OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
Subject: OSHA Response to Significant Events of Potentially Catastrophic
Consequence
A. Purpose. It is OSHA policy to respond as quickly as possible to
significant events which may affect the health or safety of employees.
1. This response requires the on-site presence of top agency
officials as well as compliance personnel. Additionally, the agency is
committed to establishing effective and on-going lines of communication with
all affected parties.
2. It is OSHA's policy to ensure that each significant event is
thoroughly and promptly investigated and that all necessary resources be
devoted to such investigations.
3. The objective of an investigation conducted pursuant to this
instruction is to determine the likely cause of the event.
4. For purposes of this instruction, a "significant event" is
defined as an occupationally related incident involving multiple fatalities,
extensive injuries, massive toxic exposures, extensive property damage, or
one which presents potential worker injury and generates widespread media
interest. Area Office response in the event of a natural disaster is not
addressed in this instruction.
B. Scope. This instruction applies OSHA-wide.
C. References.
1. OSHA Instruction CPL 2.45B, June 15, 1989, Revised Field
Operations Manual (FOM).
2. OSHA Instruction CPL 2.80, October 1, 1990, Handling of Cases
to be Proposed for Violation-By-Violation Penalties.
OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
3. OSHA Instruction CPL 2.89, Incorporating the Family of Accident
or Illness Victims into the Fatality Investigation.
4. OSHA Instruction STP 2.22A, May 14, 1986, State Plan Policies
and Procedures Manual.
D. Action. Regional Administrators and Area Directors shall ensure that
the policies and procedures explained in this instruction are implemented by
all compliance personnel.
E. Federal Program Change. This instruction describes a Federal program
change which affects State programs. Each Regional Administrator shall:
1. Ensure that a copy of this change is promptly forwarded to each
State designee, using a format consistent with the Plan Change Two-way
Memorandum in Appendix P, OSHA Instruction STP 2.22A, CH-2.
2. Explain the technical content of this change to the State
designees as requested.
3. Ensure that State designees are asked to acknowledge receipt of
this Federal program change in writing to the Regional Administrator as soon
as the State's intention is known, but not later than 70 calendar days after
the date of issuance (10 days for mailing and 60 days for response). This
acknowledgment must include a description either of the State's plan to
implement the change or of the reasons why this change should not apply to
that State.
4. Ensure that the State designees submit a plan supplement, in
accordance with OSHA Instruction STP 2.22A, CH-3, as appropriate, following
the established schedule that is agreed upon by the State and Regional
Administrator to submit non-Field Operations Manual/Technical Manual Federal
program changes.
a. If a State intends to follow OSHA's policy described in
this instruction, the State must submit either a revised version of this
instruction, adapted as appropriate to reference State law, regulations and
administrative structure, or a cover sheet
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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describing how references in this instruction correspond to
the State's structure. The State's acknowledgment of the Plan Change Two-
way Memorandum may fulfill the plan supplement requirement if the appropriate
documentation is provided.
b. If the State adopts an alternative to Federal guidelines,
the State's submission must identify and provide a rationale for all
substantial differences from Federal guidelines to allow OSHA to judge
whether a different State procedure is as effective as comparable Federal
guidelines.
5. Advise the State designees that, in implementing the State
policy, they are encouraged to follow the investigation procedures in section
G. of this instruction.
6. Advise the State designees that they may consult with the OSHA
Regional Office for technical assistance and questions relating to procedures
for response to significant events as defined in paragraph A.4.
7. Review policies, instructions and guidelines issued by the
State to determine that this change has been communicated to State
personnel.
8. Take the following actions when a significant event (as defined
in paragraph A.4.) occurs in a State:
a. Offer technical assistance to the State designee, including
the services of OSHA's Directorate of Technical Support, Office of
Construction and Engineering, and other Federal agencies. Outside
consultants may also be offered if funding is available.
b. Send a Federal monitor to the site to obtain information
about the significant event, to provide appropriate technical assistance, to
serve as liaison with the Region and the Assistant Secretary, and to monitor
the State's response.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
c. Notify the Director, Office of Field Programs, and the
Director, Directorate of Federal-State Operations, of the event and provide
periodic updates.
d. Advise the Assistant Secretary whether, based on monitoring
information, the State has sufficient resources and expertise to adequately
respond to the significant event.
F. Background.
1. OSHA's investigation of workplace conditions which cause, or
could cause, catastrophes resulting in multiple loss of life and significant
property damage is the agency's highest enforcement priority. Accordingly,
OSHA must ensure that its efforts are well focused during these complex
investigations.
2. OSHA has learned from its recent investigations of such
catastrophic events as the L'Ambiance Plaza building collapse and the
Phillips 66 Company explosion that there are common elements present in all
such successful investigations that ensure their efficiency and
effectiveness. This instruction has been developed to assist OSHA's field
personnel in the orderly investigation of these unpredictable
events.
3. Significant events of potentially catastrophic consequences may
also be addressed by elements of the National Contingency Plan (NCP) (40 CFR
30), the basic rules for Federal emergency planning, preparation and
coordination. The NCP (Section 300.120) provides for an On-Scene Coordinator
(OSC) who is responsible for directing response efforts and coordinating all
other Federal efforts at the emergency scene. The EPA usually provides the
OSC for emergencies on land while the Coast Guard provides the OSC for
emergencies on water. The NCP also establishes the National Response Team
(NRT), the Regional Response Teams (RRT) and charges these groups with
responsibility for emergency planning, preparation, and response. The NCP
names OSHA as a member of the NRT and states that OSHA "on request" will
provide advice and technical assistance to NRT/RRT agencies during
emergencies. (See Section
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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300.175.) Technical assistance may include review of site
safety plans and work practices: assistance with exposure monitoring,
providing MSDS's, giving advice on personal protective equipment, and help
with compliance questions. The NCP gives OSHA a limited role during
catastrophic events and it has been OSHA's policy not to engage in activities
that would have the effect of impeding the emergency response.
4. The OSH Act requires that OSHA respond to catastrophic events,
whether or not subject to the NCP. OSHA must be an active and forceful
protector of employee safety and health during the clean-up, removal, storage
and investigation phases of these incidents, while maintaining a visible, but
limited role during the initial response phase. Catastrophic events are
usually handled at the State and local level where the mayor, the local fire
and police departments and perhaps the governor are in charge. When a
Federal presence is warranted, the preemption of local authorities may
generate dissension or hostility which are counter-productive to the
investigation. Communication and coordination among Federal and local
agencies during their response to catastrophic events becomes crucial for
operational as well as political considerations.
G. Procedures. In the investigation of significant events, the policies
and procedures given in the FOM, Chapter VIII, should be followed, except as
identified in this instruction.
1. Preparation for Investigations of Significant Events.
a. Training.
(1) All OSHA compliance officers shall be trained in the
basic elements of this instruction within 90 days of its publication.
Refresher training on the procedures contained herein will be provided at
least annually.
(a) It is anticipated that Regional training provided
pursuant to this
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
instruction will include a mock catastrophic accident
investigation response and investigation plan
development.
(b) Training shall also provide an overview of OSHA's
activities pursuant to the NCP and an overview of RRT activities and
interagency coordination.
(2) The Regional Administrator shall also ensure that
compliance safety and health officers (CSHO's) designated as specialists
pursuant to 29 CFR 1910.120 receive training or demonstrate competence in the
area of the specialization at least annually.
(3) Individuals with specialized skills or experience may
expedite the investigative process. Therefore, Regional Administrators shall
ensure that a regional skills/expertise profile of regional personnel be
maintained as a reference for selecting staff for investigation of
significant events. The list should include CSHO's with advanced training;
such as, hazardous waste operations and emergency response, chemical industry
emphasis program and construction courses involving training on catastrophic
potential.
b. Resources.
(1) Regional Administrators shall ensure that Area Offices
maintain the full complement of equipment necessary to investigate the
hazards commonly found in the workplace. In addition, a contingency plan
shall be developed to ensure that specialized technical equipment within the
Region can be provided on-site at a significant event within 24
hours.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(2) Because equipment and supplies which may be necessary
for an accident investigation are stored at the Area Office, Area Directors
shall ensure that supervisors have ready access to the Area Office during
off-duty hours.
(3) Regional Administrators shall ensure that adequate
personal protective equipment for CSHO's is available.
(a) Each CSHO shall be trained in the proper care, use
and limitations of the personal protective equipment
(PPE).
(b) If additional PPE is necessary, it must be obtained
prior to exposure. Under no circumstances shall a CSHO be unprotected from
any hazard encountered during the course of the
investigation.
(4) The Regional Administrator shall determine the
availability of qualified consultants for the various types of anticipated
events. A listing of consultants and their specialties shall be maintained
and updated annually. Preliminary contact with these consultants shall
include discussion of items such as expertise, cost, availability,
confidentiality, etc.
(5) Availability and expertise of testing laboratories
shall also be identified.
(6) Regional utilization of the expertise of OSHA's Office
of Construction and Engineering or Directorate of Technical Support should be
coordinated through the Office of Field Programs as should requests for
support from other off-site Federal agencies such as National Institute of
Standards and Technology,
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
National Institute for Occupational Safety and Health
(NIOSH), Environmental Protection Agency (EPA), and Mine Safety and Health
Administration (MSHA).
2. Initial Response/Verification.
a. OSHA's policy is to respond to significant events as
quickly as possible; therefore, off duty telephone numbers for the following
Regional Office personnel shall be maintained and available for use by the
Area Director 24 hours a day:
(1) Regional Administrator (RA). (2) Deputy Regional
Administrator (DRA).
(3) Assistant Regional Administrator (ARA) for
FSO.
(4) ARA for Technical Support.
(5) ARA for Training, Education, Consultation and Federal
Agency Programs.
(6) Management Officer.
(7) Labor Liaison.
(8) Regional Information and Public Affairs Officer
(OIPA).
b. Notices of significant events can be received from many
sources. Regardless of the source of the notices, certain actions must be
taken to ensure that an inspection team will be adequately
prepared.
(1) If the initial report of an incident is received from
the employer, the person receiving the report shall obtain all the
information required to complete the OSHA-36, Fatality/Catastrophe Report,
if
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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appropriate. In addition to the information contained
in the OSHA-36, the person receiving the report shall attempt to obtain the
following information:
(a) Current status of the situation (i.e., is a
continuing hazard present);
(b) What the company is doing to protect employees
still on the site;
(c) Area or location of incident in relation to
neighboring plants, storage areas, or residential areas;
and
(d) Other governmental agencies on the site including
the identification of the "lead" agency (i.e., EPA, fire department,
etc.).
(2) If the initial report is received from a source other
than the employer, the person receiving the report shall attempt to obtain as
much of the above information as possible:
(a) If the Area Director feels that additional
information is necessary to ascertain the occurrence of a significant event,
the employer shall be contacted. Contacting the employer in this situation
constitutes advance notice, and the FOM, Chapter III, C.,
applies.
(b) If the Area Director is unable to obtain all the
information needed, other sources shall be contacted. This includes police
and fire departments, hospitals, television or radio stations, newspapers, or
other governmental agencies.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
(c) Immediately upon receipt of information from any
reliable source that a significant event has occurred, the Area Director
shall dispatch a CSHO and/or supervisor to the site to obtain information and
establish an agency presence.
1 The person(s) dispatched shall have all appropriate
PPE and, depending upon circumstances, may or may not begin an investigation
at this time and may not necessarily be assigned to any subsequent
inspection.
2 This individual's primary function is to gather
preliminary information regarding the incident which will be used to assess
the need for further OSHA involvement.
(d) The Area Director shall notify the Regional
Administrator as soon as possible of any indication of the occurrence of any
catastrophic event.
(e) Immediately upon receipt of clear information,
either from dispatched OSHA personnel or from press reports, the Area
Director shall notify the Regional Administrator of the event and report as
much of the following information as possible:
1 Location of accident including county and Zip
Code;
2 Company or companies involved and type of
business;
3 Type of incident (structural collapse, chemical
release, etc.);
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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4 Date and time of event;
5 Number of persons killed, injured, or unaccounted
for;
6 Status of rescue operations;
7 Whether an agency representative is on-site, or
enroute;
8 Person(s)/agency(ies) in control of
site;
9 Other organizations/agencies on
site;
10 Telephone numbers of all parties on
site;
11 Other significant information and sources of such
information.
(e) Notification of the Regional Administrator or
alternate will be attempted regardless of the time the Area Director receives
clear information concerning the incident. Regional Administrator
notification should not be delayed for details from the site if there is
significant national news media coverage of the
incident.
(f) The Regional Administrator at the time of this
initial report will advise the Area Director of the need to implement the
procedures contained in this instruction.
(g) The Regional Administrator or alternate is
responsible for notifying the National Office of any significant event. The
Regional Administrator and his staff shall have available at all times, the
home telephone numbers of the following personnel:
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
1 Assistant Secretary for OSHA and Deputy Assistant
Secretaries.
2 Director, Office of Field
Programs.
3 Director, Directorate of Compliance
Programs.
4 Deputy Regional Administrator, Assistant Regional
Administrators, and the Administrative Officer.
5 Area Directors.
6 Regional Solicitor and Assistant
Solicitor.
7 Regional Officer of Information and Public
Affairs.
8 Secretary's Representative.
(h) Immediately after being briefed by the Area
Director the Regional Administrator will attempt to notify the Director,
Office of Field Programs (OFP). If unable to reach the Director, OFP, the
Regional Administrator will attempt to notify a Deputy Assistant
Secretary.
(i) The Area Director, upon verification of the
magnitude of the event, shall assess the need for a team investigation of the
incident. Procedures outlined in paragraph G.8. of this instruction shall be
followed if a team approach is warranted.
3. Initial On-Site Investigation Activities.
a. Upon arrival at the incident scene, the OSHA representative
(CSHO or Supervisor) dispatched by the Area Director shall establish contact
with the employer and the on scene Incident
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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Commander as soon as possible. For incidents subject to the
NCP, the OSHA representative shall also contact the Federal on scene
coordinator and provide technical assistance as appropriate. The opening
conference may be delayed only if management is engaged in rescue or
emergency response activity.
(NOTE: Reference is made in paragraphs G.3. and G.7 to an
on-site OSHA representative should not be confused with the Inspection Team
Leader whose duties are described in paragraph G.8. The OSHA representative
initially dispatched to the scene by the Area Director will not necessarily
become a member or the leader of the inspection team once the comprehensive
investigation begins.)
b. The OSHA representative first on the scene shall use a
video camera to document all characteristics of the event. Continued
extensive use of the video camera is recommended throughout the initial
stages of the investigation since conditions can change rapidly in such
emergency situations. This documentation may later prove invaluable in
determining the cause of the accident. A team member shall provide a
voice-over narrative to describe what is being taped as the videotape is
recorded. Use of audio tape recorders early in the investigation is also
encouraged. Audio tapes may be transcribed once the site is
stabilized.
c. During emergency response activities the team leader shall
be available to provide assistance to responders through consultation with
the on scene Incident Commander or designee. There may be safety and/or
health concerns about entry into the accident area, and therefore, changes in
the accident scene may be necessary in order to make the area safe. Any
changes shall be carefully documented.
d. If terrorist or criminal activity is suspected, the Area
Director shall make every effort to ensure the security of OSHA personnel.
The
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
Area Director shall contact the Federal Bureau of
Investigation and/or the Bureau of Alcohol, Tobacco and Firearms with
pertinent information as soon as possible.
4. OSHA'S Role in Ensuring Protection of Emergency
Responders.
-Reserved-
5. Coordination of OSHA Activities with Other On-Site
Authorities.
a. Response of OSHA personnel to emergency situations requires
careful consideration due to the following factors:
(1) State and/or local authorities have legislated roles in
providing emergency response to ensure protection of lives and
property.
(a) The importance of OSHA's coordination and
cooperation with and technical assistance to these authorities during the
initial phases of OSHA's on-site activity cannot be
overemphasized.
(b) OSHA can often utilize reciprocal support from
local and/or State authorities to eliminate the necessity for OSHA legal
section in ensuring site and evidence control.
(2) The presence of on-site OSHA personnel, if not properly
managed, could complicate rescue operations, clean-up, or other emergency
response activities.
(3) OSHA personnel are not, in general, specifically
trained or experienced in directing emergency response or serving as the
Incident Commander, therefore;
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(a) Only those CSHO's who have received special
training in emergency response including advanced respiator use may engage in
on-site consultation activities regarding respiratory protection.
Consultation shall be through the Incident Commander, normally through the
safety official.
(b) All inspection duties during this phase of the
investigation must be performed by compliance officers who have successfully
completed all OSHA required training courses or their equivalent as outlined
in 29 CFR 1910.120(q).
(c) If no trained compliance officers are available,
the Area Director shall consult with the Regional Office to obtain personnel
with appropriate training.
b. For significant events covered by the NCP, other
governmental agencies; namely, Environmental Protection Agency (EPA), Nuclear
Regulatory Commission (NRC), U.S. Army Corps of Engineers, or the Coast Guard
may exercise management and control in emergency response and hazardous waste
site activities.
(1) Where necessary, the Area Director shall consult with
the Regional Office to determine if the spill, accident, or emergency
situation in question falls within the specific authority of another Federal
Government agency.
(2) If the Interagency Regional Response Team is activated
by the EPA or the Coast Guard, all OSHA communication and coordination will
go through OSHA's representative, to give technical assistance to the
Incident Commander, to avoid further loss of life or property
damage.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
6. CSHO Protection During Initial Phases of the
Investigation.
a. The paramount concern addressed by this section is the
protection of compliance officers. No enforcement action, or accident
investigation activity is so important as to place the life or health of the
compliance officer in danger.
b. During the initial phases of OSHA's response to a
significant event, OSHA personnel may encounter hazardous conditions which
present a significant risk to their safety and health. Among the potential
hazards that may be encountered are: highly toxic atmospheric and surface
contamination, including carcinogens, the identity and concentration of which
may not be known; explosive or corrosive atmospheres; confined spaces; and
the potential for spontaneous generation of atmospheres immediately dangerous
to life and health.
c. The team leader shall ensure that the following precautions
are taken:
(1) Prior to entering a potentially hazardous area at the
incident site, determine if any of the following prohibited entry categories
may be encountered: (a) Explosive substances are present or flammable
substances are present in concentrations exceeding 10% of the lower explosive
level (LEL).
(b) Site is on fire.
(c) Potentially hazardous unidentified substances are
present, preventing an adequate determination of precautions for the safety
or health of the CSHO.
(d) Hazardous equipment and/or mechanical devices are
operating and cannot be shut off and locked out, or pipelines cannot be
isolated and/or shut off.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(e) Adequate PPE is not available for protection
against the contaminant or biohazard present or CSHO's are not fully trained
in use of the PPE.
(f) Ionizing or non-ionizing radiation is present at
levels which would result in exposures of OSHA personnel exceeding
permissible exposure levels.
(g) Entry of pressurized chambers where decompression
facilities are not available on-site.
(h) Presence of, or high probability of rapid
generation of, atmospheres immediately dangerous to life and
health.
(i) Structure or excavation is in danger of collapse or
cave-in.
(j) Decontamination equipment is not
available.
(2) If any of the above conditions exist or is likely to
occur during the course of an inspection, the Team Leader shall refer the
particulars of the situation to the Area Director. Entry into the hazardous
area is prohibited unless entry is essential to the investigation and
approval is granted by the Area Director.
(3) Where necessary, the Area Director shall discuss the
hazardous conditions reported by the Team Leader with the Assistant Regional
Administrator for Technical Support, prior to determining an appropriate
course of action.
(4) No compliance officers shall enter any area where Level
A protection is required without specific approval by the Regional
Administrator.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
(5) Inspection activity must be carefully planned to
minimize the on-site time required, thus reducing potential exposure
time.
7. Site Control/Coordination
a. OSHA must get to the scene of the catastrophe as soon as
possible after it has occurred.
(1) The OSHA representative on-site (see G.8.) shall ensure
that the following pre- inspection actions are
accomplished:
(a) Assess the extent of damage and personal
injury;
(b) Establish appropriate security and isolation of the
area involved.
(c) Obtain the confidence and cooperation of company
and other response officials involved, especially the on scene Incident
Commander, in order to proceed in an orderly and efficient
manner.
(d) Evaluate any remaining hazards.
(e) Begin documenting (videotaping or sketching and
photographing when a video camera is not available) the accident
scene.
(f) Develop protocol for conducting the
investigation.
(g) Identify all potential witnesses to the
accident.
(h) Evaluate operating conditions just prior to the
accident.
(i) Make a preliminary estimate of the accident
cause.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(2) OSHA's initial actions shall be carefully considered.
Rather than rushing out and examining evidence immediately, they shall allow
time for briefings by the senior officials of the operating organization. The
investigators' main interest at this time is to establish a cooperative
working relationship with the employer's
representative(s).
b. It is most important to coordinate OSHA's activities with
other responders to establish jurisdiction and ensure control of the
site.
(1) OSHA shall make every effort to obtain information from
these responders (and exchange information with them to the extent permitted
by procedures).
(2) Other Federal and local agencies may also be involved
in investigation, rescue or recovery, or clean-up activities. The OSHA
representative shall contact the principal representative and establish a
cooperative arrangement. While OSHA cannot abrogate its responsibility in
favor of another agency, every effort shall be made to cooperate in obtaining
and exchanging information.
(3) The OSHA representative shall determine whether the
State or the local government authorities are on site to investigate the
accident. Contact with such authorities shall be made as quickly as possible
by the team leader to arrange for control of the site.
c. On a large inspection site, one primary employer contact
shall be identified to accompany the inspection team on walkaround
activities. This person need not be the most knowledgeable person in plant
operations but must be familiar with the area and able to contact appropriate
company and union personnel as necessary. The primary employer
contact
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
must be available for investigation activities at all
appropriate times, so as not to hinder the investigation.
d. If an employer refuses OSHA access to the accident site,
the on-site OSHA representative shall inquire as to the reason. The CSHO
shall immediately contact the Area Director and give him all available
information.
(1) The on-site OSHA representative shall continue offsite
inspection activity including gathering information from other agencies,
taking photographs and video- taping the scene from a public area, and
interviewing witnesses offsite while the warrant is being
prepared.
(2) If entry is refused, the procedures for dealing with
the refusal shall be followed, but every effort shall be made to speed the
process; e.g., telephone communications shall replace written requests. (Any
consultant projected to be used during the inspection shall be included in
the warrant application.)
(3) If the employer or other parties refuse to give access
to records, the CSHO shall carefully document what records are at issue, why
they are needed, who has custody of the records, who refused access, and when
the refusal occurred. This information shall be immediately transmitted to
the Area Director who shall determine if a warrant or an administrative
subpoena is appropriate.
(4) It may be necessary to issue administrative subpoenas
for records, documents, or other physical evidence. Due to the complexity of
an emergency condition and the potential need for a fast response, the
Regional Administrator shall consider an expedited procedure for issuing
subpoenas.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(5) If a witness refuses to be interviewed or to give a
statement, the CSHO shall document the person's name, address, title, and
information pertinent to the inspection which that person may have. This
refusal, and the information obtained, shall be transmitted immediately to
the Area Director for an administrative subpoena compelling the individual to
appear and be deposed.
e. OSHA presently has no regulation to require an employer or
any other authority to limit access or prohibit removal or disturbance of
materials which may constitute physical evidence at a worksite. The team
leader shall decide, even in the presence of police security, whether it is
necessary to place the site under 24-hour-a- day observation. Assistance of
the on scene Incident Commander shall be obtained if possible. Such
observation must continue until all necessary physical evidence is
obtained.
(1) The need for this observation is twofold. It reduces
the likelihood of further injuries to personnel and it prevents the removal
of equipment and debris from the accident area, thereby ensuring that
evidence is not tampered with or inadvertently destroyed.
(2) If it appears that either lack of site control,
material alterations, or removal of material will interfere with the OSHA
investigation, the on-site OSHA Representative shall notify the Area Director
who shall contact the Regional Solicitor (through the Regional Administrator)
to get an appropriate court order. In no case shall an OSHA representative
attempt to exert authority without such an order.
(3) The representatives of other agencies may have a need
to remove material and/or to search for missing physical evidence. In
addition, during rescue/recovery
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
operations, much of the physical evidence may be
removed, displaced, or destroyed. Therefore, it is imperative that every
effort be made, as soon as possible, to establish site control and preserve
the physical evidence by coordination with the agencies on the site,
especially the on scene Incident Commander, as well as those which will be
involved later.
f. OSHA's jurisdiction may be preempted by another Federal
agency under Section 4(b)(1) of the Act. In such cases, the guidelines given
in the FOM, Chapter III, D.6.a., shall be observed with the following special
considerations:
(1) If it is reasonably possible that OSHA has coverage,
the Area Director shall start the investigation at once and not let potential
4(b)(1) problems interfere with either notification to the Regional Office or
with the investigation. The Area Director, in consultation with the OSHA
Regional Office and the Solicitor's Office, shall determine whether OSHA has
jurisdiction over the worksite in question as quickly as
possible.
(2) Where it is likely that OSHA authority is preempted,
such as coal mine accidents, no investigation shall be conducted. The
Regional Administrator shall be notified of these incidents and technical
assistance shall be offered to the responding agency if so directed by the
Regional Administrator.
g. Inevitably circumstances will arise that are not covered by
the preceding sections of this instruction. The Area Director shall be alert
to these unusual circumstances so that proper action can be taken and their
occurrence will not hinder the investigation.
(1) 29 CFR 1903.4 authorizes the agency to seek a warrant
in advance of any attempted inspection if circumstances are such
that
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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"Preinspection process is desirable or necessary."
Issuance of anticipatory warrants is addressed in the FOM, Chapter III,
B.3.
(2) In the event of a denial of entry occurring on a
weekend, the Area Director shall determine if a warrant is needed prior to
the following Monday. If so, the Regional Administrator shall be informed of
this need and shall in turn contact the Regional
Solicitor.
(3) After approval from the Solicitor's Office,
arrangements must be made to have a magistrate sign the warrant. To
facilitate this process, the Area Director shall attempt to obtain the home
telephone numbers of the magistrates with jurisdiction in their areas for use
by the Regional Solicitor.
h. Use of Temporary Restraining Order.
- Reserved -
8. Team Inspection Procedures/Area Office Contingencies
a. As determined by the scope and magnitude of the event, it
may be necessary for the Area Director to assemble an inspection team to
provide a comprehensive approach to the investigation. Members of an
inspection team shall be selected based upon their experience and abilities.
Recommendations to the Regional Administrator for team members from outside
the Area Office or the Region may be necessary.
(See the FOM, Chapter VIII.)
(1) It may be necessary to divide the inspection team into
subgroups which address certain aspects of the
investigation.
(a) For example, one group may investigate emergency
response activity, a second group may address
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
system safety while a third group addresses
circumstances around the initial accident.
(b) Each group shall have a designated leader to
coordinate activity and interface with other groups.
(c) Each member of the inspection team must keep notes
on a daily basis of his or her activity. The notes shall be placed in the
case file.
(2) The function of an investigation team is to conduct the
OSHA investigation once the emergency response phase of the significant event
has ceased. The team shall follow existing procedures as outlined in Chapter
VIII of the FOM. In addition, the team shall:
(a) Evaluate potential hazards at the
site.
(b) Contact family members of deceased or seriously
injured according to OSHA Instruction CPL 2.89.
(c) Provide suitable progress reports to the Regional
Administrator.
(d) Be present during physical evidence sampling or
removal.
(e) Gather witness testimony and obtain written
interview statements.
(f) Obtain and assemble copies of all needed reference
documents.
(g) Complete the necessary OSHA forms.
(h) Compile the case file(s).
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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b. A supervisor or senior CSHO from the responsible Area
Office shall normally be designated as the Investigation Team Leader
(ITL).
(1) The ITL is responsible for coordinating and directing
the investigation and reporting findings to the Area Director on a daily
basis or more often if critical information is obtained.
(2) The responsibility of this role cannot be
overemphasized for it is the ITL who acts as spokesperson for the agency in
meetings with company, union, insurance, consultant, and state and local
agency officials.
(3) The ITL must be aware of the direction and findings of
other investigators as well as those of the team. Thus, the ILT's direct
investigative work must necessarily be limited since much time and effort
must be spent in effectively managing these coordinating
functions.
(4) The ITL must assimilate information from all sources
and make prompt and accurate decisions regarding the utilization of resources
which are at the leader's disposal and must promptly communicate needs and
findings to superiors.
(5) A concise chronology is an invaluable asset to this
process and is therefore required. It must include not only events related
directly to the incident but also brief notes on meetings, telephone
conversations, video and audio recordings, and decision processes, including
dates and times.
(6) The ITL must also conduct daily planning sessions with
the inspection team in order to be apprised of findings as well as to plan
strategy and clearly communicate future investigative
activities.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
c. The responsibilities of CSHOs and other team members are
not dissimilar to those of any other team inspections. Specialized
assignments, however, may be appropriate in some cases.
(1) A CSHO shall be designated as the OSHA Site Safety
Officer. This individual will be delegated the primary responsibility of
advising the ITL on the safety and security of OSHA personnel. This
specialist CSHO may also function as the primary technical advisor to those
engaged in dealing with controlling the significant event. This CSHO must be
assured direct access to the Incident Commander's safety official at the
scene. This CSHO shall report directly to the ITL.
(a) The ITL shall specify the required personal
protective equipment after consultation with the OSHA Site Safety
Officer.
(b) After the existence of an emergency situation has
been confirmed and the need for an investigation team established, no Area
Office personnel shall leave for the scene without minimum protection and
investigative equipment, as required by the FOM and specified by the OSHA
Site Safety Officer.
(2) An on-site Communications Officer shall be appointed to
ensure rapid and accurate confirmation of information to the Area Director.
The Communication Officer shall coordinate all site communications and
prepare ongoing and executive summaries of all communications and occurrences
during the incident. This person shall be located at the OSHA command
post.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(3) Personnel from outside the Area Office shall be
assimilated into the team so as to conduct an effective investigation and to
utilize their skills efficiently.
(4) Team members shall be reminded to refer media inquiries
and questions on inspection policies and procedures to the Area Director.
This is especially important for team members who are not agency or
government employees and therefore may be unfamiliar with OSHA operation and
authority.
d. A "command post" must be established at or near the site to
coordinate OSHA activities.
(1) The command post must be established as soon as it is
determined that significant event investigation procedures will be
followed.
(2) A government office or a hotel room may serve as a
command post and is ideal for meetings, briefings, storing extra personal
protective equipment, telephoning, etc.
(3) In those cases where there is no available space, it
may be necessary to use a vehicle as the on-site command post. In such
circumstances, the vehicle shall always be at a specified location and shall
have an identifying flag or pennant either mounted on the roof or flown from
the radio antenna.
e. After discussion with the Regional Administrator concerning
the scope of the investigation, the Area Director may decide to appoint an
Acting Area Director to handle normal Area Office functions during the course
of the inspection. The Area Office staff shall be notified in writing
concerning the status of office supervision.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
f. On extensive investigations it may be necessary to provide
adequate space on the site for compliance staff to review employer documents
and diagrams and to conduct interviews.
(1) If the situation arises where a company will not or
cannot provide space for compliance officers to work, the rental of a mobile
office, motel room or other working quarters may be
necessary.
(2) Area Directors shall investigate sources of temporary
offices as part of their pre- disaster planning.
(3) Office equipment needs may include the
following:
(a) Telephone Service (wired and
cellular).
(b) Copy Machine.
(c) Work Tables.
(d) PC with E-Mail Capability.
(e) Automated Telephone Answering
Machine.
(f) Fax Machine.
(g) Locking File Cabinets.
(h) Durable tags for identifying
evidence.
(i) Office Supplies.
9. Evidence. The inspection team shall ensure, to the fullest
extent possible, that all evidence at the event site remains undisturbed
until OSHA has had an opportunity to document, examine, and inspect
it.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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a. OSHA, as a Federal agency, will claim precedence over other
non-Federal investigators and will assert the right to remove evidence or
obtain samples first.
b. In the past, the employers and other public sector
investigators have been cooperative in controlling the site by limiting
access of personnel and prohibiting unauthorized removal of material from the
site.
c. The inspection team leader shall attempt to negotiate an
agreement with the employer or other controlling authority not to disturb any
evidence involved in the significant event without OSHA's consent and
negotiate a written agreement regarding preservation of all evidence in the
accident area. The following basic elements shall be addressed in the
initial agreement:
(1) Designation of the specific area subject to the
agreement;
(2) How the area will be secured; i.e., fenced with one
gate to be secured with locks from all parties, 24-hour surveillance,
etc.;
(3) Mutual agreement to not tamper, alter or change any
object within the designated area;
(4) Scope to be given to search and rescue
operations;
(5) Provision under which actions may be taken in the
interest of safety and health and for notifying OSHA of action
taken;
(6) Preservation of any object already moved at time of
agreement so that it is preserved in accordance with the
agreement;
(7) Circumstances under which evidence may be disconnected,
videotaped, photographed,
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
marked, moved, repositioned, or removed from the site;
and
(8) Timeframes by which all parties will submit proposals
for testing, removal preserving equipment and other
times.
d. Agreements shall also be sought with other investigators
about the sampling order or removal/alteration order for physical evidence.
There shall be agreement as to which agency or organization will remove
evidence or take samples first and which agencies or organizations will
accept the analysis of another or can use the same information as
another.
e. A separate supplementary agreement shall be sought
specifically dealing with the protocol for examining and/or testing
equipment. The following items shall be addressed:
(1) Prohibition against alteration of equipment in any
manner until all significant items in the plant have been documented to each
party's satisfaction;
(2) Specific dates by which identifying and diagramming the
location and condition of all pertinent equipment will start, and how
equipment is to be identified;
(3) Provisions for other parties to be present and observe
the documentation process;
(4) Specific dates and times within which OSHA will
identify equipment and other items to be removed, preserved and/or
tested;
(5) Circumstances under which the employer and other
parties may conduct appropriate tests;
(6) Circumstances under which results, data, and
information obtained as a result of testing will be shared with the employer,
the union and other interested parties;
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(7) Circumstances under which items identified by OSHA
shall be removed, and once removed, how they will be stored and secured;
e.g., within enclosed, covered area with one means of access;
and
(8) Access to the secured storage area.
f. Upon completion of the immediate firefighting or other
damage suppression activity, the scene shall be left undisturbed to the
maximum extent possible until the investigation team arrives.
(1) Team members shall identify material and possible
witnesses to the event during the earliest phases of the investigation. Plans
must also be formulated at that time to identify further physical evidence
needs.
(2) Evidence must have a "chain of custody" to be
admissible in court; also the site of the incident must remain as undisturbed
as possible for causative factors to be established.
(a) Once the required evidence has been identified, the
chain of custody must be established.
(b) The evidence must be physically identified by
either describing identifying markings or characteristics, or by marking the
item directly. Videotaping or photographing of physical evidence, prior to
and after marking, is recommended.
(c) Whatever identifying method is used, it must be
durable and must not alter the specimen.
(3) Where equipment has to be removed to eliminate
remaining hazards, a record shall be made of such action
taken.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
NOTE: Photographs or video recordings will be useful
both as a record and a basis for analysis. By including a good photographer
with the first entry of the teams, the investigators ensure that a record is
made of much valuable evidence. The investigation of the circumstances
surrounding the accident is a methodical accumulation of small bits of
information which eventually form a pattern of evidence which is necessary
for the determination of the cause. It is recommended that another team
member accompany the photographer to log, identify and document the
photographs as they are taken.
(4) Evidence shall be systematically collected. The
following guidance in the collection of needed information/data is
provided:
(a) What was the building or structure like
before--materials of construction, floor plan, etc.? Does the employer have
an "as built" drawing?
(b) What was the overall layout before the accident and
after it? Aerial photographs of the site, before and after the incident,
often provide very helpful information concerning the cause of an accident,
especially explosions. After an explosion, pertinent information would
include size and composition of material, distance traveled, where an object
stopped and what stopped it. This generally will require immediate records
of the accident site; photographs and measurements must be made before the
site is disturbed. Particular attention should be given to the location of
stray parts of equipment dislodged during the
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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accident. Each item when correlated with other findings
may lead to an explanation of the origin of the
accident.
(c) What are the names and addresses of survivors,
eyewitnesses, and persons familiar with the material or equipment involved?
Of what assistance can they be in reconstructing the sequence of
accidents/events? What was the position of fatally injured employee(s) and
survivor(s), both before and after the accident. What operations were they
performing.
(d) What operations were being conducted at the time of
the accident? Were they routine? Are there written procedures, drawings,
checklists, and quality assurance monitors? Are there any drawings or
photographs? Are chemicals involved and will any sampling or analysis be
required?
(e) What had gone on before the accident? Were there
any deviations or changes in procedures? Had anyone said there would be or
had been a problem? Did anything unusual or strange occur? Had any piece of
equipment in the area of the accident experienced frequent or abnormal
mechanical problem as prior to the accident. Was an error made and then
corrected or covered up? Had anyone complained about some event or condition
related to or similar to the accident?
(f) Were materials in use at the time of the accident
the same as those that had been used previously? Had there been a new
shipment received? Were materials taken from an old container? Were new (or
old) tools being used? Were the parts/materials used those specified in
the
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
procedure/ drawings? Does the supplier need to be
contacted? Will copies of contracts or specifications be necessary? Will
material analysis or testing be required?
(g) Was there any advance training? Were there any
unusual conditions that might warrant special training? Was there a written
standard operating procedure available? Was there a check or audit to ensure
it was followed?
(5) The accumulation of useful evidence follows a random
pattern, but the inter- relationships of various findings is often
significant. A meeting at the end of a day, to review the results obtained
by each team, is an effective means of exchanging
information.
(6) Each investigation has only limited resources that can
be devoted to it. The expenditure of continued effort at each step of the
investigation must be weighed against the anticipated results. If it appears
that the key to an accident is dependent on the location of a particularly
elusive component, extended efforts are warranted.
(7) The orderly documentation of evidence is a prime factor
for a successful investigation. Although possible causes of the accident may
be advanced during the on-site fact finding portion of the investigation,
final analysis and evaluation is best performed at the investigating team's
office after all facts have been collected and analyzed.
(a) In the analysis of an accident, it may be helpful
to outline a step-by- step sequence of each possible accident mechanism based
on evidence found.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(b) If an "evidence gap" is found in one promising
mechanism, then additional information is needed.
(8) Some time should also be devoted to evaluating the
facility's emergency procedures for their effectiveness during the accident.
It is possible several useful revisions may be
recommended.
g. Photographs taken during the inspection shall be mounted
and identified by the team member taking them as soon as they are received.
If mounting is not possible, each photograph shall be identified on the back
to indicate what it shows, and when, where, and by whom it was
taken.
h. Photos of areas of interest taken prior to the incident
shall be obtained if possible.
(1) EPA may take aerial photos to identify potential
chemical spills; if so, EPA's aerial photos shall be
obtained.
(2) Videotape news clips taken during the event showing
actual footage of the fire or subsequent explosions shall also be
obtained.
(3) The need for OSHA contracted aerial photography shall
be evaluated.
10. Communications. Effective communication is especially
important during these investigations.
a. The following communications equipment should be considered
depending upon the circumstances which arise during the
investigation.
(1) Walkie-talkies are available from the Regional Office.
Compliance officers conducting the catastrophe inspection may be able to
coordinate walkie-talkie use with the police or other government
agencies.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
(2) Pagers for key personnel are available from the
Regional Office or can be rented from commercial sources.
(3) Mobile (cellular) phones are particularly useful to
maintain communication with the Area, Regional, and National
Offices.
(4) Portable Telefax equipment can greatly assist off-site
information dissemination.
(5) Portable copy units shall be available whenever
necessary on site.
(6) A portable microcomputer with E-Mail capability shall
be available on site for use by the team in writing the accident
investigation report as well as direct transmission of
information.
(7) Access by telephone is imperative in order to
communicate with the Area Office, Regional Office and National Office. If
the team is stationed in an office space on the site, access to the
employer's telephone may be sufficient.
(a) In the event that the OSHA control site/room is a
leased space, such as a trailer, it may be necessary to obtain telephone
service through requisition.
(b) In addition to the items above, a cellular phone
will prove most useful to maintain contact with on-site team members, the
Area Office, and others as necessary.
b. A status report of the inspection shall be sent to the
National Office daily, until the situation has stabilized. The reports may
be sent, at the discretion of the Regional Administrator, directly from the
team control room by fax machine or E-Mail.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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c. A representative of the Area Office shall initiate contact
with family members of any accident victims. (See OSHA Instruction CPL
2.89.) Circumstances may warrant a collective "group" meeting with family
members in large catastrophe investigations as the investigation gets
underway and when the OSHA investigation is concluded.
d. Periodic team progress meetings are important for the team
leader and provide a way of keeping each person up to date on the progress of
the investigation. Teams shall meet frequently to review findings, discuss
possible theories of causation, and exchange information.
(1) All of the teams or as many representatives as possible
shall meet once a week to provide an overview of each one's activities
completed thus far as well as planned. (Specific times for meetings should
be designated to facilitate planning of other inspection
activities.)
(2) If inspection teams are divided into specialized areas
(e.g., system safety, emergency response activity), a mechanism must be
established so information can be exchanged. Each group shall review all
requested documents and information which could be of importance to another
and place a copy of the document in a folder kept for that purpose in the
on-site OSHA command post. All other teams shall be made aware of the
material in the folders.
e. There are two aspects of media coverage that may be
pertinent: providing information to the media, and obtaining information
from the media. Regional OIPA shall be notified of the nature and extent of
media contacts.
(1) It is reasonable to expect that reporters from radio,
TV, and newspapers will make every effort to obtain all available information
relative to an emergency situation.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
(2) To coordinate OSHA's response, only the Area Director
or the Area Director's designee shall discuss the situation with reporters.
Names of members of the investigation team shall not be given to the
media.
(3) If reporters call or contact either the Area Office or
individual team members, the reporters shall be referred to the Area Director
or to the Area Director's designee; no attempt shall be made to answer any
questions related to either the emergency, the investigation, or the
individual team members.
(4) The Area Director shall periodically review media
involvement with the office. Although the Area Director will normally be the
media contact, any Area Office staff member may make the following
statements:
(a) OSHA is investigating or is on the way to the
scene;
(b) OSHA's purpose in investigating to determine the
cause of the incident and to determine whether any standards have been
violated;
(c) After citations, if any, have been delivered to the
employer, OSHA will announce and provide copies of its findings;
and
(d) Additional inquiries should be addressed to the
Area Director.
(5) Newspapers and television may have photographs, video
tapes or other visual representations of a site prior to or following an
event that may be helpful to the investigation.
(6) Every effort (including purchase) shall be
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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made to secure visual representations from the media.
It is possible, however, that photographs or newsreel tapes will not be
released without subpoenas. The OIPA can recommend approaches to obtaining
information from the media and/or other sources.
11. Plan of Investigation. The investigation team leaders shall
develop and submit to the Area Director a written plan for investigating the
accident and to determine its cause.
a. The plan shall be submitted to the Regional Administrator
within one week. A written summary or synopsis of events to date and a
description of the accident shall be included. Periodic updates shall be made
to the plan as new information becomes available.
b. The following issues shall be considered when developing
this plan, and in conducting the investigation:
(1) Site safety.
(2) Inspection team strategies.
(3) Use of consultants.
(4) Collection of physical evidence.
(5) Equipment and evidence testing.
(6) Review of employer documentation.
(7) Document control.
(8) Media exchange.
12. Extra-Regional Technical Assistance. It may be assumed that
OSHA will need experts to serve both in determining the cause of the accident
and testifying at any subsequent legal proceedings.
a. Expert assistance available from the National Office
includes:
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
(1) Office of Construction and Engineering. This office was
formed, in part, to support investigations of large scale disasters by
providing a capability to complete technical analysis and observations.
Personnel of the office will be involved in any major construction accident
and in accidents in other industries contingent upon discussion between the
Regional Administrator, and the Director of the office or at the direction of
the Assistant Secretary.
(a) The personnel assigned to the investigation join
the investigation team and serve under the general direction of the team
leader while maintaining the capability to complete the objectives of the
technical analysis of cause.
(b) The Office of Construction and Engineering and its
personnel do not become involved with any news media and make no periodic
reports to the National Office in lieu of, or in addition to those provided
by the Regional Administrator. In most cases the Office of Construction and
Engineering will provide a formal report of the technical findings of the
investigation. This report will be provided to the Regional Administrator
for inclusion in the completed case file. Copies of the report will be
released only after citations are issued and a determination is made that no
trade secrets are revealed by its contents.
(c) Since the observation of physical evidence is
important and since this evidence should be examined before it is moved or
disturbed, it is important that the Office of Construction and Engineering be
involved in the
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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investigation as soon as possible. The Director or
Deputy Director can be reached on nights and weekends by dialing home phone
numbers provided to the Assistant Secretary and the Regional
Administrators.
(2) Directorate of Technical Support (DTS). The Directorate
of Technical Support serves as the principal source of agency expertise with
respect to scientific, engineering and medical issues. A wide range of
support activities can be requested from DTS.
(a) On-site services provided by the Health Response
Team (HRT) as well as specialists from other offices within the Directorate
are available.
(b) On-site laboratory services, occupational medicine,
specialized equipment needs, chemical and professional engineering services
and priority technical information retrieval are available to assist regional
efforts.
(c) DTS has assisted in developing inspection protocols
for investigating catastrophic releases, National Emphasis Programs for
Safety and Health in the Chemical Industry, developing OSHA training programs
and directives for system safety reviews, performing plant inspections,
review of process and instrumentation (P&I) diagrams, and researching
literature for documentation to support proposed
citations.
b. Where the circumstances of the significant event warrants
prompt action, the Area Director shall, with the concurrence of the Regional
Administrator, contact a private sector consultant and request that a
representative be sent to the accident site.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
(1) The consultant and Area Director, with concurrence of
the Regional Administrator, shall agree on the scope of the contract which
can be executed only after that agreement.
(2) If the preliminary identification of consultants and
preliminary contacts (as outlined in G.1.b.(3) of this instruction) have been
satisfactory, the companies will probably be willing to commit some time and
resources based on verbal agreements.
(3) Written contracts can be completed at a later time when
the scope of work has been defined and costs can be better
estimated.
(4) The Area Director and consultants may only negotiate
items such as cost, place, time, name, contact points, results expected,
confidentiality, limitations on the availability of money, etc. The Area
Director must be careful not to commit the Government without an approved
purchase order from OASAM.
13. Witness Interview Procedures. Written witness statements shall
be taken to obtain first hand knowledge of conditions at the time of the
accident.
a. Witnesses will be identified as indicated in paragraph
G.9.f.(1).
(1) All potential witnesses shall be identified as early as
possible in the investigation, and interviews shall be conducted promptly as
witnesses' ability to recall will diminish with time.
(2) If a union is actively involved in the inspection, it
can serve as a valuable resource by assisting in determining employees who
might have knowledge of facts relative to the accident, for example,
operations and/or maintenance records or histories of the process of
equipment.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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(3) The inspection will likely involve interviewing and
reinterviewing all available witnesses, so their names, addresses, telephone
numbers and how they can be contacted shall be carefully noted. The results
of the interviews shall be shared among all team members.
b. The primary employer contact, as outlined in paragraph
G.7.c. of this instruction, will be utilized to schedule employee
interviews.
(1) The union can assist in determining employees'
schedules so that interviews can be scheduled.
(2) Subdividing the inspection team will allow team members
to conduct more initial interviews in a short time.
(3) If reinterviews of witnesses are to be conducted, they
shall be coordinated with other team members so that everyone interested in
key witnesses can participate at the same time.
c. The value of an interview often depends on the expertise of
the interviewer and areas covered. Therefore, the following guidance is
provided:
(1) All witness interviews shall be conducted by
experienced CSHO'S.
(2) CSHO shall exercise utmost discretion in conducting
interviews of injured witnesses and family members.
(3) Witness interviews shall always be conducted in private
unless the witness requests otherwise. If management is reluctant to permit
private interviews of employees on the site, the procedures in the FOM shall
be followed.
(4) The CSHO shall carefully question witnesses to solicit
as much information as possible related to the accident,
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
including processes, procedures, practices, training,
maintenance, materials, previous accidents, and any near
accidents.
(5) Key witnesses may have to be reinterviewed as
information is developed by the inspection team. During the initial phase of
the investigation, it is more important to ask questions to determine general
facts and to help identify key witnesses-- particularly those who may have
information related to the cause of the accident.
(6) Prior to the interviews, the team leaders and members
shall develop key, critical and screening questions to ask all witnesses.
Such questions may be written down and provided to all interviewers. (a)
While a specific list of questions is highly desirable, it may be more
practical in some cases to have only a list of the topics to be
covered.
(b) This list shall be developed before any interviews
are conducted and shall include:
1 What is your name, address, telephone number, job,
and employer?
2 How long have you done your present job? Have you
ever seen any problem like this before?
3 Where were you at the time of the accident? What
were you doing? Is that your normal job? Did you notice anything
unusual?
4 How did you discover the accident? Were you close
enough to physically sense (see, hear, feel, smell)
anything?
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
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5 See also paragraph G.9.f(4) of this
instruction.
(7) If the inspection team is charged with evaluating
emergency response, the CSHO shall interview employees about what they were
instructed to do during an emergency in their building or on plant property
to evaluate the employer's training and emergency procedures, and to
determine whether employees were knowledgeable of those emergency procedures.
Interviewers shall investigate how previous emergencies, if any, were handled
and if there were any significant problems?
d. Information developed in employee interviews must be
documented for use in case file development.
(1) Interviews shall not be tape recorded as the only
record of the interview. If a tape recorder is used, the compliance officer
taking the statement shall also prepare a written statement and have the
employee read and verify by signature the accuracy of the
information.
(2) A summary of pertinent information from each witness
shall be prepared and stored with each team.
14. Background Review. A review of establishment history and
process information can be of great value to the compliance officer
conducting the investigation. The team members should review appropriate
materials as time permits.
a. An understanding of workplace terminology can be developed
through a review of the safety and health policies and documents, operating
manuals, Standard Operating Procedures (SOPs), start-up/shut-down procedures,
training manuals for operators and job safety analyses.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
(1) Such a review will help in understanding what job each
employee performs and how he/she is supposed to perform these tasks and will
eliminate unnecessary reinterviewing of witnesses.
(2) This review will also be particularly helpful if the
actual work practices do not conform with established company policies or
procedures.
b. Early in the investigation other workplaces with similar or
identical operation shall be identified.
(1) If any of these establishments are participants in OSHA
Voluntary Protection Programs (VPP), an on-site visit and discussion shall be
considered to further understand the process and operation as well as help
identify common safety and health concerns to the
industry.
(2) If the practice of the industry is of importance to
document a possible general duty clause violation, other companies can be
contacted by phone and asked to provide pertinent
information.
(3) If these companies are reluctant to provide needed
information, an administrative subpoena can again be utilized to assist in
obtaining the needed information.
15. Document Control. During the inspection effort extensive
documentation will be collected from the companies inspected. Control must
be exercised from the onset to minimize confusion.
a. All document requests shall be confirmed in writing and
shall be provided to the person representing the employer. A dated copy of
the request shall be kept in the case file and notations made when the
request was complied with.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
Health Compliance Assitance
b. An inventory or log of the documents received shall be
maintained. Each document shall be given a case file log
number.
c. Once a document is reviewed, a short summary shall be
prepared and placed in the file. The summary may be a single line or several
paragraphs.
d. Periodically the documents request log shall be reviewed to
ensure that the information is being provided in a timely manner. If
critical documents have not been received and are needed, an administrative
subpoena shall be issued if necessary.
e. If any written or visual information is identified as
"Business Confidential - Trade Secret", a secure place shall be established
for the material. A locked file cabinet shall be used with a
sign-in/sign-out log to ensure all documents are accounted
for.
16. Closing Conference. A closing conference shall not be
conducted until the Area Director, in conjunction with the Regional
Administrator, gives permission to do so.
a. The closing conference shall be conducted by the team
leaders and offered to both the employer and employee representatives.
Outside agencies, insurance companies, media, etc., shall not be allowed to
attend the closing conference without the permission of the Area Director and
the employer.
b. Each team leader shall explain the finding of the
investigation with emphasis placed on apparent violations which may have
precipitated the significant event and recommendations on how to prevent a
similar incident.
17. Final Report Preparation. With a team effort, it becomes
important to organize the group's effort so that once a majority of the
inspection activities have been concluded, a single composite case file can
be developed.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of Health Compliance Assitance
a. Each team member shall maintain a journal of each day's
activities covering things accomplished and notations of things to
do.
(1) These journals, in a standard format designated by the
ITL, shall be provided to the team leader each week.
(2) These journals, with a little modification, can later
be compiled into a chronological inspection narrative.
(3) The daily journal will also aid in citation write-up
when the inspection is completed.
b. As soon as the inspection team determines (based on
interviews or observations) that a violative condition or potential violative
condition exists, appropriate notations shall be entered on the journal and
developed as the inspection progresses.
c. The team leader shall designate the CSHO(s) responsible for
writing and assembling the final case file.
(1) Although each team and/or team member develops a
partial case file, they must be assembled by designated individuals into a
complete product.
(2) If an egregious case is to be developed, it is
particularly important to assign responsibility so that the CSHO(s) can
coordinate with the Regional Solicitors to ensure that all evidence and
documentation necessary are collected. They shall also review OSHA
Instruction CPL 2.80, to assist in asking appropriate questions on interviews
or in seeking documentation. Similar precautions shall be taken for cases
involving potential criminal violations.
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OSHA Instruction CPL 2.94 July 22, 1991 Office of
Health Compliance Assitance
18. Disclosure. OSHA's policy regarding disclosure of case file
contents is set forth in Chapter XIV of the FOM.
a. Any release of official case file information shall be
conducted in accordance with those guidelines.
b. If there is to be an official press release concerning the
disaster investigation, the Regional Administrator, in consultation with the
Area Director and Regional OIPA, shall draft one for National Office approval
prior to issuance of the citation(s).
H. Program Evaluation. It is OSHA's policy to evaluate the effectiveness
of this instruction each time its procedures are implemented. Therefore,
Regional Administrators shall submit a critique of the procedures outlined in
this instruction within 90 days of the completion of an investigation of a
significant event. In addition, Regional Administrators conducting such
investigations shall submit a proposed investigation scenario for industry
specific conditions which are not fully covered by this instruction. These
scenarios will be reviewed for incorporation into this instruction, as
appropriate.
Gerard F. Scannell Assistant Secretary
DISTRIBUTION: National, Regional and Area Offices Compliance Officers State
Designees NIOSH Regional Program Directors 7(c)(1) Project Managers
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