Near Miss Report

VESSEL NAME (OPTIONAL)  VESSEL TYPE DATE
DESCRIPTION OF EVENT 

 

 

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.

 

RELEVANT FACTORS/CONDITIONS SURROUNDING THE EVENT(e.g. weather, lighting etc)

 

 

IMMEDIATE ACTION TAKEN 
DIRECT CAUSE (e.g. failure to follow procedures, inadequate or defective equipment etc) 

 

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 

 

 

ANY OTHER REMARKS

 

Closed out on board / Office support required (delete as applicable)

 

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