations revealed that the boats used were not adequately equipped or arranged for safe personnel transfer under open sea conditions. In swell conditions of approximately 1 meter, the boats were unable to maintain sufficient stability, and on some boats, handrails were either incorrectly positioned or entirely absent. In addition, no recovery equipment for man-overboard situations was available on the boats. During night-time transfers, insufficient lighting was observed both on the boats and on the vessel. The situation was assessed as a near-miss with the potential for serious consequences.
Evaluation
This near-miss highlights the high level of risk associated with personnel transfers in open sea conditions and demonstrates the critical importance of using boats that are suitable for such environments. Insufficient stability, lack of proper handholds, and the absence of recovery equipment significantly increase the risk of falling overboard and the inability to respond effectively to an emergency. Inadequate lighting during night operations further elevates these risks by limiting visibility.
This case clearly demonstrates that not every boat is suitable for every operating condition in open sea transfers. Boats selected for personnel transfer must be appropriate for the prevailing sea state, operational distance, and time of operation, and must meet minimum safety requirements in terms of stability, handholds, recovery equipment, and lighting. Near-miss reporting serves as a critical learning tool by enabling the early identification of such systemic deficiencies and helping to prevent serious accidents.
Near-Miss Case 9 – Rope Failure During Bollard Pull Test
Near-Miss Description
During preparations for a bollard pull test conducted as part of a tugboat operation at a port area, a tensioned towing rope suddenly failed at a point close to the vessel. The broken rope recoiled under high tension and was thrown toward a monitoring cabin and the surrounding shoreline area. No injuries occurred; however, the situation was classified as a near-miss with the potential for serious consequences. Following the incident, the relevant parties were requested to provide information regarding the root cause analysis and the occupational health and safety measures taken or planned.
Evaluation
This near-miss clearly demonstrates that high-energy operations such as bollard pull tests can create life-threatening risks within seconds. In the event of rope failure under load, the resulting snap-back effect poses a severe risk of serious injury or fatality to anyone within the failure line and surrounding area. The fact that the rope failed near the vessel and recoiled toward the shore highlights that the risk zone is not limited to the immediate operational area.
The incident suggests that the rope’s condition, service history, and load capacity may not have been sufficiently assessed prior to the test. In addition, inadequate isolation of the test area and the absence of clearly defined safety zones for snap-back hazards contributed to an elevated risk level. This case demonstrates the critical importance of periodic rope inspections, verification of equipment suitability, and the establishment of wide and clearly defined exclusion zones during high-tension operations. Near-miss reporting plays a vital role not only in documenting such events, but also in transforming them into opportunities for systemic improvement and learning, thereby helping to prevent similar accidents in the future.
