별지 제2호서식(제4조제10항 관련)

REPORT OF QUESTIONS

In reply to the following questions with regard to the ship collision accident which occurred on                at

between               and

I, the undersigned, wish to state, as hereunder, in compliance with the request of the Investigator.

3303-333-012741일                                                                       190㎜×268㎜

1988.10. 7. 승인                                                                    (일반용지 54g/㎡)

PART Ⅰ. General information

A. Person questioned

1. Name, rank, the date of birth and address of person interviewed

Name :

Rank :

Date of birth :

2. Duty and position at the time of accident :

3. Kind of competency certificate :

Issue date :                   Expire date:

4. Nationality :

5. Present address(Letter address) and telephone number, e-mail address

6. Educational background in navigation/marine engineering :

7. Experience on board ship

- present position :      years

- previous position :     years

8. Date on board this ship :

B. Ship

1. Name of the ship :

2. IMO Number and Call Sign :

3. Gross tonnage/deadweight tonnage :                 /

4. Flag State/port of registry :                     /

5. Hull material : steel, light alloy, wood, GRP, other(          )

6. Hull construction :single hull/double hull/double bottom/double side/mid deck/ other(           )

7. Type of the ship :

8. Registered ship owner :

Address :

Telephone No. :

9. Ship manager/operator :

Address :

Telephone No. :

10. Building yard :

11. Date of delivery :

12. Hull number :

13. Principal dimension of the ship

L.O.A                meters(feet)

Breadth              meters(feet)

Depth                meters(feet)

14. Type and horse power of Main engine :

15. Propulsion type : steam/diesel/other

- Number of Propeller:

- Type of propeller : Fixed/Controllable pitch/other

16. Fuel oil (HFO, MFO, MDO)

- Main Engine:

- Aug. Engine:

17. Bow thrust

- Fore :

- Aft  :

18.  Details of ship certificates(issuing authority/date of issue/expiry(dd-mm-yy)

1) LOAD LINE :                        /                 /

2) CARGO SHIP SAFETY CONSTRUCTION :              /             /

3) CARGO SHIP SAFETY EQUIPMENT :                  /            /

4) CARGO SHIP SAFETY RADIO :                        /             /

5) PASSENGER SHIP SAFETY :                          /              /

6) IOPP :                       /                /               /

7) MINIMUM SAFE MANNING :                         /              /

8) INTERNATIONAL TONNAGE, 1969 :                  /              /

9) DOC :                       /                /               /

10) SMC :                     /                /               /

19. Classification society :

20. Number of crew on ship's certificate :           persons

21. Any deviation with steering compass :           degree

22. Position of bridge

From bow	meters(feet)

Height of eye from sea level	meters(feet)

23. Average speed and number of engine revolution

a. Sea speed               (Knots)               (R.P.M)

b. Harbour speed           (Knots)               (R.P.M)

Full         :

Half         :

Slow        :

Dead slow   :

24. Turning circle

Port                        Starboard

- transfer :	meters(feet)	meters(feet)

- advance :	meters(feet)	meters(feet)

25. Stopping distance

Critical (Full Ahead -> Full Astern):                 meters(feet)

26. Was the steering efficiency of steerability? : good/ bad

C. Navigational Equipments

1. Number/ type /maker of Radar(S or X-band / ARPA function)

Main radar :        /                    /

Sub radar :         /                    /

- Linked with speed log or manual speed data?

- Visible screen in day light without radar hood?

2. Type/maker of Electronic Chart Display System

3. Type/maker of GPS(Global Positioning System)

4. Type/maker of EPA(Electronic Plotting Aids)

5. Type/maker of ATA(Automatic Tracking Aids)

6. Type/maker of VDR(Voyage Data Record)

7. Type/maker of Course  Recorder

- Course and rudder :

- Course only :

8. Type/maker of Echo Sounder

9. Type/maker of Engine Logger

10. Type/maker of AIS (Automatic Identification System)

D. Life-saving Appliances

1. Inflatable liferaft

Capacity:

Date of last survey/ Expire date:                  /

2. Marine Evacuation System(MES) : Vertical/ Slide

3. Lifeboat : Davit launched / Free fall / Enclosed/Open type

Capacity :

4. Type of personal life-saving appliance used:

Immersion suit/ Life jacket / Personal Floatation Device/ Anti-explosure suit/ Life buoy

E. The voyage in which the accident occurred

1. Date/time of the accident?( LT :            )(GMT+    h)

2. ① Where is the location of the accident?

Lat. :

Long. :

② How did you learn the position and who got it?

3. Last port of call :

4. Time and date of its departure :

5. Draft at the time of its departure

Fore  :             meters(feet)

After :             meters(feet)

6. Freeboard :          meters(feet)

7. Port of destination :

8. ① Was life-saving equipments in accordance with regulations? (yes/no)

② When was it last inspected?

9. ① When and where were the last boat and fire drills held?

② Are they recorded in the log? (yes/no)

10. ① Number of crew and passengers on voyage

Crew :         persons,     Passenger :     persons

② Was the full complement according to manning scale or manning certificate on board and if not, what was the reason?

③ Did officers and engineers hold certificates according to their positions (any dispensations)?

④ Did the navigational and engineering watch arrangements conform with the requirements specified for the ship by the flag state or the operating company?

⑤ Were all persons for each watch properly rested?

⑥ What were the work pattern and duties of the crew involved during the 24 hours(or longer) prior to the accident?

11. Specify the name, age, rank and home address of each deceased, missing or injured person.

Dead (Missing) :

Injured :

12. Type and quantities of cargoes loaded.

PART 2. Collisions between vessels

1. Charts

① The issuing authority and number of the chart used:

② The date of the last small correction:

If an electronic chart display system was in use, obtain a full description of equipment, data base inputs and data base updating.

2. What was the weather and sea state prior to and at the time of the collision?

Weather :

Wind direction and velocity :

Tidal current :

Height of wave :

Visibility:

3. ① Who was the officer on watch on the bridge?

Rank:                  Name:

② Where and what was the master doing at the time of the collision and when did he come up on to the bridge?

③ Who was at the helm?

Rank:                     Name:

④ Was anyone else on the bridge immediately before and at the time of the collision?

4. ① Who was at lookout and where was he stationed?

② Who was the engineer on watch in the engine room?

5. What type of steering gear was the ship installed? Was the ship at manual mode or at automatic mode at the time of the collision?

6. What was the composition of the deck and engine room watches?

Deck part :

Engine part:

7. What course was being steered prior to the collision?

- True :

- Gyro :

8. What was the ship's heading at the time of the collision?

9.. What speed was the ship making prior to and at the time of the collision?

10. Was there any defect or deficiency in the ship, her navigational aids or equipment or in the ship's radio installation?

11. What lights was the ship turned on at the time of collision? (describe navigational lights turned on)

12. ① What range of radars were in use prior to and at the time of the collision?

Main radar :

Sub radar :

② Was a radar plot being carried out?

③ If the radar was not functioning, give the reason for this and date of breakdown.

13. Was the course recorder in use prior to and at the time of the collision?

14. Was the engine logger in use prior to and at the time of the collision?

15. ① How did you observe the other vessel at first, by your naked eyes (with Binocular) or radar?

② In which direction and what time was the other vessel first observed?

③ On what course did the other vessel appear to be heading?

And what speed was she apparently making?

16. ① What lights of the other vessel could be seen?

② Direction(from your heading), time and distance observed

17. When did you feel the risk of collision?

18. ① What sound signals were heard from the other vessel?

② When did you hear the signals?

19. ③ Was the fog signal sounded from your own ship before the collision?

④ If so, what signal and how often was it made?

⑤ Was the signalling equipment in good condition?

20. ① At what time and what manoeuvres did your own ship make to avoid or lessen the force of the collision?

② How did your ship use engine, bridge control or engine room control?

21. What manoeuvres were seen to be made by the other vessel?

22. Have you ever talked with the duty officer of the other ship before the collision on VHF?

- Time    :

- VHF Ch.:

- Details  :

23. What speed was the other vessel assumed to be making at the time of collision?

24. Where was each vessel hit? (Draw a diagram with marking the headings and collision angle)

25. How were the two ships cleared away after collision? Were there any other  contacts between the two before clearing away? (Sketch the contact)

26. ① Had any member of the crew or the master been seen to drink alcohol during the last 8 hours prior to or immediately before the collision?

② Had any member of the crew or the master been seen to take any drug prior to or immediately before the collision?

③ Had any member of the crew or the master been seen to be behaving in an unusual or irrational manner or been found to be smelling of alcohol prior to or immediately before the collision?

④ Did anyone on board your own ship commit any error or act of neglect that you are aware of?

27. Did all lifesaving appliances and equipment operate satisfactorily?

28. What did you do to save the crew member of the other ship?

29. What in the witness' opinion was the cause of the collision?

30. Specify the damage to your own ship and if possible also the damage to the other vessel.

31. Any damage sustained to the cargoes?

32. Was any distress alert or urgency signal sent? If so, give details and results obtained.

33. Were there any subsequent events such as oil pollution, sinking, loss of life, etc. after the collision?

34. Please state any other information, evidence, etc. with regard to this collision.

PART 3. Grounding or striking bottom

1. What course was being steered prior to the grouding/striking?

- True :

- Gyro :

2. What was the speed immediately before the accident?

3. Were there any obstacles to be avoided on your course?

4. Where and what were you doing at the time of the accident?

5. How often did you fix your position on the navigational chart?

6. Why couldn't you avoid the grounding/striking against the objects?

7. Was there any defect or deficiency on the ship, her navigational aids or equipments?

8. What type of steering gear was the ship installed?

9. Was the ship at manual mode or at automatic mode prior to and at the time of the collision?

10. Had the steering gear been tested in accordance with SOLAS regulation V/26?

11. What was the weather and sea state prior to and at the time of the collision?

Weather :

Wind direction and velocity :

Drift of tidal current :

Height of wave :

Visibility:

12. ① Was the radar in use prior to and at the time of the grounding?

② Was the radar plot being carried out?

③ If the radar was not functioning, give the reason for this and date of breakdown.

13. ① Who was the officer on watch on the bridge?

② Who was on the bridge immediately before and at the time of grounding?

③ When was the master called and when did the master come on to the bridge?

14. Was there a pilot on board and was the ship being conned under his advice? Obtain name and licence number of the pilot.

15. ① Was there a lookout on duty and where was he stationed?

② Who was he?

16. When and where the magnetic compass last adjusted and deviation tables drawn up ?

17. Was the ship listed before the grounding?

18. Was the accident affected by tidal current?

19. Was any cargo derrick, boom or gear so positioned that the magnetic compass,   or other navigational aid could have been adversely affected?

20. Were the sounding taken immediately after running aground?

21. Was the echo sounder in used at the time of the grounding?

22. ① Had any member of the crew or the master or the pilot been seen to imbibe alcohol during the 8 hours prior to or immediately before the grounding?

② Had any member of the crew or the master or the pilot been seen to take any drug prior to or immediately before the grounding?

③ Had any member of the crew or the master or the pilot been seen to be behaving in an unusual or irrational manner or been found to be smelling of alcohol prior to or immediately before the grounding?

23. Was any error or act of negligence seen to be committed by the master, a crew member or pilot?

24. Any damage sustained to the hull and cargoes?

Hull :

Cargoes:

25. Were there any subsequent events such as oil pollution, sinking, loss of life, etc. after the accident?

26. Was the ship refloated? By what assistance?

27. Any other informations

PART 4. Fire or explosion

1. What was the operational condition of the ship at the time of the accident?

(     ) Sailing

(     ) Loading

(     ) Unloading

(     ) Awaiting departure

(     ) Under repair

(     ) Other, please state:

2. Local condition when fire was discovered:

․Date/time

․Wind force/direction

․Sea state(Beaufort scale)

․Ship's heading/course

3. Part of ship where fire broke out

4. Probable cause of fire

(     ) Cargo operation

(     ) Maintenance

(     ) Hot work

(     ) Self ignition of the cargoes

5. How were the persons onboard alerted ?

6. Means by which fire was initially detected

(      ) Fixed fire detection system

(      ) By ships crew or passenger

(      ) Unknown

7. When and where did you see the fire/explosion for the first time?

8. How and by whom was the fire discovered?

9. Who was on watch and where were they?

10. What did you do immediately after discovering out the fire?

11. what was the course and speed at the time of the accident?

12. What steps were taken to extinguish the fire?

13. What was the weather, the direction and force of the wind?

14. The performance of structual fire protection (fire resisting and fire-retarding bulkheads, doors, etc) (방화구조의 성능);

․Containment and extinguishment of any fire in the space of origin.

․Protection of means of escape or access for fire fighting

․Adequacy of structual fire protection

15. Ship's portable fire-extinguishing equipment used (foam, dry chemical, CO₂, water, etc.)

16. Fixed fire-extinguishing installations;

․ Specify the type

․ Were fixed fire-extinguishing systems used in an attempt to extinguish the fire?

․ Did the use of fixed fire-extinguishing systems contribute to the extinguishment of the fire?

17. The action taken by the crew to contain, control and suppress fire and explosion in the space of origin.

18. Was outside assistance provided (e.g. fire department, other ship, etc.) and, if so, what equipment was used?

19. Qualification and training of the crew concerned in the accident.

20. Were the company procedures, including hot work, in place?

21. If the procedures were in place, were they correctly implemented?

22. Time taken to fight fire from first alarm.

․to control the fire :

․once controlled, to extinguish the fire :

23. Total duration of fire :           days/hours

24. Damage caused by fire

․Loss of life, or injuries to personnel

Name :

Rank :

․Hull damage :

․Cargo damage :

․Release of pollutants

Type of pollutants :

Quantity :

25. Was there any failure of the fire-fighting equipment of system when used?

If yes, were the equipment and/or system maintenance records up to date(e.g. serviced)?

26. Was there an adequate supply of air on board for self-contained breathing apparatus or was outside assistance needed to supply such air?

27. Observations and comments:

28. In the case of fire in cargo space:

① Was a watch kept in the holds during loading/discharging? If so, who maintained watches in the hold in which fire broke out?

② What type of cargo was there in the hold or compartment in which fire broke out?

③ Describe the condition of the cargo when loaded. Was it raining when the cargo was being loaded/discharged?

④ Sketch the position and nature of the cargo in the hold or cargo space concerned.

⑤ Were there any dangerous goods on board? (yes, no)

Name of the dangerous cargo :

If so, were they loaded, stowed and segregated in accordance with the provisions of the IMDG Code? (yes, no)

⑥ If bulk cargo was carried, was it loaded, stowed and segregated and cared for in accordance with all applicable provisions of the BC Code? (yes, no)

⑦ Was the temperature in the hold checked at regular intervals and were readings entered in the log? Had the temperature risen?

⑧ Had anyone been in the hold or cargo space where fire broke out since leaving port? Who was the last person to be in the hold or space and was anything unusual seen?

⑨ Whilst in port, were notices of prohibition of smoking in and near the holds and on deck by the crew or shore side?

⑩ Did the witness see anyone smoking in the hold or near the open hatchway to the hold in which fire broke out?

What action was taken to stop this and was it successful?

⑪ Were ventilators covered by wire mesh spark arrestors?

⑫ Were there fire dampers?

⑬ Was the mechanical ventilation shut down?

⑭ What fire extinguishing device were available to extinguish fire in the holds or spaces concerned? What extinguishers were used?

⑮ Was any particular odour noticed before the fire was discovered?

Was any smoke seen? What colour was it?

For cargoes other than bulk cargoes, what kind of packing was used?(Burlap sack, Paper bag, Tins, Drum or Container) Were they stained or in good condition?

29. In the case of fire in engine room.

① Was the oil burner system for boilers/the fuel system for main and auxiliary engines oiltight?

If not so, was there any leakage in any oil pipe and where was it located?

② Were drip trays with drainage to the waste oil tank provided under the fuel oil installations?

If so, how often were the trays cleaned and when were they last cleaned?

③ Where were service tanks located?

④ Were the cofferdams satisfactory?

⑤ Were there quick-closing valves on service tanks and how could they be closed? Were they closed?

⑥ Were there discharge valves on the service tanks and if so, where did they discharge to?

⑦ Were exhaust pipes insulated as required by regulation? Did the fire break out near them?

⑧ What type of fixed fire extinguishing system was fitted in the engine and boiler rooms? Was it used, and if so, what effect did it have on the fire?

⑨ What portable fire extinguishing appliances were provided in the engine and boiler room and where were they placed?

Were they in proper order and easily accessible? what effect did they have on the fire?

⑩ Were the empty (oil) tanks in gas free condition?

⑪	Was any work being performed in the vicinity which could produce sparks?

What types of tools were being used?

⑫ What type of lighting was being used?

⑬ Was oil pumped to service tank prior to the fire?

If so, who was watching the pump?

Was there an oil spill (by overflowing)?

⑭ How much oil was there in the service tanks at the time of the fire? How much oil was there in the drip trays under the service tanks?

․Service tank :

․Drip tray :

⑮ In the case of a crank case explosion, were bearings overheated or was there any failure in the oil supply before the explosion?

When was the lubricating oil last analysed? What was the result of the analysis?

30. In the case of fire in the accommodation space:

① Was there a party or other social gathering in any of the accommodation spaces at the time of the accident?

② Was any highly flammable fluid (petrol, thinners etc.) kept in any accommodation space?

③ Have you ever seen anyone smoking in the area which the fire broke out?

④ How were living quarters heated? (electronic heater, stove, hot air)

⑤ Did any automatic warning or extinguishing system function?

31. ① When was the electrical installation last inspected by a classification society or competent surveyor?

Was all found to be in accordance with applicable regulations?

② Was there any electrical wiring, lighting or other appliance located where the fire broke out? Was the current on?

32. When was the fire extinguishing equipment last surveyed?

33. Had a ship surveyor or a classification society made any recommendation regarding the ship, its machinery or equipment which had not been carried out?

34. What in the witness' opinion was the cause of the fire?

PART 5.  Engine damages

1. When was each piston last overhauled?

2. When were top and bottom end bearings and the main bearings last inspected before the damage, and with what result?

3. When were indicator cards last taken and with what result?

4. When was the lubricating oil temperature and pressure last taken before the damage occurred?

5. When was the exhaust temperature last taken before the damage?

6. When was the lubricating oil last examined and with what result?

7. When was the lubricating oil in the system last changed?

PART 6. Other damages to the ship, or to property other than the ship

1. What happened?

2. Why did it happen?

3. What was the extent of the damage?

4. Outline the events leading up to the accident.

5. Visibility, weather and sea state at the time of the accident.

6. Was there any known defect or deficiency in the ship, its hull, superstructure, closing appliances or equipment before the incident occurred?

7.  ① Were all the cargo-handling appliances and gears in order when last used prior to the accident occurred?

② Did anyone notice anything wrong with any equipment while using it just before the accident?

③ When and by whom was the said equipment inspected and was this entered in the record book?

④ Were the prescribed certificates in order?

⑤ Is the safe working load clearly marked on the cargo-handing equipment?

⑥ What kind of work was being done at the time of the accident?

⑦ When, where and by whom were the last load tests carried out for the cargo-handling equipment?

8. ① If a floating object was damaged, what was it?

② Was anyone injured?

9. Was there any damage to any harbour installation, light, beacon or other property?

10. What in the witness' opinion was the cause of the accident?

11. Has the ship received any navigational warning by radio or other means advising of the wreck or other hazard struck?

12. What was the date and number of the last notice to mariners received on board?

PART 7. Dangerous Goods or Marine Pollutant

1. Type of pollutant

2. UN number/IMO hazard class(if applicable)

3. Name and address of manufacturer, or consigner, or consignee

4. Type of packing

5. Quantity of goods remaining on board

6. Quantity of goods lost

7. Method of stowage and securing

8. Where stowed and quantities in each compartment/container

9. Extent of damage

10. Why did the incident happen?

11. What work was in progress at the time of the accident?

12. Was there equipment failure?

13.  ① Has the incident been reported to the nearest coastal state? (yes, no)

② To which station?

14. ① What has been done to mitigate the pollution?

② How much chemical was used for it?

PART 8. Personal injury or death

1. Full name, date of birth, and home address of the injured or deceased person.

2. Who ordered the work to the injured/deceased person?

3. By whom was he/she examined?

4. Was there anything unusual with regard to the injured/deceased person's mental health, state of mind or behaviour before the accident (signs of nervousness, depression or other abnormality)?

5. When and how was it first discovered that the person concerned was sick/injured?

6. ① What symptoms did the injured/deceased person have (pains in the region of the heart, breast or stomach, vomiting, fever, diarrhea, unconsciousness, paralysis, confusion, restlessness, etc.)? Describe symptoms and course of events in as much detail as possible.

② What illness was he/she thought to be suffering from?

③ What treatment did he/she receive on board for the illness/injury?

7. ① Did the injured/deceased person receive regular attention, how often and by whom?

② Was anyone appointed to keep watch over him/her?

8. ① Was medical advice obtained by radio?

② Where and when was medical advice received?

③ What medical advice was received?

9. ① Who was the last person to see and speak to the injured/deceased person before injury/death?

② How did he/she behave at that time?

10. ① Did the injured/deceased person imbibe alcohol or drug prior to the accident/death? If so, how often he/she did it?

② Was he/she indisposed before the accident (lack of sleep, hangover, etc.)?

11. In poisoning cases :

① What substance caused the poisoning?

② How was the substance stored and used on board?

③ Who was responsible for its storage and use?

④ How was the container marked?

⑤ Has the injured/deceased person been informed of the dangers connected with the substance and the precautions to be taken when using it?

⑥ What was the injured/decease person using the substance for?

12. In accident cases :

① How did the accident happen?

② Was the accident attribute to any fault, negligence or lack of due care and attention of the master, an officer, crew member or other person?

③ Was the accident attribute to any fault or deficiency in the ship, its hull, equipment, fittings or appliances or accessories?

④ What precautions were being observed while work was in progress?

⑤ If deck cargo was being carried, were regulation guard rails or lifelines, walkways and ladders arranged and safe access provided?

⑥ If work was being done in a hold, tank or other space where gas might accumulate or where there might be a lack of oxygen, had the hold tank or space been properly ventilated?

⑦ Was the tank, hold or space tested with a gas detector? In that case,

- What gas detector was used?

- Were lifelines being used?

- Was anyone on watch at the hatch coaming on deck?

⑧ What type of cargo was being or had been carried in the hold tank or space ?

⑨ What type of cargo was carried in the hold tank or space for the last voyage before the accident?

- When was that cargo discharged?

- Had the hold, tank or space been cleaned and gas-freed when the accident occurred?

⑩ If work was being done from a stage or bosun's chair, inboard or outboard, did  the injured/deceased person have a rope or lifeline round his waist?

⑪ Was the accident attributed to the nature of the cargo, or any fault, deficiency or carelessness with regard to the manner of stowing or securing it?

⑫ Describe the type of gas-masks and smoke masks provided on the ship.

- When last was it inspected before the accident?

- When oxygen flasks were last filled and checked?

- When was last drill and instruction given in the use of the equipment prior to the accident?

- Who was responsible for its maintenance and instruction?

⑬ Who was the officer on watch?

- Who was responsible for and in charge of the work?

⑭ What was the weather at the time of the accident (wind, sea state, etc.)?

⑮ If the accident was attributed to the failure of cargo-handing gear, the record book and prescribed certificates are to be produced.

- When was the equipment last tested?

- Is the safe working load clearly marked on the cargo-handing gear?

- By what was the load being lifted or moved when the accident occurred?

13. Give any other information with regard to the death.

14. What, in the opinion of the witness, was the cause of the accident?

PART 9. Shift of cargo

1. If the cargo consisted of grain, ore or other bulk cargo, were all recommended measures taken to prevent shift of cargo?

2. If shifting boards were used, were the boards approved by any authority and by whom?

3. If bulk cargo was being carried and holds were not completely filled, what arrangements were made to prevent the cargo shifting?

4. ① If timber was carried on deck, how many uprights were used on each side and how far apart were they?

② What were the dimensions of the uprights and how were they fastened to the deck and bulwarks?

③ How much were the height of on deck cargoes from the deck?

5. ① How was deck cargo lashed?

② Were the lashings regularly checked and tightened?

6. How much bunkers, fresh water, ballast and other weights was the ship carrying on departure?

7. ① Did the ship develop a list and if so, to which side and to what angle?

② At what time did the list first develop.

8. What steps were taken to right up the ship after the list had appeared?

9. Was the ship listing before the shift of cargo occurred?

10. How was the cargo in the holds secured?

11. What was the cause of the shift of cargo?

12. What was done to secure the cargo after it had started shifting?

13. ① Did any authority or institution supervise the loading of the ship, and if so, which?

② Was a certificate issued? (If so, obtain a copy of the certificate)

14. Specify the damage caused to the ship, equipment and cargo as a result of the shift of cargo.

15. Was anyone on board injured?

16. Who was on watch on deck and in the engine when the cargo shifted?

17. Did the ship have to seek a port of refuge or request assistance?

I hereby certify that the above statement is correct in every detail.

Date : 20   .    .     .

The rank and name of the Interviewee :

Signature

The name of the Investigator :                         Signature

Korean Maritime Safety Tribunal