Event Report Form

Date of Report:

Person Reporting:

Company:

Date/Time of Event:

Vessel Information
Vessel Name:

IMO/Lloyd's No:

Type of Event/Casualty:

Vessel Location:

Estimated Cost of Damage:

Weather Conditions:
Clear
Partly Cloudy
Cloudy
Fog
Rain
Snow
Storm
Other:

Visibility
0-1/2 mile
1/2-1 mile
1-5 miles
5+ miles

Wind
N
NW
W
SW
S
SE
E
NE
Variable
Wind Speed kts

Tidal Conditions:
High
Low
Stand
Extreme High
Extreme Low

Current
Ebb
Slack
Flood

Vessel Operations Underway at time of Event:
Bunkering
Lightering to:
Lightering from:
COW/Tank Cleaning
Ballasting/De-ballast
Bilge Pumping
Vessel Underway
Discharging Cargo
Loading Cargo
At Anchor
Internal Transfer
Other:

Identity of any Facilities and/or other Vessels Involved:

Oil Spill Information (if applicable):
Type of Oil:
Gasoline
Hydraulic
Crude
Asphalt/Creosote
Kerosene
Diesel
Bunker
Lube
Other Refined Product:
Amount Spilled:(barrels)
Amount Recovered:(estimate)

Government Agencies To Which Event Reported:

Cause and Contributing Factors -- Brief analysis of any known causes and contributing factors for each event that considers, at a minimum, human error, equipment or technology failure, and maintenance or inspection deficiencies.
Equipment/Material Failure:
Electrical
Equipment Design
Mechanical/Equipment Failure
Metal Fatigue
Structural Failure
Other:

External:
Fog
Heavy Weather
Ice
Lightning
Rain
Reduced Visibility
Snow
Tidal Conditions
Wind
Other:

Human Error:
Communications
Company Policy
Complacency
Drugs/Alcohol
Inexperience
Forgetfulness
Improper Equipment Use
Improper Maintenance
Inaccurate Computation
Inattention
Insufficient Personnel
Procedural Error
Lack of Training
Unspecified
Other:

Narrative & Discussion

Prevention Measures -- Description of measures taken to prevent a reoccurrence of each event, including changes to the operating or maintenance procedures, personnel policies, vessel crew and organization, or the vessel's technology.