Bermuda Government

Department of Maritime Administration

THE MERCHANT SHIPPING ACT 2002

RETURN BY A MERCANTILE MARINE SUPERINTENDENT OR PROPER OFFICER OF

INFORMATION OBTAINED AS A RESULT OF AN INVESTIGATION INTO THE CAUSE OF A
DEATH IN A BRITISH SHIP OR OF A MASTER OR, SEAMAN WHOSE
DEATH OCCURRED OTHERWISE THAN ON BOARD

Name of deceased (Surname Sex Date of birth (if Occupation, rank, or Usual residence at time Nationality
first, in BLOCK LETTERS) known) or age profession of death or loss

Date of death or loss Place of death or loss (latitude and longitude Cause of death
if at sea)

Name of ship in which deceased was serving or Official number and port of registry Gross tonnage
last served

A – TO BE COMPLETED IN EVERY CASE OF DEATH

Questions to be put by the Officer Answers
1. Between which ports was the ship sailing at the time of the 1
occurrence?
2. What was (a) the date of the commencement of the voyage 2 (a)
and (b) the date of leaving the last port? (b)
3. What was the nature of the cargo? 3

4. Was a deck load carried? 4

5. When and where was the deceased engaged? Or if a person 5 Date Place
not employed on the ship, state date and port of boarding.
6. About how long had he been at sea previously? 6

7. Was he competent for the work (a) for which he was engaged; 7 (a)
(b) on which he was employed at the time of the occurrence? (b)
8. Had any complaint been made as to 8 (a)
(a) accommodation; (b) ventilation; (c) sanitary arrangements; (b)
(d) ship’s gear, life-saving or other equipment; (e) food; (f) (c)
water; (g) medical stores ? If so particulars should be stated on (d)
the last page. (e)
(f)
(g)
9. Had any complaint been made of (a) ill-treatment; (b) threats; 9 (a)
(c) neglect ? If so particulars should be stated on the last page. (b)
(c)
10. Were the hands employed (a) sufficient, and (b) efficient 10 (a)
(b)
11. If he was a member of the engine department and on duty, 11
what was the temperature in the engine-room at the time of his
becoming ill or injured ?
12. (a) Was medical or surgical aid obtained ? If so, (b) within 12 (a)
what time after the occurrence ? If not, (c) state reasons. (A (b)
copy of any medical testimony obtainable should be attached) (c)
13. If the ship did not carry a doctor, state whether or not 13 (a)
dangerous drugs (morphine, omnopon) were administered. If (b)
they were, state number of times.
ROSF. INQ 16 (Rev. 04/03) Page 1 of 4
14. Has an inquiry been held by a Coroner, Police Magistrate, or 14
other such authority ? If so, state the result and attatch a copy
of the report of the inquiry
15. Was the occurrence reported to the proper authority upon the 15
first opportunity ? If not, state reasons.

B – TO BE COMPLETED IN EVERY CASE OF DEATH BY ACCIDENT, VIOLENCE, SUICIDE OR DISAPPEARANCE

Questions to be put by the Officer Answers
1. (a) Was deceased on duty, (b) what was he doing, and (c) 1 (a)
where was he at the time of the occurrence ? (State the exact (b)
part of the ship). (c)
2. If others were at work with him were they (a) sufficient, and 2 (a)
(b) efficient? (b)
3. How long had he been on duty ? 3

4. Was the ship being navigated with proper seamanlike care, 4

and with due regard to the safety of the men at work
5. Did any portion of the ship or of her rigging, gear, machinery, 5
or cargo carry away or sustain any damage or loss at or about
the time of the occurrence ? If so, state particulars.
6. If the deceased was employed upon any duty of exceptional 6
danger, what means were adopted to secure his safety ?
7. What was the state (a) of the weather and (b) of the sea? 7 (a)
(b)
8. If death was the result of a fall down a hatchway, bunker, etc., 8 (a)
(a) Why was it not securely closed? (b) If dark, how was it (b)
lighted? And (c) What means were taken to prevent accident? (c)
9. Do the circumstances point to suicide? If so, state them and 9
also whether the deceased showed signs of mental weakness,
worry or depression.
10. If the deceased is missing, how is the disappearance to be 10
accounted for? Are there any reasons for supposing that it is
due to accident, suicide or violence?
11. If the deceased was drowned was he seen to go overboard? If 11
so, by whom?
12. Had he quarreled with anyone on board? 12

13. Was he known or believed to have any private or family 13

trouble?
14. Was he (a) under the influence of intoxicants or narcotics? or 14
(b) suffering from the effects of previous excess?
15. If, at the time of the occurrence, he was going from or to the 15 (a)
ship (a) what sort of gangway was used, (b) how was the (b)
gangway lighted, (c) how was the wharf or quay lighted, and (c)
(d) what steps were taken to prevent accident? (d)
16. Was (a) a life buoy thrown to deceased or (b) a boat launched? 16 (a)
and if so (c) within what time after he went overboard? If not (b)
(d) state reasons. (c)
(d)
17. (a) Where was the nearest life buoy kept, and 17 (a)
(b) how was it secured? (b)
18. What other attempts were made to rescue deceased? 18

19. If injured what treatment was given? 19

20. (a)What more could have been done for the deceased, and (b) 20 (a)
by what means might the occurrence have been prevented? (b)
21. (a) In your opinion was any person to blame? If so, 21 (a)
(b) who, and (c) in what manner? (b)
(c)
ROSF. INQ 16 (Rev. 04/03) Page 2 of 4
22. Was deceased discharged from ship, and (b) if so, was it on 22 (a)
account of accident? (b)
23. In your opinion what was (a) the primary cause of the 23 (a)
occurrence, and (b) the immediate cause of death. (b)

C – TO BE COMPLETED IN CASE OF DEATH BY DISEASE

Questions to be put by the Officer Answers
1. What was (a) the nature of the disease? or (b) if the disease 1 (a)
was not diagnosed by a doctor, of what did the deceased (b)
complain?
2. What was the length of the illness? 2

3. What were the chief symptoms? 3

4. If the illness was infectious or contagious, or can be traced to 4

the water (used for any purpose), food, cargo, ballast, stores,
bilges, etc., going on shore or other ships – or to any other
cause, state particulars.
5. What steps were taken to prevent further infection? 5

6. On what date was the patient transferred to the ship’s 6

hospital? If not placed in the hospital, state the reasons, and
where accommodated.
7. (a) Who attended the patient and (b) what treatment was 7 (a)
given? (b)
8. Was deceased known to have received any injury or hurt from 8
any accident, fight, drunkenness, etc., to which his illness can
be attributed?
9. If a case of sudden death, from heart trouble, a fit etc., state 9
whether deceased had previously suffered from the complaint.
10. Was deceased (a) a temperate habits, (b) under the influence 10 (a)
of intoxicants or narcotics, or (c) suffering from previous (b)
excess? (c)
11. (a) Was deceased discharged from the ship, (b) if so, was it on 11 (a)
account of illness? (b)
12. In your opinion what was (a) the primary cause of the illness, 12 (a)
and (b) the immediate cause of death? (If the first cause was (b)
injury, etc., Section B of this form should also be completed).
Additional Questions Answers

ROSF. INQ 16 (Rev. 04/03) Page 3 of 4

 FULL PARTICULARS OF THE DEATH (SO FAR AS KNOWN) SHOULD BE GIVEN HERE

Copies of entries in the official log book, including any particulars given in the tabular form in the log book, should be included or
attached. It is not sufficient to refer here to the fact that log entries have been made on form RBD 1.

Persons examined

Name Occupation, rank or profession Was statement taken

Surname first (in BLOCK LETTERS) (yes or no)

The foregoing information has been obtained by my investigation into the cause of death.

Statements listed above are attached

No statements were taken
(delete as applicable)

Port of ________________________ on _________ day of _____________________ 20 _______

Signature _______________________________________________________________________

Title __________________________________________________________________________

This form when completed should be sent by airmail to: Department of Maritime Administration
P.O.Box HM 1628
Hamilton HM GX
Bermuda

ROSF. INQ 16 (Rev. 04/03) Page 4 of 4