RLM 109 - RLM 260 - Rev.06 18

(This form located in RLM-260, Annex 10.1 Form RLM-109, Report of Vessel Casualty or Accident.
OFFICE OF THE DEPUTY COMMISSIONER

Phone: (703) 790-3434
OF MARITIME AFFAIRS, R.L. Fax: 703-790-5655
LISCR, LLC E-Mail: investigations@liscr.com
REPORT OF VESSEL CASUALTY OR ACCIDENT

INSTRUCTIONS
1. An original of this form shall be submitted to the Maritime Administrator as 4. This form should be completed by the Master or person in charge, or, if neither
soon after the occurrence of the casualty as possible. is available, by the owner or his duly authorized agent.
2. This form must be completed in full. Entries which do not relate to a particular 5. Attach crew list to this form. Attach separate Form 109-1 to this report for each
case should be indicated as not applicable by inserting the initials "N.A." person killed or injured and incapacitated in excess of 72 hours as a result of the
3. Dates should be filled in as yyyy/mm/dd. vessel casualty reported herein.
I. PARTICULARS OF VESSEL
1. Name of Vessel 2.Official Number / IMO # 3. Year built 4. Gross Tonnage 5. Net Tonnage
6. Type of Vessel (See Note 1.) 7. Propulsion (See Note 2.) 8. Place Built
9. Name of Owner 10. (a) Name, Address and Telephone of Managing Agent
10. (b) Class Society (Abbreviation):

11. (a) Name of Master or Person In Charge (b) Citizenship) (c) Date of Birth (d) License Grade and Date of Issue
II. PARTICULARS OF CASUALTY

12.(a) Date of Casualty (b) Time(Local or Zone) (c) Zone Description (d) Time of Day
 Day  Night  Twilight

13. Geographical Location of Casualty (See Note 3.) 14. Geographical Name of Body of Water
15.(a) If Casualty occurred underway, Port of Departure (b) Date of Departure (c) Port to Which Bound
16.(a) Nature of Cargo (Describe and give amounts in Long Tons) (b) Amount Dry Cargo (c) Amount Bulk Liquid (d) Amount Deck Cargo
17. Speed in Knots Prior to Casualty 18. True Course Prior to Casualty 19. Draft Forward 20. Draft Alt
21. Atmospheric Conditions at Time of Casualty (Check one or more of the following)
 Clear  Partly Cloudy  Overcast  Fog  Rain  Snow  Other (Specify)
22. Distance of visibility 23. Wind 24. Sea 25. Wind Direction
 Under 2 Miles  Light  Smooth to Slight
 Moderate to Rough 26. Direction of Sea
 2-5 Miles  Moderate to Fresh
 Over 5 Miles  Storm to Hurricane  High 27. Direction of Swell
28. Navigation Equipment (Check one or more of the following) 29. Communications Equipment (check one or more of the following)
 Radar ( S Band, or  X Band)  ARPA  VDR/S-VDR  Radiotelephone  CW (Key)
 operative  Inoperative  Install  In use with Other Vessels  In use with Other Vessels
 Used  Used  Used  In use with Shore Stations  In use with Shore Stations
 Data Secured?  Not Used  Not Used
30. Auto Alarm Transmitted by your Vessel? 31. Rules of the Road Applicable at Time
 Yes  No  International  Other (specify)
Note 1. Type of Vessel - General Cargo, Oil Tanker, Ore/Oil Carrier, Passenger, Bulk Carrier, Ore Carrier, Tug, etc.
Note 2. Propulsion - Steam Reciprocating, Steam Turbine, Turbo-Electric; Diesel, Diesel, Diesel-Electric, etc.
Note 3. Location - If open sea, Latitude and Longitude; give distance to and name of nearest shore; if near coast give distance and true bearing to charted object; if in
port, straits, river, channel, etc., give name.
FORM RLM-109 (REV. 06/18) Page 1

32. Nature of the Casualty (Check one or more of the following. Give pertinent details in item 33.)
COLLISION WITH OTHER VESSEL(S)( Give Name and Flag of Other Vessels) EXPLOSION/FIRE (Other)
GROUNDING
FOUNDER (Sinking)
COLLISION WITH FLOATING OR SUBMERGED OBJECTS CAPSIZING WITHOUT SINKING
COLLISION WITH FIXED OBJECTS (Piers, bridges, etc.) FLOODING, SWAMPING, ETC., WITHOUT SINKING
COLLISION WITH ICE HEAVY WEATHER DAMAGE
COLLISION WITH AIDS TO NAVIGATION CARGO DAMAGE (No Vessel Damage)
COLLISION (Other) MATERIAL FAILURE (Vessel Structure)
EXPLOSION/FIRE (Involving cargo) MATERIAL FAILURE (Engineering machinery, including main
propulsion, auxiliaries, boilers, evaporators, deck machinery,
EXPLOSION/FIRE (Involving vessel's fuel)
electrical, etc.)
FIRE (Vessel's structure or equipment) EQUIPMENT FAILURE
EXPLOSION (Boiler and associated parts) CASUALTY NOT NAMED ABOVE
EXPLOSION (Pressure vessels and compressed gas cylinders)
33.DESCRIPTION OF CASUALTY (Events and circumstances leading to casualty and present when it occurred. Attach diagram and additional
sheets, if necessary.)
34.Number of Personnel Crew Passengers Other Totals 35. Estimated Property Losses Dollars (USA)
(a) On Board (a) To vessel $
(b)Known dead (b) To cargo $
(c) Missing (c) To other property $
(d) Injured 35. Is Vessel a Total Loss?  Yes  No

37. Remarks (Indicate assistance rendered by shore stations and vessels; recommendations for corrective safety measures pertinent to this casualty; include
explanation of any unsatisfactory lifesaving equipment. Attach additional sheets, if necessary.)
38. Deck Officer on Duty at Time of Casualty 39. Engineer on Duty at Time of Casualty
Name Name
Capacity License No. Capacity License No.
40.Date of Report 41. Submitted by (Print name) 42. Signature 43. Title
FORM RLM-109 (REV. 06/18) Page 2

RLM 109 - RLM 260 - Rev.06 18

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(This form located in RLM-260, Annex 10.1 Form RLM-109, Report of Vessel Casualty or Accident.

OFFICE OF THE DEPUTY COMMISSIONER

REPORT OF VESSEL CASUALTY OR ACCIDENT

10. (b) Class Society (Abbreviation):

II. PARTICULARS OF CASUALTY

 Day  Night  Twilight

FORM RLM-109 (REV. 06/18) Page 1

(a) On Board (a) To vessel $

(b)Known dead (b) To cargo $

(c) Missing (c) To other property $

(d) Injured 35. Is Vessel a Total Loss?  Yes  No

Capacity License No. Capacity License No.

FORM RLM-109 (REV. 06/18) Page 2

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