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FORM NO : SEHQ/SHE-26
MONTH
TOTAL CREW
ONBOARD
A
Events
Personal Injury
without loss of
time
Personal Injury
resulting in Loss
of Time
LTI - Personnel
Injury resulting in
lost workday.
Unable to do any
work next day
(8hrs or more)
Property Loss
Events
Off Hire/
Stoppages
Spill or
Environment
events
How many this
month ?
B
Personal Injury
Property Loss
Events
Off Hire/
Stoppages
Spill or
Environment
events
Source Cause Codes
Knowledge PK
Skills PS
Attitude PA
Operation EO
Design ED
Age EA
Insufficient PI
Non-existant PNE
Not followed PNF
C
KPI
LTH LTIF
Total Offhire
Hours (OFH)
OHF
Number of Off Hires this year
Number of Stoppages this year (without off hire)
Total Stoppage Hrs
Percent Availability
General Comments : (Please provide brief reason / total hrs / date of the of Injuries, off hires - for the reporting month)
Accumulated LTI - (How many cases of Lost Time
Injuries - LTI this year ?)
How many accidents this year?
Operating days without Accident
Last accident occurred on:
How many Incidents this year?
Procedure
Key Performance Indicator (KPI) of events for the Calendar Year (From 01 January to 31 December)
Parameter
Comments
People
Equipment
Comments:
1. List brief details of above events occurred this month . For personal injury list how many working hours lost. If he did light work ,then it is not treated as
LTI
2. Lost Time Injuries (LTI) : Lost Time Injuries are the sum of Fatalities, Permanent Total Disabilities**, Permanent Partial Disabilities and Lost Workday
Cases. (LTIs = Fatalities + PTD + PPD + LWC)
Ple refer to guide lines given on subsequent pages of this form regarding definition of LWC,PTD, PPD and LTI.
Root cause analysis of the Events for the reporting month (Skip this if no events this month)
The counts and comments are to be recorded for the current month only.
Count: Always mark count as 1 for each event, if relevant. E.g.: If accident happened due to People-skills, and Equipment-Design then the count will be 1
divided by the no of causes (i.e 1 divided by 2) which means 0.5 for each cause. If we have more than one incident/accident etc on board during the
month due to the same cause then it has to be counted once for each event. E.g.: 2 accidents in the month due to Equipment- Design. Count is 1+1 = 2.
Parameter
Accidents
Near Miss
MONTHLY SAFETY AND QUALITY REPORT
VESSEL
Number of Undesirable Events for the reporting month
(Ref Form SHE-27)
Accident
Hazardous
Occurrence /
Near Miss
(No losses)
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