Safety checklist

June 2009

SAFETY CHECKOFF FORM

Observer Name
Vessel Name

OMB Control #0648-xxxx. Expires xx/xx/xxxx.

Trip Number
Vessel Number

Safety Check list (Offshore 20+ Miles)
USCG Safety Exam Decal #
Life Saving Equipment
Life Raft?

Date issued:

Type

Distance Rating:

Inspection Date:

Life Raft Hydrostatic Release Expiration Date:

Capacity?
Total # of People Onboard:
(This number is including the Observer)

EPIRB Location:

EPIRB Battery Expiration Date:

EPIRB Hydrostatic Release Expiration Date:
Personal Flotation Device for each person on board (POB) ?
Immersion Suit for each POB?

Location(s):
(only required above 32'00 N latitude)

Orange Ring Buoy(s) with Line attached?
Distress Flares?

Location(s):
Location(s):

Expiration Date for each distress flare.
Parachute

Smoke

Hand

Hand

Parachute

Smoke

Hand

Hand

Parachute

Smoke

Hand

Hand

Fire Fighting Equipment

Fire Extinguishers Charged?

Location 1:

Location 3:

Location 2:

Location 4:

Communication Equipment
Single Side Band
VHF

Other

Vessel Call Letters:
Satellite Phone # (if applicable)
Vessel Cell Phone # (if applicable)

First Aid Kit?
Ditch Bag?

Location(s):
Location(s):

Detailed Description of Vessel and Comments:

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June 2009

OMB Control #0648-xxxx. Expires xx/xx/xxxx.

SAF ET Y C HEC K O FF FO RM
STA TION BILL
Per son Over board
S ignal:

Posit ion

Fire
S ignal:

Station/Br ing/Duty

Trip #

Flooding
S ignal:

Station/Br ing/Duty

Station/Br ing/Duty

Abandon Ship
S ignal:

Station/Br ing/Duty

C aptain

C rew

C rew

C rew

Observer
Date per forme d

Vessel Sa fety O rientat io n (check all perfo rmed)
V essel L ayo ut:
Engine on/off , steer ing, ge ar se lec tion, etc.
S hut of f and c rossover va lves.
Alarm s: what they a re, what the y mea n, re por ting inope rative alarm s.
Entrapme nt: e xit routes.
H az ards: hatches, winches, mac hiner y, line s, slippery areas, sta bility c onc erns, e tc .

Em ergency A ssig nments (not o n the Station Bill): Each C rew M em ber's Specific D uties In
Launching survival c raft and recovering lif e boats and r escue boats.
D onning im mersion suits and we arable P FDs.
M aking a voice radio distress ca ll.
Using visual distre ss signa ls.
Activa ting the gener al alarm .

Pre- Trip Saf et y Sk ill( s)
At least once per m ont h an d before each new d ep art ure, on e safet y sk ill /ass ign ment m ust be p erform ed and log ged. In the s pace below l ist th e ski ll (s )
p erform ed and/ or i nclud e safet y ass ign ment , t hen s ign and date at the b ott om .

O bserver Signa ture and Date:
C apt ain Signa ture and Date:
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