What are FISHER Reports?

The Global Fishing Industry Accident Data Management System

Is there a case for a Voluntary, Confidential Reporting System?

The prevailing wisdom is that accident reporting systems should be formally developed through maritime administrations as per the accepted commercial maritime model – see the Global Integrated Shipping Information System (GISIS) database on Maritime Casualties and Incidents. However, it is important to note that fishers may be reluctant to report accidents to the authorities. It has been suggested that the establishment of an effective industry-run confidential reporting system is possibly the single greatest innovation that could be made to improve world fishing safety.

The premise is simple. If a system’s users – the people at the “sharp end” of day-to-day operations – can be encouraged to report the safety problems they encounter to a program they can trust, safety goals will be reached much sooner than if we never hear the stories of those lessons learned. By providing a no-blame reporting channel, we can actively work on preventing reoccurrence and reducing the unnecessarily high accident and fatality rate at sea.

One of the particular interesting observations in the “Draft Guidelines to Competent Authorities in Implementing an Accident Reporting and Analysis System for Small Fishing Vessels” Report was that “the accident reporting and analysis functions should be separated from the regulating and law enforcement functions”. [See page 30]. Expanding somewhat on this observation then, the voluntary option is floated as it is noted that fishers may be reluctant to report accidents to the authorities (Fisheries Departments, Coastguard or Police). Acknowledging this, yet recognising the importance of accident reporting, it may be that a confidential reporting system is established to supplement the mandatory program.

This approach has proven very successful in other high-risk industries, notably maritime, aviation and nuclear.

For examples of how this has worked, in the aviation industry, see:

·     AviationSafety Network (part of the Flight Safety Foundation)

·     Also: Skybrary

The commercial maritime sector currently runs two confidential reporting programs (for which we are international Ambassadors):

·      The Nautical Institute’s MARS Program

·      CHIRP (Confidential Hazardous Incident Reporting Program)

The thinking underpinning FISHER Reports is simple:

  • When organizations and industries want to learn more about safety incidents and why people did what they did, the best approach seems to be to simply ask the participants.
  • People are generally willing to share their knowledge if they are assured their identities will remain confidential, and the information they provide will be protected from disciplinary and legal consequences.
  • A properly structured confidential, voluntary, non-punitive incident reporting system can be used to share this information.
  • Such a system has the means to ask, and frequently answer, the question of why. There is no substitute for knowing why a system failed or why a human erred.
  • A voluntary accident reporting system cannot succeed without the cooperation, oversight, and guidance of the community that will use it. It must be viewed as a safety information resource accessible and responsive to all.
  • A voluntary reporting system usually must exclude from its protections some types of incidents, such as criminal acts and intentional unsafe acts.
  • The safety data gathered from accident reporting can be used to identify system vulnerabilities and gain a better understanding of the root causes of human error.
  • Accident reporting data is complementary to the data generated by mandatory, statistical, and monitoring systems.
  • The ultimate achievement of an accident reporting system is that it can prevent accidents and fatalities.
These principles shape our beliefs and practices.

FISHER reports will provide a valuable source of information of industry practice, providing for effective risk management advice and assistance to industry participants. The desired outcomes from this initiative will be industry awareness creation, and the identification of actions that can be taken to improve fishing industry health and safety outcomes. This can ultimately lead to improvements in standards, practices, procedures and training & education practices.

We will also provide a report back portal to share the stories, and the valuable learnings arising from the misfortune of others.

We won’t be doing this alone or in isolation – we’re also Ambassadors for both the MARS and the CHIRP confidential event reporting services. So, with the support of these two well-known international maritime reporting initiatives, lessons learned in the fishing industry can be brought to international and IMO attention, further promoting the Foundation’s tagline of “Sharing the Lessons”.

This is a dedicated fishing program – essentially the fishing industry “owns it”. The Foundation intends to extract as much information as possible from the reports, build up trust with the industry, and form a valuable data base of industry beliefs and practice.

We’re strong advocates of learning from accidents, and sharing the lessons, so this will allow us to find out what is REALLY happening out there, not just the stuff that gets reported through the official channels. There is currently a dearth of real information out there in the fishing industry – this scheme will start addressing that problem.

In order to tackle the problem of human error particularly in the fishing industry, a database of self-reported errors in incidents is required in addition to the independent investigation of fishing accidents and serious incidents. This information will serve as input for further research.

The investigation and analysis of FISHER reports will start filling in the gaps left by current accident investigations, mandatory event reporting, and other information gathering systems. The program can ultimately be an accurate early warning system that identifies problems related to emerging technologies and global economic trends.

This initiative will serve as a powerful reminder that, despite the best of intentions, even well-trained and well-meaning people, operating on well-found vessels, are still capable of making mistakes. The de-identified stories arising from these reports will serve to reinforce the message that we must remain vigilant at all times to ensure the ongoing safety of ourselves and others.

The collection and management of FISHER reports will be a free service to Industry. This confidential reporting system will allow for full reporting of accidents (and near misses) without fear of identification or litigation.

The FSF will administer the program’s details, oversee its products and services, guarantee confidentiality, and ensure that de-identified incident data and the results of special studies are communicated responsibly to interested parties.

As outlined, there are a number of ways a FISHER report can be generated – online, via App, email, etc. Every report that is received will be acknowledged and considered, with feedback provided to the reporter before closure of the report.

On being received, reports are validated as far as is possible and reviewed with the objective of making the information as widely available as possible whilst maintaining the confidentiality of the source. Anonymous reports may not always be actioned as they cannot be validated. When appropriate – and while maintaining strict confidentiality – report information is discussed with relevant reporters with the aim of finding a resolution. Only depersonalised data will be used in discussions with third party organisations and the confidentiality of the reporter assured in any contact with an external organisation.

No personal details are retained from reports received. After ensuring that the report contains all relevant information, all personal details are returned to the reporter with an acknowledgement email or letter. Each report is allocated unique reference identification. The reporter may, if he/she wishes, contact the Foundation office for additional information by using the report reference identification.

The report in a dis-identified format will be discussed by the Foundation Board, and, where permission has been given by the reporter, shared with MARS and / or CHIRP as required. The foundation will publish many of the reports on various media to present as many “lessons learnt” as possible back to the Industry.

Finally, the depersonalised data will be recorded in a secure database for further analysis of key topics and trends. Dis-identified summary data can be made available to other safety systems and professional bodies.

We will actively seek out root causes, identify the lessons learnt and consider how best this information can be used to prevent reoccurrence elsewhere in the fishing industry.

To facilitate the confidential reporting of accidents, we have developed a mobile phone App

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