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 Marine Casualty Investigation

Dashboard My courses Marine Casualty Investigation Evaluation Case Study Assessment
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Question 1
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  ACCIDENT & INCIDENT  INVESTIGATION FORM             
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Marked out of
 Initial Report (Section A)               

 Full Report (Section A + B)  
1

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question A     
IGOR NAUMOVYCH

1 2
Lat:   34346 N

KYOKUHO MARU NO.2
Vessel’s Long: 135231 E
Vessel :
Posi on:
Finish attempt ...
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(Exmp: Lat: 45.6 N    Long: 056.7 W)

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Day:       07

Day:       07
Month: Feb
Month: Feb
Date &
Date & Time
Time of
Year:     2012 Reported : Year:     2012
Occurrence :

Time:     1247 LT
Time:     1226 LT
(Exmp: 1525 ) LT

(Exmp: 1525 ) LT

Reported
Master Reported To : Company A
By:

Report Report Issued Master

02/2012
Number: by
(Your Name - Your Rank)

Details of Injured / Affected Person(s):

Second Officer: male, 56 Fifth grade maritime officer (navigation) Date of issue: Septem

Type of Effects

Fatality
First Aid Case (FAC)
Rest. Work Case (RWC)
Med. Treatment Case (MTC)
Lost Work day Case (LWC)
Perm. Partial Disability (PPD)
Perm. Tot. Disability (PTD)
  

Type of Occurrence

Fall from elevation

Fall from same level (slips, trips)
Struck against
Struck by
Hit by particles/debris
Caught by/in/between
Cut by/in/with
Exposure to heat
Exposure to cold
Exposure to electricity
Exposure to radiation
Exposure to noise
Exposure to smoke/fumes
Exposure to chemicals
Exposure to biological
Manual Handling/Carrying
Over stress/Ergonomic factors

Other Personal Injuries     :  No If yes,  no

Body Location of Injuries  :  no

Loca on of Occurrence

Accommodation
Bridge
Deck
Engine Room - Machinery Spaces
Pump rooms
Enclosed Spaces(Cargo/Bunker)
Enclosed Spaces (Ballast)
Enclosed Spaces (Machinery)
Aloft-overboard
Ashore

Type of Work

Mooring/Lifting/Rope handling
Deck & Engine Departmrnt Operational Work
Galley/Catering Work
Inspection, Repair, Maintenance
Drills/Testing/Exercising
Transit/Access
Non-Work Related
Other

Condi ons & Addi onal Details

Vessel Sea
At sea Weather was Cloudy Calm
was was

Ligh ng 9C Sea
Good Air Temp. 10 C
was Temp.
 

Wind
2 m/s Other                                    wind velocity: 2.0 m/s;
Force

Seafarer was:                                                                                   At authorised place of work Sober On

Duty  

(If yes, total hours worked prior to accident)                      10

Number of hours worked in 24 hours prior to the accident:   10

Was protective clothing/equipment being used?                 Yes  

Was negligence or in misconduct a factor?                               Yes

Was breakage of equipment/ rope a contributory factor?    No   

 If yes, state type of equipment:                                      no  

Nature of Failure:                                                        failure to use proper equip

Descrip on of Accident

The chemical tanker KYOKUHO MARU No.2 left Komatsu Wharf, Izumi-otsu Port, Izumi-otsu 

Additional Sheets Attached:                        Yes  

Photographs Attached:                                                                    Yes  

Medical Treatment given on board & By Whom:                         No  

                                                                         If yes;  no  

Witness(s) Name and Rank

Chief Engineermale 35 Sixt  

Furnished Witness(s) Statements of Occurrence - attached to this form  Yes

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