Note: Department of the Interior (Department or DOI) and U.S. Geological Survey (Bureau or USGS).
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 Designated Agency Safety and Health Official (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-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.
(2) Three or more employees, volunteers, contractors, emergency fire fighters, or public individuals hospitalized.
(3) Property damage (including site mitigation or cleanup) and/or an operating loss of $250,000 or more.
(4) Consequences that a Bureau DASHO judges to warrant further investigation using these serious accident investigation procedures.
E. Serious Wildland and Prescribed Fire-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 comprises 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 the Office of Managing Risk and Public Safety (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 investigation¾the 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 Occupational Safety and Health Administration (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 by telephone 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 by telephone at 1-800-321-OSHA [6742]). MRPS can be notified via its telephone 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.
1.5 Accident Investigation Responsibilities/Requirements, Appointment of an SAIT or a TI.
A. Bureaus.
(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-related serious accident occurs, ensure that the investigation is conducted in accordance with Appendixes 2 and 3.
B. Bureau DASHO.
(1) Immediately authorize and appoint an SAIT or a TI for the Bureau head and with the assistance of the bureau safety manager (see Sections 1.6D and 1.6E of this appendix). The SAIT composition is described in Section 1.6. In the case of a serious fire-related accident occurring during a Department of Agriculture (USDA) Forest Service-managed fire, a DOI-managed fire, or a jointly-managed fire, the SAIT will include personnel from both the DOI and USDA.
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 7-2 describes a protocol for determining which agency (USDA or DOI) has the lead for a wildland and prescribed fire-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) Ensures 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) Ensures that appropriate qualified personnel and resources are immediately available to conduct and support an investigation.
(4) Ensures 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 without formal processes, as requested.
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:
(1) 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.
(2) 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.
(3) 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.
(4) 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.
(5) 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.
(6) 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.
(1) Initiates and makes (in conjunction with the Bureau DASHO and Bureau safety manager) all telephone and written notifications of the accident as described in section 1.4A, B, and C above.
(2) Provides for and emphasize treatment and care of employees involved or affected by the accident.
(3) Briefs the SAIT or TI upon arrival and facilitate and support the SAIT or TI, as requested.
(4) Implements critical stress management procedures, as needed.
(5) Initiates actions to notify family members of the situation.
(6) Ensures 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.
(7) Ensures 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 of the following members:
(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.
(1) 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.
(2) 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.
C. 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.
(1) Secures the accident site and identify all possible witnesses.
(2) Photographs (color prints, other than self-developing film) the accident site and related tools and equipment which might aid the SAIT or TI.
(3) Briefs 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:
(1) Completes the Just-in-Time training/orientation process.
(2) Discusses the purpose and scope of the investigation and the process to be followed, including report formats, time constraints, and interview schedules. The Team Leader ensures 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) Arranges 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) Arranges 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:
(1) Ensures the scene is secured.
(2) Becomes familiar with the site.
(3) Ensures that hazards are identified.
(4) Identifies, documents, and attaches physical evidence, as necessary.
(5) Photographs/sketches the accident scene if it has not already been done.
(6) Releases 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 days between the Bureau DASHO’s receipt of the SAIT or TI Management Report (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 these same 21 working days, 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 nominally includes the Factual Report, the Management Report, explanations of concurrence and/or non-concurrence 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 Department 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.