No: EML/FO/022

Issue No : 02
INCIDENT INVESTIGATION REPORT FORMAT Rev. No: 00
Page 1 of 5

Report Status: Initial Report Interim Report Final Report

SECTION A - GENERAL:
VESSEL: IMO No.:
REPORT NO.: INCIDENT TITLE:
DATE OF REPORT: DATE OF INCIDENT:
Please attach completed report to the relevant incident report form for recording purposes.

INVESTIGATORS(Name & Designation) ORGANIZATION / DEPARTMENT REMARKS / SIGNATURE

REVIEWED BY (Name & Designation) DATE REMARKS / SIGNATURE

APPROVED BY (Name & Designation) DATE REMARKS / SIGNATURE

Record of Requests for Extension of Investigation Report completion deadline

EXTENTION REQUESTED BY (Name & DATE OF NEW
REASON / SIGNATURE
Designation) REQUEST DEADLINE

EXTENTION APPROVED BY (Name & REMARKS / SIGNATURE DATE NEW

Designation) APPROVED DEADLINE

SECTION B – PURPOSE:
The purpose of this investigation is to identify causes leading to the subject incident and to establish corrective and
preventive action to avoid such an incident in the future. This investigation does not seek to determine or apportion
liability.

SECTION C – SUMMARY OF INCIDENT :

Short Overview of events no more than 200 words:
 No: EML/FO/022
Issue No : 02
INCIDENT INVESTIGATION REPORT FORMAT Rev. No: 00
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SECTION D – VESSEL INFORMATION:

Name of Vessel
IMO No.
Call Sign
Summer Deadweight
Gross Tonnage
Length Overall
Type of Vessel
Owner
Manager
Port of Registry
Flag
Year Built
Building Yard
Classification Society
Any other information relevant to the incident:

SECTION E – VOYAGE INFORMATION:

1. LOCATION
Port / Country
At Sea: Latitude /Longitude / Place
Departure Date / Time
From / To

2. OPERATIONS
Operational Status : Sailing /Anchorage /
alongside etc
Voyage Phase: Loaded / Ballast
Underway True Course / Speed
Draft Fwd /Aft / Mean (Mtrs)

3. VISIBILITY : Good Fair Poor

Nautical Miles
Outdoor Ambient Light

4. ATMOSPHERIC / SEA CONDITIONS

Sea State
Wind Speed / Direction
Bottom Depth (Under Keel) (Mtrs)
Currents / Tides
Ice Conditions
Other

SECTION D – ANALYSIS:
 No: EML/FO/022
Issue No : 02
INCIDENT INVESTIGATION REPORT FORMAT Rev. No: 00
Page 3 of 5

The purpose of the analysis is to determine the contributory causes and prevent similar incidents occurring in the
future.

1. NARRATIVE:

2. FACTUAL INFORMATION (Based on Investigation)

3. ANALYSIS TO DETERMINE CASUAL FACTORS AND ACTIONS:

 No: EML/FO/022
Issue No : 02
INCIDENT INVESTIGATION REPORT FORMAT Rev. No: 00
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3.1 Causes:
From the above sequence of events, facts and analysis the following causes have been established by using Marine Root Cause Analysis MapTM by ABS

3.1.1 Intermediate Cause(s)

3.1.2 Root Cause – (Basic / underlying cause(s))

3.2 Action(s):
 No: EML/FO/022
Issue No : 02
INCIDENT INVESTIGATION REPORT FORMAT Rev. No: 00
Page 5 of 5

Based upon the causes identified above, the following Actions are recommended by this report.
3.2.1 Corrective Action(s)

3.2.2 Preventive Action(s)

3.3 Action(s) Responsibility:

Remedial actions required to correct immediate causes and aimed at preventing
reoccurrence. Following individual(s) / department(s) are assigned with remedial action &
target date.
Action Item:

Priority High Medium Low

Responsible Individual / Department
Dead Line

4. LESSON(s) LEARNT:

SECTION E – APPENDICES: