No: TOM/FO/002

REPORT OF “NEAR MISS”, ACCIDENTS OR Issue No:02

“ANY OTHER INCIDENT / OBSERVATION” Rev No: 00
Page 1 of 2

Section A - Identifying

Report: Near Miss Accident Other Incident / Observation

Incident Category:
Personal Accident Health Ship Contact

Explosion Fire Property Damage

Contamination Spill / Leak Security

Other Specify:
Note in case of Personal accident fill up form TOM/FO/028
Name of Vessel / Position Date / Time Of Incident (GMT) Date of Report

Onboard Location of the Near Miss /

Report Number
Incident (as specific as possible)

Consequence Categorization * Potential Categorization * Risk of Reoccurrence (H/M/L) **

*Refer to A-2.0-SHP-TOM-02 Incident Reporting and Investigation. Section 5.0

**Refer to risk matrix provided in Page 2 of TOM-FO-064

Property / Machinery / Equipment Environmental Release / Other

Security
Damage Actual or Potential Loss
What Damaged Type Type

Location Location Location

Nature of
Impact Impact
Damage

Breach of any Regulation / Requirement:

Flag State Port State Control Class

IMO Oil Major / Vetting Company

Other Specify:
Note: Please Specify details in the description

To be filed in File No. 103

 No: TOM/FO/002
REPORT OF “NEAR MISS”, ACCIDENTS OR Issue No:02
“ANY OTHER INCIDENT / OBSERVATION” Rev No: 00
Page 2 of 2

Section B – Description
Description of Near Miss, Accident or “Any Other Incident / Observation” Detected:

DETECTED BY Name Rank

Immediate Response Actions Taken: ( Use separate sheets if required)

Section C – Cause Analysis

Root Cause : (Please refer to SHP/TOM/02 and Use Form EML/FO/022if required)
Reasons for the occurrence:

Proposed by: Signature Date :

Reviewed / Approved by Master Signature Date :

Corrective / Preventive Actions Based On Root Cause Identified: ( Use separate sheets if required)
Corrective Action:

Preventive Action: (if any)

Proposed date of completion of corrective / Preventive actions:

Proposed by Verified by Approved by Safety
Master DPA Committee
Date Date Date

Section D – Follow Up
Implementation Of Corrective / Preventive Actions: (State If The Corrective Actions Taken Are Effective Or Not )

Date of final completion:

Verified By Master (Name, Signature and Date)

Follow Up Verification And Comments.

Verified By Company representative : Date :

To be filed in File No. 103