CG-2692 Report of Marine Accident, Injury or Death

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0001

U.S. Coast Guard
REPORT OF MARINE CASUALTY

Expires: xx/xx/xxxx

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...)

5. USCG Certificate of
Inspection issued at:

14. Date (of occurrence)

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

AFT.

FWD

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

USCG License

20. Name of Pilot

State License

YES
YES
YES
NO
NO
NO
19a. Home or Work Street Address (City, State, Zip Code) 19b. Home or Work Telephone No. 20a. Home or Work Street Address (City, State, Zip Code) 20b. Home or Work Telephone No.
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

ELECTRICAL FAILURE

WAKE DAMAGE

STRUCTURAL FAILURE

22. Conditions
C. TIME

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

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.
NUMBER

Empty

Loaded

25c.

25b.
Total

OF

TOTAL

MAXIMUM

H.P. OF

SIZE OF TOW

VESSELS

TOWING

WITH TOW-

TOWED

UNITS

BOAT(S)

25d. (Describe in Block 44.)
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

CG-2692 (11/12)

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SECTION III. PERSONNEL ACCIDENT INFORMATION
27. Person Involved

27c. Status

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

MALE or

FEMALE

DEAD

INJURED

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

Passenger

M ISSING

Other

28. Birth Date

29. Telephone No.

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 to Casualty (Name, Address, Telephone No.)
46. Witness to Casualty (Name, Address, Telephone No..)

SECTION V. PERSON MAKING THIS REPORT

47c. Title

47b. Address (City, State, Zip Code)

47. Name (PRINT) (Last, First, Middle)

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

CG-2692 (11/12)

INVESTIGATOR

(Name)

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

FORMAL
APPROVED BY (Name)

DATE

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INSTRUCTIONS
FOR COMPLETION OF FORM CG-2692
REPORT OF MARINE CASUALTY
AND FORM CG-2692A, BARGE ADDENDUM
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):
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;
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;
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;

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

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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 202-4262675). 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 404-633-5313). (Ref. 42 USC
9603; 33 CFR 153; 49 CFR 171.15)
COMPLETION OF THIS FORM
8. In accordance with 46 CFR 4.05-1, the vessel owner,
agent, master, operator, or person in charge shall complete
this form. 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, e-mail or fax this form within
five days of the casualty to the Coast Guard Sector, Marine
Safety Unit, or Activity nearest the location of the casualty
or, if at sea, nearest the arrival port.
10. When a casualty meets the requirements of a serious
marine incident as defined in 46 CFR 4.03, the owner,
agent, master, operator, or person in charge, is required to
submit a CG-2692B in accordance with 46 CFR 4.06-60.

11. 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.
Reportable marine casualty information is needed for Coast Guard investigations of vessel casualties involving death, vessel damage, property loss and
data, as mandated by Congress (see 46 USC 6301).
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 (16250001), Washington, DC 20503.

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Privacy Act Notice
(CG-2692, CG-2692A, CG2692B)
Authority: 46 U.S.C. §6301 and Title 46, Code of Federal Regulations (CFR), Part 4 authorizes
the collection of this information. Specifically, 46 CFR 4.05-10 mandates that vessel owners,
agents, masters, operators, or persons in charge file a written report of any marine casualty
required to be reported under § 4.05-1. The written report must be provided on Form CG-2692
(Report of Marine Accident, Injury or Death) supplemented as necessary by appended Forms
CG-2692A (Barge Addendum) and CG-2692B (Report of Required Chemical Drug and Alcohol
Testing Following a Serious Marine Incident).
Purpose: The Coast Guard uses this information in gathering facts to determine causes
surrounding reportable marine casualties. This information assists in promoting the safety of life,
property, and the protection of the marine environment through preventing the reoccurrence of
accidents.
Routine Uses: Reportable marine casualty information is needed for Coast Guard investigations
of vessel casualties involving death, vessel damage, property loss and data reports as mandated by
Congress (See 46 U.S.C. 6301). Information gathered is also used to determine whether new or revised
safety initiatives are necessary. Additionally, chemical testing information is needed to improve Coast
Guard detection and reduction of drug use by mariners. The information contained on forms CG2692, CG-2692A, and CG-2692B may be disclosed under the Freedom of Information Act (FOIA)
via a written FOIA request.
Disclosure: Furnishing this information is mandatory per 46 CFR Part 4.05-10; failure to furnish
the requested information for occurrences that are reportable marine casualties may result in civil
penalty sanctions as outlined in 33 CFR Part 1. Coast Guard credentialed mariners may be
subject to administrative adjudication per 46 CFR Part 5 for reporting failures. Some of the
casualty information collected on this form may be made available for public inspection; however,
information collected is protected from use in civil litigation per 46 U.S.C. §6308. Personal
privacy information will not be disclosed routinely. Social Security numbers are not mandated on
this form.

CG-2692 (11/12)

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