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Department of the Interior

Departmental Manual

Effective Date: 3/12/99

Series: Safety Management

Part 485: Safety and Occupational Health Program

Chapter 7: Incident/Accident Reporting/Serious Accident Investigation

Originating Office: Office of Managing Risk and Public Safety

485 DM 7

7.1 Purpose. To specify:

A. Requirements for the reporting of Departmental incidents and accidents and additional requirements for the reporting of Departmental serious accidents.

(1) For reporting purposes, a Departmental incident is an unplanned event involving Departmental property, employees, volunteers, contractors, emergency fire fighters, the public or the environment that could have resulted in an injury, illness, or material loss, but did not. If there is injury, illness or loss of property, the incident is reported as an accident.

(2) In brief, a Departmental serious accident is an accident involving a death and/or three or more persons hospitalized and/or Departmental property loss in excess of $250,000. A complete serious accident definition is given in Section 1.3 of Appendix 1 of this Chapter.

B. Requirements for conducting a serious accident investigation involving Departmental employees, volunteers, contractors, emergency fire fighters, or the public, when Departmental property and/or operations are involved (except aviation mishaps which will be investigated by the Office of Aircraft Services (OAS) in accordance with 352 DM 6).

7.2 References.

A. 29 CFR 1960, Subpart I, Recordkeeping and Reporting Requirements.

B. Department of the Interior "Serious Accident Investigation." (Appendix 1 of this Chapter.)

C. Department of the Interior "Wildland and Prescribed Fire(s)-Related Serious Accidents." (Appendix 2 of this Chapter.)

D. Memorandum of Understanding between the Department of the Interior and the Department of Agriculture, October 26, 1995. (Appendix 3 of this Chapter.)

7.3 Incident/Accident Reporting Requirements.

A. Supervisor Requirements. The appropriate immediate supervisor will record all incidents and accidents into the Safety Management Information System (SMIS). SMIS is managed by the Office of Managing Risk and Public Safety (MRPS).

(1) The SMIS Accident/Incident Report is the official Departmental method for reporting incidents and accidents. A SMIS Accident/Incident Report is defined as the electronic entry of factual and supplemental incident/accident information into SMIS. The Internet address is: http://www.smis.doi.gov. At their discretion, individual bureaus may develop mechanisms to supplement this reporting process.

(2) Each bureau will designate its headquarters safety office(s) as the Office of Record for SMIS Accident/Incident Reports and for additional serious accident investigation reports as described in Appendix 1 of this Chapter. This information will be controlled in accordance with Privacy Act and Freedom of Information Act requirements.

B. Employee Requirements. Employees are required to immediately report to their supervisors every job-related incident or accident. Accidents include:

(1) An injury, occupational illness, or death connected with the performance of work duties by employees, volunteers, contractors, or emergency fire fighters under Departmental jurisdiction.

(2) An injury or death to the public and/or property damage related to Departmental operations.

(3) A fire resulting in at least $500 loss involving vehicles, motorized equipment, aircraft, watercraft, structures, or contents of any property under Departmental control.

(4) Property damage or injury resulting from the operation of Departmental, General Services Administration (GSA), privately-owned, or commercially-leased vehicles, or motorized equipment used for official business.

(5) Other property under Departmental control that is damaged by accident, whether or not it is to be repaired or replaced, and regardless of who caused the damage-- employee, volunteer, contractor, emergency fire fighter or public individual.

(6) Shelter deployments and entrapments as a result of wildland and prescribed fire(s)-related operations.

C. Work-Related Injury Reports.

(1) Appropriate employee injury compensation forms will be prepared by the involved employee or his/her representative. (See 20 CFR 10.)

(2) SMIS can generate the Office of Workers' Compensation Programs CA-1 Form, "Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation," and CA-2 Form, "Notice of Occupational Disease and Claim for Compensation," based on information submitted to the SMIS Accident/Incident Report.

D. Investigation Requirements.

(1) Except for serious accidents, immediate supervisors will investigate and record into SMIS all incidents and accidents that occur under their jurisdiction.

(2) For a serious accident, the immediate supervisor must still initiate the recording of the accident into SMIS, but the report must also be reviewed by the Agency Administrator of the facility incurring the accident. Serious accident investigation requirements and responsibilities are listed in the next section and Appendix 1. An Agency Administrator is the bureau facility/organization manager who has direct line authority over employee activity when and where a serious accident occurs. Examples of such administrators include: a National Park Service Park Superintendent, a Bureau of Indian Affairs Agency Superintendent, a Bureau of Land Management District Manager, and a U.S. Fish and Wildlife Service Refuge Manager.

(3) The bureau Designated Agency Safety and Health Official (bureau DASHO) will ensure that serious accidents are fully investigated in accordance with Appendix 1 of this Chapter. Appendix 1 contains requirements for serious accident investigations; time frames for completion of reports; immediate notifications; the use of a Serious Accident Investigation Team (SAIT) versus a Trained Investigator (TI); SAIT composition; responsibilities and qualifications; and report recommendation follow-up procedures.

(4) Wildland and prescribed fire(s)-related serious accidents will be investigated in accordance with Appendix 2 of this Chapter.

E. Accident/Exposure Logging Requirements.

(1) Immediate supervisors, with the oversight of bureau regional/area/state/ divisional and/or bureau headquarters safety offices, will review and record job-related SMIS Accident/Incident Reports, including first-aid cases, into SMIS within 6 working days following the date appropriate management was notified of the occurrence. This is the equivalent of entering incident/accident reports on Occupational Safety and Health Administration (OSHA) Form 200, "Log of Occupational Injuries and Illnesses." (See 29 CFR 1960.67.)

(a) Copies of the report can be retrieved through SMIS.

(b) Bureaus may establish additional procedures to facilitate this process.

(2) Office of Workers' Compensation Programs (OWCP) information will be entered into SMIS by MRPS.

(3) Continuation of Pay information will be entered into SMIS by MRPS.

(4) Employee hours worked will be entered into SMIS by MRPS.

(5) Bureaus with volunteer programs will enter volunteer exposure information into SMIS.

(6) Bureaus can also enter emergency fire fighter hours, contractor hours and vehicle mileage information into SMIS.

F. Serious Accident Reporting Requirements.

(1) Serious accidents, as defined in Appendix 1 of this Chapter, must be reported in the same manner as incidents/accidents in general (described in Sections 7.3A, B, and C above). Additional requirements are identified in Sections 7.3F(3)(6) below. Bureaus will establish appropriate procedures for reporting serious accidents.

(2) Definitions:

(a) Preliminary Notice. A written notice to the Departmental Designated Agency Safety and Health Official (Departmental DASHO) by the involved bureau of a serious accident, as a follow-up to the initial telecommunications notification. The Preliminary Notice is forwarded within 48 hours of the accident and should contain only basic facts that are intended for information sharing purposes only.

(b) Factual Report. A written report to a bureau head and bureau DASHO by the SAIT or TI completed within 45 calendar days of an accident. The Factual Report contains only the bare facts related to the serious accident without any inferences, conclusions, or recommendations. Copies of the Factual Report or factual information gleaned from the Report may be distributed to other bureaus and agencies by MRPS.

(c) Management Report. A written report by the SAIT or TI to a bureau head and bureau DASHO completed within 45 calendar days of an accident. The Management Report contains all of the bare facts that are contained in the Factual Report, but also contains the results of the investigation - the SAIT or TI opinions as to why management control systems did not prevent the accident (if applicable), and recommendations for preventing similar accidents.

(3) A serious accident involving an employee fatality and/or the hospitalization of 3 or more employees will be reported telephonically by the Agency Administrator of the bureau organization incurring the accident to the U.S. Department of Labor OSHA Area Office that is geographically closest to the accident site.

(a) This telephonic report must be made within 8 hours of the accident occurrence, as required by 29 CFR 1960.70. Each report will include the following information: establishment name, location of accident, time of the accident, number of fatalities or hospitalized employees, contact person, phone number, and a brief description of the accident.

(b) If the report cannot be made during OSHA regular business hours, Monday through Friday, then the report can be made through the OSHA telephone hotline (1-800-321-OSHA [6742]).

(4) The bureau DASHO, bureau safety manager and the Director, MRPS, will be informed of a serious accident as soon as possible through established bureau reporting procedures for serious accidents. This applies to all serious accidents. The Director, MRPS, can be contacted on the MRPS telephone hotline (1-888-581-2610). This link is available on a 24-hour daily basis. The MRPS Director will notify the Departmental DASHO and others as appropriate.

(5) At the direction of the bureau DASHO, the bureau safety office will provide a written Preliminary Notice to the Departmental DASHO, with a copy to MRPS, within 48 hours. If the serious accident involves an employee fatality and/or 3 or more employees hospitalized, the Preliminary Notice will include information provided to OSHA as described in Section 7.3F(3) above.

(6) A SMIS Accident/Incident Report will be entered into SMIS by the Agency Administrator of the bureau organization incurring the accident in accordance with Section 1.3A(1) above. Following completion of the serious accident investigation Factual Report and Management Report, the bureau safety office will update the SMIS Accident/Incident Report to reflect the investigation's findings and recommendations, as accepted by the bureau head and/or bureau DASHO.

G. Special Accident Reports. In addition to Departmental accident reporting requirements, certain accidents require additional reporting as follows:

(1) Aircraft Accident Reports. The OAS Aviation Safety Office will coordinate the investigation of Departmental aircraft accidents/incidents with the National Transportation Safety Board. Incidents with potential for causing an aviation mishap will be identified, investigated and documented as appropriate by the OAS Aviation Safety Office. (See 352 DM 6 for additional information.) This does not eliminate the requirement for the bureau to submit a SMIS Accident/Incident Report.

(2) Aviation Mishap Information System (AMIS) Reports. The AMIS is an electronic data (files) storage based system encompassing all aspects of aviation mishap reporting within the Department. Categories of reports include aircraft mishaps, aviation hazards, aircraft maintenance deficiencies, and airspace intrusions. The system uses the SafeCom (Form OAS-34) to report any condition, observance, act, maintenance problem, or circumstance which has potential to cause an aviation-related mishap. Submitting a SafeCom is not a substitute for "on-the-spot" correction(s) to a safety concern, rather it is a tool used in the documentation, tracking, and follow-up corrective action(s) related to a safety issue. (See 352 DM 1 for additional information.)

(3) Boat or Vessel Accident Reports. If a Departmental vessel (including vessels under contract and vessels permitted to operate on Department waters) is involved, a Boating Accident Report, U.S. Coast Guard (USCG) Form 3865, will be completed by the Agency Administrator of the bureau organization incurring the accident whenever an accident occurs in U.S. or territorial waters and results in the loss of life, injury causing incapacitation in excess of 72 hours, or property damage in excess of $500. (See 33 CFR Part 173.55 - Report of Casualty or Accident.)

(4) GSA Motor Vehicle Accident Reports. Operator's Report of Motor Vehicle Accident, Standard Form (SF) - 91, and Statement of Witness, SF-94, (if applicable) will be prepared and forwarded by the head of the bureau organization incurring the accident to the bureau safety office serving the vehicle operator (or the GSA safety office serving as the fleet manager) when a GSA motor vehicle is involved in a Departmental accident. The SF-91 and SF-94 Forms are also required if the vehicle is bureau-owned, leased or rented, and involves public injury or damage.

(5) Wildland and Prescribed Fire(s)-Related Shelter Deployments and Entrapments. The initial report of shelter deployments and/or entrapments will be made in accordance with instructions listed in National Fire Equipment System (NFES) form No. 0869. The final reports, which are completed at the local level, will be forwarded to the National Interagency Fire Center for review, data collection and dissemination.

H. Annual Accident Summary and Reports.

(1) As stated in Section 7.3E above, the compendium of bureau SMIS Accident/Incident Reports housed in SMIS constitutes the equivalent of the OSHA Form 200, "Log of Occupational Injuries and Illnesses." Copies can be retrieved from SMIS on a "specific location" basis to meet reporting requirements for the OSHA Log and Summary reports.

(2) An original log and other supplementary records will be maintained at each bureau establishment. In situations where, for reasons of efficient administration or practicality, a bureau must maintain these records at a place other than at each establishment, a copy of the records will be made available at each establishment under the control of the local safety office. "Facts Only" may be released from a SMIS Accident/Incident Report in accordance with Privacy Act and Freedom of Information Act requirements.

(3) Departmental individuals with Safety and Occupational Health Program responsibilities can obtain SMIS-generated Departmental and bureau special reports on occupational injuries, illnesses, accidents and incidents, such as SMIS Accident/Incident Report compendiums, and reports describing indicators such as OWCP costs and injury/illness lost time rate. (See 29 CFR 1960.26(a)(1) and 20 CFR 10.12.) Other Departmental personnel may be authorized access to SMIS by MRPS.

(4) A copy of the annual injury and illness summary for an establishment will be posted no later than 45 calendar days after the close of the fiscal year, or otherwise disseminated, in writing, to all employees of that establishment.

(5) Copies of the annual injury and illness summary will be posted for a minimum of 30 consecutive days, in a conspicuous place(s) where notices to employees are customarily posted. In situations where establishment activities are physically dispersed, the notice may be posted at the location to which employees report each day. If employees do not primarily work at, or report to, a single location, the notice may be posted at the location from which employees operate to carry out their activities. Each bureau should take appropriate steps to prevent the summary report from being altered, defaced, or covered by other material.

I. Retention of Records. Records are to be retained in accordance with applicable OSHA regulations, and general record schedules published by the National Archives and Records Administration. In particular:

(1) Employee occupational injury/illness information will be retained on site by the bureau for at least five fiscal years following the year of occurrence.

(2) Occupational injury/illness records will be retained as part of the employee's medical record in the SF-66D, Employee Medical Folder. This folder is an official extension of the Official Personnel File system.

(3) Accident reports will be retained by the appropriate bureau designated safety and occupational health Office of Record. Accident information entered and maintained in SMIS meets the intent of this requirement.

J. Accident Reviews.

(1) Bureaus will establish appropriate procedures for review of accidents. For individual accidents, this will include second level management and/or safety management review of the SMIS Accident/Incident Reports as they are entered into SMIS. Bureaus, at their discretion, should establish procedures for review of organization-wide accident information.

(2) MRPS may establish a Serious Accident Review Board, an ad hoc group of safety and health professionals convened to conduct periodic review of serious accidents and resulting investigations. The Board will be responsible for developing Departmental accident prevention recommendations for serious accidents and other selected incidents.

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485 DM 7

APPENDIX 1

SERIOUS ACCIDENT INVESTIGATION

1.1 Purpose.

A. To establish a process for the investigation of serious accidents and the identification of findings and recommendations for preventing the recurrence of similar accidents.

B. To establish procedures for reporting serious accident facts and serious accident investigation findings and recommendations to the bureau head and the Departmental DASHO.

1.2 Scope.

A. This Appendix is mandatory for investigation of all serious accidents occurring within Department jurisdiction.

B. These procedures may be used by bureaus for investigating other incidents.

C. The investigation establishes facts and the sequence of events related to a serious accident; determines the contributing causes of the accident, including management system deficiencies, when applicable; and identifies ways to prevent a recurrence of the accident in any Departmental operation. Serious accident investigation products are not to be used to place blame for the accident. Witness statements and other findings are not to be used as the basis for disciplinary action.

D. Aircraft accidents are investigated by the OAS (See 352 DM for the requirements.)

E. Wildland and prescribed fire(s)-related entrapments are investigated by a bureau regional/state/area/divisional entrapment investigation team.

1.3 Definitions.

A. Bureau. Major organization within the Department, including the Bureau of Indian Affairs; the Bureau of Land Management; the Bureau of Reclamation; the Minerals Management Service; the National Park Service; the Office of Surface Mining, Reclamation, and Enforcement; the U.S. Fish and Wildlife Service; the U.S. Geological Survey; and [for the purposes of this Part 485] the Office of the Secretary.

B. Agency Administrator. The bureau facility/organization manager who has direct line authority over employee activity when and where a serious accident occurs. Examples of such administrators include: a National Park Service Park Superintendent, a Bureau of Indian Affairs Agency Superintendent, a Bureau of Land Management District Manager, and a U.S. Fish and Wildlife Service Refuge Manager.

C. DASHO. Designated Agency Safety and Health Official (see 29 CFR 1960.6).

D. Serious Accident. A Department-related accident as a result of an employee action or Departmental condition or activity which results in:

(1) One or more job-related fatalities or imminently fatal injuries or illnesses to employees, volunteers, contractors, emergency fire fighters, or the public, or

(2) Three or more employees, volunteers, contractors, emergency fire fighters, or public individuals hospitalized, or

(3) Property damage (including site mitigation or cleanup) and/or an operating loss of $250,000 or more, or

(4) Consequences that a bureau DASHO judges to warrant further investigation using these serious accident investigation procedures.

E. Serious Wildland and Prescribed Fire(s)-Related Accident. A serious accident that occurs during any wildland fire or prescribed fire activity, or to personnel working in direct support of these activities.

F. Preliminary Notice. A written notice to the Departmental DASHO by the involved bureau of a serious accident, as a follow-up to the initial telecommunications notification. The Preliminary Notice is forwarded within 48 hours of the accident and should contain only basic facts that are intended for information sharing purposes.

G. Serious Accident Investigation Team (SAIT). A team of at least four members, appointed by a bureau DASHO with the assistance of the bureau safety manager, chosen to investigate a serious accident and to report the accident facts and corresponding conclusions and recommendations. The team is comprised of a Team Leader, an Accident Investigation Advisor, a Chief Investigator and a Technical Specialist(s). These individuals are described below in Section 1.6.

H. Trained Investigator (TI). An individual (or a private sector or governmental investigative agency) appointed by a bureau DASHO to investigate a serious accident in lieu of a bureau DASHO-appointed SAIT. Trained Investigators meet the qualifications and training requirements for SAIT Chief Investigators. Additionally, specialized investigative agencies can be chosen specifically because of being qualified in the type of loss occurring.

I. Just-in-Time Training. Video cassette training and orientation for the SAIT to be employed after the SAIT has been formed and assembled in the general accident location, but before the information gathering phase of the investigation has begun. Just-in-Time training orients SAIT members toward the purpose of the accident investigation, SAIT member roles and responsibilities, and the establishment of SAIT cohesiveness. The Team Leader is responsible for ensuring that Just-in-Time Training is conducted.

J. Factual Report. A written report to a bureau head and bureau DASHO by the SAIT or TI completed within 45 calendar days of an accident. The Factual Report contains only the bare facts related to the serious accident without any inferences, conclusions, or recommendations. Copies of the Factual Report or factual information gleaned from the Report may be distributed to other bureaus and agencies by MRPS.

K. Management Report. A written report by the SAIT or TI to a bureau head and bureau DASHO completed within 45 calendar days of an accident. The Management Report contains all of the bare facts that are contained in the Factual Report, but also contains the results of the investigation - the SAIT or TI opinions as to why management control systems did not prevent the accident (if applicable), and recommendations for preventing similar accidents.

L. First Executive Level Manager. A field manager at a high bureau executive level, such as a region/state/area/division director, who reports directly to the bureau head.

1.4 Emergency Aid/Immediate Notification - Requirements.

A. The first employees to arrive at a serious accident scene should obtain emergency aid for the injured, and protect others from injury and property from unnecessary damage, but must then immediately notify the Agency Administrator and those specified in the affected bureau's accident reporting procedure.

(1) Bureaus will establish appropriate procedures, ensuring the following notifications, as a minimum, are made in the event of a serious accident: the bureau head, the bureau DASHO, the bureau safety manager, the OSHA Area Office geographically nearest to the accident site, potential members of the SAIT, and other personnel necessary to begin the investigation.

(2) The bureau DASHO will also ensure that the Departmental DASHO and MRPS are notified in a timely manner.

B. The bureau will immediately file a telecommunications report on the serious accident to MRPS. The OSHA Area Office having jurisdiction over the accident site must also be contacted telephonically within 8 hours if the serious accident involves an employee fatality(ies) and/or three or more employees hospitalized. (After business hours and on weekends, OSHA can be notified telephonically at 1-800-321-OSHA [6742]). MRPS can be notified via its telephonic hotline (1-888-581-2610).

C. These telecommunications are followed by a written Preliminary Notice to the bureau DASHO, with a copy to MRPS, to be sent within 48 hours of the accident. OSHA may request a copy of the written notice.

D. The bureau will contact the family/families of the involved employee(s) and provide details as appropriate. Family and employee critical incident stress management briefings and counseling should be provided as needed.

E. Upon receiving notification of a serious accident, MRPS will notify the Departmental DASHO, the Office of the Secretary, the Office of the Solicitor, the Departmental Information Office, the OSHA Office of Federal Agency Programs, and others as appropriate.

F. See 352 DM for additional requirements regarding immediate notifications for aviation accidents and serious aircraft incidents.

1.5 Accident Investigation Responsibilities/Requirements -

Appointment of an SAIT or a TI.

A. Bureaus will:

(1) Ensure that adequate administrative procedures are in place to promptly begin the accident investigation.

(2) Ensure that appropriate qualified personnel and resources are immediately available to conduct and support an investigation. Technical specialists should be immediately dispatched to begin the initial gathering of factual information and evidence, including photographs of the accident scene, environmental information, examination of equipment and materials, and other time-sensitive data.

(3) Ensure that the local Agency Administrator immediately acts to secure the accident site to protect physical evidence.

(4) Ensure that the SAIT or TI has full authority to investigate, interview individuals, search records, record and attach evidence, and obtain resources necessary to complete the investigation.

(5) Where a wildland and prescribed fire(s)-related serious accident occurs, ensure that the investigation is conducted in accordance with Appendices 2 and 3 of this Chapter.

B. The bureau DASHO will:

(1) Immediately authorize and appoint, for the bureau head and with the assistance of the bureau safety manager, an SAIT or a TI. (See Sections 1.6D and 1.6E of this Appendix.) The SAIT composition is described in Section 1.6 below. In the case of a serious fire-related accident occurring during a Department of Agriculture Forest Service-managed fire, a Department of the Interior-managed fire, or a jointly-managed fire, the SAIT will include personnel from both the Department of the Interior and the Department of Agriculture.

Note 1: SAIT members will be selected in such a manner as to eliminate any perception of bias. The objective is to obtain an accurate investigation, absent any real or perceived improper management influence of the investigation results. For example, SAIT members should not be from the local region/state/area/division experiencing the serious accident. This does not preclude, however, a local region/state/area/division safety professional from observing the investigative process.

Note 2. Appendix 2 describes a protocol for determining which Agency (Department of Agriculture or Department of the Interior) has the lead for a wildland and prescribed fire(s)-related serious accident investigation involving employees from both agencies and also a protocol for determining which of the Department of the Interior bureaus would have a lead for the investigation.

(2) Ensure that the SAIT or TI is promptly dispatched within 48 hours of the accident, and that the resources and procedures to do so are in place.

(3) Ensure that appropriate qualified personnel and resources are immediately available to conduct and support an investigation.

(4) Ensure that the OSHA Area Office nearest to the serious accident is offered the opportunity to participate in the investigation. It may choose to conduct a separate investigation of the accident. If so, all factual information and evidence will be made available to its investigators, as requested, and without formal processes.

Note: Upon completion of the bureau investigation and report, the same OSHA Office, at its request, will be provided with appropriate information, as identified in 29 CFR 1960.29(d).

After the investigation is completed, the bureau DASHO will:

(5) Obtain the Factual Report from the SAIT or TI (due within 45 calendar days of the accident occurrence) and ensure that a copy is sent forthwith to MRPS for possible abstracting to other bureaus and agencies.

(6) Obtain the Management Report from the SAIT or TI (also due within 45 calendar days of the accident occurrence) and initiate a review that will accept or reject its recommendations.

(7) Ensure, upon acceptance of Management Report recommendations, that a corrective action plan is developed by the bureau First Executive Level Manager whose organization incurred the accident. The plan must incorporate management initiatives developed to address the causal factors of the accident, based on the Management Report recommendations. The corrective action plan is to be completed within 21 working days of receipt of the Management Report.

(8) Ensure that the bureau head then forwards the Management Report and its recommendations along with the corresponding corrective action plan to the Departmental DASHO. This constitutes the final, complete serious accident report to the Department.

(9) Ensure that, within 90 days of the accident, the bureau First Executive Level Manager whose organization incurred the accident, personally briefs the bureau head on the accident, with an emphasis on identifying and correcting any management deficiencies contributing to the accident.

(10) Ensure that when all corrective actions have been implemented, the bureau head will notify the Departmental DASHO, the Office of the Solicitor, and others as appropriate.

C. The Agency Administrator will:

(1) Initiate and make (in conjunction with the bureau DASHO and bureau safety manager) all telephonic and written notifications of the accident as described in Section 1.4A, B and C above.

(2) Provide for and emphasize treatment and care of employees involved or affected by the accident.

(3) Brief the SAIT or TI upon arrival, and facilitate and support the SAIT or TI as requested.

(4) Implement critical stress management procedures, as needed.

(5) Initiate actions to notify family members of the situation.

(6) Ensure that steps are taken to secure the accident site to protect evidence until the SAIT or TI has completed on-site work, and has released the site back to the Agency Administrator.

After the investigation is completed, the Agency Administrator will:

(7) Ensure correction of any deficiencies noted in the Management Report recommendations and corrective action plan. The Agency Administrator will provide a status report to the bureau DASHO, through the First Executive Level Manager, at least every 90 days until all appropriate corrective actions are implemented.

1.6 SAIT Composition -

TI Alternative.

A. The SAIT will be comprised as follows:

(1) Team Leader. A senior bureau management official, at the equivalent level of associate/assistant regional/state/area/division director or higher. The Team Leader will direct the investigation and serve as the immediate point of contact with the bureau DASHO.

(2) Accident Investigation Advisor. An experienced safety and occupational health specialist or manager, who acts as an advisor to the Team Leader, to ensure that the investigation focus remains on safety and health issues. The Accident Investigation Advisor also works to ensure that strategic management issues are examined.

(3) Chief Investigator. A qualified accident investigation specialist responsible for the direct management of all investigation activities. The Chief Investigator reports to the Team Leader.

(4) Technical Specialists. Personnel who are qualified and experienced in addressing specific technical issues such as arson, third-party liability, weather, terrain, and specialized occupations, activities, skills and equipment.

Note: All SAIT members must take the Just-in-Time accident investigation training. The Team Leader is responsible for arranging this training and should contact the bureau safety manager for assistance. Additionally, the Accident Investigation Advisor and Chief Investigator must have satisfactorily completed the OSHA Serious Accident Investigation Course (80-hour course) or equivalent.

B. Administrative support personnel will be made available through the Agency Administrator to facilitate gathering of factual information and evidence, and to assist in research, document preparation and briefing materials.

C. Additional expertise may be required to complete the investigation. Local personnel, including those from the work unit that had the accident, may be utilized as needed, but are not considered to be part of the SAIT.

D. The use of a SAIT is the preferred approach to the investigation of serious accidents. However, in situations where the accident causes appear to be unrelated to Departmental management processes and controls, or in cases where there are no people affected by the accident, such as accidents involving only property damage, the bureau DASHO may elect to use a TI in lieu of the SAIT. A TI may be used (in lieu of a SAIT) to conduct the investigation providing all requirements in Section 1.7 of this Appendix are fulfilled. In such cases, the TI will provide a serious accident Factual Report and a Management Report, as required in Section 1.8 of this Appendix.

E. If the TI option described in Section 1.6D of this Appendix is exercised, the bureau DASHO will notify the Departmental DASHO in writing, giving the reasons for the use of this alternative.

1.7 Conduct of the Investigation.

A. The Agency Administrator will:

(1) Secure the accident site and identify all possible witnesses.

(2) Photograph (color prints - other than self-developing film) the accident site and related tools and equipment which might aid the SAIT or TI.

(3) Brief the SAIT or TI on the task that was being performed at the time of the accident and any other information that may assist the investigation.

Note: If the SAIT or TI and Agency Administrator determine at this time that there are time sensitive corrections that must be implemented to prevent a similar accident, the SAIT or TI should report this immediately to the bureau head through appropriate channels.

B. The SAIT or TI will have access to all evidence, photographs and their negatives, sketches, witness statements, official records, and any other data that may aid the investigation.

C. At the initial meeting of a SAIT, the Team will:

(1) Complete the Just-in-Time training/orientation process.

(2) Discuss the purpose and scope of the investigation and the process to be followed, including report formats, time constraints, and interview schedules. The Team Leader will ensure that the Team is focused on examining technical and procedural issues related to equipment and operations. The Team will also be directed to examine strategic management issues to identify management or operational processes, procedures or shortcomings that may have contributed to the accident.

(3) Arrange for a briefing from the Agency Administrator on the background and preliminary details of the accident, as well as status of the accident site. The SAIT should consider site security, current site hazards, and possible personal protective equipment required by the Team.

(4) Arrange for clerical and administrative support.

D. The SAIT should then develop an action plan and schedule based on the following outline to ensure the efficient use of time and resources:

(1) Make an initial visit to the accident site.

(a) Verify security at the accident site.

(b) Take photographs and make sketches.

(c) Identify and document evidence.

(d) Become acquainted with the system or process.

(e) Identify environmental conditions.

(2) Collect supporting documentation.

(3) Interview witnesses, managers, supervisors, and others.

(4) Release the accident site.

(5) Prepare the Factual Report.

(6) Analyze evidence and witness statements.

(7) Formulate opinions and recommendations, and prepare the Management Report.

(8) Conduct briefings.

(9) Catalog evidence and transfer it to the bureau safety office.

E. At the accident site, the SAIT or TI will:

(1) Ensure the scene is secured.

(2) Become familiar with the site.

(3) Ensure that hazards are identified.

(4) Identify, document, and attach as necessary, physical evidence.

(5) Photograph/sketch the accident scene if it has not already been done.

(6) Release the scene as soon as possible.

F. The SAIT or TI should identify and gather supporting documentation, such as operating procedures, inspection and maintenance records, equipment service manuals, training records, building drawings, schematics, flow diagrams, safety meeting and/or committee minutes, and copies of any investigative reports made by local law enforcement or fire response authorities. Copies of pertinent data will be made part of the investigation record.

G. Prior to interviewing the witnesses, the SAIT or TI should review any written witness statements and make a list of specific questions for each witness.

H. If evidence of criminal activity other than negligence, dereliction of duties, disobedience of a directive, or possible third-party liability is discovered, the SAIT or TI should discontinue the investigation and notify the Federal Bureau of Investigation and local law enforcement authorities, Office of the Inspector General (OIG) and the bureau DASHO immediately. If the evidence is based on confidential witness statements, the SAIT or TI should not disclose the individual statements, but provide a list of all witnesses to the law enforcement authorities and/or OIG.

1.8 Reports and Action.

A. The SAIT or TI should immediately report through appropriate bureau channels to the bureau head, or designee, any time sensitive corrective actions that need to be taken to prevent a similar accident.

B. The bureau DASHO will provide the Departmental DASHO a written preliminary notice within 48 hours on the basic facts (no opinions or recommendations) surrounding the accident.

C. The SAIT or TI will provide the Factual Report and the Management Report to the bureau DASHO, through the bureau safety manager, within 45 calendar days of the accident.

D. The SAIT or TI will also provide an original and a copy of the completed Factual Report and the Management Report to the bureau head, through the bureau DASHO and the bureau safety manager, within 45 calendar days of the accident occurrence. The bureau safety office is the Office of Record for these reports.

E. The bureau DASHO will ensure that a copy of the Factual Report is sent forthwith to MRPS for possible abstracting to other bureaus and agencies.

F. Within 21 working days of receipt, the bureau DASHO, on behalf of the bureau head, will transmit the Management Report to the Departmental DASHO. The transmittal will include a statement of concurrence or nonconcurrence with the SAIT or TI opinions and recommendations. The transmittal will also note corrective actions already taken or proposed, and recommendations for actions by higher management and/or other agencies.

(1) During the 21 working day period between the bureau DASHO's receipt of the SAIT or TI Management Report and its transmittal to the Department DASHO, the bureau will have an opportunity to review and comment on the Report. The Report is not to be changed in any way. The bureau will prepare a transmittal memorandum which will include, based on management input, concurrence or nonconcurrence for each Report recommendation. If nonconcurring, the memorandum will include an explanation of the decision.

(2) During this same 21 working day period, the First Executive Level Manager whose organization incurred the accident, will ensure that a corrective action plan addressing the Management Report recommendations is prepared. This plan will then be submitted to the bureau head for inclusion in the package forwarded to the Departmental DASHO.

G. The bureau safety office will prepare an Abstract of a Serious Accident Investigation for the Departmental DASHO within 30 working days from the receipt of the Factual Report and the Management Report. The Abstract provides a summary of what happened and discusses direct and indirect contributing causes for the accident and recommendations for preventing similar accidents, without identifying the specifics of the accident. The Departmental DASHO may distribute the abstract to other Federal, State or local government sources as appropriate.

H. The final package submitted to the Departmental DASHO, which includes nominally the Factual Report, the Management Report, explanations of concurrence and/or nonconcurrence with the Management Report findings, and a corrective action plan, constitutes the bureau's final complete serious accident report. The complete report is subject to Departmental DASHO review with possible feedback to the bureau. MRPS becomes the Office of Record for the report.

1.9 Management Action.

A. Within 90 days of the accident, the First Executive Level Manager whose organization incurred the accident will personally brief the bureau head on the accident. The briefing should include factual information, as well as actions taken to address findings identified in the SAIT or TI Management Report. Emphasis should be placed on identifying and correcting any management deficiencies that contributed to the accident.

B. The bureau DASHO, on behalf of the bureau head, will require the First Executive Level Manager to implement the corrective action plan. The responsible Agency Administrator will submit a status report to the bureau DASHO, with a copy to the First Executive Level Manager, at least every 90 days until all appropriate corrective actions have been implemented.

C. The SAIT or TI may be requested by the bureau head to make oral presentations to bureau and or Departmental management on the opinions and recommendations included in the report.

D. Upon request by OSHA, a formal presentation on the accident will be provided by the requested bureau individual(s) and/or the SAIT or TI, detailing the factual findings of the investigation.

E. The Departmental DASHO may request the bureau heads to review their operations in light of the Management Report findings and recommendations, asking that they ensure appropriate safeguards are in place to prevent similar accidents.

F. Upon completion of the investigation, the bureau head may be requested to personally brief the Secretary to explain the accident and corrective actions put in place to prevent similar accidents.

1.10 Investigation Closing.

A. When all corrective actions have been implemented, the bureau head, in conjunction with the bureau DASHO, will notify the Departmental DASHO, the Office of the Solicitor, and others as appropriate.

B. The SAIT or TI will itemize the collection of evidence and supporting documentation and turn it over to the bureau safety office, as the Office of Record, for retention unless determined otherwise by the Office of the Solicitor.

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485 DM 7

APPENDIX 2

WILDLAND AND PRESCRIBED FIRE(S)-RELATED SERIOUS ACCIDENTS

2.1 Purpose. To provide guidance in the conduct of wildland and prescribed fire(s)-related serious accident investigations.

2.2 Scope. Except as noted within this Appendix, wildland and prescribed fire(s)-related serious accidents will be investigated in accordance with procedures identified in Appendix 1 of this Chapter.

2.3 Policy.

A. Serious accidents occurring as a result of wildland and prescribed fire(s)-related activities will be investigated to the fullest extent possible. Interagency investigations will be conducted whenever a serious fire-related accident occurs on a U.S. Department of Agriculture (USDA) Forest Service managed fire, a Department managed fire, or a jointly managed fire. Serious Accident Investigation Teams will include personnel from both the Department and the USDA. (See Appendix 3, executed in October 1995 and still in effect.)

B. At the discretion of the bureau DASHO, when a serious accident occurs which involves a Department employee on an incident managed by a State cooperator under State jurisdiction or under Federal jurisdiction, the bureau may elect to establish representation on the investigation team or establish a liaison to the team.

C. Shelter deployments and entrapments require additional reporting beyond the serious accident investigation reports described in Appendix 1 of this Chapter. Shelter deployments and entrapments will be investigated following National Wildfire Coordinating Group (NWCG) guidance contained in the NWCG Fire Entrapment Investigation and Review Guidelines memorandum of July 27, 1993. Each bureau will incorporate the procedural guidance within its individual bureau directive system.

2.4 SAIT Lead. Interagency (Department/USDA) SAIT lead will be determined as follows:

A. Agency-lead investigations will be conducted whenever only one agency is responsible for managing a fire, and a wildland and prescribed fire(s)-related serious accident occurs that affects only personnel or lands of that same agency. The agency responsible for managing the fire will lead the investigation with other agencies or Tribes.

B. In situations where two or more Department bureaus are responsible for managing a wildfire and a wildland and prescribed fire(s)-related serious accident occurs, those bureaus will agree whether to conduct a co-lead or single bureau lead investigation.

C. Co-lead investigations will be conducted whenever:

(1) A wildland and prescribed fire(s)-related serious accident occurs on a USDA Forest Service/Department jointly managed fire, or

(2) A wildland and prescribed fire(s)-related serious accident involving USDA Forest Service personnel occurs on a Department managed fire, or

(3) A wildland and prescribed fire(s)-related serious accident involving Department personnel occurs on a USDA Forest Service managed fire.

2.5 Investigation Process.

A. The investigation process for wildland and prescribed fire(s)-related serious accidents will be as identified in Appendix 1 of this Chapter, except as noted in Section 2.5B below.

B. A bureau DASHO may delegate to the bureau Fire Director the authority to determine the Chief Investigator and some Technical Specialist members of the SAIT. This is desirable because of the dynamic nature of the wildland fire environment and the ability of the Fire Director to expeditiously dispatch these personnel to the accident site. The Fire Director will advise the bureau DASHO of individuals dispatched so they can be identified in the SAIT appointment.

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485 DM 7

APPENDIX 3

MEMORANDUM OF UNDERSTANDING

BETWEEN THE

UNITED STATES DEPARTMENT OF THE INTERIOR

AND THE

UNITED STATES DEPARTMENT OF AGRICULTURE

I. Purpose

This Memorandum of Understanding establishes the basis for interagency investigation of serious fire-related accidents.

II. Introduction

If the causal factors of a serious fire-related accident are identified, effective corrective actions to prevent a recurrence can be taken. Interagency investigations add perspective and enhance the mix of skills and knowledges on the investigation team. Interagency investigations are especially important where there are common management and corrective action issues.

III. Policy

Interagency investigations will be conducted whenever a serious fire-related accident occurs on a USDA Forest Service managed fire, a Department of the Interior managed fire, or a jointly managed fire. Aircraft accidents occurring during wildland fire operations will be investigated by the National Transportation Safety Board, the USDA Forest Service, and the Department of the Interior in accordance with established law and agreements.

IV. Definitions

a. Serious Fire-Related Accidents - accidents occurring to personnel participating in wildland fire suppression or prescribed burning operations, or to personnel working in direct support of those activities, which result in one or more fatalities or the hospitalization of three or more personnel.

b. Co-Lead Investigations - Team leaders from both Departments and team members from both Departments.

c. Agency-Lead Investigations - Single team leader and team members from both Departments.

V. Procedures

Interagency investigation teams will include personnel from both the Department of the Interior and the Department of Agriculture. Representatives of the Department of Labor, Occupational Safety and Health Administration, will be invited to participate in these investigations, or will be given full support to conduct their own investigation.

a. Co-Lead Investigations will be conducted whenever:

1. A serious fire-related accident occurs on a USDA Forest Service/Department of the Interior jointly managed fire, or,

2. A serious fire-related accident involving USDA Forest Service personnel occurs on a Department of the Interior managed fire, or,

3. A serious fire-related accident involving Department of the Interior personnel occurs on a USDA Forest Service managed fire.

b. Agency-Lead Investigations will be conducted whenever only one agency is responsible for managing a fire, and a serious fire-related accident occurs affecting only personnel of that same agency. The agency responsible for managing the fire will lead the investigation.

VI. Timeframes

The report should be completed and a copy submitted to the appropriate Departmental Designated Safety and Health Official(s) within 45 calendar days of the accident.

VII. Training and Qualifications

Team Leaders, Investigators and Specialists will meet minimum training and qualification standards as jointly established by the Department of Agriculture, the Department of the Interior, and the National Wildfire Coordinating Group.

3/12/99 #3237

Replaces 6/10/91 #485A-1

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