Audit

Incident/Accident/Near Miss Details (CIRCLE ONE)
Date & Time of Incident/Accident/Near Miss
Location of Incident/Accident/Near Miss

Incident/Accident/Near Miss Severity?

Vessel Name/Location

Incident Type (select all that apply)

Please describe type of incident

Name of on-duty supervisor at time of incident?

Was medical attention administered?

What kind of medical attention was administered?

Please detail medical attention

Incident Summary

Describe what happened. Please be detailed but state only facts.

Do you wish to include a timeline of events for this incident?

Incident Timeline

Build a timeline of key incident events below

Event
Event Date / Time

Event Description

What were the weather / environmental conditions at the time of the incident?

Describe the weather / environmental conditions at the time of the incident

Evidence and Attachments
Which of the following do you need to attach to this report to accuractly document this incident?
Evidence Log

Please log all relevant evidence below

Evidence

Evidence Description

Evidence ID number (if applicable)

Type of evidence

Photos of evidence (if applicable)

Please detail any further information regarding this evidence (if applicable)

Damage Log

Please log all relevant damage details below

Damage

Damage description

ID number (if applicable)

Photos of damage (if applicable)

Please detail any further information regarding this damage (if applicable)

Other Items Log

Please log all relevant details of other items below

Item

Item description

ID number (if applicable)

Photos of item (if applicable)

Please detail any further information regarding this item (if applicable)

Equipment Log

Please log all relevant equipment details below

Equipment

Equipment Make

Equipment Model

Equipment ID number (if applicable)

Photos of equipment (if applicable)

Please detail any further information regarding this equipment (if applicable)

People involved

Please document all people involved in this incident

Person
Person

Full Name

ID number

Contact phone number

What is this person's relation to the incident? (select all that apply)

Describe this person's relation to the incident

Please describe this person's involvement with the incident, including all relevant information

Attach any relevant photos regarding this person

Do you want to log a statement for this person?

Statement

Statement regarding incident

Person Signature
Date & Time of Statement

Has this person sustained an injury?

Injury Details
Type of injury or illness? (select all that apply)

Describe type of injury or illness

Parts of body affected? (select all that apply)

Please describe injury location

Describe this injury or illness

What was the cause of this injury or illness?

Corrective Actions

Are corrective/further actions required with regard to this incident?

Please add any corrective actions to the appropriate questions above before completing this incident investigation

Have all required corrective actions been added as Actions to this inspection?

Root Cause Analysis / Contributing Factors
What were the contributing factors to this incident occurring? (select all that apply)

A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

Has the root cause of this issue been able to be identified?

Why is the root cause for this issue unable to be identified at this time?

How likely is this incident to reoccur in future?

What is the root cause of this incident? Please consider and include all contributing factors

Has the root cause of this issue been rectified or eliminated?

How was the root cause rectified or eliminated?

Please attach any relevant photos or media

Please provide any relevant further details

How likely is this incident to reoccur in future?
Sign Off

Further action/follow-up/investigation required?

Name of person/people to follow up

Name & Signature of Investigator