This section captures essential identification details of the vessel, offshore installation, or facility involved in the incident. Accurate identification is critical for international maritime authorities and classification societies.
Vessel/Platform Name
IMO Number/Unique Identifier
Flag State/Registry
Classification Society
Vessel Type/Platform Function
Gross Tonnage (GT)
Operator/Company Name
Operator Contact Email
24-Hour Emergency Contact Number
Provide fundamental details about the incident occurrence. This information enables rapid categorization and prioritization by response authorities worldwide.
Date & Time of Incident (UTC)
Date & Time Report Submitted (UTC)
Incident Status at Time of Reporting
Ongoing
Contained
Resolved
Escalating
Describe current ongoing situation and immediate risks:
Explain escalation factors and additional resources required:
Primary Incident Category (Select all that apply)
Collision
Grounding/Stranding
Fire/Explosion
Structural Failure
Equipment Failure
Pollution Event
Personnel Injury/Fatality
Security Incident
Adverse Weather Damage
Navigational Error
Cargo Shift/Loss
Loss of Propulsion/Steering
Offshore Platform Incident
Underwater Hazard Contact
Initial Severity Rating (1=Minor, 5=Catastrophic)
Has this incident resulted in any pollution to the marine environment?
A dedicated Pollution Event Details section will appear later in this form. Please complete all pollution-related questions thoroughly.
Proceed to the Casualties & Damage Assessment sections as applicable.
Precise location data is essential for emergency response coordination, pollution trajectory modeling, and maritime safety analysis. Provide all available positional information.
Latitude (Decimal Degrees)
Longitude (Decimal Degrees)
Water Depth at Location (meters)
Location Type
International Waters
Territorial Waters
Exclusive Economic Zone (EEZ)
Port/Anchorage
Coastal Waters (<12nm)
Restricted Waterways
Offshore Installation Area
Marine Protected Area
Describe the protected area designation and potential environmental sensitivity:
Nearest Landmark/Port/Offshore Installation
Is the vessel/platform within any designated Particularly Sensitive Sea Area (PSSA)?
Specify PSSA name and any special reporting requirements:
Is the incident location within a mandatory Ship Routing or Reporting System?
Specify system name (e.g., TSS, MAREP) and any notifications made:
Meteorological and oceanographic conditions significantly influence incident causation, response effectiveness, and pollution behavior. Provide objective observations where possible.
Wind Direction & Speed (knots)
Sea State (Beaufort Scale)
Wave Height & Direction (meters)
Visibility (nautical miles)
Current Speed & Direction (knots)
Air & Sea Temperature (°C)
Were there any abnormal meteorological phenomena (e.g., squall, waterspout, ice accretion)?
Describe the phenomenon and its impact on the incident:
Were accurate weather forecasts available prior to the incident?
Explain limitations in weather information availability:
Understanding the operational mode and status of the vessel/platform provides critical context for root cause analysis and regulatory assessment.
Operational Status at Time of Incident
Underway - Coastal Navigation
Underway - Ocean Passage
At Anchor
Mooring/Manoeuvring
Cargo Operations
Bunkering/Refuelling
Tank Cleaning
Maintenance/Repairs
Standby/Drifting
Platform Drilling Operations
Platform Production Operations
Platform Under Tow
Total Persons Onboard (POB)
Total Crew Onboard
Passengers/Contractors/Visitors Onboard
Cargo Onboard (Type & Quantity)
Ballast Condition
Were cargo/ballast operations in progress at time of incident?
Specify operation phase and any deviations from procedure:
Was a navigation watch properly established?
Explain watchkeeping arrangements and any deficiencies:
This section must be completed if any pollution was indicated in the Incident Overview. Provide comprehensive details for spill assessment, trajectory modeling, and response resource allocation.
Pollutant Type(s) Released
Crude Oil
Heavy Fuel Oil (HFO)
Marine Diesel/Gas Oil
Lubricating Oil
Chemicals (Hazardous Liquid)
Chemicals (Hazardous Solid)
Sewage/Grey Water
Garbage/Plastics
Ballast Water
Bilge Water
Natural Gas/LNG
Other Substance
Estimated Total Quantity Released (with units)
Rate of Release (if continuous)
Time Pollution Started
Time Pollution Stopped (if applicable)
Source of Pollution
Cargo Tank/Pipeline
Fuel Tank/Pipeline
Bunkering Hose
Engine Room/Bilge
Container Overboard
Platform Process System
Platform Pipeline
Subsea Wellhead
Other Source
Is the source completely secured and stopped?
Describe ongoing release and containment challenges:
Has a pollutant trajectory been modeled?
Provide trajectory direction, speed, and predicted shoreline impact:
Are sensitive environmental resources at risk?
Identify at-risk resources (fisheries, marine sanctuaries, coastlines):
Pollution Response Effectiveness Assessment
Very Poor
Poor
Adequate
Good
Excellent
Document all human impacts resulting from the incident. This information is critical for search and rescue coordination and casualty investigation.
Were there any fatalities as a result of this incident?
Number of Fatalities
Were there any injuries requiring medical attention?
Number of Injured Persons
Were any personnel reported missing?
Number of Missing Persons
Was medical evacuation (MEDEVAC) required?
Specify number evacuated, method (helicopter/vessel), and receiving medical facility:
Are all surviving persons accounted for and in safe condition?
Describe safety status and any ongoing risks to personnel:
Injury Details Summary
Personnel ID/Initials | Role/Position | Injury Type/Severity | Hospitalization Required? | Current Status | ||
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Comprehensive damage evaluation is essential for determining vessel/platform seaworthiness, pollution risk, and salvage requirements.
Has the vessel/platform sustained any structural damage?
Describe location, extent, and nature of structural damage:
Is there damage to the hull affecting watertight integrity?
Specify breach location, size, and ingress rate if known:
Are there any machinery or equipment failures?
Failed Systems/Equipment
Main Engine
Auxiliary Engine
Steering Gear
Navigation Systems
Communications
Pollution Control Equipment
Firefighting Systems
Ballast System
Cargo Pumps
Dynamic Positioning
Other Critical Equipment
Has the vessel lost propulsion or steering capability?
Specify systems affected and estimated time to restoration:
Is the vessel/platform in danger of sinking or capsizing?
Provide stability assessment and urgency of salvage intervention:
Overall Damage Severity (1=Superficial, 5=Severe/Total Loss)
Has a formal damage stability assessment been conducted?
Assessment Reference Number
Explain why assessment has not been possible:
Document all immediate actions taken to secure the vessel/platform, protect personnel, and mitigate environmental damage. This demonstrates compliance with international safety management principles.
Was the Emergency Alarm sounded and muster stations activated?
Explain alternative notification method and any delays:
Was the Ship/Platform Emergency Response Plan activated?
Specify which procedures were implemented ad-hoc:
Were pollution containment measures deployed (booms, dispersants, etc.)?
Specify equipment deployed, deployment time, and effectiveness:
Was there any evacuation of non-essential personnel?
Specify number evacuated, method, and safe refuge location:
Were firefighting or other emergency teams mustered?
Specify team type and response actions taken:
Has the vessel been anchored, beached, or taken under tow for safety?
Provide details of action taken and current status:
Overall Emergency Response Effectiveness
Chaotic
Poor
Adequate
Good
Outstanding
Record all external support received or requested, including search and rescue, salvage, and pollution response resources.
Has a MAYDAY or PAN-PAN been broadcast?
Specify time broadcast and any responding stations:
Are Search and Rescue (SAR) services involved?
Specify SAR authority, assets deployed, and coordination frequency:
Has a salvage or towage contract been initiated?
Specify contractor, contract type (LOF, Towcon), and ETA on scene:
Are specialized pollution response resources deployed?
Specify resources (vessels, aircraft, equipment) and responsible authority:
Has the vessel/platform been requested to proceed to a place of refuge?
Specify refuge location and any conditions imposed:
External Resources On Scene
Resource Name/Callsign | Resource Type | Organization/Authority | ETA/Time On Scene | Role/Function | ||
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Collect contact information for all key witnesses and personnel involved in the incident. Statements should be obtained as soon as practicable while memories are fresh.
Master/Officer in Charge Full Name
Master/OIC License/Certificate Number
Master/OIC Contact Details
Has the Master/OIC provided a preliminary statement?
Ensure statement is obtained within 24 hours if practicable and safe to do so.
Were other vessels/platforms in vicinity that may have witnessed the incident?
List vessel names, call signs, and approximate distances:
Key Witness Contact Log
Witness Name | Role/Position | Contact Method | Statement Obtained? | Statement Reference | ||
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Document all notifications made to coastal states, flag states, and international bodies. Timely reporting is a legal requirement under MARPOL, SOLAS, and other international conventions.
Has the Flag State Administration been formally notified?
Flag State Notification Time (UTC)
Explain reason for delay and planned notification time:
Has the Coastal State/Port Authority been notified?
Specify authority name, contact person, and acknowledgment received:
Has the incident been reported to the Regional Port State Control (PSC) Authority?
PSC Report Reference Number
Has the classification society been notified?
Classification Society Notification Time
Has the vessel's insurance provider (P&I Club) been notified?
P&I Club Reference Number
For pollution events: Has the Regional Oil Spill Response Centre been activated?
Response Centre Case Number
For security incidents: Has the Designated Authority (SOLAS XI-2) been notified?
Security Incident Reference
Which IMO Instruments are potentially applicable to this incident?
MARPOL 73/78
SOLAS 1974
STCW 1978
COLREGS 1972
LLMC 1976
CLC 1992
Fund Convention
SAR Convention
OPRC 1990
Other
Preserve all evidence and documentation for investigation purposes. Digital evidence is critical for reconstructing events and determining causation.
Has the Voyage Data Recorder (VDR) been secured and data preserved?
VDR Data Download Reference
Explain why VDR data could not be secured:
Have engine room and bridge logbooks been preserved?
Specify alternative record-keeping measures:
Have nautical charts and passage plans been secured?
Have relevant maintenance records been preserved?
Records Location/Storage Reference
Upload Photographs of Damage/Pollution (if safe to obtain)
Upload Supporting Documents (log extracts, checklists, etc.)
Has a formal chain of custody been established for evidence?
Establish chain of custody immediately to ensure evidence admissibility.
Evidence Inventory Log
Evidence Item | Format (Digital/Physical) | Custodian Name | Time Secured | Storage Location | ||
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Outline planned and completed actions following the incident. This demonstrates proactive safety management and commitment to preventing recurrence.
Has a preliminary root cause analysis been conducted?
Summarize preliminary findings and contributing factors:
Have immediate corrective actions been implemented?
List actions taken to prevent immediate recurrence:
Has a formal incident investigation team been appointed?
Investigation Team Leader Name
Specify timeline for investigation team appointment:
Will the vessel/platform proceed to a repair facility?
Intended Repair Port/Facility
Is there a need for ongoing environmental monitoring?
Specify monitoring plan, parameters, and duration:
Has a media/public statement been prepared?
Spokesperson Contact Information
Next Incident Review/Update Date
The undersigned declares that the information provided in this report is, to the best of their knowledge, accurate and complete at the time of submission. False declaration may constitute a serious breach of international maritime law.
Report Prepared By (Full Name & Position)
Report Prepared By Contact Details
Signature of Preparer
Signature Date & Time (UTC)
Authorized By (If different from preparer)
Is this an initial report or an update?
Additional Comments or Information Not Covered Above
To configure an element, select it on the form.