Marine Incident Response Record Marine Safety Act 2010 (Vic), Marine Safety Regulations 2012 (Vic)This form is to be used by registered marine search and rescue organisations to report a response to a marine incident. When you submit this report, a copy will be sent tomarineincidents@transportsafety.vic.gov.au as well as the email address you provide. MIR number Description of incident Date and time (required) Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Hour 000102030405060708091011121314151617181920212223 Minute 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Incident type (required) -- Please select --Disablement of vesselCapsizingClose quartersCollisionExplosionFireFloodingGroundingLoss of stabilityLoss of vesselOnboard incidentOther personal injuryPerson overboardSinkingStructural failureSwampingFalse alarmPerson in trouble in waterNon-marine incident (specify) Of vessels With floating object With overhead obstruction With submerged object With fixed object With animal With wharf Unintentional Intentional Loss Presumed loss Falls within vessel Crushing or pinching Other onboard injury Hit by vessel or propeller Diving incident Skiing incident Hit submerged or floating object Parasailing incident Caused by an operating vessel Unintentional Intentional How serious was the incident? (required) The list below is ranked in order of severity from top to bottom. Choose the most severe aspect of the incident by selecting only one option. Fatality Serious injury Vessel lost Other vessel damage Damage to property only No damage Where did it happen? (required) Location description where the incident initially occurred (e.g. 2 nautical miles SW of Barwon Heads) Coordinates - Longitude and latitude of where the incident initially occurred. Degrees, minutes and decimal minutes (to two or three decimal places) Coordinates - Longitude - Degrees (required) Coordinates - Longitude - Minutes (required) Coordinates - Longitude - Decimal Minutes (required) S Coordinates - Latitude - Degrees (required) Coordinates - Latitude - Minutes (required) Coordinates - Latitude - Decimal Minutes (required) E What happened, what steps were taken when responding and what was the outcome? (required) How was the incident reported? (required) Telephone Radio call Visual sighting Flare sighting Mayday EPIRB Other Please specify other Name of complainant (required) Contact telephone number (required) Vessels and persons Was a vessel involved in the incident? (required) No - Go to question 12. Yes - Go to question 9. Vessel registration number Vessel registration number not known Vessel origin -- Please select --VICNSWQLDSAWATASNTACTAMSAForeignUnkown What is the type of vessel? -- Please Select --Mechanically poweredSail poweredHuman powered Open Cabin cruiser Half cabin Houseboat Sea plane Ski boat Tender Hovercraft Personal water craft Yacht/Catamaran (off the beach) Yacht (keel boat) Windsurfer Trailer sailer Kite Kayak Canoe Raft Rowing boat Rowing (racing shell) Tender Contributing factors What factors contributed to the incident? (choose all that apply) Human Alcohol or drugs Failure to keep a proper lookout Inexperience Lack of maintenance Ill health Error of judgement Insecure mooring Navigational error Unable to swim Excessive speed Fatigue Lack of fuel Overloading Other (specify) Other human factor Material Inadequate stability Inadequate buoyancy Equipment - machinery Equipment – electrical Equipment – hull failure Equipment – navigational Equipment – rig failure Fuel system blockage Other (specify) Other material factor Environmental Restricted visibility Wash Wind/sea state Bar conditions Tidal conditions Floating or submerged object Other (specify) Other environmental factor Respondents and response details Provide details of the respondent and response Organisation that responded (required) Vessel Call sign/unit (required) Vessel type Date and time activated (required) Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Hour 000102030405060708091011121314151617181920212223 Minute 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Time arrived on scene (24 hour) (required) Hour 000102030405060708091011121314151617181920212223 Minute 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Total time spent: Total hours (required) Total minutes (required) Action taken (choose one only) (required) Search only Search and tow Tow only Search and rescue Resolved en route Investigation only Other assistance given (specify) Please specify other assistance given Additional vessel? (required) Yes No Additional vessel Call sign/unit Vessels/assets tasked Date and time activated Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Hour 000102030405060708091011121314151617181920212223 Minute 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Time arrived on scene (24 hour) Hour 000102030405060708091011121314151617181920212223 Minute 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Total time spent on scene: Total hours Total minutes Action taken (choose one only) Search only Search and tow Tow only Search and rescue Resolved en route Investigation only Other assistance given (specify) Other assistance given Details of person who completed this form Name (required) Response agency (required) Contact telephone number (required) Email address (required) Privacy Transport Safety Victoria (TSV) collects and holds the personal information provided in this application to assist the Director, Transport Safety (Safety Director) to administer the Marine Safety Act 2010 (Vic) and Marine Safety Regulations 2012 (Vic). TSV is committed to protecting personal information in accordance with its obligations under the Marine Safety Act 2010 (Vic). The personal information provided in this form may be disclosed to other government agencies in accordance with section 306 of the Marine Safety Act 2010 (Vic) and section 177 of the Transport Integration Act 2010 (Vic). It is an offence under the Marine Safety Act 2010 (Vic) to give information that is false or misleading. The individuals whose personal information is collected on this application have a right to seek access to this personal information and to seek correction of any error in the personal information held. All individuals whose personal information is included with this application should be informed of this fact. For more information on privacy please refer to TSV's privacy statement at www.transportsafety.vic.gov.au/privacy. Was this page helpful? Was this helpful Yes No Any comments? 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