The process for incident reporting within an organization is often one of the most important protocols to set in place as part of an effective safety program. Without accurate and timely incident record keeping, organizations risk wasting valuable resources on inefficient response times and inadequate investigation efforts. To ensure that all incidents are reported quickly and efficiently, it is beneficial to have a standard protocol in place such as a Maib Incident Report Form. These forms provide detailed information about accidents, injuries, property damage or losses due to negligence, allowing management teams to make informed decisions regarding preventative measures while keeping track of legalities stemming from incidents occurring in your organization. Here we will break down what exactly comprises a Maib Incident Report Form so you can be confident your processes promote consistent analysis with each case that comes up.
| Question | Answer |
|---|---|
| Form Name | Maib Incident Report Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | electronic accident book template, ncident, accident book pdf, accident book template download |
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
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
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T el. No.
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Section B
Date and time of
Voyage |
departure from last port
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from |
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From: |
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and to: |
To: |
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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 |
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Vessel lost or abandoned |
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Vessel damaged |
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Other accident or incident |
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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; |
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Injured part |
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Age |
Kind of injury |
worked before |
Duration of last |
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passenger) |
of body |
Whether on duty |
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incident |
off duty period |
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* 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