7/23/2019 Ams t17 Rev0 Ucua Report

1/2

Allianz Middle East Ship Management LLC

UNSAFE ACT / UNSAFE CONDITION REPORT (UC / UA)

NOTE: 1. Observer will comle!e ri"#! si$e o% !#e Reor! &'$ sec!io's A !o E.. S#is S&%e! o%%icer will e's*re !#&! imor!&'! reor!s &re $isc*sse$ $*ri'" +SE mee!i'" &'$ %*r!#er &c!io' is comle!e$

w#ere 'ecess&r.,. +SE De&r!me'! will co'$*c! &'&lsis- i$e'!i% !r&i'i'" &'$ c&sc&$e le&r'i'" oi'!s !o &ll vessels

Name of vessel : Date of Report :

Location : Time of Report :

Tick UA/UC (Hazard): UA UC

ection A ! "#$R%$R& NA'$ dentification Cecklist (Tick)

*osition of *eople

Risk of falling from height

Risk of staying under loadection # ! UA/UC (HA+ARD) DC"%$R$D Risk of contact with electric current

Risk of contact with hazardous substances

Risk of being stuck by objectsRisk of being caught in, on, between objectsRisk of poor manual handlingOthers: _____________________________

ection C ! L"CAT"N ", UA/UC (HA+ARD) Reactions of *eopleAdjusting PP

!hanging position"topping #ob

ection D ! ''$DAT$ ACT"N TA-$N$

Others: _____________________________

*ersonal *rotective $.ipment

%o &ead Protection

%o yes, ars or 'ace Protection

%o "afety &arness

%o Respiratory Protection

ection $ 0 AN1 ,URTH$R ACT"N R$2UR$D "R TA-$N (TC- )%O

%o 'oot Protection

%o !o(eralls at work site

)" %o *ork (est + ifejacket

"3server&s i4natre:

Date:

Others:__________________________________

ection , 0 ,URTH$R ACT"N TA-$N (#5 ips afet5 "fficer): Tools and $.ipment

-sing wrong tools for the job

-sing tools incorrectly

Others:

__________________________________

ection H 0 To 3e filled 35 2H$ department *rocedres / Trainin4

Procedures not known + understood

Procedures not followed

Poor housekeeping

3standard Condition

P&"e 1 o%

Teml&!e No: AS T1Iss*e D&!e: 0 0.012

Rev No: 0Rev D&!e: N3R

7/23/2019 Ams t17 Rev0 Ucua Report

2/2

Allianz Middle East Ship Management LLC

.aintenance

/nspection

Others: ____________________________

P&"e o%