F/SMSO/11/1-V1

PT DIMENSI SURYA BAHARI

EMPLOYEE NOT SUITABLE FOR EMPLOYMENT
PT. CAKRA BAHANA

NAME : RANK :

LAST VESSEL : SIGNED OFF :_________________________

MAIN REASON FOR NON SUITABILITY

This section should be completed, including all of the facts, and backed up by written adminstrative
investigation, evidence and any relevant documentation. The individual concerned must be given
the opportunity to respond.

MASTER/ CHIEF ENGINEER RESPONSIBLE :

APPROVED : SIGNATURE : DATE :

TECHNICAL / MARINE SUPTS

SUPERINTENDENT MARINE
MARINE PERSONNEL

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 PT DIMENSI SURYA BAHARI F/SOPM/11/1-V1

RESPONSE OF CREW

Signed : __________________

LIST OF ATTACHMENTS :
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PT DIMENSI SURYA BAHARI

NO. 4. SHIPBOARD MAINTENANCE

 F/SOPM/9/2(a)-V1
PT DIMENSI SURYA BAHARI
INCIDENT REPORT
*(Non-Conformities/Hazardous Occurrences/Technical Deficiencies)

Ship : * In Port/At Sea

INCIDENT DETAILS Date : Time :

Accident Potential : High : ___________ Medium : _________ Low : ____________

Ship's position at time of accident Speed __________________________

State of weather and sea condition at time of accident
Exact location onboard ship where accident occured
State the visibility and condition at the vicinity of the accident

CORRECTIVE ACTION TAKEN

(eliminate immediate hazard)

Sign/Date :
Superintendent/Master

CONTRIBUTING FACTORS
[determine root cause(s)]

Equipment Factors

Human Factors

Environment Factors

CORRECTIVE ACTION TO PREVENT RECURRENCE

[recommendations to reduce/eliminate root cause(s)]

Sign/Date :
Master/Designated Person

CORRECTIVE ACTION TO PREVENT RECURRENCE

Sign/Date :
Date of corrective action implemented Master/Designated Person

Sign/Date : Sign/Date :
Chief Engineer/Officer Master
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