Form Cg-2692 - Report Of Marine Accident, Injury Or Death - U.s. Department Of Homeland Security
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4OM B C ont rol N o. 1625-0001
RCS No. G-MOA
U.S. DEP ARTME NT OF
REPORT OF MARINE ACCIDENT,
HOMELAND SECURITY
MISLE NOTIFICATION NUM B E R
INJURY OR DEATH
U.S. COAST GUARD
C G-2692 (R ev. 06-04)
SECTION I. GENERAL INFORMATION
5. USCG Certificate of
1. Name of Vessel or Facility
2. Official No.
3. Nationality
4. Call Sign
Inspection issued at:
6. Type (Towing, Freight, Fish, Drill, etc.)
7. Length
8. Gross Tons
9. Year Built
10. Propulsion (Steam, diesel, gas, turbine...)
11. Hull Material (Steel, Wood...)
14. Date (of occurrence)
15. TIME (Local)
12. Draft (Ft. - in.)
13. If Vessel Classed, By Whom: (ABS, LLOYDS,
DNV, BV, etc.)
FWD
AFT.
16. Location (See Instruction No. 10A)
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
20. Name of Pilot
USCG License
State License
YES
YES
YES
NO
NO
NO
20a. Street Address (City, State, Zip Code)
19a. Street Address (City, State, Zip Code)
19b. Telephone Number
20b. Telephone Number
21. Casualty Elements (Check as many as needed and explain in Block 44.)
FIREFIGHTING OR EMERGENCY EQUIPMENT
NO. OF PERSONS ON BOARD
FLOODING; SWAMPING WITHOUT SINKING
FAILED OR INADEQUATE
DEATH - HOW MANY?
CAPSIZING (with or without sinking)
(Describe in Block 44.)
LIFESAVING EQUIPMENT FAILED OR
MISSING - HOW MANY?
FOUNDERING OR SINKING
INADEQUATE (Describe in Block 44.)
INJURED - HOW MANY?
HEAVY WEATHER DAMAGE
BLOW OUT (Petroleum exporation/production)
HAZARDOUS MATERIAL RELEASED OR INVOLVED
FIRE
EXPLOSION
(Identify Substance and amount in Block 44.)
ALCOHOL INVOLVEMENT
(Describe in Block 44.)
COMMERCIAL DIVING CASUALTY
DRUG INVOLVEMENT (Describe in Block 44.)
OIL SPILL - ESTIMATE AMOUNT:
ICE DAMAGE
DAMAGE TO AIDS TO NAVIGATION
OTHER (Specify)
CARGO CONTAINER LOST/DAMAGED
STEERING FAILURE
COLLISION
MACHINERY OR EQUIPMENT FAILURE
(Identify other vessel or object in Block 44.)
ELECTRICAL FAILURE
GROUNDING
WAKE DAMAGE
STRUCTURAL FAILURE
22. Conditions
E. DISTANCE (miles
B. WEATHER
C. TIME
D. VISIBILITY
of visibility)
CLEAR
DAYLIGHT
GOOD
A. Sea or River Conditions
(wave height, river stage,
RAIN
TWILIGHT
FAIR
F. AIR TEMPERATURE
etc.)
(F)
SNOW
NIGHT
POOR
G. WIND SPEED &
FOG
DIRECTION
OTHER (Specify)
H. CURRENT SPEED
& DIRECTION
23. Navigation Information
24a. Time and
24. Last
SPEED
Date of Departure
Port
AND
MOORED, DOCKED OR FIXED
Where
COURSE
Bound
ANCHORED
UNDERWAY OR DRIFTING
25.
25a.
25b.
25c.
25d. (Describe in Block 44.)
Empty
Loaded
Total
Length
Width
PUSHING AHEAD
NUMBER
TOTAL
MAXIMUM
FOR
TOWING ASTERN
OF
H.P. OF
SIZE OF TOW
TOWING
TOWING ALONGSIDE
VESSELS
TOWING
WITH TOW-
ONLY
MORE THAN ONE TOW-BOAT ON TOW
TOWED
UNITS
BOAT(S)
SECTION II. BARGE INFORMATION
26e. USCG Certificate of
Inspection Issued at:
26. Name
26a. Official Number
26b. Type
26c. Length
26d. Gross Tons
26f. Year Built
26g.
26h. Draft
26i. Operating Company
SINGLE SKIN
AFT
FWD
DOUBLE
26j. Damage Amount
26k. Describe Damage to Barge
BARGE
CARGO
OTHER
PREVIOUS EDITION IS OBSOLETE
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