Please return without delay to:

Bundesstelle für Seeunfalluntersuchung (BSU)

Bernhard-Nocht-Str. 78

D-20359 Hamburg

Merchant Shipping
Sea/Marine Accident Report Form

Nature of accident

Location of accident

Time of accident (date and time)

Voyage 1st vessel involved 2nd vessel involved

from
to

Last port of departure

Purpose of voyage

1. Vessel particulars
Name of vessel

Kind/Nature/Type

Nationality / Flag

IMO Identification Number

MMSI Number

Call sign / Register No.

Port of Registry

Size in BRZ (gross space figure)/GRT

NRZ (net space figure)//NRT

Deadweight in m/t

Displacement at time of accident

Length overall

Breadth overall

Draft at time of accident F M A F M A

Year and place built

2. Propulsion
Main engine(s) (type, maker)

Engine power (HP/kW)

Propulsion (type and number)

(screw, Voith, jet, etc.)

Service speed

Speed at time of accident

3. Owner/Operator/
Agent/Charterer
Owner
(Name and postal address)
Ship's husband/
Supplier/Charterer/
Freighter
(Name and postal address)

4. Persons on board at
time of accident
Crew (number)
Other persons (status/number)

Captain/Master (name)

Other participants (status/names)

(use extra sheet if necessary)

5. Damage
Personal injury
brief description

Property damage
brief description

6. Whereabouts of vessels

7. Weather, sea and Wind (direction and force) Sea state/swell (direction and force)
current
at time of accident
Visibility Clouds/rainfall

Air temperature Water temperature

Current direction and intensity

HW (time) LW (time) Water level

Standard port Sunrise Sunset

Other data

Place: Date

___________________ ___________________ ______________________________

(Signature)
 Annex Crew

1. Ship's Crew – Passengers – Persons Involved – Witnesses

Ship's crew certificate Copy

issued on attached not attached
issued by valid until

Number of crew acc. to crew certificate

Actually on board Crew list

attached not attached
Missing crew members (number, rank)

Other persons on board List of persons

(number and status)
attached not attached

2. Master and crew

(insofar as these were involved in the accident or made observations as witnesses)

Rank Name, first name Address/telephone no. License/qualification Location and function
date of birth at time of accident
Master

1st Officer

2nd Officer

3rd Officer

Chief Eng.

2nd Eng.

3rd Eng.

Other persons
Helmsman

Lookout

Pilot(s)
 Annex Radar

Particulars of radar use

Please use a separate form for each radar unit!

Number of radar units on board

1. Unit particulars
Maker/manufacturer Type/model Unit No.

Year built Last service Range Nature of display

2. Operation particulars
Operating mode at time of accident/nature of In operation since Range selected
display
Anti-clutter for sea and rain Force

o no o yes
Image quality Interference

Plotting carried out Plotting method Whereabouts of plotting documents

o no o yes

3. Particulars of radar observer

Rank

Name First name Date of birth Place of birth

Address

License issued on issued by

Nature of radar observation Duration of observation from - to Breaks from - to

permanent with interruptions occasional

Activities before taking over radar observation

4. Particulars of observation
First location of targets

Range in miles Distance Direction Time

Manoeuvre started on basis of radar image Manoeuvre started on basis of optical sighting

Special observations regarding accident none see report

5. Shore radar advice

Station Advised as of

Name of adviser First name Date of birth Place of birth

Address

License issued on issued by

Report of radar adviser attached

yes no
 Check list I

1. Supplementary vessel particulars

1.1 Vessel particulars

Construction yard Construction material

Class/special class features Classification society

Length between perpendiculars Moulded breadth

Draft
at port of departure before the accident after the accident
F M A F M A F M A

Trim
at port of departure before the accident after the accident

List (degrees port/stbd)

at port of departure before the accident after the accident

Stability (GM in cm, period of roll in sec.)

at port of departure before the accident after the accident

Special features/Remarks

1.2 Propulsion/bunker/stores
Type of propulsion
Nature and number Direction of rotation
- Fixed-pitch propeller

Number and arrangement

- Variable-pitch propeller

Number and arrangement

- Voith-Schneider

Number and arrangement

- Azipod drive/Schottel drive

Number and arrangement

- Jet drive

- Other

Nature and amount at time of accident Consumption/h

Fuel

Nature and amount

Lubricants

Nature and amount

Hydraulic fluids

Nature and amount

Other water-hazardous substances

Ballast

1. Supplementary vessel particulars

Check list I A
1.3 Manoeuvring units
Rudder/steering gear
Type Operating mode

Rudder design Maximum rudder angle

e.g. high-performance rudder/Becker's
rudder

Infinitely variable drive used yes no

Automatic pilot (maker/manufacturer) In operation Type/nature and number of rudder blades

yes / no

Special features/Remarks

Bow thruster
Nature and number Output

Stern thruster
Nature and number Output

1.4 Manoeuvring data

Maximum speed

Speed at time of accident through the water over ground

Speed table

Loaded In ballast

Sea River Sea River

Full ahead

Half ahead

Low ahead

Very slow
ahead
Output astern
%
Stopping distance and time (full ahead to full astern) m min

Reversing time

Turning circle to port to stbd

at full speed ahead in ballast loaded

Maximum path ahead in hard rudder position fully loaded m ballast m

Special features/Remarks

1. Supplementary vessel particulars

Check list I B
1.5 Navigational equipment
Number Kind Make Date of last inspection In operation
if appropriate yes / no
Standard magnetic
compass

Gyro compass

Echo sounder/
Echograph

Log

Radar

Automatic tracking aid

LORAN unit

Satellite navigator

Turn indicator

Radioequipment

Daylight signalling
lamp
Transmitting heading
device (THD)
Automatic identifi-
cation system (AIS)
Track control system

Voyage data recorder

(VDR)
Other

Nautical charts and

nautical publications
 Check list II
When checking ship's papers always note:
2. Ship's papers issued on, issued by, valid until, if appropriate scope of validity etc.

2.1 Sea ships

2.1.1 General ship's papers

Certificate of registry

Other flag certificate

Tonnage certificate

Sailing permit (trade range)

Class certificate

2.1.2 Safety certificate (national/international)

Safety certificate (for passenger vessels)

Safety construction certificate (for cargo ships)

Safety construction and equipment certificate

Safety radiotelegraphy certificate (for cargo ships)

Radiotelephony certificate (for cargo ships)

Exemption certificate

Freeboard certificate

International certificate of fitness for the carriage of dangerous chemical in bulk

International certificate of fitness for the carriage of liquefied gas in bulk

International oil pollution prevention certificate

International pollution prevention certificate for the carriage of noxious liquid substances in bulk

International sewage pollution prevention certificate

Document authorisation for the carriage of grain (Grain Certificate)

Document of compliance with the regulations of SOLAS (IX/4.1 and 4.2) (International Ship Safety Management – ISM)

Safety Management Certificate (SMC) SOLAS Rule IX/4.3

High-speed Craft Safety Certificate (SOLAS Rule X/3)

Permit to operate high-speed craft in accordance with Section 1.9 of the HSC Code
 2. Ship's papers
Check list II A

2.1.3 Log books

Oil log

Cargo log

2.1.4 Miscellaneous

Transfer certificate

issued on: by:

Certificate of fitness to be towed

issued on: by:

 Check list III

3. Details of the marine accident (insofar as these are not contained in the attached documents)

3.1 Voyage prior to the marine accident

Guidelines for the voyage planning in accordance with Rule 34 Solas Chap. V
Decision A893 (21) maintained and documented: yes no
if appropriate documented by:

In the event of accidents with pilot on boards

Pilot Card handed out: yes no
If no, why not?

Voyage planning/manoeuvre planning

discussed and agreed with pilot yes no

3.2 Position/measures before the accident incident

Type of navigation

terrestrial celestial radio nav. radar

Last determined ship's position

Last courses/distances steered

Last rates of speed/speed through water

Advice from shore radar/coastal radio station or the like

First detection of other vessel/object

Bearing Distance

Navigational obstacles

environmental (e.g. weather or traffic situation) personal (e.g. fatigue, illness, alcohol)

Visual signals set/seen

lights shapes perceptibility

Sound signals given/heard

frequency

3. Details of the marine accident

 Check list III A

3.3 Watch crews at the time of the accident

Bridge

Deck

Engine

Sea chart(s) used last amended:

worked with:
paper sea chart yes no

ECDIS licensed on: by:

only with Ecdis (no paper charts necessary any longer)

Manoeuvres – engine/rudder

Command Execution Manoeuvre signals (which?)

Execution

Signals given
no yes if yes, which?

3.4 Position/activities after the accident incident

Position

Contact established with the other party to the accident

Exchange of news/information

- with the other party to the accident

- with other bodies

- content of the information

- compulsory reports

Search, rescue, salvage actions

Assistance and support provisions to/by third parties an

Tug Ice breaker Other

Details if appropriate Requested

Protection and safeguarding provisions

Provisions to limitation of damage

 3. Details of the marine accident
Check list III B

3.5 Consequences of the accident

Nature of the accident

Nature of the injury/damage

- Personal injury

l Injured persons, fatalities, missing persons (name and address, function)

l Personal particulars

- Damage to ship

- Damage to cargo

- Damage to third parties

- Damage/pollution to waters

Amount of loss/damage

Cause of accident – if appropriate reasons why cause was not investigated

Other particulars relating to the marine accident

 Check list IV

1. Documents – records – plans etc.

Insofar as appropriate or necessary,

particulars on the following points:
1) – on board
2) - kept
3) – entries changed
4) - studied
5) – extracts made
6) - copied
7) - secured/confiscated

Ship's log

Bridge log/daybook

Engine log

Manoeuvre log/daybook

Radio log/daybook

Manoeuvre recorder/printer

Course recorder/printer

Data printer

Navigational publications and directories

Sea charts used – last on board amendments

General arrangement drawing

Individual drawings

Stability documents

Stowage plan

Miscellaneous

Check list V

5. Cargo particulars
Cargo
Nature

Deck cargo
Nature

Obstacles to visibility

no yes, if appropriate nature of obstacles to visibility

Dangerous goods

Nature

Quantity

Stowage

Special instructions

If appropriate specification

Ballast

Nature

Quantity

Other cargo particulars

 Check list VI

6. Data sheet for preparing an activity profile

Name of vessel: Rank:

Name: Education:
Qualification:
Address:
Telephone: Telefax:
Operator:
Telephone: Telefax:
Date of embarkation: Port of embarkation:
Duration of voyage:

Overview of activities in the 96 hours before the accident

(Day X = date of accident)

Hour Day 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

X–4

X–3

X–2

X- 1

Day X

(X: time of accident; F: food/meals; W: watch duty; M: maintenance work; S: sleep; C: cargo watch;
R: recreation times including time on shore; A: alcohol consumption)

Health status:
Personal particulars:
Documents to be enclosed with the questionnaire (where available):

o Detailed report by the Master on the course and cause of the marine accident
o Report by the watch-keeping officer
o Sketches of the accident
o Photos
o Prints of the course recorder, data printer, relevant evidence
o Extracts from deck and engine logs
o Records by the vessel particulars recorder
o Statements by witnesses of the accident
o Crew list and crew certificate
o Reports by surveyors
o Expert opinions by experts (if appropriate post mortem findings too)
o Inspection reports by domestic or foreign authorities (e.g. water police)
o General arrangement plan of the vessel
o Detail drawings (e.g. engine room, ventilation systems, machinery and equipment,
hatches) cargo handling gear, anchorage
o Further data for investigating the cause of the accident:
o Bridge Poster
o Pilot Card

_______________________ __________________________ ______________

Place Date Company/Authority/Office Signature