Cg 2692 Form PDF Details

The CG-2692 form, mandated by the Department of Homeland Security and especially utilized by the U.S. Coast Guard, is a comprehensive report designed to cover a wide range of maritime incidents, including marine casualties, commercial diving accidents, and Outer Continental Shelf (OCS)-related casualties. This form is an essential tool in the assessment and documentation of incidents that have significant impacts on the safety of vessels and facilities, the welfare of individuals on board, and the marine environment. It serves a crucial role in enforcing safety regulations and fostering a culture of accountability and prevention in maritime operations. The form includes detailed sections for reporting vessel or facility information, the reasons for submitting the report, associated party details, casualty specifics, and the person making the report. Additionally, it outlines specific instructions for its completion, ensuring that reports are filed accurately and comprehensively. Utilized in a variety of circumstances, such as unintended groundings, loss of propulsion, incidents requiring professional medical treatment, and occurrences causing significant environmental harm, the CG-2692 plays a pivotal role in the U.S. Coast Guard's efforts to investigate and mitigate the risks associated with maritime activities. Furthermore, the form's structured framework for reporting, which can include additional documentation through appendices for barge addendums, drug and alcohol testing addendums, personal casualty addendums, and involved persons and witnesses addendums, provides a thorough account of the event, aiding in the Coast Guard's investigation process and potential regulatory reviews aimed at enhancing maritime safety.

QuestionAnswer
Form NameCg 2692 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namescg form 2692, cg 2692 form, casualty marine report, coast guard 2692

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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

 

 

 

 

 

 

 

 

 

 

 

 

9.

FOR

TOWING

ONLY

9a. Arrangement:

Pushing Ahead

Towing Astern

Towing Alongside

9b. Number of Vessels Towed: Empty

Loaded

Total

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

Length feet

Widthfeet

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 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:

CG-2692 (04/18)

Page 1 of 3

Section IV - Casualty 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?

(If Yes, identify those individuals for whom evidence has

Yes No 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. 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

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

25. Signature:

26. Date

27. Title

28. Address

29. Telephone No.

30. Email

CG-2692 (04/18)

Page 2 of 3

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.

CG-2692 (04/18)

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Step no. 1 of submitting cg 2692

2. Soon after this part is completed, go on to type in the applicable information in all these: Divingrelated injury to any, The above facility or vessel was, Death, Injury to or more persons in a, Injury causing any person to be, OCS Facility only Damage, OCS Facility only Damage to the, OCS Facility only Damage to a, Section III Associated Parties, Name of Owner, Telephone, Name of Operator or Manager, Telephone, Address, and Email address.

Find out how to prepare cg 2692 portion 2

People who work with this form frequently make mistakes when filling out The above facility or vessel was in this section. Ensure you go over whatever you enter right here.

3. This next part should also be relatively easy, Property Damage Estimated Damage, Describe the Extent of Property, Longitude, Vessel, Facility, Cargo, Other, Status of Involved Persons If, Total Number of Persons, On Board the Vessel, Injured, Dead, Missing, and Page of - these blanks has to be filled in here.

Stage no. 3 in submitting cg 2692

4. Filling in Was This Casualty a Serious, Yes, Not at this Time But is Likely to, If Yes or Is Likely to Become an, a Is there any evidence of alcohol, b Did any individual directly, Yes, If Yes identify those individuals, Yes, If Yes note the individuals who, c Individuals with evidence of, d Is there evidence that alcohol, Yes, If Yes discuss in block b, and Nature and Circumstance of the is crucial in this fourth section - make certain that you invest some time and fill in every blank!

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