• BEFORE YOU START – know your 4 options for completing this report! use the method that works best for you!

      method 1 -- just fill out the form and type your narrative in the narrative box.

      method 2 -- prepare the narrative ahead of time in a different program (google docs or notes app on your phone, etc.) and copy and paste it into the narrative box.

      method 3 -- prepare the narrative ahead of time in a different program, save it, and attach it as a separate file to your report at the end, same as attaching pictures or other documentation.

      method 4 -- submit this form with the narrative section blank, then use the MSO Addendum Form to submit your narrative separately at a later time.

      Note that the MSO Addendum Form can also be used to add ANY additional information, pictures, or files to your report after submitting it.

  • PILOT'S REPORT OF MARINE SAFETY OCCURRENCE

    State of Washington Board of Pilotage Commissioners

  • WAC 363-116-200 1 (b)

    A state licensed pilot and state licensed pilot trainee involved in a near-miss occurrence shall complete the board-required Report of Maritime Safety Occurrence form and file it with the board as soon as possible after the near-miss occurrence, but in no event more than ten days afterwards. If a pilot trainee is involved, both the pilot trainee and the supervising pilot shall file a Report of Marine Safety Occurrence. A near-miss occurrence is where a pilot and pilot trainee successfully takes action of a non-routine nature to avoid a collision with another vessel, structure or aid to navigation, to avoid a grounding of the vessel or to avoid causing damage to the environment. Information relating to near-miss occurrences provided by a pilot and pilot trainee on this form shall not be used for imposing any sanctions or penalties against the pilot or pilot trainee involved in the occurrence. A state pilot or pilot trainee may also use this form on a voluntary basis for reporting out of the ordinary occurrences or concerns for navigational safety encountered or observed during the course of piloting a vessel as well as safety issues encountered or observed on the vessel, the dock, or in the area around the vessel.
  • Date of Occurrence*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type of report*
  • Type of Near Miss*

  • TYPE OF OCCURRENCE (INDICATE ALL THAT APPLY)

  • Piloted Vessel Loss of Propulsion and/or Equipment Malfunction*
  • Other Issue(s)

  • LOCATION INFORMATION

    (PLACE NAME/DESCRIPTION, TSS LOCATION, TERMINAL)
  • TSS Location?*
  • TSS location:
  • Terminal Location?*
  • Terminal location:

  • PILOTED VESSEL INFORMATION (AKA "OWN VESSEL")

    Please provide the information for your pilotage assignment -- even if there were no problems with the piloted vessel, aka "own vessel" -- as this is the context for the MSO. If MSO is reporting an issue with another vessel, then describe the other vessel(s) in next section "Other Vessel(s) Involved"
  • Vessel Type
  • Flag State
  • LOA/WIDTH UNITS
  • DRAFT UNITS
  • Was vessel master notified of intent to file this report?

  • OTHER VESSEL(S) INVOLVED?

    If issue was Tug Use Difficulty list tug(s) in this section. If issue was COLREGS/Nav rules list offending vessel(s). And/or list any other vessel(s) involved or affected by other issue(s).
  • Other Vessel(s) Involved?*
  • Give name and/or description of vessel. Add more rows for additional vessels

  • ENVIRONMENTAL CONDITIONS

  • Light Condition

  • NARRATIVE DESCRIPTION OF OCCURRENCE (OR UPLOAD SEPARATE DOCUMENT)

  • Topics to Consider: How problem arose, How problem was discovered, Contributing factors, Actions or inactions, Experience, Procedures, Judgments, Decisions, Personal alertness, Perceptions, Communications, Language difficulty, Ship design

    Please include intended route.

  • Was VTS called?
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