F/SMSO/9/3-V1

PT DIMENSI SURYA BAHARI

Vessel's Name : Date :

Key Performace Indicator (1st/2nd/3rd/4th quarter)

No. Key Performance Indicator Target/Objective Remarks. (For This Quarter)

1. Ship visit by S & Q Minimum of 1 visit per year Date :

Department per vessel Name

2. Superintendents sailing Minimum of 2 per year per Date

onboard (Tech/Marine & vessel Name
Ops Supt)

3. Sea staff seminars onboard/ A minimum of 2 seminars Date

ashore per year

4. Deck
Dtd :
Minimum of 4 near-miss (Nos) Dtd :
Hazardous Occurences reports per month 2 dek/
"Near Miss" 2 engine Eng
Dtd :
(Nos) Dtd :

5. Date of Incident(s) :
Minor Personal Injury 2 or less minor work
(Requiring only first aid related injuries per vessel Name of
treatment on board) per year. Personnel :

6. Date of Incident(s) :
Personal Injury 2 or less minor work
(Requiring medical related injuries for the Name of
treatment on board) fleet. Personnel :
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F/SMSO/9/3-V1
PT DIMENSI SURYA BAHARI

Key Performace Indicator (1st/2nd/3rd/4th quarter)

No. Key Performance Indicator Target/Objective Remarks. (For This Quarter)

7. Mooring related incidents 20% yearly reduction in Date of Incident(s) :

(excluding personal injury) mooring related incidents

8. Incidents 20% yearly reduction in the

(Hull, structure, procedures, total number incidents/ Date of Incident(s) :
training, and other non- technical deficiencies.
technical issues)

9. Technical deficiencies 20% yearly reduction in the

(Engine Room, Cargo total number incidents/ Date of Incident(s) :
system, Bridge Equipment) technical deficiencies.

10.
20% yearly reduction in the Date of Inspection
Oil Major Inspections number of applicable
observations
No. Of Deficiency

11. Internal Audit 20% yearly reduction in the Date of Audit :

(ISM,ISPS) number of non-
conformities
No. of NC :

12. External Audit 20% yearly reduction in the Date of Audit :

(ISM,ISPS) Port5/Flag state number of non-
and Terminal Inspections conformities
No. of NC :
No. of NC :

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 Chart 'A'
PT DIMENSI SURYA BAHARI
Incident/Accident Causation Chain
Consequence Incident / Accident
- Personal injury/Death - Slips / Trips / Falls
- Ship damage - Personnel/Equipment contact
- Property damage - Exposure - harmful substances
- Financial impact - Exposure - harmful environment
- Environmental damage - Fire / Explosion
- Media exposure - Collision / Contact damage
- Commercial damage - Grounding / Stranding
- Marine / Air pollution

Direct Cause Indirect Cause

Unsafe Acts : Personal factors :
- Operating equipment without - Physically inadequate
authority. - Mentally inadequate
- Removing/making safety devise - Lack of knowledge/skill
- Inoperable, using defective - Stress
equipment. - Improper motivation
- Improper use of equipment
- Not using PPE Job factors :
- Improper lifting or task position - Inadequate supervision
- Servicing equipment in operation - Inadequate leadership
- Horseplay - Inadequate engineering
- Under influence of drink/drugs - Inadequate purchasing
- Inadequate maintenance
Unsafe conditions : - Inadequate work standards
- Inadequate guards/barriers
- Inadequate/improper PPE
- Defective
- Tools/equipment/material
- Workspace restriction
- Hazardous environment conditions
- Noise, high/low temperatures
- Inadequate/excessive lighting
- Inadequate ventilation
- Poor housekeeping

Root Cause
Lack of planning
Lack of Standards
Lack of compliance
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 F/SMSO/9/2(b)-V1
PT DIMENSI SURYA BAHARI
INCIDENT INVESTIGATION REPORT
Record No. :________________________

Ship : Incident : Date :

Team leader : Team member :

Detail Events :

Causation :

Root Cause :

Sign/Date :
Designated Person

Sign/Date : Sign/Date :
Chief Engineer/Officer Master
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 F/SMSO/9/2(a)-V1
PT CAKRA BAHANA
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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