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Accident Incident Report: General Information

The document is an accident incident report form that collects information about an accident or incident. It collects general information about the incident like location and type. It also collects details of the occurrence including date, time, weather, and a brief description. Recommendations for corrective actions may also be included.

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opytnymoryak
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90 views2 pages

Accident Incident Report: General Information

The document is an accident incident report form that collects information about an accident or incident. It collects general information about the incident like location and type. It also collects details of the occurrence including date, time, weather, and a brief description. Recommendations for corrective actions may also be included.

Uploaded by

opytnymoryak
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ACCIDENT INCIDENT REPORT

Company Forms and Check Lists

Date : 03.04.01
Rev.No : 1
Prep. : MGV
App. : CAP
Section: 02
Page : 1 of 2

General Information
Voyage

No

Charterers
Location (Port or coordinates)
Date

Type of Accident / Incident


It Involves

Injury/ Death / Pollution / Third Parties/Other

Report Dtails
Time:

Date:
Completed by :

Attached Documents with this Report

Photographs / Sketches

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Page No
Page No
Page No
Page No
Page No
Page No
Page No
Page No

Recommendations / Suggestions For Corrective Actions

Yes/No

Page No

Injury report
property /Equipment Damage Report
Third Party Involvement Report
Notifications Report
Letters / Idemnities
Accident / Incident Investigation Report
Witness Voluntary Statement

Other

......................................................................................

.............................................................................................
.............................................................................................

Description of Occurrence
Date:

Time :
Place Of Occurrence

On Board
Long
Lat
Location on Board
Sea state
Winds
Temperature
Visibility
Other (Ice-snow on deck etc.)
C:\FORMS\02_0010.PDF

Ashore
Name of Port
Name of Berth
Weather conditions

Force

Direction

Force

Direction

Fahrenheit

Celsius

MT LADON

ACCIDENT INCIDENT REPORT


Company Forms and Check Lists

Date : 03.04.01
Rev.No : 1
Prep. : MGV
App. : CAP
Section: 02
Page : 2 of 2

Brief Description of Incident


.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
Safety Officer

Master

Signature

Signature

INSTRUCTIONS :
To be filled in every time there is an incident on board . To be kept in the Safety Officer's file Section 4 and a copy
to be forwaded to the Office

C:\FORMS\02_0010.PDF

MT LADON

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