This thesis describes twenty-seven near-miss experiences by ten merchant marine officers on the U.S. Great Lakes. The experiences are related in the first person and include actions by self, other bridge watch members, and other vessels. The focus of the work is on the relationship between the near-miss experience and the organizational implications related to those experiences. The survey of the literature defines the near-miss experience and two major previous efforts to obtain and record maritime near-misses. The conceptual context places the near-miss in the traditional maritime organization which is defined through analysis of boundary and environment, horizontal and vertical differentiation, integration, conflict resolution, information generation, and reward structures. The conceptual context also describes three alternative perspectives of organization; systemic, social-political and architectural. The thesis is exploratory in nature: how and why the near-miss occurred and remained a near-miss rather than becoming an accident. Five propositions relating to anticipated changes in the organization structure are used as the basis for case-study analysis. These propositions relate to the changing of the organization structure by one or more persons on the bridge watch. The propositions are supported by about one-fifth of the related experiences. An additional proposition is also supported by about one-fifth of the related experiences. Recommendations include the continued collection and codification of near-miss experiences, experimentation using full-mission simulation, and research into the potential for near-misses under the one-person bridge organization structure.

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