Form O 03 SMS Report

MV / ‫ السفينة‬: Year / ‫ سنة‬:

Back / ‫السابق‬ Master / ‫ الربان‬: Month / ‫ شهر‬:

Vessel / ‫ السفينة‬: Master / ‫ الربان‬: Date / ‫ تاريخ‬:

Incident/Accident: Near Miss: Observation: Non Conformity: Critical Equipment Failure:
‫حادث‬ ‫حادث وشيك‬ ‫مالحظة‬ ‫عدم مطابقة‬ ‫فشل معدات حرجة‬

Loss Score: 1 / 2 / 3 (Delete as appropriate)

Negligible (Score 1): Minor Lost time (Stay away from job < 1day), Single minor injuries, First aid, Operation loss cost <5K,
Minor damage< 5K USD, Loss of containment on deck or near miss.
Critical (Score 2):Major lost time (Stay away from job 1day - 1 week), Operation loss cost 5K-1Million USD, Moderate and/or
Significant damage 5K-1Million USD, Oil spill < 10 barrels.
Catastrophic (Score 3): Stay away from job > 1 week, Single and Multiple deaths & fatality, operation loss cost> 1Million USD,
Major damage > 1Million USD, Oil spill > 10 barrels.
A Description / Proposal for Improvement / ‫ مقترح التحسين‬/‫( السرد‬to be described by master) / (‫)يتم وصفه بواسطة الربان‬

B Corrective Action / ‫( اجراءات تصحيحية‬Proposed by Master and defined by DPA)/(‫)مقتراحة من الربان ومحددة من الشخص المعين على البر‬

C Root Cause Analysis / ‫( تحليل السبب الجذري‬Proposed by Master and defined by DPA)/(‫)مقتراحة من الربان ومحددة من الشخص المعين على البر‬

D Preventive Action / ‫( االجراءات الوقائية‬Proposed by Master and defined by DPA)/(‫)مقتراحة من الربان ومحددة من الشخص المعين على البر‬

AGREED TIME LIMIT FOR ACTION:

Revision: 01.July.2022 Approved by MD Page 1 of 2

 Form O 03 SMS Report

ACKNOWLEDGEMENT BY DEPARTMENT MANAGER/MASTER:

PERSON/ DEPARTMENT RESPONSIBLE FOR CORRECTIVE ACTION:

Date of Implemention on board:

‫تاريخ التنفيذ على متن السفينة‬ ‫( توقيع الربان‬Signature by master)

Date of Completion of Implementation:

‫تاريخ االنتهاء من التنفيذ‬ ‫( توقيع الربان‬Signature by master)

Date of reviewing and approval by DPA

(Signature by DPA)

Revision: 01.July.2022 Approved by MD Page 2 of 2