MARINE INCIDENT REPORT

PLEASE PRINT FULL NAME AND ADDRESS OF PERSON COMPLETING REPORT

Name: John Joseph S. Candido
Address: Marintoc,Mobo,Masbate
Contact Number: 09067780822
Date: 10/07/16

Signature:

Incident Location
Date: __________________
Time: ___________
Location__________________________
Optional (if known) Latitude: ___________________
Longitude______________________

Complete each section by placing an X in the appropriate box (es).

Type of Incident
Collision
Other Incident
Of Vessel
Hit by propeller/vessel
With a fixed object
Skiing Incident
With a floating object
Parasailing Incident
With an animal
Diving Incident
With overhead object
Other ___________
With submerged object
With wharf

Grounding

Structural Failure

Intentional

Loss of Stability

Unintentional

Fire
Explosion

Capsizing

Person Overboard

Sinking

On board Injury

Swamping
Flooding
Loss of Vessel

Falls within a vessel

Crushing/Pinching
Other on board Injury

Environmental Conditions
Weather
Water
Visibility
Clear
Calm
Good
Hazy
Choppy
Fair
Cloudy
Rough
Poor
Rain
Very Rough
Flood
Strong current
Time of Day
Fog
Night
Day
Sunrise

Wind

Wind Direction

None

SW

Light (1>8 knots)

Moderate (8>15 knots)

E SE

Strong (15>20 knots)

Storm (over 30 knots)

NE
Unknown

Twilight

Location
Inland Waters (eg. River, estuary, lake, dam)
Major damage
Inshore Waters (up to 3 nm offshore)
Moderate damage
Enclosed Waters (eg. Bay/Harbour)
No damage
Offshore Waters (more than 3 nm offshore)
Property damage only

Operation at Time of Incident

Underway
Being towed
Fuelling/Bunkering
Towing
Drifting

Contributing Factors (Environmental)

(Equipment)
Restricted visibility
stability
Tidal conditions
Equipment failure
Floating/Submerged object
Wind/Sea state
Bar conditions
Wash of passing vessel
Others _______________
_______________

Severity
Fatal incident
Serious injury
Vessel lost

Berthing

Tied to berth

At anchor

Others ______________

Material

Factor

Inadequate

Machinery
Navigation
Electrical
Hull failure
Others

Vessel Type
Commercial / Merchant
Passenger (Class 1)
Others __________
Passenger (Class 2)
Fishing Boat (Class 3)
Hire and drive (Class 4)

Recreational
Motor Boat
Paddle boat (canoe, etc.)
House Boat
Sailing Boat

Ship Particulars
Name of vessel:
_____________________________
Type of Vessel:
_____________________________
Year Built:
_____________________________
Length Overall:
_____________________________
Breadth Moulded:
_____________________________
Gross Tonnage:
_____________________________
Service Speed:
_____________________________

Hull Material
Steel
Fiberglass/GRP

Aluminum
Ferro-Cement

Timber
Other ______________

INCIDENT DESCRIPTION
Use the space below to provide a full discussion (including a diagram) of the incident and events
leading up to the incident. (if insufficient space, provided a separate page)

Description of Damage to Vessel:

Description of the Incident:

Diagram of Incident:

DECLARATION (To be signed by the person completing the incident report)

I declare that the information provided by me in this incident report is true to the best of my
knowledge and belief and that I have made this report knowing that if it is tendered in evidence I
will be guilty of a crime if I have wilfully included in this report which I know to be false or that I
do not believe to be true.
Signed:
______________________________________
_______________________________
Witness:
_____________________________________
_______________________________
Date: ________________________________________

Print

Name:

Print

Name: