Near Miss Report
| VESSEL NAME (OPTIONAL) | VESSEL TYPE | DATE |
| DESCRIPTION OF EVENT
|
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| POSSIBLE CONSEQUENCESe.g. Personal injury such as fall, hit, burn, contact with toxic substance etc, damage (e.g. collision, grounding, fire, pollution etc) or any other.
|
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| RELEVANT FACTORS/CONDITIONS SURROUNDING THE EVENT(e.g. weather, lighting etc)
|
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| IMMEDIATE ACTION TAKEN | ||
| DIRECT CAUSE (e.g. failure to follow procedures, inadequate or defective equipment etc)
|
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| ROOT CAUSE (e.g. lack of training/familiarisation, personal factors, job factors, control management factors, instructions not clear or enforced, lack of supervision) | ||
| ACTION TAKEN ON BOARD TO AVOID RE-OCCURRENCE
|
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| ANY OTHER REMARKS | ||
Closed out on board / Office support required (delete as applicable)
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