Free CG2692.PDF - Federal

OMB Control No. 1625-0001 U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-2692 (Rev. 06-04)
1. Name of Vessel or Facility 6. Type (Towing, Freight, Fish, Drill, etc.) 11. Hull Material (Steel, Wood...) 7. Length

REPORT OF MARINE ACCIDENT, INJURY OR DEATH
SECTION I. GENERAL INFORMATION
2. Official No. 8. Gross Tons 3. Nationality 9. Year Built 4. Call Sign

RCS No. G-MOA
MISLE NOTIFICATION NUMBER

5. USCG Certificate of Inspection issued at:

10. Propulsion (Steam, diesel, gas, turbine...) 14. Date (of occurrence) 15. TIME (Local)

12. Draft (Ft. - in.)

FWD
16. Location (See Instruction No. 10A) 18. Name, Address & Telephone No. of Operating Co.

AFT.

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

17. Estimated Loss of Damage TO:

VESSEL CARGO OTHER

19. Name of Master or Person in Charge

USCG License

20. Name of Pilot

USCG License YES

State License YES

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

YES NO 19b. Telephone Number

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

NO NO 20b. Telephone Number

21. Casualty Elements (Check as many as needed and explain in Block 44.) NO. OF PERSONS ON BOARD DEATH - HOW MANY? MISSING - HOW MANY? INJURED - HOW MANY? HAZARDOUS MATERIAL RELEASED OR INVOLVED (Identify Substance and amount in Block 44.) OIL SPILL - ESTIMATE AMOUNT: CARGO CONTAINER LOST/DAMAGED COLLISION (Identify other vessel or object in Block 44.) GROUNDING 22. Conditions B. WEATHER A. Sea or River Conditions (wave height, river stage, etc.) CLEAR RAIN SNOW FOG OTHER (Specify) 23. Navigation Information MOORED, DOCKED OR FIXED ANCHORED 25. FOR TOWING ONLY UNDERWAY OR DRIFTING 25a. NUMBER OF VESSELS TOWED 26a. Official Number 26g. 26h. Draft FWD Empty Loaded Total 24. Last Port Where Bound 25c. TOTAL H.P. OF TOWING UNITS MAXIMUM SIZE OF TOW WITH TOWBOAT(S) 26b. Type 26c. Length Length Width 25d. (Describe in Block 44.) PUSHING AHEAD TOWING ASTERN TOWING ALONGSIDE MORE THAN ONE TOW-BOAT ON TOW 26d. Gross Tons 26e. USCG Certificate of Inspection Issued at: C. TIME DAYLIGHT TWILIGHT NIGHT D. VISIBILITY GOOD FAIR POOR E. DISTANCE (miles of visibility) F. AIR TEMPERATURE (F) G. WIND SPEED & DIRECTION H. CURRENT SPEED & DIRECTION SPEED AND COURSE 25b. WAKE DAMAGE FLOODING; SWAMPING WITHOUT SINKING CAPSIZING (with or without sinking) FOUNDERING OR SINKING HEAVY WEATHER DAMAGE FIRE EXPLOSION COMMERCIAL DIVING CASUALTY ICE DAMAGE DAMAGE TO AIDS TO NAVIGATION STEERING FAILURE MACHINERY OR EQUIPMENT FAILURE ELECTRICAL FAILURE STRUCTURAL FAILURE OTHER (Specify) FIREFIGHTING OR EMERGENCY EQUIPMENT FAILED OR INADEQUATE (Describe in Block 44.) LIFESAVING EQUIPMENT FAILED OR INADEQUATE (Describe in Block 44.) BLOW OUT (Petroleum exporation/production) ALCOHOL INVOLVEMENT (Describe in Block 44.) DRUG INVOLVEMENT (Describe in Block 44.)

24a. Time and Date of Departure

SECTION II. BARGE INFORMATION
26. Name 26f. Year Built 26j. Damage Amount BARGE CARGO OTHER PREVIOUS EDITION IS OBSOLETE

SINGLE SKIN DOUBLE

AFT

26i. Operating Company

26k. Describe Damage to Barge

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PAGE 2 OF CG-2692 (REV. 06-04) SECTION III. PERSONNEL ACCIDENT INFORMATION
27. Person Involved MALE or DEAD MISSING 28. Birth Date 29. Telephone No. 30. Job Position FEMALE INJURED 27b. Address (City, State, Zip Code) 27a. Name (Last, First, Middle Name) 27c. Status Crew Passenger Other 31. (Check here if off duty)

32. Employer - (if different from Block 18., fill in Name, Address, Telephone No.) 33. Person's Time 34. Industry of Employer (Towing, Fishing, Shipping, Crew Supply, Drilling, etc.) 35. Was the Injured Person Incapacitated 72 Hours or More? 36. Date of Death

A. IN THIS INDUSTRY B. WITH THIS COMPANY C. IN PRESENT JOB OR POSITION D. ON PRESENT VESSEL/FACILITY 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.)

YEAR(S)

MONTH(S)

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

47c. Title 47d. Telephone No.

47a. Signature 47e. Date

FOR COAST GUARD USE ONLY MISLE Incident Investigation Activity Data Entry: NONE PRELIMINARY
Yes Yes No No

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

DATA COLLECTION
INVESTIGATOR (Name)

FORMAL
APPROVED BY (Name) DATE

Serious Marine Incident Major Marine Casualty

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INSTRUCTIONS FOR COMPLETION OF FORM CG-2692 REPORT OF MARINE ACCIDENT, INJURY OR DEATH 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; 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. 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. 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) 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. B. Death; 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. B. Death; Injury to 5 or more persons in a single incident;

C. Injury causing any person to be incapacitated for more than 72 hours. DIVING 6. Diving casualties include injury or death that occurs while using underwater breathing apparatus while diving from a vessel or OCS facility. 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: 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