This form is an approved form for the purpose of s.36 of the Marine Safety (Domestic Commercial Vessel) National Law Regulation 2013 and can be used to make a recommendation to the National Regulator in relation to a periodic/renewal survey in accordance with the requirements of the Marine Surveyors Accreditation Guidance Manual. It is a minimum set of information expected by the National Regulator for a periodic survey, it is not intended to be an exhaustive list.

Surveyed vessel details

Vessel name	Displayed Unique Identifier	AMSA issued UVI

Length (measured)	Survey location	Date of survey

Service category and person number survey was conducted for

E.g. 2C 2 2 2 0 E.g. within LCS coverage areas

Service category	Crew	Unberthed passengers	Berthed passengers	Special persons	Operational limits

Indicate type of survey conducted

Phase	Type of survey	Survey Scope	Documentation expected
Periodic/renewal	In water survey	Full Partial	Survey report and recommendation (901)
Out of water survey	Full Partial
Special Renewal Items (10 year intervals)	Full Partial
Shaft survey	Full Partial	Shaft report (638)
Lightship check	Full Partial	Lightship report (653) or declaration (752)
Loadline	Full Partial	Loadline survey report (139)
Transitional	Renewal in support of Initial survey (transitional)	Full Partial	Survey report and recommendation (901)
Commissioning	Commissioning survey	Full Partial	Survey report and recommendation (901)

Documentation

Classification society	Last classification survey

Life raft certificate(s)

Type (Coastal / SOLAS / ORL)	Capacity	Serial no.(s)	Due date

Lightship measurement date Residual current devices last test date Megger insulation test date (within 5 years)

EPIRB	Fixed fire-fighting installation / Service report / Certificate

Exp Date: Serial No.:

Valid stability documentation on board	Electrical compliance certificate	LPG compliance certificate

Yes No

Ships Equipment (including but not limited to checks of expiry dates, signage, condition, that any special purpose requirements are satisfied, and that the equipment is operational and of the correct type.)

Item	Comment
Pyrotechnics and container	Rocket	Hand	Smoke	Exp.
Medical supplies	Scale
Torch(es)
Daylight signalling lamp
Nav lights/code flags/day shapes	Tested
Lifejackets & whistles	Type	No
Type	No
Type	No
Lifejacket lights	Exp	No
Sound signals (whistle / bell / horn)
Magnetic compass
Deviation Card	Calibration date
Nav.Aids - Radar, GPS, barometer, clock, AIS
Depth sounder / Lead line
Engine instruments (on the bridge)
Radio communications batteries, radio lights and voltmeter / hydrometer	Radio call sign Station called Time & date Signal strength & modulation VHF HF
Satellite Phone (Number#)

Item	Comment
Charts and publications
Lifebuoys	Type: Smoke/light: No. Type: Line: No. Type: Light: No. Type: Plain: No.
Buoyant appliances	Type	Capacity
Life raft hydrostatic release
Rescue boat/life raft, launching arrangements and lighting installation and expiry date
Portable fire extinguishers/ fire blanket	Type	No.	Exp.
Fire bucket
Fire and safety plan posted
Fireman’s outfit
Logbooks, maintenance records, drill records and manifests as necessary

Anchor(s)

Anchor	Weight	Type	Chain: Size & Length	Rope: Size & Length
1.
2.

Deck Survey (Including but not limited to inspection of access ways and escape paths, checking of guardrails, stairs and hatchways, checking of weathertight and watertight boundaries and inspection and testing of anchors and winches)

Item	Comment
Anchor (condition)
Anchor chain shackles / anchor rope (condition where visible)
Anchor windlass
Bulwarks, guardrails, stairs and grab rails
Hull / deck (where visible)
Escapes, freeing ports and scuppers
Weather tight doors / hatches and latching devices
Windows / side scuttles and deadlights
Passenger boarding, seating and berths
Bollards and deck cleats

Fire Systems (including but not limited to testing of hydrants and hoses, inspection of structural fire protection for damage and/or missing tape or pins, testing of fire detection system and reviewing servicing reports.)

Item	Comment
Structural fire protection
Fixed fire system
Fire detectors/alarms
Fire dampers
Fire pump system

Emergency alarms and stops (including but not limited to inspection and testing of fuel shut-offs, remote shutdowns, fire flaps, and emergency lighting.)

Item	Comment
Bilge alarms
Emergency power
Emergency lighting
Remote fuel shutoffs
Remote stops
Fan shutoffs
Fire dampers/flaps

Machinery (including but not limited to verification of installed machinery, checking piping condition and standard (including for deterioration or corrosion), checking

connections and skin fittings, testing bilge pumps, checking exhaust system for thermal insulation and provision against back-flooding and checking of instruments, gauges and guards.)

Item	Comment
Engine	Make: Model: kW: RPM: Number:
Gearbox	Make: Model: Ratio: Number:
Auxiliary machinery	Type	Kwp
Machinery guards
Raw Water piping
Exhaust system / lagging
Valves and skin fittings (disassembled at renewal)
Bilge pumps / piping / valves / manifolds	Pump type:
Refrigeration equipment / fixed LPG installation
Compressors / Air receivers / Relief valves
Instruments (within the machinery space)
Engine room cleanliness
Steering gear / rudder stops
Emergency steering
Fuel tank fill / vents
Fuel lines / hose clips & clamps
Self-closing gauges
Fuel tank electrical bonding
2nd means of starting

Electrical (including but not limited to verification of location of batteries, inspection of the condition and securing of wiring, checking venting arrangements, checking labelling and isolation of fuses and reviewing testing and installation reports.

Item	Comment
Wiring / switchgear
Distribution boards
Batteries / installation
Shore supply
Residual current devices
Earth leakage monitoring

Out of water survey Items (including but not limited to removal of shipside valves, inspection of shafts and propellers, checking window mullions for cracks and leaks, inspection of anchor cable (removed from vessel) and checking of vessel structure for signs of corrosion, osmosis and/or de-lamination.)

Item	Comment
Hull / deck internally
Hull / deck external out of water
Internal buoyancy (renewal only)
Sea water tanks (renewal only)
Voids / peaks internally
Anchoring (out of vessel – renewal only)
Internal examination of chain locker (renewal only)
Shaft Coupling and Stern Gland
Shaft Bracket / Appendages
Stern Bearing and Propeller Shaft Bearing Clearance:
Propellers / rudders
Shaft (fully withdrawn at renewal)
Rudder Stock and Bearing (Renewal only – fully withdrawn from vessel)	Clearance:
Keel Cooling

To be inspected every second renewal survey

Item	Comment
UT Measurement of Hull (Metallic Vessels)
Withdraw sample fastening from hull (Wooden vessels)
Hull in way of removable ballast
Verify internal foam buoyancy (if not carried out at previous renewal survey)
Pressure Test all Sea Water pipes
Internal Inspection of Fuel Tanks
Internal inspection of other tanks

Safety Management System (SMS)

Note: These five questions are optional and do not form part of the survey.

Does the operator have a documented SMS?	Yes	No (If no, provide details below)

Was the vessels SMS on-board, sighted / explained?	Yes	No (If no, provide details below)

Was a risk register/ risk controls (SOP’s, logbooks etc) sighted / explained?	Yes	No (If no, provide details below)

Were emergency plans sighted / explained?	Yes	No (If no, provide details below)

Were logs of emergency drills sighted / explained?	Yes	No (If no, provide details below)

Details:

New recommended Conditions / Disputed Items / Deficiencies (will not resolve) / Item(s) not required

Surveyor notes to appear on next vessel report

Additional supporting documentation

The following documentation is provided to support this recommendation:

Item #	Document Name

Additional rows may be added by clicking the tab key at the end of the last entry.

Recommendation

On conducting the survey(s) I make the following recommendation:

Recommended - Where a surveyor recommends a survey the vessel must fully comply with the applicable legislation and standards and the vessel must not have any outstanding deficiencies. See SAGM – 2.9.1 and 2.9.2.

Recommend with Conditions - Where a surveyor recommends with operational or environmental conditions, the vessel must fully comply the applicable legislation and standards and the vessel must not have any outstanding deficiencies. The surveyor must provide details of the condition they think should be imposed in the Recommended Conditions / Disputed Items / Deficiencies (will not resolve) / Item(s) not required / Comments section above and provide documentation to support the recommendation. See SAGM – 2.9.3

Recommend with Dispute - Where a surveyor recommends a vessel, and there is one or more deficiencies that have a status of ‘disputed’. Other than the disputed items, the remainder of the vessel must comply the applicable legislation and standards and the vessel must not have any other outstanding deficiencies. The surveyor must provide details of the disputed items in the Recommended Conditions / Disputed Items / Deficiencies (will not resolve) / Item(s) not required / Comments section above and provide documentation to support the recommendation. See SAGM – 2.9.4

Details required by SAGM Ch. 2.9.4 provided.

Do Not Recommend - Where a surveyor does not a recommend a survey the surveyor must fully detail the deficiencies with status of ‘will not resolve’. The surveyor must provide details in the Recommended Conditions / Disputed Items / Deficiencies (will not resolve) / Item(s) not required / Comments section above and provide documentation to support the recommendation. See SAGM – 2.9.5

Checklist for transitional vessels renewal survey

This section is to be completed when conducting survey for a vessel that has triggered transitional and requires renewal survey as specified in MO503 section 9(1). E.g. Change in lightship

The vessel complies with the requirements of NSCV Parts C5C , C5D , C7A , C7B & C7C (as applicable)

A copy of the vessel’s stability book has been provided with person weights in accordance with NSCV Part C6

A copy of the last RCD test report or current installation report has been provided

A copy of the C4 compliant fixed fire system specification and installation report has been provided

Surveyor’s declaration

I declare that:

I have conducted survey(s) as indicated, of the above mentioned vessel, in accordance with the applicable standards as set out in Marine Order 503 Certificates of Survey, and that to the extent evident from the inspection/s carried out I am satisfied that the vessel meets the standards.

I consent to the Australian Maritime Safety Authority using and disclosing the information provided in this form for purposes associated with the administration of the Marine Safety (Domestic Commercial Vessel) National Law Act 2012.

I understand and acknowledge that the Australian Maritime Safety Authority, as the National Regulator, may ask that I provide any information or document that the National Regulator reasonably considers necessary in relation to this recommendation.

Name of Surveyor	Surveyor identification number

Recognised Organisation / company or trading name

Signature of surveyor	Date

Where to Lodge

Lodge online via MARS (Preferred), or by email to DCVapplications@amsa.gov.au , or by mail to: Australian Maritime Safety Authority, Attention: Vessel Safety Unit, GPO box 2181, Canberra ACT 2601, Australia

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