Cg 2692 Form – Fill Out and Use This PDF

DEPARTMENT OF HOMELAND SECURITY	OMB No: 1625-0001
U.S. Coast Guard	Exp. Date: 03/31/2019

REPORT of MARINE CASUALTY, COMMERCIAL DIVING CASUALTY, or OCS-RELATED CASUALTY

Section I - Reporting Vessel/Facility Information

1.	Vessel or Facility Name					2.	Vessel Official Number or IMO Number	3.	Vessel Flag
4.	Vessel Length					5.	Vessel Gross Tons	6.	Vessel Propulsion Type
			Feet		Meters
7.	Vessel or Facility Type					8.	Vessel or Facility Service or Occupation

Section II - Reason for Submitting this Report (Check all that 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 $75,000

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 (Fill all fields that apply)

13.	Name of Owner	Telephone	14.	Name of Operator or Manager	Telephone
	Address	Email address		Address	Email address
15. Name of Master or Person-In-Charge (Last, First, Middle)		Telephone	16.	Name of Agent (Last, First, Middle)	Telephone
	Address	Email address		Address	Email address
17.	Name of Dive Supervisor (Last, First, Middle)	Telephone	18.	Name of Pilot (Last, First, Middle)	Telephone
	Address	Email address		Address	Email address

Section IV - Casualty Information

19. Date/Time (local) of Occurrence					20. Location-Name of Body of Water or Waterway: Latitude:	River Mile Marker:
					Longitude:	OR
21. Property Damage Estimated Damage Cost(s) to:					Describe the Extent of Property Damage
Vessel: $		Cargo: $
Facility: $		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:

On Board the Vessel:

Injured:

Dead:

Missing:

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Section IV - Casualty Information (continued)

23. Was This Casualty a Serious Marine Incident (SMI) as Defined in 46 CFR 4.03-2?

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?

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. Attach additional sheets if necessary.):

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

Section V - Person Making this Report

CG-2692 (04/18)

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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 or an uninspected recreational 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. http://www.uscg.mil/top/units/

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,” CG-2692D to provide a list of all involved persons and witnesses to the casualty being reported. The CG-2692D may also be used to provide data on persons involved or witnessing a marine casualty or commercial diving casualty.

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 OCS-related 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.

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