Incident Investigation Form OGU.02.09

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(Z-042000-01FRM) (Ver.1.

0)

INCIDENT INVESTIGATION FORM

INCIDENT INVESTIGATION FORM

Ser. No: OGU/No.02 /

09
A. Name of Ship
B.

Date

and

LNG OGUN
Time

of

06-DECEMBER-2009 / 06:29 UTC

Incident
C. Location of Incident

UPPER DECK, PORT SIDE

D. Type of Incident: **

OIL SPILL

** Personal Injury / Damage to own Vessel / Damage to other parties / Damage to


Environment / Oil Spill / Others

(In case of personal Injury, attach the Marine Injury / Accident Report together with this Form)

E.

Brief

Description

of

Incident:

(attach

separate

sheet

for

additional

information, if required)
SPILLAGE OF OIL FROM CARGO HYD POWER PACK HEADER

F1. Immediate cause(s):


What Unsafe Acts or Conditions caused the incident ?
NA

F2.

Was Risk Assessment carried out and sent to Company for Approval ?

YES / NO
F3. If reply to F2 is YES, What is the Ref. No. of the Risk Assessment. Ref No:
XXX/YY
G. Root Cause(s):
FAILURE OF ONE FLANGE PACKING FROM HYDRAULIC HEADER OF THE HYD
POWER PACK FOR CARGO.

H. Are there any breaches of Company / Legislative / Other requirements ?


NO

I. Corrective Action(s): (Recommendation to prevent recurrence)


THE FLANGE WAS DISMANTLED AND O-RING REPLACED.

J. Name, Signature and Date


Investigator : GURAU OCTAVIAN
06-DECEMBER-2009

Company Rep.

INCIDENT INVESTIGATION FORM

K. Comments

(Z-042000-01FRM) (Ver.1.0)
L. Comments:

EXCELLENT SAFETY AWARNESS AND


RESPONSE OF THE CREW.

M. Note of Receipt (by Office) /Date/ Serial Nn.

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