Form CG-2692 Report of Marine Accident, Injury or Death

OMB Control No. 1625-0001
RCS No. G-MOA

REPORT OF MARINE ACCIDENT,
INJURY OR DEATH

U.S. DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-2692 (Rev. 06-04)

MISLE NOTIFICATION NUMBER

SECTION I. GENERAL INFORMATION
1. Name of Vessel or Facility
6. Type (Towing, Freight, Fish, Drill, etc.)
11. Hull Material (Steel, Wood...)

7. Length

12. Draft (Ft. - in.)

3. Nationality

4. Call Sign

8. Gross Tons

9. Year Built

10. Propulsion (Steam, diesel, gas, turbine...)
14. Date (of occurrence)

13. If Vessel Classed, By Whom: (ABS, LLOYDS,
DNV, BV, etc.)

AFT.

FWD

5. USCG Certificate of
Inspection issued at:

2. Official No.

16. Location (See Instruction No. 10A)

15. TIME (Local)

17. Estimated Loss of Damage TO:

18. Name, Address & Telephone No. of Operating Co.

VESSEL
CARGO
OTHER

19. Name of Master or Person in Charge

USCG License

20. Name of Pilot

19a. Street Address (City, State, Zip Code)

YES
NO
19b. Telephone Number

USCG License
YES

20a. Street Address (City, State, Zip Code)

State License
YES

NO
NO
20b. Telephone Number

21. Casualty Elements (Check as many as needed and explain in Block 44.)
FIREFIGHTING OR EMERGENCY EQUIPMENT
FAILED OR INADEQUATE
(Describe in Block 44.)
LIFESAVING EQUIPMENT FAILED OR
INADEQUATE (Describe in Block 44.)

NO. OF PERSONS ON BOARD

FLOODING; SWAMPING WITHOUT SINKING

DEATH - HOW MANY?

CAPSIZING (with or without sinking)

MISSING - HOW MANY?

FOUNDERING OR SINKING

INJURED - HOW MANY?

HEAVY WEATHER DAMAGE

HAZARDOUS MATERIAL RELEASED OR INVOLVED

FIRE

BLOW OUT (Petroleum exporation/production)

(Identify Substance and amount in Block 44.)

EXPLOSION
COMMERCIAL DIVING CASUALTY

ALCOHOL INVOLVEMENT
(Describe in Block 44.)

ICE DAMAGE

DRUG INVOLVEMENT (Describe in Block 44.)

OIL SPILL - ESTIMATE AMOUNT:

DAMAGE TO AIDS TO NAVIGATION
OTHER (Specify)

CARGO CONTAINER LOST/DAMAGED

STEERING FAILURE

COLLISION
(Identify other vessel or object in Block 44.)

MACHINERY OR EQUIPMENT FAILURE

GROUNDING

STRUCTURAL FAILURE

ELECTRICAL FAILURE

WAKE DAMAGE

22. Conditions
B. WEATHER
A. Sea or River Conditions
(wave height, river stage,
etc.)

C. TIME

E. DISTANCE (miles
of visibility)

D. VISIBILITY

CLEAR

DAYLIGHT

GOOD

RAIN

TWILIGHT

FAIR

SNOW

NIGHT

POOR

F. AIR TEMPERATURE
(F)
G. WIND SPEED &
DIRECTION

FOG
OTHER (Specify)

H. CURRENT SPEED
& DIRECTION

23. Navigation Information
MOORED, DOCKED OR FIXED
ANCHORED
25.
FOR
TOWING
ONLY

UNDERWAY OR DRIFTING
25a.
Empty

Loaded

TOTAL

MAXIMUM

OF

H.P. OF

SIZE OF TOW

VESSELS

TOWING

WITH TOW-

UNITS

BOAT(S)

NUMBER

TOWED

25d. (Describe in Block 44.)

25c.

25b.
Total

Length

Width

PUSHING AHEAD
TOWING ASTERN
TOWING ALONGSIDE
MORE THAN ONE TOW-BOAT ON TOW

SECTION II. BARGE INFORMATION
26. Name

26a. Official Number

26f. Year Built

26g.

SINGLE SKIN

26h. Draft
FWD

26b. Type

AFT

24a. Time and
Date of Departure

24. Last
Port
Where
Bound

SPEED
AND
COURSE

26c. Length

26d. Gross Tons

26e. USCG Certificate of
Inspection Issued at:

26i. Operating Company

DOUBLE
26j. Damage Amount

26k. Describe Damage to Barge

BARGE
CARGO
OTHER
PREVIOUS EDITION IS OBSOLETE

Reset

PAGE 2 OF CG-2692 (REV. 06-04)
SECTION III. PERSONNEL ACCIDENT INFORMATION
27c. Status

27a. Name (Last, First, Middle Name)

27. Person Involved
MALE or

FEMALE

DEAD

INJURED

Crew
27b. Address (City, State, Zip Code)

Passenger

MISSING

Other
29. Telephone No.

28. Birth Date

30. Job Position

31. (Check here if off duty)

32. Employer - (if different from Block 18., fill in Name, Address, Telephone No.)
33. Person's Time

YEAR(S)

A. IN THIS INDUSTRY -

34. Industry of Employer (Towing, Fishing, Shipping,
Crew Supply, Drilling, etc.)

MONTH(S)

B. WITH THIS COMPANY -

35. Was the Injured Person Incapacitated 72 Hours or
More?

C. IN PRESENT JOB OR POSITION D. ON PRESENT VESSEL/FACILITY -

36. Date of Death

E. HOURS ON DUTY WHEN ACCIDENT OCCURRED 37. Activity of Person at Time of Accident
38. Specific Location of Accident on Vessel/Facility
39. Type of Accident (Fall, Caught between, etc.)

40. Resulting Injury (Cut, Bruise, Fracture, Burn, etc.)

41. Part of Body Injured

42. Equipment Involved in Accident

43. Specific Object, Part of the Equipment in block 42., or Substance (Chemical, Solvent, etc.) that directly produced the Injury.

SECTION IV. DESCRIPTION OF CASUALTY
44. Describe how accident occured, damage, information on alcohol/drug involvement and recommendations for corrective safety measures.
sheets if necessary).

(See instructions and attach additional

45. Witness (Name, Address, Telephone No.)
46. Witness (Name, Address, Telephone No.)

SECTION V. PERSON MAKING THIS REPORT
47. Name (PRINT) (Last, First, Middle)

47c. Title

47b. Address (City, State, Zip Code)
47d. Telephone No.

47a. Signature
47e. Date

FOR COAST GUARD USE ONLY
MISLE Incident Investigation Activity Data Entry:
NONE

PRELIMINARY

DATA COLLECTION

Serious Marine Incident

Yes

No

Major Marine Casualty

Yes

No

INVESTIGATOR

(Name)

REPORTING OFFICE:
MISLE Incident Investigation Activity Number (if applicable)
INFORMAL
DATE

FORMAL
APPROVED BY (Name)

DATE

Reset

INSTRUCTIONS
FOR COMPLETION OF FORM CG-2692
REPORT OF MARINE ACCIDENT, INJURY OR DEATH
AND FORM CG-2692A, BARGE ADDENDUM
OCS FACILITIES

WHEN TO USE THIS FORM
1. This form satisfies the requirements for written reports
of accidents found in the Code of Federal Regulations for
vessels, Outer Continental Shelf (OCS) facilities, mobile
offshore drilling units (MODUs), and diving. The kinds of
accidents that must be reported are described in the
following instructions.
VESSELS
2. A vessel accident must be reported if it occurs upon the
navigable waters of the U.S., its territories or possessions;
or whenever an accident involves a U.S. vessel; wherever
the accident may occur. (Public vessels and recreational
vessels are excepted from these reporting requirements.)
The accident must also involve one of the following (ref.
46 CFR 4.05-1):

4. All OCS facilities (except mobile offshore drilling units)
engaged in mineral exploration, development or production
activities on the Outer Continental Shelf of the U.S. are
required by 33 CFR 146.30 to report accidents resulting in:
A.

Death;

B.

Injury to 5 or more persons in a single incident;

C.
Injury causing any person to be incapacitated for
more than 72 hours;
D.
Damage affecting the usefullness of primary
lifesaving or firefighting equipment;
E.
Damage to the facility in excess of $25,000
resulting from a collision by a vessel;

A.
All accidental groundings and any intentional
grounding which also meets any of the other reporting
criteria or creates a hazard to navigation, the environment,
or the safety of the vessel;

F.
Damage to a floating OCS facility in excess of
$25,000.

B.
Loss of main propulsion or primary steering, or
an associated component or control system, the loss of
which causes a reduction of the maneuvering capabilities
of the vessel. Loss means that systems, component parts,
subsystems, or control systems do not perform the
specified or required function;

5. Foreign vessels engaged in mineral exploration,
development or production on the U. S. Outer Continental
Shelf, other than vessels already required to report by
Instructions 2 and 3 above, are required by 33 CFR
146.303 to report casualties that result in any of the
following:

C.
An occurrence materially and adversely affecting
the vessel's seaworthiness or fitness for service or route
including but not limited to fire, flooding, failure or damage
to fixed fire extinguishing systems, lifesaving equipment or
bilge pumping systems;
D.

Loss of life;

A.

Death;

B.

Injury to 5 or more persons in a single incident;

C.
Injury causing any person to be incapacitated for
more than 72 hours.
DIVING

E.
An injury that requires professional medical
treatment (beyond first aid) and, if a crewmember on a
commercial vessel, that renders the individual unfit to
perform routine duties.

6. Diving casualties include injury or death that occurs
while using underwater breathing apparatus while diving
from a vessel or OCS facility.

F.
An occurrence not meeting any of the above
criteria but resulting in damage to property in excess of
$25,000. Damage cost includes the cost of labor and
material to restore the property to the condition which
existed prior to the casualty, but it does not include the
cost of salvage, cleaning, gas freeing, drydocking or
demurrage.

A.
COMMERCIAL DIVING. A dive is considered
commercial if it is for commercial purposes from a vessel
required to have a Coast Guard certificate of inspection,
from an OCS facility or in its related safety zone or in a
related activity, at a deepwater port or in its safety zone.
Casualties that occur during commercial dives are covered
by 46 CFR 197.486 if they result in:

MOBILE OFFSHORE DRILLING UNITS
3. MODUs are vessels and are required to report an
accident that results in any of the events listed by
Instruction 2-A through 2-F for vessels. (Ref. 46 CFR
4.05-1, 46 CFR 109.411)

1. Loss of life;
2. Injury causing incapacitation over 72 hours;
3. Injury requiring hospitalization over 24 hours.

In addition to the information requested on this form,
also provide the name of the diving supervisor and, if
applicable, a detailed report on gas embolism or
decompression sickness as required by 46 CFR
197.410(a)(9).
Exempt from the commercial category are dives for:
1. Marine science research by educational
institutions;
2. Research in diving equipment and technology;
3. Search and Rescue controlled by a government
agency.
B. ALL OTHER DIVING. Diving accidents not covered
by Instruction (6-A) but involving vessels subject to
Instruction (2), VESSELS, must be reported if they result
in death or injury causing incapacitation over 72 hours.
(Ref. 46 CFR 4.03-1(c)).
HAZARDOUS MATERIALS
7. When an accident involves hazardous materials, public
and environmental health and safety require immediate
action. As soon as any person in charge of a vessel or
facility has knowledge of a release or discharge of oil or a
hazardous substance, that person is required to
immediately notify the U. S.
Department
of
Homeland Security's National Response Center (telephone
toll-free 800-424-8802 - in the Washington, D.C. area call
202-426-2675). Anyone else knowing of a pollution
incident is encouraged to use the toll-free telephone
number to report it. If etiologic (disease causing) agents
are involved, call the U.S. Public Health Service's Center
for Disease Control in Atlanta, GA. (telephone 404-6335313). (Ref. 42 USC 9603; 33 CFR 153; 49 CFR 171.15)
COMPLETION OF THIS FORM
8. This form should be filled out as completely and
accurately as possible. Please type or print clearly. Fill in
all blanks that apply to the kind of accident that has
occurred. If a question is not applicable, the abbreviation
"NA" should be entered in that space. If an answer is
unknown and cannot be obtained, the abbreviation "UNK"
should be entered in that space. If "NONE" is the correct
response, then enter it in that space.
9. Once completed, deliver or m ail this form as soon as
possible to the Coast Guard Marine Safety, Marine
Inspection or Activities Office nearest the location of
the casualty or, if at sea, nearest the arrival port.

10.

Amplifying information for completing the form:

A. Block 16 - "LOCATION" - Latitude and longitude
to the nearest tenth of a minute should always be entered
except in those rivers and waterways where a mile marker
system is commonly used. In these cases, the mile
number to the nearest tenth of a mile should be entered. If
the latitude and longitude, or mile number, are unknown,
reference to a known landmark or object (buoy, light, etc.)
with distance and bearing to the object is permissible.
Always identify the body of water or waterway referred to.
B. Tug or towboat with tow - Tugs or towboats with
tows under their control should complete all applicable
portions of the CG-2692. SECTION II should be
completed if a barge causes or sustains damage or meets
any other reporting criteria. If additional barges require
reporting, the "Barge Addendum," CG-2692A, may be
used to provide the information for the additional barges.
C. Moored/Anchored Barge - If a barge suffers a
casualty while moored or anchored, or breaks away from
its moorage, and causes or sustains reportable damages
or meets any other reporting criteria, enter the location of
its moorage in Block (1) of the CG-2692 and complete the
form except for Blocks (2) through (13). The details will be
entered in SECTION II for one barge and on the "Barge
Addendum" CG-2692A, for additional barges.
D. SECTION III - Personnel Accident Information SECTION III must be completed for a death or injury. In
addition, applicable portions of SECTIONS I, II and IV
must be completed. If more than one death or injury
occurs in a single incident, complete one CG-2692 for one
of the persons injured or killed, and attach additional
CG-2692's, filling out Blocks (1) and (2) and SECTION III
for each additional person.
E. BLOCK 44 - Describe the sequence of events
which led up to this casualty. Include your opinion of the
primary cause and any contributing causes of the casualty.
Briefly describe damage to your vessel, its cargo, and
other vessels/property. Include any recommendations you
may have for preventing similar casualties. ALCOHOL
AND DRUG INFORMATION. Provide the following
information with regard to each person determined to be
directly involved in the casualty: name, position aboard the
vessel, whether or not the person was under the influence
of alcohol or drugs at the time of the casualty, and the
method used to make this determination. If toxicological
testing is conducted the results should be included; if
results are not available in a timely manner, provide the
results of the toxicological test as soon as practical and
indicate that this is the case in block 44 of the casualty
form.

NOTICE: The information collected on this form is routinely available for public inspection. It is needed by the Coast
Guard to carry out its responsibility to investigate marine casualties, to identify hazardous conditions or situations and to
conduct statistical analysis. The information is used to determine whether new or revised safety initiatives are necessary
for the protection of life or property in the marine environment.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control
number.
The Coast Guard estimates that the average burden for this report is 1 hour. You may submit any comments concerning the accuracy of this burden
estimate or any suggestions for reducing the burden to: Commandant (G-MOA), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management
and Budget, Paperwork Reduction Project (1625-0001), Washington, DC 20503