REPORT OF NON-CONFORMITY, ACCIDENT, NEAR MISS & HAZARDOUS

OCCURRENCES

Ship’s : Reported by : Ship

Name Department
IMO No. : Report No. / : /
Date
Port : Date Rectified :

Type of Report
`
☐ Non-conformity ☐ PSC Deficiency ☐ Hazardous
(Safety) Occurrence
☐ Non-conformity ☐ PSC Detention ☐ Near Miss
(Security)
☐ Classification Society ☐ DPA – ☐ Accident
Superintendent
☐ Flag State – RO ☐ P&I Inspection ☐ Other

Process: This report should be filled in, whenever a non-conformity, accident, or hazardous
occurrence is reported. In the same report the possible cause, the corrective actions, the name of
responsible person to carry out the corrective action and the spare parts which have been used or
requested, should be declared. A copy of this report should remain onboard the ship and the
original one should be forwarded to the Head Offices of the Company.

Description of the incident / non-conformity (exact description, data, facts)

Corrective Action(s):

Preventive Action(s):

DPA Evaluation and Remarks(s):

Report of Non-Conformity, Accident & Hazardous Occurrences Page 1 of

Report 2
 Master Signature Designated Person
Signature

Report of Non-Conformity, Accident & Hazardous Occurrences Page 2 of

Report 2