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To meet Regulations of ANNEX VI of the International Convention for the
Prevention of Pollution from Ships, 1973 and its 1978 Protocol, as amended.

Initial Survey Renewal Survey Intermediate Survey Annual Survey

Name of Ship : Distinctive Letters : Port of Registry:

Gross Tonnage: Dead Weight (metric tons): Year of Build:

Managers (or agents) :

Place of survey: in dry-dock on slipway afloat Survey Commenced :

At: Survey Completed :

Note: i. Fields should be filled with YES, NO or N/A as required.

ii. All negative entries (NO) should be clarified under "Surveyor's Notes" with reference by item number.

1. International Air Pollution Prevention Certificate No. on board expires

2. Cargo Ship Safety Construction Certificate No. on board expires
3. Cargo Ship Safety Equipment Certificate No. on board expires
4. If any of the following has been carried out details are to be included in the narrative of the report:
Repairs and / or Renewals carried out
Alterations affecting the Certificate / Statement
Alterations, renewal and / or replacements affecting the Records of Construction and Equipment
If any of the above have occurred was the record of Construction and Equipment on board amended if necessary?
5. Have any changes been made or any new equipment installed which would affect the validity of the Certificate?
(If so, list of alternations and / or renewals under Surveyor's Notes, Item 41).
6. Were all other Statutory and Classification Certificates valid at the time of the survey?
7. Was the structure, equipment, systems, fitting arrangements and materials examined for compliance with the relevant
requirements of MARPOL 73/78 Annex VI?


8. Are there certificates for compliance with the NOx Technical Code onboard for each engine required to be Certified?
(refer to section 2.2.1 of the Records of Construction and Equipment).
9. Is there an approved Technical file for each Certified engine on board?
10. Is there type approval certificate on board for each incinerator on board?
11. Is there type approval certificate on board for the exhaust gas cleaning system?
12. Are there bunker delivery notes on board as required by regulation 18? (shall be retained for a period of three years after the fuel
oil has been delivered on board.
12.1 Are the representative samples of the fuel oil on board as required by regulation 18? (shall be retained until the fuel oil
is substantially consumed, but not less than 12 months from the date of delivery).

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13. Does any system or equipment onboard contain Ozone Depleting Substances?
- Reg. 12 does not affect the Ozone Benign substances (have zero ODP and are not ODS) such as: HFC (R-125, R-134a, R-227ea
or FM-200, R-404a, R-407A-D, R-410A, R-417A, R-507, etc) and R-717(Ammonia), R-744 CO2), HC (R-290(Propane,R-600
Butane,R-600a Isobutane etc. ), R-718 (water)
If yes please indicate as follows :
Type of Equipment / system Location Type of Ozone depleting Substances
R-22, R-123, R-124, R-401A, R-401B, R-
402A, R-402B, R-403A, R-403B, R-408A,
R-409A, R-411B etc.
i) Domestic refrigerator

ii) Provisions refrigerator

iii) Provisions freezers

iv) Air condition units

v) Others :

13.1 In case vessel’s equipment contains ODS then List of this equipment along with Ozone Depleting Substances Record
Book is maintained on board and verified by the attending surveyor.
14. Is any system or equipment still in use or approaching its allowable date to remain onboard?
If Yes, advise Owners it must be removed and disposed of to appropriate reception facilities


Use 15, 16 or 17 dependant upon the method indicated in the approval technical file.

15. Verification of the engine parameter check method.

15.1 Review engine documentation and the record book of engine parameters
15.2 Has the engine undergone any modifications or adjustments since last surveyed?
15.3 Conduct survey as detailed in the on-board system in the technical file.
15.4 If an electronic engine management system is used, check against the original settings.
16. Verification of the simplified measurement method.
16.1 Review engine documentation.
16.2 Confirm test procedure approved.
16.3 Confirm test equipment correct type and calibrated in accordance with the NOx Technical Code.
16.4 Confirm correct test cycle used for the on-board confirmation test measurements.
16.5 Was a fuel sample taken during the test and submitted for analysis?
16.6 Submit a copy of the test report for approval on completion.
17. Direct measurement and monitoring method.
17.1 Review engine documentation.
17.2 Confirm test equipment calibrated in accordance with the NOx Technical code and operational.
17.3 Current data available reviewed on board and confirmed that weighted average NOx emissions in accordance with
the NOx Technical code.
17.4 Review and confirm the past three month’s engine operating data. In accordance with the Technical file.
18. After-treatment device is installed.
18.1 From an external examination verify the after-treatment device is in generally satisfactory condition.
18.2 Verity its operation and NOx compliance.
18.3 If additional substances are introduced (e.g. steam, water, urea, etc.) verify consumption meter operation.
18.4 Confirm any adjustments or modifications are recorded in the Engine’s record book of engine parameters.
18.5 Where adjustments or modifications are outside the Technical file limits, confirm they have been verified as not
exceeding the NOx limits.

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19. From an external examination verify the exhaust cleaning system is generally in satisfactory condition.
20. Is the exhaust cleaning system operating correctly with manufacturer’s instructions?
21. Are there records of the changeover to and from low sulphur fuel during transit through Sox Emission Control Areas?
22. Where equipped with tanks for low (0.1% m/m) and normal (3.5% m/m) sulphur content fuel are switching arrangements
provided and operational?
23. Review bunker notes for carriage of correct quality fuel(s).


24. From a general examination, was the vapor collection piping in a satisfactory condition?
25. Is a means provided to eliminate the collection of condensate in the system, such as drains in low points of the line end, and
are drains operable?
26. Is the piping electrically continuous and electrically bonded to the hull, and mean of bonding intact?
27. Are the isolation valves at the vapor manifolds operational and do the valve position indicators operate correctly?
28. Are the ends of each line properly identified as vapor lines?
28.1 Are the vapor connections flanges in accordance with industry standards?
29. Where portable vapor hoses are provided, are they in good condition, and electrically continuous?
29.1 Are the hose ends properly marked as vapor hoses?
30. Is the closed gauging system operational and the readouts in the cargo control are functional?
31. Is an overflow control system provided? (level alarm)
31.1 Do the audible and visual alarms operate?
31.2 Are the alarms properly labeled?
31.3 Does the power failure alarm operate?
31.4 Is there a means to check the operation of the alarms and is this means operational?
32. Are high and low pressure alarms provided in each main vapor line?
32.1 Do these alarms operate at the correct set points?
33. Are the high level and high level (overliff) alarms independent of each other?


34. From an external examination, was each incinerator in a generally satisfactory condition and free from leaks of gases or smoke?
34.1 Are the warning and instruction plates legible and secured in a prominent location?
34.2 Is the manufacturer’s name, incinerator model number / type and capacity in heat units per hour permanently marked
on the incinerator?
34.3 Are incinerator casing insulation arrangements in good condition?
35. Are the following alarms and safety devices operational?
35.1 Flue gas high temperature alarms and shutdown.
35.2 Flue gas high temperature alarms and shutdown.
35.3 Combustion temperature control and shutdown.
35.4 Combustion chamber negative pressure.
35.5 Flame safeguard control, alarms and shutdown.
35.6 Are all alarms both visual and audible functioning and do they indicate the cause of the failure?
35.7 Power loss alarm and auto shutdown arrangements.
35.8 Low fuel oil pressure alarm / shutdown.
35.9 Emergency stop switch and electrical isolating arrangement.

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36. Was it verified that the O2 content in the combustion chamber is between 6-12%?
37. Are complete instruction and maintenance manuals available on board?
38. Is the staff suitably trained?
39. Are drip trays fitted under each burner, pump, strainer and are they in a good condition?
40. Was the combustion chamber flue gas outlet temperature verified as between 850-1200oC?


41. Alterations or modifications:

41.1 Describe in detail system and equipment or parts which have been altered or modified.

41.2 Verification of the type approval certificate of the installed equipment carried out :

42 Describe in detail parts which remain to be examined, and deficiencies, if any

43. The I.A.P.P. Certificate with No. was endorsed on

44. A Short Term I.A.P.P. Certificate with No. was issued on

45. It is recommended that:

A full term I.A.P.P.Certificate valid until to be issued by the Head Office of the Society, or

No Full Term I.A.P.P.Certificate is to be issued before the survey is completed.

Surveyor to International Naval Surveys Bureau - I.N.S.B.

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