Fillable Form 2: Near Miss / Safety Observations / (Port of London Authority)

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Form 2: Near Miss / Safety Observations / (Port of London Authority)

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  • 92 check-boxes
  • 25 other fields

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File type: PDF

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Near Miss / Safety Observations / Incident, Non-compliant
Pilot Transfer and Boarding Arrangements
Number: FM 0221
Issue:
2
Date: 13/01/2020
AUTHOR: DHM (Lower) Reviewed by: DHM (Lower) Document ID: FM 0221
OWNER: Harbour Master (SMS & VTS) Review Date: 13/01/2020 Review Due: 13/01/2021
This form is to be used for all Marine incidents (Incident / Near miss /Safety Observations, Non-compliant Pilot
Transfer and Boarding Arrangements). Completed forms are to be returned to the Harbour Masters department
within 24 hours.
SECTION 1 – PERSONNEL DETAILS
PLA Staff ☐
PLA / Medway Pilot ☐
PEC Holder ☐
Master / Owner ☐
Other (State) ☐____________
Surname:
Job Title or No:
Email Address:
SECTION 2 – VESSEL DETAILS
Vessel Name
Container Vessel ☐
PLA Vessel ☐
IMO Number
Dredger ☐
Recreational Vessel ☐
LOA
Fishing Vessel ☐
Ro-Ro Vessel ☐
Beam
General Cargo ☐
Tanker ☐
Draft
Government / Military ☐
Tug ☐
Air Draft
Hovercraft ☐
Workboat ☐
Freeboard
Large commercial yacht ☐
Other (Please specify)
Loaded / Ballast
Passenger Vessel ☐
Specified Vessel
Yes ☐ No ☐
Pilot Boat ☐
Manoeuvring Characteristic:
SECTION 3 – INCIDENT DETAIL & CATEGORY
Incident ☐
Near Miss ☐
Location:
Time:
Date:
Embarking / Boarding ☐
Disembarking / Landing ☐
Underway / Making way ☐
At Anchor / Berthed ☐
Category of Incident or Near Miss (Please tick all that apply)
Breach of Regulations ☐
Security ☐
Collision ☐
Non-Compliant Pilot Transfer Arrangement ☐
Contact ☐
Non-Complaint Boarding Arrangement ☐
Deficiency Fire / Explosion ☐
Wash / Draw off ☐
Environment ☐
Other (Please State): ☐
Floating Hazard ☐
Loss of hull Integrity ☐
Man overboard ☐
Navigation Hazard ☐
Pollution ☐
Swamping ☐
SECTION 4 –WEATHER & TIDAL INFORMATION (Please tick all that apply)
Weather
Visibility (mile)
Wind Speed / Gusts
& Direction
Sea State
Swell Height
Light
Conditions
Tidal
Information
Clear ☐
V Good > 25 ☐
0-10kts ☐
Calm ☐
0-0.5m
☐
Daylight ☐
HW ___:____
Fog/Mist ☐
Good < 25 ☐
10-20kts ☐ ☐
Slight ☐
0.5-1.0m ☐
Dawn ☐
STN ________
Rain ☐
Mod < 5 ☐
20-30kts ☐ ☐
Mod ☐
1.0-2.0m ☐
Dusk ☐
Neap ☐
Snow ☐
Poor < 2 ☐
30-40kts ☐ ☐
Rough ☐
2.0-3.0m ☐
Darkness ☐
Spring ☐
Sunny ☐
V.Poor <0.5 ☐
40-50kts ☐ ☐
V.Rough ☐
3.0-4.0m ☐
Floodlight ☐
Slack ☐
Overcast ☐
Unknown ☐
50-60kts ☐ ☐
High ☐
4.0-5.0m ☐
Artificial ☐
Flood ☐
Unknown ☐
E N S W
5m+ ☐
Ebb ☐
SECTION 5 – DESCRIPTION OF SEQUENCE OF EVENTS LEADING TO THE END OF
THE OCCURRENCE ( Please use sketches to help explain if appropriate )
Box will expand as text is added (delete unused lines)
SECTION 6 – PLEASE STATE WHY YOU THINK THE OCCURRENCE HAPPENED AND
ACTIONS TAKEN TO PREVENT RE-OCCURRENCE
Box will expand as text is added (delete unused lines)
Any Witnesses/Names of persons who saw what happened:
I verify that, to the best of my knowledge, the details given above are accurate
Signature_________________________________ Date________________________________
To complete this report online please go to www.PLA.co.uk/Incidents or send to:-
Upper-Email – HMU@PLA.co.uk – Teddington to Dagenham
Post – Harbour Master (Upper) Pinnacle House, 23-26 St Dunstan’s Hill, London, EC3R 8HN
Lower – Email – Lowerdistrict@PLA.co.uk – Dagenham to the Estuary (PLA Outer Limits)
Post – Harbour Master (Lower ) London River House, Royal Pier Road, Gravesend, Kent, DA12 2BG
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Form 2: Near Miss Safety Observations (Port of London Authority)

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Completed 4 May 2021

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