Maib Incident Report Form PDF Details

The Maib Incident Report Form plays a crucial role in ensuring maritime safety by mandating Masters, Skippers, and Owners to report both accidents and occurrences that pose danger. This requirement, established by the Merchant Shipping (Accident Reporting and Investigation) Regulations, serves not just as a procedural necessity but as an active measure towards enhancing maritime safety standards. Accidents that lead to severe consequences such as death, significant injury, vessel loss, stranding, collisions, fires, explosions, or substantial environmental harm must be meticulously documented. Moreover, incidents threatening to lead to similar outcomes are also expected to be reported. The form outlines a comprehensive procedure for documenting the incident details, including the time, location, and nature of the incident, alongside specific sections dedicated to the details of any injuries or fatalities. It reassures those involved that completing and signing the form is not an admission of liability. The guidance emphasizes clarity in reporting and encourages contact with the Marine Accident Investigation Branch for advice. This form serves as a critical tool in understanding the circumstances leading to marine incidents, facilitating investigations, and fostering a safer maritime environment.

QuestionAnswer
Form Name MAIB Incident Report Form
Form Length 4 pages
Fillable? Yes
Fillable fields 38
Avg. time to fill out 10 min
Other names electronic accident book template, incident, accident book pdf, accident book template download

Form Preview Example

M A R I N E A C C I D E N T I N V E S T I G A T I O N B R A N C H

I nci dent R epor t F or m

F or O fficial U se R ef

C ode

T he M erchant S hipping (A ccident R eporting and I nvestigation) R egulations require M asters, S kippers and Owners to report accidents and dangerous occurrences. T hey are encouraged to report hazardous incidents as well. T he terms are explained in the R egulations and in the M erchant S hipping N otice on accident reporting. B riefly, they include any accident leading to death or significant injury, or to loss or abandonment of the vessel or to her suffering material damage; any stranding, collision, fire, explosion or major breakdown; any incident causing harm to any person or the environment; and any incident which might have led to injury or which hazarded the ship.

Please read the M erchant S hipping N otice for further details and advice, or telephone M A I B on 023 8039 5500.

One form should be completed for each incident.

Please return the completed form to: M arine A ccident I nvestigation B ranch

First Floor, C arlton House,

C arlton Place,

Southampton, SO15 2DZ,

U nited K ingdom

C ompl eti ng and si gni ng thi s for m does not consti tute an admi ssi on of l i abi l i ty of any k i nd, ei ther by the per son mak i ng the r epor t or any other per son.

Please complete the form clearly, using black or blue ink.

Please

athe boxes.

S ecti on A

Day

M onth Y ear

Date of I ncident

Name of vessel

Official Number or Fishing Number or (if non-U K ) C all Sign

Name and address of owner or manager

T ime of I ncident (state whether U T C (G M T ) or local time):

Previous name (if changed in last 6 months)

I f fishing vessel please state type (eg stern trawler, crabber etc)

Name and Port of R egistry or Flag of any other vessel involved

:

T el. No.

1

Section B

Date and time of

Voyage

departure from last port

:

from

 

From:

 

and to:

To:

 

 

 

 

 

Location of incident (eg latitude & longitude or name of port, or other geographical reference)

Responsibility: was incident caused principally by persons

on another vessel, or shoreside Yes persons, or persons not sailing

with your vessel?

No

Weather and visibility at time of incident

Type of incident (please tick appropriate boxes)

Fatal injury

 

Non-fatal injury

Vessel lost or abandoned

 

Vessel damaged

 

 

 

 

 

 

Other accident or incident

Section C - Details of person(s) killed or injured

(This section should be com- pleted if any person has been killed or injured)

Place of incident (eg engine room; galley)

How many person(s) suffered an accident which resulted in death or injuries preventing the performance of the normal full range of duties for 3 days or more after the day of the incident?

Please complete the questions in the table for each person.

Position (eg rank; rating;

 

Injured part

 

* Hours

*

*

 

Age

Kind of injury

worked before

Duration of last

 

 

passenger)

of body

Whether on duty

 

 

incident

off duty period

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

* For operational staff only

If more than 6 persons suffered reportable accidents please continue on page 4.

2

Section D

Please give a brief description of the sequence of events leading to the incident.

if necessary continue on page 4.

Section E

1.Please state how you think the incident happened.

2.Has any action been recommended by you as a result and if so, what?

3.Has any action been taken and if so, what?

if necessary continue on page 4.

3

Section F

Signed

Name

Master or Owner's repre- sentative

Date

To be completed by the ship's

Safety Officer if applicable

Signed

Name

Date

Section G

(if applicable)

If the incident involved a reportable personal accident or was a dangerous occurrence and there is an elected Safety Repre- sentative on board the vessel, he must be shown the completed report and allowed to write in this section any comments which he may wish to make. If the injured persons are represented by different Safety Representatives, each may make additional comments if desired in the space below but in any event, they should all sign the form.

Signed

Safety Representative

Name

Date

This space may be used as an extension of Sections C, D, E and G. Please state clearly which sections are being expanded.

If there is insufficient space in any part of this form for your answers or comments, please use a plain sheet of paper as a continuation sheet and fasten it securely to this form. Please indicate in the box below the number of sheets used.

Number of continuation sheets

4

How to Edit Maib Incident Report Form Online for Free

This guide provides a step-by-step approach to accurately filling out the MAIB Incident Report Form to ensure regulatory compliance.

1. General Information
Enter the incident date, vessel name, and identification details (Official Number or Call Sign). Specify the time of the incident and whether it is UTC (GMT) or local time.

2. Incident Details
Record the voyage details, weather, and visibility during the incident. Check the boxes that apply to the type of incident (e.g., fatal injury, vessel lost).

3. Location and Responsibility
Detail the incident's location with latitude and longitude or port name. Indicate who was responsible for the incident, such as another vessel or shoreside personnel.

4. Details of Person(s) Affected
List affected individuals, detailing their age, position, injury type, and whether they were on duty. Include hours worked before the incident and the duration of the last off-duty period.

5. Description and Analysis
Describe the events leading to the incident and analyze its cause. Note any actions recommended or taken to prevent similar incidents.

6. Signatures and Additional Comments
Ensure the Master or Owner's representative signs the form. If there is a Safety Officer or Representative, include their signatures and comments.

7. Attach Additional Information
If more space is needed for your responses, attach continuation sheets and indicate the number used. This ensures all pertinent information is captured for review.

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