Form DRAFT_CG-2692 Report of Marine Casualty, Commercial Diving Casualty, o

OMB No.1625-0001
Exp. Date: 01/31/2016

DEPARTMENT OF HOMELAND SECURITY
U.S.COASTGUARD

Report of Marine Casualty, Commercial Diving Casualty, or OCS-related Casualty
Section I - Reporting Vessel/Facility Information:
1. Vessel or Facility Name
4. Vessel Length

2. Vessel Official Number or IMO Number

3. Vessel Flag

5. Vessel Gross Tons

6. Vessel Propulsion Type

__feet __ meters
7. Vessel or Facility Type

8. Vessel or Facility Service or Occupation

9.

9a. Arrangement:

FOR
TOWING
ONLY

__ Pushing Ahead

Empty

__ Towing Astern

Loaded __________

__ Towing Alongside

Total

9b. Number of Vessels Towed:
__________

9c. Maximum Size of Tow/Tow-Boat(s):
Length

__________ feet

Width

__________ feet

9d. Did one or more of the barges in the tow cause or
sustain damage in the marine casualty?
__ Yes

__________

__ No (If Yes complete and attach one or
more CG-2692A forms to this report)

Section II - Reason for Submitting this Report (Check all the apply):
10. The above vessel was involved in a Marine Casualty consisting in (46 CFR 4.05-1 and 4.05-10):
 → 1. Unintended grounding or an unintended strike of (allision with) a bridge
 → 2. Intended grounding or intended strike of a bridge that created a hazard to navigation, the environment or the safety of the vessel, or that meets any of the
criteria in 3 through 8 below
 → 3. Loss of main propulsion, primary steering, or any associated component or control system that reduces the maneuverability of the vessel
 → 4. Occurrence materially and adversely affected the vessel’s seaworthiness or fitness for service or route
 → 5. Loss of life
 → 6. Injury that requires professional medical treatment (treatment beyond first aid) and, if the person is engaged or employed on board a vessel in commercial
service, that renders the individual unfit to perform his or her routine duties
 → 7. Occurrence causing property damage in excess of $25,000
 → 8. Occurrence involving significant harm to the environment
11. The above facility or vessel was involved in a Commercial Diving Casualty involving (46 CFR 197.484):
 → 1. Loss of life
 → 2. Diving-related injury to any person causing incapacitation for more than 72 hours.
 → 3. Diving-related injury to any person requiring hospitalization for more than 24 hours
12. The above facility or vessel was involved in an OCS Facility Casualty Resulting in (33 CFR 146.30 and 146.35):
 → 1. Death
 → 2. Injury to 5 or more persons in a single incident
 → 3. Injury causing any person to be incapacitated for more than 72 hours
 → 4. OCS Facility only - Damage affecting the usefulness of primary lifesaving or firefighting equipment
 → 5. OCS Facility only - Damage to the facility exceeding $25,000 resulting from a collision by a vessel with the facility
 → 6. OCS Facility only - Damage to a floating OCS facility exceeding $25,000

Section III - Associated Parties Information:
13. Name of Owner

14. Name of Operator or Manager

Address

Telephone

15. Name of Master or Person-in-Charge (Last, First, Middle)
Address

Address

16. Name of Agent (Last, First, Middle)

Telephone

17. Name of Dive Supervisor (Last, First, Middle)
Address

Telephone

Address

Telephone

18. Name of Pilot (Last, First, Middle)
Telephone

Address

Telephone

Section IV - Casualty or Accident Information
19. Date/Time (local) of Occurrence

20. Location
Name of Body of Water or Waterway:
------------------------------------------------------------------------------------------------------------------------------------------------------------------Latitude:
OR
River Mile Marker: __ __ __ . __
Longitude:

21. Property Damage
Estimated Damage Cost(s) to:

Describe the Extent of Property Damage:

Vessel:

$ ____________________

Facility:

$ ____________________

Cargo:

$ ____________________

Other:

$ ____________________

22. Status of Involved Persons (If there are 1 or more injured, dead or missing persons complete and attach one or more CG-2692C forms to this Report)
Total Number of Persons:

CG-2692 (Rev. XX-16)

On Board the Vessel __________ Injured: __________ Dead: __________

Missing: __________

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Section IV - Casualty or Accident Information (continued)
23. Was This Casualty a Serious Marine Incident (SMI) as Defined in 46 CFR 4.03-2?
__ Yes __ No __ Not at this Time, But Is Likely to Become an SMI

(If Yes or Is Likely to Become an SMI complete/attach one or more CG-2692B forms to this report)

24a. Is there any evidence of alcohol or drug use by or intoxication of individuals
directly involved in the casualty?
__ Yes

__ No (If Yes, identify those individuals for whom evidence has been
obtained and specify the method to obtain such evidence in
block 24c)

24b. Did any individual directly involved in a casualty refuse to submit to, or
cooperate in, the administration of a timely chemical test, when directed by a law
enforcement officer or by the marine employer?
__ Yes

__ No (If Yes, note the individual(s) who refused in block 24c)

24c. Individuals with evidence of drug or alcohol use, evidence of intoxication, or who refused to submit/cooperate in a timely chemical test (if more space is needed, continue
in block 25c)

24d. Is there evidence that alcohol use contributed to this casualty?
__ Yes

__ No (If Yes, discuss in block 25b)

25. Nature and Circumstance of the Casualty:
25a. Activity or Operation Being Conducted at the Time of the Casualty:

25b. Description of the Casualty (casualty events and the conditions and actions that were believed to be causal factors as well as any hazards created as a result of the
casualty):

25c. Any other comments, including with respect to use of or need for emergency equipment:

Section V - Person Making this Report
24. Name (PRINT) (Last, First, Middle)

25. Signature

27. Title

28. Address

29. Telephone No.

30. Email

CG-2692 (Rev. XX-15)

26. Date

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INSTRUCTIONS FOR COMPLETION OF FORM CG-2692
REPORT OF MARINE CASUALTY, COMMERCIAL DIVING CASUALTY, OR OCS-RELATED CASUALTY
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 (CG-INV), U.S. Coast Guard
Stop 7501, 2703 Martin Luther King Jr Ave SE, Washington, DC 20593-7501 or Office of Management and Budget, Paperwork Reduction Project (1625-0001), Washington, DC 20503.
WHEN TO USE THIS FORM
1. This form satisfies the requirement for written reports of casualties and accidents found in the Code of Federal Regulations for vessels, commercial diving operations, and Outer Continental Shelf
(OCS) facilities. Depending on the circumstances surrounding an incident, a written report may be required if it meets one or more of the conditions described in instructions 2 – 4.
2. VESSELS. If you are the owner, agent, master, operator, or person in charge of a vessel, other than a public vessel, recreational vessel, or state-numbered vessel, you must submit a report if your
vessel:
A. is involved in a marine casualty or accident that occurs upon the navigable waters of the United States, its territories or possessions and meets any of the criteria in block 10, or
B. is a United States vessel involved in a marine casualty or accident, wherever such casualty or accident occurs, that meets any of the criteria in block 10, or
C. is a foreign vessel engaged in OCS activities as defined in 33 CFR 140.10 and is involved in a marine casualty or accident that meets any of the criteria in block 10, or
D. is a foreign tank vessel operating in waters subject to the jurisdiction of the United States, including the Exclusive Economic Zone (EEZ), which involves significant harm to the environment or
material damage affecting the seaworthiness or efficiency of the vessel.
3. DIVING.
A. Commercial Diving. If you are the master or person in charge of a vessel or facility from which a commercial diving operation is conducted: (1) at any deepwater port or the safety zone thereof as
defined in 33 CFR Part 150; (2) from any artificial island, installation, or other device on the Outer Continental Shelf (OCS) and the waters adjacent thereto as defined in 33 CFR Part 147 or otherwise
related to activities on the OCS; (3) from any vessel required to have a certificate of inspection issued by the Coast Guard, including mobile offshore drilling units, regardless of their geographic
location; or (4) from any vessel connected with a deepwater port or within the deepwater port safety zone or from any vessel engaged in activities related to the OCS, you must submit a report if there
is a diving casualty meeting the criteria in block 11, except if the diving operation is:
1. performed solely for marine scientific research and development purposes by educational institutions,
2. performed solely for research and development for the advancement of diving equipment and technology, or
3. performed solely for search and rescue or related public safety purposes by or under the control of a governmental agency.
B: All Other Diving. Any occurrence of injury or loss of life to any person while diving from a vessel subject to instruction 2 and using underwater breathing apparatus must be reported under
instruction 2.
4. OUTER CONTINENTAL SHELF (OCS) FACILITIES. If you are the owner, operator, or person in charge of an OCS facility engaged in OCS activities as defined in 33 CFR 140.10, you must submit a
report if your facility is involved in a casualty or accident that meets any of the criteria in block 12.
COMPLETION OF THIS FORM
5. In accordance with 46 CFR §4.05-10, 46 CFR §197.486, and 33 CFR §146.35, this form shall 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 block is not applicable, the abbreviation “NA” should be entered in that space. If the answer is unknown and cannot be obtained before the report has
to be submitted (i.e. within 5 days of the accident), the abbreviation “UNK” should be entered in that block. If “NONE” is the correct response, enter it in the block.
6. Once completed, deliver, email, or fax this form within 5 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.
7. Tugs or towboats with tows under their control shall complete blocks 9a through 9d and, if one or more barges in their tow causes or sustains damage or meets any other reporting criteria, use the
“Barge Addendum,” CG-2692A to report information on the barge(s) involved.
8. If an incident involves multiple barges suffering or causing damage while moored or anchored (such as in a fleeting area), or breaking away from their moorage and causing or sustaining damage, enter
the location of the moorage in Block 1 of the CG-2692 and complete the form except for blocks 2-8. Details for the barges will be entered on the CG-2692A. If a single barge is involved in a marine
casualty while moored or anchored, it shall be documented as any other vessel using the CG-2692.
9. If the casualty meets the criteria for a serious marine incident as defined in 46 CFR §4.03, use the “Chemical Drug and Alcohol Testing Addendum,” CG-2692B to report information on required drug
and alcohol testing following a serious marine incident.
10. If one or more persons on the vessel or facility were injured, killed, or missing as a result of the casualty, use the “Personnel Casualty” Addendum,” CG-2692C to report information on the extent of all
personnel casualties.
11. For facilities and vessels engaged in OCS activities who are reporting a casualty in accordance with 33 CFR §146.35 or 33 CFR §146.303, use the “Involved Persons and Witnesses Addendum,” CG2692D to provide a list of all involved persons and witnesses to the casualty being reported.
12. Block 20 – “Location”: Always identify the body of water or waterway. 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 those 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.
Privacy Act Notice
(CG-2692, CG-2692A, CG-2692B, CG-2692C and CG-2692D)
Authority: Title 46, United States Code (U.S.C.) §6301, Title 46, Code of Federal Regulations (CFR), Parts 4 and 197, and Title 33, CFR Part 146 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 46 CFR §4.05-1, 46
CFR §197.486 mandates that persons in charge of vessels or facilities file a report of any diving casualty required to be reported under 33 CFR §197.484, and 46 CFR §146.35 mandates that owners,
operators, or persons in charge of an OCS facility or vessel engaged in OCS activities file a report of any OCS-related casualty required to be reported under 33 CFR §146.30. For marine casualties,
diving casualties when the diving installation is on a vessel, and The written report must be provided on Form CG-2692 (Report of Marine Casualty, Commercial Diving Casualty, or OCS-Related
Casualty) supplemented as necessary by appended Forms CG-2692A (Barge Addendum), CG-2692B (Chemical Drug and Alcohol Testing Addendum), CG-2692C (Personnel Casualty Addendum), and
CG-2692D (Involved Persons and Witnesses Addendum). The forms may be used for diving casualties when the diving installation is on a facility or for OCS-related casualties that are not also marine
casualties under 46 CFR Part 4.
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 injury, death, property damage, environmental damage and dangerous
conditions and for preparation and submission of data reports mandated by Congress (see 46 U.S.C. 6301). Information gathered is also used to determine whether new or revised safety laws,
regulations, and policies 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
CG-2692, CG-2692A, CG-2692B, CG-2692C, and CG-2692D may be disclosed under the Freedom of Information Act (FOIA) in response to a written FOIA request.
Disclosure: Furnishing this information is mandatory per 46 CFR §4.05-10. Failure to furnish the requested information for occurrences that are reportable marine casualties, diving casualties, or OCSrelated 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 (Rev. XX-15)

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