Pilot Incident Report

Please complete the electronic form below or you may print off the form using the following link and send it in to the Harbour Master's Department.  Pilotage Incident Report Form  

Type of Incident

Name:
Email:
Authorised Pilot: Authorised Pilot Exemption: Certificate Number:	Yes      Yes
A Collision / Close Quarter Situation	Yes:     No:
B Grounding	Yes:     No:
C Loss of anchor	Yes:     No:
D Other (Specify):	Yes:

1 Ship's Name:
2 Owners:
3 Agent:
4 GRT/NRT:
5 Length overall in metres:
6 Beam in metres:
7 Draught in metres:
8 Last Port of call:
9 Destination in CHA Pilotage Area:
10 main engine propulsion (Diesel/steam/gas):
11 Bow / stern thrusters fitted:
12 Machinery defects (state):
13 Unusual handling characteristics (state):
14 Date of occurence (day / date / month / year):
15 Time (local) (use 24 hour clock):
16 Predicted tide time / height (1st High only)	HW M Soton:     P'mouth: LW M Soton:     P'mouth:
17 Set / rate of tide at time of incident
18 Wind direction / speed
19 Sea state (use Beaufort scale)
20 Visibility (in miles)
21 Name of other vessel / object involved
22 Place of incident
23 Position of incident, by bearing / distance form (select well known datum)
24 How was position obtained
25 Ship’s heading at time of incident
26 Echo sounder in use	Yes:     No:
27 Sounding trace retained (if no, why?)	Yes:     No:
28 Type of lookout maintained
29 Was radar watch being kept (if yes what mode?)
30 Speed at time of incident
31 Engine(s) setting
32 Bridge control	Yes:     No:
33 Bow / stern thruster in use	Yes:     No: Setting:
34 Compass in use (Mag/Gyro/solid state)
35 Tugs in use at time of incident	Yes:     No:
36 Names of tugs / position
37 Time incident first reported
38 Estimated course and speed of other vessel
39 Name of other vessel
40 Lights / signals displayed (own ship)
41 Lights / signals displayed (other ship)
42 Sound signals (own)
43 Sound signals (other)
44 VHF used prior to incident VHF R/T Channel	Yes:     No: Mode:
45 Was a dangerous substance being carried	Yes:     No:
46 Damage to own ship
47 Damage to other ship or objects
48 Injuries
49 Action taken after incident
50 Written statement from Master If yes please send original to: Deputy Harbour master VTS Building 37 Berth Eastern Docks Southampton SO14 3GG	Yes:     No:
51 How did the incident occur – describe in your own words supported by any chart, drawing, sketch, photograph or other evidence that may assist the investigating panel in their findings. Please send and hard copy information to: Deputy Harbour master VTS Building 37 Berth Eastern Docks Southampton SO14 3GG