Professional Documents
Culture Documents
FORM CSSL-002
"Important and highly secret"
ACCIDENT REPORT OF DEATH
(The first report of the incident)
Kepada : DPA
Fax
:.......................
Tanggal : . . . . . . . . . . . . . . . . . . .
Delivery time ... ... ... ... UTC
KM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Voy : . . . . . . . . . . . . . . . . . . . . . . . Dari : . . . . . . . . . . . . . . . . . . . . . .
Tujuan : . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Tanggal/Waktu Kejadian : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................
3. Lokasi
Kejadian : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................
4. Type and summary of events (see the report impacts). (EXPLANATION)
5. The death/ of the missing person
Name
:. . . . . . . . . . . . . . . . . . . . . .
Jabatan
:......................
6. Tingkat
pencemaran : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................
7. The magnitude of the damage/loss
a) Ship Building Machine : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................
b)
Load : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.....................
............................................................
.................................
c) part of the ship
Lainnya : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.......................
............................................................
................................
8. related parties reported.
a local port Administrator) (according to the procedure of handling the pollution
of the sea).
b) companies that deal with pollution (request local representatives)
9. The State of the weather and the sea.
10. Kalaik-Ocean (ship's ability to move its own machine).
11. Should help from the army.
12. The time schedule of the next talks (Say a method of communication used)
FORM CSSL-003
Strictly Confidential
TUBRUKAN
(The Second Report)
To
Date
Km.
1.
2.
3.
: DPA
:
:
Fax:
Time:
Nahkoda:
yes/no
yes/no
yes/no
yes/no
yes/no
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
18. Show diagram of ships in the vicinity of, the conditions and then linats
voyage (on separate sheet).
19. Data data on other vessels involved impacts:
(1) the name of the Ship
:
(2) flag
:
(3) the owner of the ship
:
(4) Ship operated
by company
:
(5) the starting Harbour
:
(6) the port of destination
:
(7) the charge
:
Jasa Raharja (8)
:
To
KM
: DPA
:
FORM CSSL-004
Date:
"It Is Very Important And Confidential"
WRECKED/STRANDED
(the second report)
To
: DPA
(Fax No.)
Tanggal : . . . . . . . . . . . . . . . . . . . . . .
Nomor : . . . . . . . . . . . . . . . . . . . . . .
KM : . . . . . . . . . . . . . . . . . . . . . .
Nahkoda : . . . . . . . . . . . . . . . . . . . . . .
Person Name
:....................................
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Minor Injuries
People Name
: ... ... ... ... ... ... ... ... ... ... ... ...
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
9. the following Events
1. Kebakaran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . Yes/No
2. Kebocoran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . Yes/No
3. Tumpahan
Minyak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes/No
10. Building damage ship outline
Bow, starboard (front, Center, rear), stomach left side (front, Center, rear),
The stern of the ship.
11. Damage to the machine
1. Kerusakan mesin
induk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes/No
2. Kerusakan Mesin Kemudi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . Yes/No
3. Kerusakan daun
kemudi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes/No
4. The ability of moving themselves ... ... ... ... ... ... ... ... ... ... ... ... ... ... ....
Yes/No
12. the urgent circumstances
1. Is it necessary to leave the ship ... ... ... ... ... ... ... ... ... ... .... Yes/No
2. The command to leave the ship time (HR..........) ... ... ... ... ... Yes/No
3. will help rescue needed......................... Yes/No
4. Request by the hour ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... Yes/No
5. use of the machine (machine motion, though time hours ... ... ... ... ... ... ... ...
...)
Anchored Time : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . )
Rudder (Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......)
The Other ( . . . . . . . . . . . . . . . ). (the time of commencement of the task.
Time . . . . . . . . . )
13. The use of navigation equipment
FORM CSSL-005
Kepada : DPA
Fax No. : . . . . . . . . . . . . . . . . . . . . . . . .
.............
Tanggal : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nomor : . . . . . . . . . . . . . .
person Name:...............................
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
2. Person Injured
Heavy injury
person name:...............................
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Minor injuries
person name: ... ... ... ... ... ... ... ... ... ....
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Nama : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
10. the following Events.
1. Kebakaran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . Yes/No
2.
Kebocoran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . Yes/No
11. Building Damage ships in outline.
Bow, starboard (front, Center, rear), stomach left side (front, Center, rear),
The stern of the ship
12. Damage to the machine
1. Kerusakan mesin induk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . Yes/No
2. Kerusakan mesin
kemudi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes/No
3. Kerusakan daun kemudi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . Yes/No
4. The ability of moving themselves ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ....
Yes/No
13. the urgent circumstances
1. Is it necessary to leave the ship ... ... ... ... ... ... ... ... ... ... ... ... ... ... Yes/No
2. The command to leave the ship time (hour) ... ... ... ... ... ... ... ... ... ... .... Yes/No
3. will help rescue needed................................. Yes/No
4. Permintaan oleh kapal
jam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes/No
FORM CSSL-008
"Important and highly secret"
DAMAGE TO THE AIRCRAFT IS IMPORTANT
(THE PARENT ENGINE)
The Second Report
To
: DPA
Fax No.:......................
Tanggal
:........................................
Nomor : . . . . . . . . . . . . . . . . . . . . . .
KM
:........................................
Nahkoda : . .
....................
1. Time and date of the occurrence of the failure
hour: ... ... ... ... ... ... ... ...
date:...................
2. The place where the unknown
malfunction ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ....
3. Place the damage done
a. Baringan/distance from an object:
b. Lintang / Bujur : . . . . . . . . . . . . . . . . . . . . . . . . (U/S) (L/B) . . . . . . . . . . . . . . . . .
......................
4. Ship around the (possibility of impingement with other ship)
Yes/No
5. The dangers of navigation around the (betting, odds etc.)
Yes/No
6. Removal to driving to the manual Already not/yet
7. The goals of the international sign of "uncontrolled ship" already
not/yet
8. Tighten the observations (additional personnel, radar, VHF) already
not/yet
9. Hold a call ask for attention from the ship
around (VHF, lights) Already
not/yet
10. Weather and sea conditions
Wind Direction : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Wind speed
weather :......................
Current Direction
:..............................
Current
Velocity : . . . . . . . . . . . . . .
11. Hanyutnya ship
Arah
:..............................
Never drift: ... ... ...
... ... ... ... n. m/h
12. Anchor Preparation Alread
not/yet
To
.....
Date
: DPA
Fax No. : . . . . . . . . . . . . . . . . . . . . . . . .
:.................................
:.............................
KM
:.................................
.............
No
Helmsman : . . . . . . . . . . . . . . . .
FORM CSSL-007
To
.....
Date
: DPA
Fax No. : . . . . . . . . . . . . . . . . . . . . . . . .
:.................................
:.............................
KM
:.................................
.............
No
Helmsman : . . . . . . . . . . . . . . . .
1. The time and date of occurrence of the hour: ... ... ... ... ... ... ... ... ....
Date : . . . . . . . . . . . . . . . . . . . . . . . . . .
2. The place where the occurrence of failure..........................................................
3. Relationship with ships about (the possibility of
impingement with other ship)
Yes/No
4. The dangers of navigation around (betting, odds)
Yes/No
5. Manual Removal to driving into
yes/no
6. The details of the designation of Compass
Gyro Compass: Magnetic Compass:
7. Perform a sign intrnasional
"Uncontrolled Ship"
Already/Not Yet
8. Tighten the observations
(additional personnel, radar, VHP)
Already/Not Yet
9. Hold a call asking for the help of the ship ship around
(VHMPI terms of lights)
Already/Not
Yet
10. An estimate of the weather and sea conditions
Wind Direction : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Wind speed
weather :......................
KKM
NAHKODA
FORM CSSL-010
REPORT EXERCISES THE ROLE OF FIREFIGHTER
KM
:____________________
:_______________
Voyage number
:____________________
____________
1.
Nomor
Date of reporting
2.
3.
: ____
4.
Total time required since the signal fires dibunykan up to readiness equipment
the firefighters arrived on the scene of the fire: minutes.
5.
6.
The conditions of the waterproof door, fire door (fire door), how HER close and
the time required to act ... ... ... ... ... ... minutes
7.
When a fire broke out in a room, does the blower/fan have all been
extinguished................................................. Yes/No
8.
9.
Pemeriksaaan
firefighting
equipment
10
.
12
.
13
.
The Other
14
.
KKM:
first Officer
Helmsman
Nomor
Date of reporting
1.
2.
:_______
: ____ _ _ _ _
Pelabuhan : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........
3.
Lifeboat number:
Lifeboat exercise Commander:
4.
Total time required since the signal decrease lifeboats sounded up to readiness
in the location of lifeboat: ... ... ... ... ... ... ... ... ... ... ... .... minutes.
5.
Total time required since in location s/d drop in position ... ... ... ... .... . minutes
6.
Examinatio
n of the
lifeboat
equipment
Conditions during the attempted path: ... ... ... ... ... ... ....
There are good/leakage/damaged
The State of fuel tank: ... ... ... ... ... ... ... full/half/empty
7.
8.
9.
Personnel who have not followed the exercises caused a pedestal an:
Name:
Position:
Reason:
10
The Other
11
.
Know
KKM
First Officer
Helmsman
:____________________
:________________
Voyage number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
____________
Nomor
Date of reporting
1.
2.
: ____
Lifeboat number:
Lifeboat exercise Commander:
4.
Total time required since the signal decrease lifeboats sounded up to readiness
in the location of lifeboat: ... ... ... ... ... ... ... ... ... ... ... .... minutes.
5.
Total time required since in location s/d drop in position ... ... ... ... .... . minutes
6.
Examinatio
n of the
lifeboat
equipment
Conditions during the attempted path: ... ... ... ... ... ... ....
There are good/leakage/damaged
The State of fuel tank: ... ... ... ... ... ... ... full/half/empty
7.
8.
9.
10
The Other
AT THE SAME TIME TRY TO PLANE CARRIED ABOVE THE RADAR SWITCHED ON
LIFEBOAT
11
.
Know
KKM
First Officer
Helmsman
CSSL FORM-015
EMERGENCY STEERING DRILLS REPORT
KM
:____________________
:________
Voyage number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_____
Nomor
Date of reporting
: ____
Tanggal : . . . . . . . . . . . . . . . . . . . . .
Start hour ... ... ... ... ... ... ... ... up to
hour . . . . . . . . . .
2.
3.
Already/Not
Yet
4.
Already/Not
Yet
5.
Already/Not
Yet
6.
Already/Not
Yet
Try the emergency steering engine with manual (without engine)The movement of the rudder position cikar I 0 -P15 , the time
required
........
seconds
The movement of the rudder position II cikar P15 -S15 , the time
required
........
seconds
The movement of the rudder position cikar III S15 -P15 , the
time required
........
seconds
........
seconds
8.
Yes/No
9.
........
people
10
.
11
.
Name:
Position:
12
.
13
.
The Other:
KKM
First Officer
Helmsman
FORM CSSL-013
REPORT POLLUTION PREVENTION ROLE OF EXERCISE
KM
:____________________
:________
Voyage number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_____
1.
Nomor
Date of reporting
: ____
The old date and exercise POLLUTION PREVENTION & CHARGING BUNKER
the start date up to hours hours
3.
4.
5.
Check the condition of the charging hose (completeness installed) check the
charging hose fastening bolts/nuts and gasket that
6.
The total number of personnel involved in the exercise: ... ... ... ... ... people
7.
The number of personnel who guard duty with respect to absent: ... ... ... ... ...
the people.
8.
The Other
WHILE TRYING TO START THE AIRCRAFT RADAR ON MENHIDUPKAN TURN ON
10
.
FORM CSSL-014
PERRALATAN RESCUE DEMONSTRATION EXERCISE REPORT
KM
:____________________
Nomor
:________
Voyage number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date of reporting : ____
_____
INFLATABLE LIFERAFT
No
.
Pengikatannya conditions
Good/Damag
ed
Description
2.
3.
2.
3.
FORM CSSL-016
REPORTS OF
KM
:____________________
:________
Voyage number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_____
Nomor
Date of reporting
: ____
The old dam date exercise Ladder: ... ... ... ... ... ... ... ... ....
Mulai jam . . . . . . . . . . . . . . . . . . . . . . . . . . . , to,
2.
3.
4.
5.
Yes/No
Already/Not Yet
Already/Not Yet
Already/Not Yet
Already/Not Yet
Already/Not Yet
6.
Action Nahkoda:
-
Already/Not Yet
Already/Not Yet
Already/Not Yet
8.
Already/Not Yet
Already/Not Yet
Already/Not Yet
Already/Not Yet
9.
Already/Not Yet
10
.
Take photo-photo
11
.
Already/Not Yet
Already/Not Yet
13
.
The number of personnel who have not followed the exercise due to a
reason: ... ... ... ... ... people
14
.
15
.
Wianta
16
.
FORM CSSL-017
CHECKLIST EMERGENCY-OPERATION OF HELICOPTERS
ACTION
PERSONN
EL
Nahkoda
Evaluation of risks
Nahkoda
Nahkoda
Nahkoda
Nahkoda
Nahkoda
Propagator
I
CHECK
Propagator
I
Propagator
I
Make sure the deck is free of gas close all the doors
Propagator
I
Propagator
II
Propagator
II
Propagator
I
Propagator
I
Propagator
II
Marconist
Nahkoda
Officer of
the guard
Nahkoda
Officer of
the guard
Officer of
the guard
Officer of
the guard
All
All
FORM CSSL-018
CHECKLIST EMERGENCY SHEDDING POLLUTION
ACTION
PERSONN
EL
Inventor
All
Officers
Officers
Propagator
I
Propagator
I
KKM
Propagator
I
Nahkoda
Nahkoda
CHECK
Nahkoda
Nahkoda
Nahkoda
Nahkoda
Chef/KKM
ACTION
Experiment With Alarm
All personnel assembled
PERSONNEL
Inventor
All
Inventor
Inventor
CHECK
Inventor
Two trained
Personnel
Propagator I
Propagator I
Team
Team
Team
Team
Nahkoda
Marconist
Use Stretcher
Chef
Team
Team
Nahkoda
Marconist
Nahkoda