Fillable BOARD OF PILOT COMMISSIONERS MARINE INCIDENT REPORT (MyFloridaLicense)

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BOARD OF PILOT COMMISSIONERS MARINE INCIDENT REPORT (MyFloridaLicense)

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BOARD OF PILOT COMMISSIONERS
MARINE INCIDENT REPORT
Section 310.111, Florida Statutes, and the Rules of the Board of Pilot Commissioners
promulgated thereunder, require the reporting of all collisions, groundings, strandings or other
marine perils sustained by vessels on which there was employed a licensed State Pilot or
Certified Deputy Pilot. This shall be reported to the office of the Board or the piloting consultant
within 48 hours of the occurrence. In addition, a written report shall be submitted to the
Department on forms and in the manner prescribed by the Department within seven (7) days of
the occurrence. HOWEVER ANY MARINE INCIDENT INVOLVING OIL SPILLAGE,
POLLUTION, PHYSICAL INJURY OR DEATH S
HALL BE REPORTED TO THE BOARD OR
THE PILOTING CONSULTANT BY TELEPHONE OR TELEGRAM WITHIN 24 HOURS OF
THE OCCURRENCE IN ADDITION TO THE REQUIRED WRITTEN REPORT.
SEND TO: Board of Pilot Commissioners or Galen Dunton
2601 Blair Stone Road 1770 Hammock Drive
Tallahassee, FL 32399-0773 Amelia Island, FL 32034
850.717.1980 904.277.0039
850.617.4456 (fax) 865.251.9761 (fax)
NOTE: “Not Available” or “N/A” is not an acceptable response to any question. Failure to fully
and accurately complete this report will result in disciplinary action against the licensed State
Pilot or Certified Deputy Pilot.
1. Name and License Number of Pilot:
2. Port:
3. Date of filing of this report:
4. Initial report of incident as required by Section 310.111, Florida Statutes:
Date:
Time: AM / PM
Indicate if the incident was reported to the Board Office or to the Pilot Consultant.
5. Was there any oil spillage, pollution, physical injury or death involved in this incident?
YES NO
If the answer is “YES”, give complete details of the oil spillage, physical injury or death
on a separate sheet to be attached to this report.
6. Name of vessel, type, flag, and gross registered tonnage upon which you were serving
as Pilot:
1
7. Length and beam of vessel:
8. If U.S. flag vessel, indicate whether operating under register or enrollment. If uncertain,
provide available information concerning employment: last port, next port, origin, or
destination of cargo discharged or loaded, etc.
9. If the incident was a collision, name, flag, type and gross registered tonnage of the other
vessel(s) involved:
10. If the incident was not a collision but involved striking a dock or wharf, a moored vessel
or other property, give the name of the vessel(s) or other property involved:
11. Were tugs being utilized during the incident?
YES NO
If the answer is “YES”, provide the name of the tug(s), horsepower of the tug(s) and the
propulsion type of the tug(s).
12. Provide the specific position of the incident (describe in terms of channel, nearby buoys,
lights, daymarks, pier or berth designations, etc.).
13. Provide the specific nature of the incident.
2
3
14. Time and location of the boarding and leaving of the vessel by the Pilot:
15. Weather conditions at the time of the incident:
General description of weather:
State of tide:
Wind direction (from):
Speed (knots):
Current direction (from):
Force (knots):
16. Drafts of your vessel at the time of the incident:
Forward:
Midships: Aft:
17. Depth of water at position of incident:
18. Detailed description of damage to vessel you were piloting, if any:
19. Detailed description of damage to other vessel(s) of property, if any:
20. Name, address and phone number of agent vessel upon which you were serving as
Pilot:
21. Name, address and phone number of agent and/or owner of other vessel(s) or property
involved:
You should attach a copy of the bell book or the ship’s log entries covering this incident. If
necessary, you may attach additional pages containing remarks or comments regarding this
incident.
________________________________
Signature of Pilot Print Name of Pilot
/________________ ________________________________
Date DP/SP License # Telephone Number
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BOARD OF PILOT COMMISSIONERS MARINE INCIDENT REPORT (MyFloridaLicense)

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Completed 21 January 2021

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