本报告须由船长或负责人因应意外事故性质而填写.doc

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All spaces must be completed. Enter N.A. when the information sought is not applicable.政府船隻意外事故報告須由政府船塢海事主任填寫。Reports of accidents to Government vessels should be completed by the Marine Officer of Government Dockyard.對於所填報的資料，海事處只會用於調查方面。Information contained in this report will be used solely for the purpose of investigation by Marine Department.本報告旨在研究可否從中汲取教訓，以及須採取那些行動來預防同類意外事故再度發生。 所以在對事件記憶還清晰時完成這份表格是最為重要的。The purpose of this report is to find out whether there are any lessons to be learnt and what actions need to be taken to prevent the recurrence of similar accidents. It is therefore important to complete the form whilst the events are still fresh in the memory.這份表格的空位若不敷應用，請另紙書寫。Use extra sheet of paper if the space in the form is insufficient.請填妥一切細節，如有以下及有關之文件，則連同其副本交回 : 所用海圖連航數據、航向記錄器紙卷、回聲測深儀紙卷、正式航海日誌、航海日誌草本和機艙日誌所填寫的資料、船舶移動或車鐘記錄簿或主機轉數記錄、船員名單和有關這意外的損壞情況或其他證據的照片。Please return this form with full details with copies of the following documents if available and relevant : chart in use with track data, course recorder roll, echo sounder roll, entries in log books (official, deck & engine), movement or bell book or engine movement data logger, crew list and photographs of damage or other evidence relating to the accident.(請將這份表格交回九龍新油麻地避風塘填海區海輝道30號海事處海港巡邏組。 電話:2385 2791 ; 傳真:2359 7009)(Please return this form to Harbour Patrol Section, Marine Department, 30 Hoi Fai Road, New Yau Ma Tei Typhoon Shelter Reclamation, Kowloon. Telephone 2385 2791 Fax 2359 7009)海上意外事故報告REPORT OF MARINE ACCIDENT意外事故類別:(請圈上適用者)碰撞/接觸, 擱淺/觸礁, 沉沒/下沉, 失火/爆炸, 翻覆/傾側, ,結構故障 機械損壞, 器材損壞, 惡劣天氣損壞, 失蹤, 其他, (請註明: )Type of Accident :(Please circle as appropriate)Collision/Contact, Stranding/Grounding, Foundering/Sinking, Fire/Explosion, Capsizing/Listing,Structural Failure, Machinery Damage, Damage to Equipment, Heavy Weather Damage, Missing Vessels,Other, (please specify: )1.船隻名稱(正楷)2.正式號碼/IMO號碼/牌照號碼/呼叫訊號*Name of Vessel (Block Letters)Official No./IMO No./Licence No./Call Sign*3.船籍Nationality4. 船籍港/固定停靠港Port of Registry/Home Port 5.總噸位Gross Tonnage6.總長度Length Overall7.船隻類別Type of Vessel8.建造日期Date of Construction9.(a)船長/負責人*中英文姓名Name of Master/Person in Charge*(Chinese/English)10.(a)輪機長/輪機操作員*中英文姓名Name of Chief Engineer /Engine Operator*(Chinese/English)(b)証書號碼Certificate No.(b)証書號碼Certificate No.(c)証書級別Grade of Certificate(c)証書級別Grade of Certificate(d)簽發日期、地點Date and Place of Issue(d)簽發日期、地點Date and Place of Issue(e)電話號碼:Tel. No.:(e)電話號碼: Tel. No.:*刪去不適用者Delete as appropriate.M.O. 461 (Revised 3/2004)11.船東/代理人/經營人*名稱或姓名、地址Name and address of owner/agent/operator *電話號碼:Tel No.:Fax No.:傳真號碼:E-mail :電郵 :12.啟航地點，日期Departed from and date of sailing13.目的地Destination14.肇事之際 船上負責人的姓名, 職級Name and Rank of Person in charge at the time of accident地點: Place :日期 :Date :15.是否過境船隻Vessel in Transit是*Yes*否*No*16.有否向海事處申報過境Had Transit Reported to the Marine Dept.有*Yes*無*No*17.日期, 時間Time and Date18.天氣狀況State of Weather19.風向, 風力Wind Direction and Force20.能見度(米/海里*)Visibility (metres/nautical miles *)21.海面,湧浪狀況State of sea & swell22.肇事現場地理位置(經緯度或距基準點的方位)Geographical Position of accident (either in Lat. & Long. or from a reference point)本船喪生人數No. of lives lost own vessel本船受傷人數No. of persons injured own vessel本船失蹤人數No. of persons missing from own vessel23.船員Crew24.乘客Passengers25.船員Crew26.乘客Passengers27.船員Crew28.乘客Passengers29受傷類別Nature of injury(請圈上適用者)(Please circle as appropriate)A. 頭顱骨、脊柱或盆骨發生骨折Fracture of the skull, spine or pelvisB. 以下部位的骨骼的任何部分發生骨折 -(i) 手臂，但不包括手腕或手；(ii) 腿，但不包括足踝或足Fracture of any bone:- in the arm other than in the wrist or hand;- in the leg other than in the ankle or footC. 喪失手或足Loss of a hand or foot人數No. of personsD. 任何眼睛失去視力Loss of sight of an eyeE. 身體多處受傷Multiple injuriesF. 失去知覺Loss of conscious人數No. of persons其他, 請註明(例如: 瘀傷、割傷，流血)Other, please specify (e.g. bruise, minor cuts, bleeding etc) 30.該船和貨物損毀情況Damage to vessel and / or cargo31.燃油（噸）Bunker on board (tonnes)柴油（噸）Diesel Oil on board (tonnes)潤滑油（噸）Lube Oil on board (tonnes)32船隻是否在各方面均為適航Was the vessel seaworthy in all respects?33.船上若有持執照的香港領港員, 其姓名是什麼Name of the Hong Kong licensed pilot, if any34.意外事故始末 Detailed account of the accident 這部份的空位若不敷應用，請另紙書寫。Use extra sheet of paper if the space is insufficient.碰撞所須填報的資料Particulars Required for Collision35.最初察覺來船時，本船的真航向是甚麼? 度(真航向)What was the true course of own vessel when the other was first observed? Degrees (T)36.最初察覺來船時，本船的航速是多少節? 節What was the speed in knots of own vessel when the other was first observed? Knots37.最初見到來船時，其真方位在何? 距離多遠? 度(真方位)X 米 / 海里 *What was the true bearing and range of other vessel when first seen? Degrees (T) X metres / nautical miles * 38.最初察覺來船時，其真航向是什麼? 以雷達測定還是據估計所得? 度(真航向)What was the true course of other vessel when first observed? From radar, or by estimation? Degrees (T)39.最初見到來船時，其燈號是什麼顏色? 在碰撞之前多久才見到其燈號?What was the colour of light or lights of other vessel first seen, and how long before collision?40.碰撞之際，來船船首的真方向是甚麼? 度(真方向)What was the true direction of other vessels head at the time of collision? Degrees (T)41.本船的輪機有否減慢或剎停? (請詳加說明)Were engines of own vessel slowed down or stopped? (Give details)42.碰撞發生時，本船估計航速是多少節? 節What was the estimated speed in knots of own vessel when collision took place? Knots43.有否裝置並展示航行燈? (請詳加說明)Were navigation lights fitted and shown? (Give details)44.你有否聽到任何聲號和 / 或見到任何燈號? (請詳加說明)Did you hear any sound signal and / or see any light signal? (Give details)45.你有否發出任何聲號和 / 或燈號? (請詳加說明)Did you give any sound signal and / or light signal? (Give details)46.碰撞之後，來船有沒有留下其名稱?有否在附近守候?Did the other vessel give her name and standby after collision?47.來船的名稱、牌照號碼及 / 或呼叫信號 / IMO號碼是什麼?What was the name, licenses number and/or call sign / IMO Number of other vessel?觸礁或擱淺所須填報的資料Particulars Required for Grounding or Stranding48.最後所見的陸地標記、航標或浮標是什麼? 何時見到?What, and at what time, were the last landmarks, beacons, or buoys visible?49.是否以任何航標、燈塔或其他定位儀器來測定方位?Were bearings obtained from any beacon lighthouse, or from any other position finding device?50.這些方位是在擱淺之前多久測定的?How long before stranding were these bearings obtained?51.擱淺之前，是否正在使用回聲測深儀? (請詳加說明)Was the echo sounder being used before stranding? (Give details)52.肇事之際，駕駛真航向是什麼? 度(真航向)What was the true course steered at the time of accident? Degrees (T)53.擱淺之際，航速是多少節? 節What was the speed in knots at the time of stranding? Knots54.意外事故是否因海圖未有標明的障礙物所致?Was the accident due to an uncharted obstruction?55.觸礁之前，輪機或舵機是否損壞或無法操作?Had the engine(s) or steering gear broken down or become inoperative before grounding?沉船所須填報的資料Particulars Required for Foundering or Sinking56.沉船之前，輪機是否損壞或無法操作?Had the engine(s) broken down or become inoperative before foundering?57.沉船之前，舵機是否損壞或無法操作?Had the steering gear broken down or become inoperative before foundering?58.何時察覺裂縫? 又或巨浪何時湧進船艙?What time was the crack observed or heavy seas shipped into the hold?59.船上共有多少個抽水泵? 這些泵的流量總共多少?How many pumps were on board? What were the total capacity of the pumps?60.曾經使用多少個抽水泵?How many pumps were used?61.沉船之前，駕駛真航向或航速是什麼? 度(真航向)What was the true course steered and speed before the vessel foundered? Degrees (T)62.即將沉船之前，航程的環境是怎樣的?What were the circumstances of the voyage immediately before the foundering?63.曾經採取什麼措施來防止這意外?What measures were taken to prevent the accident?64.意外事故的可能成因是什麼?What was the likely cause of the accident?失火所須填報的資料Particulars Required for Fire65.何時、何處首先起火?When and where the fire started?66.何時察覺失火? 如何察覺?When and how the fire was detected?67.曾經採取什麼行動?What action was taken?68.起火的可能成因是什麼?What was the likely cause of the fire?船隻進水所須填報的資料Particulars Required for Flooding69.進水起因是甚麼?What was the cause of flooding?70.最初何時察覺進水?When did you first notice it?71.是否所有閉鎖裝置均已關妥?Were all the closing appliances in shut position?72.進水前，是否有任何損毀或毛病?Was there any damage or defect before flooding?73.曾採取甚麼措施去阻止進水?What measures were taken to stop the flooding?74.曾經使用多少個抽水泵及有多少個可操作的抽水泵?How many pumps were operational and how many were used? 10 海上意外 船上值班人員位置及職務Marine Accident Locations and Duties of Officers on Board船名 (Ships Name) : _ 發生意外時間/日期 (Accident Time/Data): _姓名 (Name)職位 (Rank/Rating)在船上位置 (Location on Board)職務 (操舵瞭望，指揮或其他)Duties (Steering, Lockout, Command or others)值班時間(Watch)對上一更值班人員姓名(Name of previous watch officer)船長簽名及船章 (Signature of Master and Ships Chop): _日期 (Date):_草圖Sketch Plan北N承保人資料 (承保小輪、渡輪和遊樂船隻的第三者保險)Particulars of Insurer (Covering Third Party Liability in respect of Launches & Ferry and Pleasure Vessels)(i)保險公司名稱 :Insurance Co. :(ii)保單號碼 :Policy No. :(iii)屆滿日期 :Expiry Date :提供以上資料者的簽署、全名、職位和地址 :Signature, full name, designation and address of person providing the above information簽 署Signature全 名Full Name職 位Designation地 址 :Add