Privileged.

Prepared in anticipation of litigation.

<INSERT PHOTO HERE>

INCIDENT INVESTIGATION REPORT

<Insert keywords here>

<SHIP NAME>
<INCIDENT ID NUMBER (Omnisafe NC)>
ACTUAL RISK LEVEL: POTENTIAL RISK LEVEL:

DATE OF INCIDENT
<DD/MM/YYYY>
Prepared by:
<Insert name(s) here>
Date:
<Insert date here>
Version:
<Insert version number here>
REFER TO IMS HSSE Manual 2.4.7 – Investigating Non Conformance & Incidents

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
Page 1 of 10
Sign-off Sheet

Responsibility Date Signature

Draft Significant Incident Insert investigation

Investigation Report completed leader name

Proposed actions and FLEET MANAGER

recommendations accepted

Actions captured in Omnisafe Insert

superintendent
name
Shipping Incident Review and /or DPA
Fleet Incident Report (FIR)
prepared and sent to fleet
Actions captured must be closed out in Omnisafe and this report must be attached in Omnisafe
prior to close out of the Omnisafe N/C report

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
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Table of Contents Page

PURPOSE.....................................................................................................................................................4
EXECUTIVE SUMMARY.................................................................................................................................5
EVENTS LEADING UP TO THE INCIDENT....................................................................................................6
DESCRIPTION OF THE INCIDENT AND CONSEQUENTIAL DAMAGE OR INJURIES.......................................7
CAUSE ANALYSIS........................................................................................................................................8
ACTIONS TO AVOID RECURRENCE.............................................................................................................9
Reference Section..................................................................................................................................10

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
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Purpose

{State the objectives and scope of the Investigation. See guidance section 1 for
information. Also state the investigation team here.}

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
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Executive Summary

{Provide an overview of the incident. Restrict to no more than two pages where
possible.}

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
Page 5 of 10
Events Leading Up To the Incident
{Provide the relevant facts and details prior to the incident occurring. See
guidance section 2 and 3 for information required.}

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
Page 6 of 10
Description of the Incident and Consequential Damage or
Injuries

{Provide the relevant facts and details of the incident. See guidance section 2
and 3 for information required.}

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
Page 7 of 10
Cause Analysis
{Provide details about all contributing factors and causes.
Also see guidance section 4 for determining Incident category and Incident Type.
Also see guidance section 5 for determining Direct and Root causes.}

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
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Actions to Avoid Recurrence
{Provide details of all necessary corrective and preventive actions. Summarize
the actions in the table provided.}

No. Cause Recommendation / Actionee(s Target Completio

Action ) Date n Date

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
Page 9 of 10
Reference Section

{List documents and other evidence that has been obtained during the
investigation.}

<SHIP NAME>
STASCO FORM – 558 Incident Investigation Report – Revision: JANUARY 2018
Page 10 of 10