Vessel Incident Report

NOTE
• When a marine accident occurs in connection with a vessel, the master of that vessel (and the owner of the vessel if aware of the accident)
must send a report to Transport for NSW containing particulars of the accident as soon as practicable by the quickest means available.
• Failure to comply with this requirement is an offence.
• Submission of this form will satisfy your reporting obligations.
• Transport for NSW may contact you for further information to determine whether an investigation into the marine accident is required. If
contacted you are obliged to provide details as requested to the best of your knowledge.
To assist in completing this form, please refer to the Explanatory Notes at the end of this document. For further information and assistance
telephone 13 12 36 (option 2) (8.30am to 4.30pm) - 7 days a week. Please forward completed form to: Maritime Investigations Unit, NSW
Maritime, Locked Bag 5100, CAMPERDOWN, NSW 1450 or email to [email protected]

Details of Incident
Date of Time of Waterway on which
incident: incident: incident occurred:
Location on Incident Severity Rating:
waterway: (See Explanatory Note 1)

DETAILS OF OPERATOR (MASTER) – VESSEL 1 DETAILS OF OPERATOR (MASTER) – VESSEL 2

Surname: Surname:

Given names: Given names:

Date of birth: Date of birth:

day month year day month year

Gender: Male Female Gender: Male Female

Residential address: Residential address:

Suburb: Suburb:

State: Postcode: State: Postcode:

Private Business Private Business

number: number: number: number:

Mobile number: Mobile number:

Email address: Email address:

QUALIFICATIONS AND EXPERIENCE – VESSEL 1 QUALIFICATIONS AND EXPERIENCE – VESSEL 2

Boat licence: Boat licence:
(See Explanatory Note 2) (See Explanatory Note 2)

Licence type: Licence type:

Licence number: Licence number:

Expiry: Expiry:
day month year day month year

Other: Other:
(Please specify) (Please specify)

Certificate of Competency: Certificate of Competency:

(See Explanatory Note 3) (See Explanatory Note 3)

Certificate type: Certificate type:

Certificate number: Certificate number:

Expiry: Expiry:
day month year day month year

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SENSITIVE: PERSONAL
 AYF qualifications Type: AYF qualifications Type:

Interstate State Interstate State

(e.g. QLD): (e.g. QLD):

International Country International Country

(e.g. UK): (e.g. UK):

Other (please specify): Other (please specify):

DETAILS OF OWNER – VESSEL 1 DETAILS OF OWNER – VESSEL 2

Surname: Surname:

Given names: Given names:

Date of birth: Date of birth:

day month year day month year

Gender: Male Female Gender: Male Female

Residential address: Residential address:

Suburb: Suburb:

State: Postcode: State: Postcode:

Private Business Private Business

number: number: number: number:

Mobile number: Mobile number:

Email address: Email address:

DETAILS OF VESSEL 1 DETAILS OF VESSEL 2

Vessel name: Vessel name:

Commercial Vessel (See Explanatory Note 4) Commercial Vessel (See Explanatory Note 4)

Vessel type: Vessel type:

Survey/permit number: Survey/permit number:

Expiry: Expiry:
day month year day month year

Recreational Vessel (See Explanatory Note 5) Recreational Vessel (See Explanatory Note 5)

Vessel type: Vessel type:

Vessel registration number: Vessel registration number:

Expiry: Expiry:
day month year day month year

Hull Material (See Explanatory Note 6): Hull Material (See Explanatory Note 6):

People on Board: People on Board:

Adults Female: Male: Adults Female: Male:

*Children Female: Male: *Children Female: Male:

*Children are less than 12 years of age *Children are less than 12 years of age

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SENSITIVE: PERSONAL
 DETAILS OF ENGINE – VESSEL 1 – ENGINE 1 DETAILS OF ENGINE – VESSEL 2 – ENGINE 1
Propulsion: Inboard Outboard Sterndrive Propulsion: Inboard Outboard Sterndrive

Fuel: Petrol Diesel Other (please specify) Fuel: Petrol Diesel Other (please specify)

Manufacturer: H/power: Manufacturer: H/power:

DETAILS OF ENGINE – VESSEL 1 – ENGINE 2 DETAILS OF ENGINE – VESSEL 2 – ENGINE 2

Propulsion: Inboard Outboard Sterndrive Propulsion: Inboard Outboard Sterndrive

Fuel: Petrol Diesel Other (please specify) Fuel: Petrol Diesel Other (please specify)

Manufacturer: H/power: Manufacturer: H/power:

DAMAGE TO VESSEL AND/OR PROPERTY

VESSEL 1 – DAMAGE VESSEL 2 – DAMAGE

Lost Major Minor No Damage Lost Major Minor No Damage

Vessel $ Property $ Vessel $ Property $

NATURE OF INCIDENT

VESSEL 1 VESSEL 2

Operation at Time Operation at Time

of Incident: (See of Incident: (See
Explanatory Note 7) Explanatory Note 7)

Type of Incident: Type of Incident:

(See Explanatory (See Explanatory
Note 8) Note 8)

Contributing Contributing
Factors to Incident: Factors to Incident:
(See Explanatory Note 9) (See Explanatory Note 9)

WEATHER AND WATER CONDITIONS

WEATHER WATER CONDITIONS WIND WIND DIRECTION VISIBILITY TIDE

Clear Calm None N NE Good Flood (in)

Hazy Choppy Light (1>9kt) E SE Fair Ebb (out)
Cloudy Rough Moderate (10>15kt) S SW Poor Slack
Rain Very Rough Fresh (16>25kt) W NW Darkness
Flood Strong Current Gale (Over 25kt) (Night Time)

DETAILS OF DECEASED AND INJURED PERSONS

Serious injury = Hospitalisation, other than for observation, Minor Injury = First aid only given at site or at hospital

Injury Type Role on vessel Lifejacket

Name Address DOB Gender Fatal/Serious/ (See Explanatory Hospital Name
M/F worn
Minor Note 10) Yes/No

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SENSITIVE: PERSONAL
 ALCOHOL AND DRUG TESTING
Role on vessel
Name Address Telephone DOB Gender
M/F
(See Explanatory Breath Test Analysis Result
Note 10)

DETAILS OF WITNESSES

Name Address Telephone

DETAILS OF CREW ON BOARD COMMERCIAL VESSEL AT TIME OF INCIDENT

Role on vessel
Name Address Telephone DOB (See Explanatory Qualifications
Note 10)

Please use this section to draw a map of the area and details of the incident

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SENSITIVE: PERSONAL
 INCIDENT DESCRIPTION
Describe what happened (sequence of events) include failure of equipment. If diagram is needed, use grid sheet. Include any
information regarding the involvement of alcohol and/or drugs in causing or contributing to the incident. Include any descriptive
information about the use of PFDs (Lifejackets).

Personal Information Collection Notice: Section 99 of the Maritime Safety Act 1998 requires Masters of vessels (and Owners if they
are aware of the accident) to provide a marine accident report. Our Privacy Statement explains how we will use and manage your
Personal Information in accordance with the Privacy and Personal Information Act 1998, and, where relevant, the Health Records and
Information Privacy Act 2002. You can obtain a copy of our Privacy Statement at www.transport .nsw.gov.au/privacy-statement or call
us on 13 12 36 (option 2) to request a copy.

PERSON COMPLETING REPORT (Please use BLOCK letters)

Name:

Private
Address: number:

Suburb: Business
number:
State: Postcode: Mobile
number:
Signature: Date: day month year

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SENSITIVE: PERSONAL
 EXPLANATORY NOTES
Explanatory Note 1 – Incident Severity Rating Explanatory Note 8 – Type of Incident
• Fatal incident • Capsizing
• Serious injury • Close Quarter
• Vessel lost • Collision with vessel
• Other vessel damage • Collision with fixed object
• Property damage only • Collision with floating object
• No damage • Collision with submerged object
• Explosion/Fire – fuel
• Explosion/Fire – non fuel
Explanatory Note 2 – Boat Licence Type • Fall overboard
• NSW General Boat Licence • Fall in vessel
• NSW PWC Licence • Grounding
• Other (please specify) • Hull splitting (structural failure)
• Person hit by vessel/propeller
Explanatory Note 3 – Certificate of Competency • Sinking
• Swamping
• Coxswain • Unknown
• Master NC < 24m
• Master NC < 35m
• Master/Mate NC < 80m Explanatory Note 9 – Contributing Factors to Incident
• Master (Inland Waters) • Alcohol/Drugs
• Master Class III • Excessive or Unsafe Speed
• MED 3 NC • Fault of Equipment
• MED 2 NC • Fault of Hull
• MED 1 NC • Fault of Machinery
• Engineer Class 3 NC • Hazardous Waters
• Improper Loading
Explanatory Note 4 – Commercial vessel Type • Lack of Judgement
• No Proper Lookout
• Class 1 Passenger Vessel • Overloading
• Class 2 Non Passenger Vessel • Weather Conditions
• Class 3 Fishing Boat • Other (please specify)
• Class 4 Hire and Drive • Unknown
• Other (Please specify)

Explanatory Note 10 – Role on Vessel

Explanatory Note 5 – Recreational vessel type
• Crew
• Cabin runabout • Master
• Motor Cruiser • Passenger
• Canoe/kayak • Skier/Wakeboarder/Aquaplaner
• Houseboat • Observer
• Inflatable • Swimmer/Diver
• Open runabout
• Paddle (Row) Boat
• Personal Watercraft (Jet Ski)
• Sailing Vessel
• Other (please specify)

Explanatory Note 6 – Hull Material

• Aluminium
• Ferro-cement
• Fibreglass
• Plywood
• Steel
• Timber
• Other (please specify)

Explanatory Note 7 – Operation at time of incident

• Aground
• At Anchor/Moored
• Being Towed
• Berthed
• Drifting
• Fishing
• Fuelling
• Organised Competition/Aquatic Event
• Towing a vessel
• Underway
• Waterskiing/aquaplaning/parasailing
• Other (please specify)

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SENSITIVE: PERSONAL