127
4
10 Convertible
BOATING ACCIDENT REPORT
FORM APPROVED
OMB NO.211-0010
DEPARTMENT OF
TRANSPORTATION
U.S. COAST GUARD
C.G. 1865 (REV. 1/88)
The operator/owner of a vessel used for recreational purposes is required to file a report in writing whenever an accident results in: loss of life or disappearance from a
vessel, or an injury which requires medical treatment beyond first aid: or property damage in excess of $200 or complete loss of the vessel. Reports in death and injury
cases must be submitted within 48 hours. Reports in other cases must be submitted within 10 days. Reports must be submitted to reporting authority in the state where
the accident occurred. This form is provided to assist the operator in filing the required written report.
COMPLETE ALL BLOCKS
(indicate those not applicable by “NA”)
OPERATOR TELEPHONE NUMBER
NAME AND ADDRESS OF OPERATOR
NAME AND ADDRESS OF OWNER
AGE OF OPERATOR
DATE OF BIRTH
OWNER TELEPHONE NO.
RENTED BOAT
[ ] YES
[ ] NO
NUMBER OF
PERSONS ON
BOARD
OPERATOR’S EXPERIENCE
This type of boat
Other boat operating Exp.
[ ] Under 20 Hours
[ ] Under 20 Hours
[ ] 20 to 100 Hours
[ ] 20 to 100 Hours
[ ] 100 to 500 Hours
[ ] 100 to 500 Hours
[ ] Over 500 Hours
[ ] Over 500 Hours
FORMAL INSTRUCTION IN BOATING SAFETY
[ ] None [ ] State
[ ] U.S. Power Squadrons
[ ] USCG Auxiliary
[ ] American Red Cross
[ ] Other (Specify)
VESSEL NO.
(this vessel)
BOAT REGISTER. NO.
BOAT NAME
BOAT MAKE
BOAT MODEL
MFR HULL IDENTIFICATION NO.
TYPE OF BOAT
[ ]
Open Motorboat
[ ]
Cabin Motorboat
[ ]
Auxiliary Sail
[ ]
Sail (only)
[ ]
Rowboat
[ ]
Canoe
[ ]
Other (Specify)
HULL MATERIAL
[ ]
Wood
[ ]
Aluminum
[ ]
Steel
[ ]
Fiberglass
[ ]
Rubber/vinyl
[ ]
Other
PROPULSION
No. of engines
Horse Power (total)
Type of fuel
CONSTRUCTION
Length
Year built (boat)
Has boat had a Safety Examination? [ ] Outboard [ ] NO
For current year? [ ] YES [ ] NO
Year
Indicate whether
[ ] USCG Auxiliary Courtesy Marine Exam
[ ] State/local examination [ ] Other
ACCIDENT DATA
DATE OF ACCIDENT
TIME
am
pm
NAME OF BODY OF WATER
LOCATION (Give location precisely)
Lat
Long
STATE
NEAREST CITY OR TOWN
COUNTY
WEATHER
[ ]
Clear
[ ]
Rain
[ ]
Cloudy [ ]
WATER CONDITIONS
[ ]
Calm (waves less than 6”)
[ ]
Choppy (waves 6” to 2’)
[ ]
Rough (greater than 6’)
[ ]
Strong Current
TEMPERATURE
(Estimate)
Air
F
°
Water
F
°
WIND
[ ]
None
[ ]
Light (0 - 6 mph)
[ ]
Moderate (7 - 14
mph)
[ ]
Strong (15 - 25
VISIBILITY
DAY
NIGHT
[ ] Good [ ]
[ ] Fair [ ]
[ ] Poor [ ]
ENGINE
[ ]
Outboard
[ ]
Inboard
gasoline
[ ]
Inboard
diesel
[ ]
Inboard-out-
OPERATION AT TIME OF ACCIDENT
(Check all applicable)
[ ] Commercial Activity
[ ] Drifting
[ ] Cruising
[ ] At Anchor
[ ] Maneuvering
[ ] Tied to Dock
[ ] Approaching Dock
[ ] Fueling
[ ] Leaving Dock
[ ] Fishing
[ ] Water Skiing
[ ] Hunting
[ ] Racing
[ ] Shin Diving/
[ ] Towing
Swimming
[ ] Other (Specify)
[ ] Being Towed
TYPE OF ACCIDENT
(Check all applicable)
[ ]
Grounding
[
] Collision with
[ ]
Capsizing
Fixed Object
[ ]
Flooding [ ]
Collision with
[ ]
Sinking
Floating Object
[ ]
Fire or explosion (fuel)
WHAT IN YOUR OPINION CONTRIBUTED TO
THE ACCIDENT (Check all applicable)
[ ] Weather
[ ] Alcohol use
[ ] Excessive speed
[ ] Drug use
[ ] No Proper Lookout [ ] Fault of Hull
[ ] Restricted Vision
[ ] Fault of Machinery
[ ] Overloading
[ ] Fault of Equipment
[ ] Improper Loading [ ] Hunting
[ ] Racing
[ ] Operator Inexperience
[ ] Hazardous Waters [ ] Operator Inattention
[ ] Other (Specify)
PERSONAL FLOTATION DEVICES (PFDS)
PROPERTY DAMAGE
FIRE EXTINGUISHERS
Estimated amount
This boat $
Other boat $
Other Property $
Were they used? (If yes, list
Type(s) and number used.)
[ ] Yes [ ] No [ ] NA
Types:
DESCRIBE PROPERTY DAMAGE
NAME AND ADDRESS OF OWNER OF DAMAGED
PROPERTY
Was the boat adequately equipped with
COAST GUARD APPROVED FLOTATION
DEVICES?
[ ] Yes [ ] No
Were they accessible?
[ ] Yes [ ] No
Were they serviceable?
[ ] Yes [ ] No
Were they used by survivors? [ ] Yes [ ] No
What type? [ ] I, [ ] II, [ ] III, [ ] IV, [ ] V (specify)
Were PFD’s properly used?
[ ] Yes [ ] No
Adjusted
[ ] Yes [ ] No
Sized
[ ] Yes [ ] No
Include any comments of PFD’s under ACCIDENT DESCRIPTION on other side of form
Was the vessel carrying NON approved
flotation devices?
[ ] Yes [ ] No
Were they accessible?
[ ] Yes [ ] No
Were they used?
[ ] Yes [ ] No
If Yes, indicate kind.
Appendix D:
Summary of Contents for 41 CONVERTIBLE
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Page 103: ...103 410 Convertible Appendix A SCHEMATICS 12 volt DC...
Page 104: ...410 Convertible 104 AC Shore to Panel wiring...
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Page 107: ...107 410 Convertible Batteries and Cables...
Page 108: ...410 Convertible 108 Hydraulic Steering...
Page 109: ...109 410 Convertible Engine Control System...
Page 110: ...410 Convertible 110 Fuel System...
Page 111: ...111 410 Convertible Fuel Valves...
Page 112: ...410 Convertible 112 Fresh Water System...
Page 113: ...113 410 Convertible Sea Water Systems...
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Page 115: ...115 410 Convertible Rudder Assembly Coupler Assembly Shaft Transmission Coupler Shaft Coupler...
Page 116: ...410 Convertible 116 Shaft Seal Assembly Prop Assembly Shaft Propeller Key Prop Nuts Cotter Key...
Page 117: ...117 410 Convertible Sling Locations...
Page 118: ...410 Convertible 118 Cradle and Blocking positions...
Page 120: ...410 Convertible 120 MAINTENANCE LOG Hours Date Dealer Service Repairs...
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Page 138: ...410 Convertible 138 Albemarle Boats 140 Midway Dr P O Box 349 Edenton NC 27932...