**Serious Accident Investigation**

**Factual Report Example**

**Forest Service Format**

**FOR OFFICIAL USE ONLY**

**ATV Fatality**

**Field Office**

**Bureau of Land Management**

**Location**

**Date**

**[Picture]{.underline}**

[Privacy Act]{.underline}

[This report contains information protected by the Privacy Act.
Disclosure of protected information is a violation of the Privacy Act of
1974, as amended, (U.S.C. 552.a).]{.underline}

**[ACCIDENT INVESTIGATION FACTUAL REPORT]{.underline}**

**Accident:** All Terrain Vehicle Rollover Fatality

**Location:** Field Office, Location

**Date:** Date

**Investigation Serious Accident Investigation Team**

**Team Leader:**

Name:

Title:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Signature Date**

**Chief Investigator:**

Name:

Title:

**Investigation Team Members:**

Name:

Title:

**Technical Consultant:**

Name:

Title:

**[Table of Contents]{.underline}**

  ------------------------------------------------------------------------- ---------
  **Executive Summary                                                       **4**
  ....................................................**                    

  **Narrative                                                               **6**
  ...............................................................\...**     

  **Investigation Process                                                   **11**
  ...................................................**                     

  **Findings                                                                **12**
  ...................................................................**     

  **Causes                                                                  **14**
  .....................................................................**   

  **Contributing Factors                                                    **14**
  ................................................\...**                    

  **Maps, Illustrations and Photographs ..............................**    **16**

  **Appendices                                                              **17**
  ............................................................\...**        
  ------------------------------------------------------------------------- ---------

**[Executive Summary]{.underline}**

On August 2, 2004 a Seasonal Biological Technician for the Bureau of
Land Management, died as a result of an All Terrain Vehicle accident.

The victim was a male (62) years of age in good physical health and had
been an employee with the BLM for 5 seasons.

The victim arrived for work on the morning of (August 2, 2004). He
confirmed his work plan and schedule with his supervisor. His assignment
was to conduct land and health surveys in the (location area of the
unit). They had previously discussed the need for an All Terrain Vehicle
in order to accomplish the work and had reserved a machine and loaded it
into a vehicle. The supervisor through conversations with the employee
was confident that the employee had the expertise in ATV operation to
accomplish the assigned task without assistance. They discussed the work
to be accomplished, the travel routes, and the planned return time to
the office of 1600 to 1630 hours.

The victim departed for the (work area) and no further contact was
received during the day.

At approximately 1615 the supervisor noticed that the victim had not
returned from the field nor had there been any communication received
from him. The supervisor initiated a radio and telephone search and when
no contact had been received by 1730 hours he began notifying Field
Office management and enlisting personnel for a search operation. Field
Office personnel were organized into 3 search teams. The County Sheriffs
Office was notified and the County Search and Rescue organization put on
standby.

Field Office search parties were dispatched to the planned work area and
began searching at approximately 2030 hours. The victim's truck was
located at 2120 hours. At 2224 hours the victim was found pinned under
the ATV he had been operating. After a first aid assessment, the victim
was presumed to be deceased and notification was made to the search
parties and Sheriff Personnel. Two Field Office search personnel secured
the accident site and remained there until the County Sheriffs Deputies
arrived.

At 0200 hours on (August 3, 2004) County Sheriffs Deputies and a body
recovery team arrived and assumed control of the accident scene. They
conducted an investigation of the body, equipment, and area. The
Sheriffs Deputies initial determination was the victim had lost control
of the ATV he was operating while trying to climb a steep pitch in the
road and rolled the vehicle. In the course of the events during the
accident the victim became trapped under the ATV and subsequently died.

The ATV was moved from its resting location by SAR personnel and was
found to have no substantial damage. It was driven out and released to
BLM personnel. Field Office search personnel were debriefed and released
home.

The body was recovered, prepared for transport, and released to the
Deputy Coroner for a post mortem examination. The results of the post
mortem showed that the victim had very few external injuries and they
were limited to abrasions which would be consistent with an accident of
this type. The victim was found to have neither internal injuries of
consequence nor any other physical conditions that could have caused the
accident. The cause of death for the victim was determined to be
positional asphyxiation due to the weight of the All Terrain Vehicle
pressing him down and not allowing the exchange of oxygen. No accurate
time of death has been established.

**[Narrative]{.underline}**

**Monday July 26, 2004**

Field Office Ecologist and seasonal Biological Technician (victim)
discussed the need for an All Terrain Vehicle (ATV) to accomplish
planned survey work. The Biological Technician was to conduct land
health assessments in the (project work area). This area is located
approximately 20 miles north of the Field Office and in rough and steep
terrain. It was decided an ATV was required and the Biological
Technician should plan to use one. A plan was made for specific sites to
be visited and surveyed.

**Friday July 30, 2004**

The Seasonal Biological Technician (victim) came into the Field Office
to reserve an ATV for the work planned on August 2, 2004. The vehicle he
reserved was a (make and model). This is large, 4-wheel drive ATV with
an automatic transmission and weighs approximately 600 pounds. It is
owned by the Bureau of Land Management (BLM) assigned to the Wild Horse
and Burro Program Manager, but is often used by other employees in the
performance of their duties. The Biological Technician (victim) is
reported to have inspected the vehicle to ensure it was in good working
order and ready for use. He also secured his supervisors pickup truck to
transport the ATV to the work area. He was instructed by his supervisor
to find a helmet that fit.

**Monday August 2, 2004**

At 0800 hours the Biological Technician (victim) and his supervisor
discussed his plan and field work schedule for the day. They had
previously determined that the Biological Technician (victim) was to
conduct land health surveys in the (project area name) 20 miles north of
(location). They referred to a map, planned his route and the locations
he was to visit. The roughness of the terrain was discussed as a
potential hazard. No formal Risk Assessment was documented. The
supervisor determined that the victim had a helmet, field radio, and
cell phone. His cell phone number was confirmed. The Biological
Technician (victim) took his supervisors (GOV) pickup truck in order to
transport the All Terrain Vehicle to the work area, and departed for the
field. He planned to return at approximately 1600 (4 pm) to 1630 (4:30
pm) hours.

No further contact was made with the Biological Technician (victim)
during the day.

At 1615 hours the Supervisor noticed that the Bio Tech (victim) had not
returned to the Field Office and checked the vehicle yard for his pick
up. It had not yet arrived.

At 1630 hours the supervisor began a radio and telephone search but was
not able to contact the employee. The supervisor then drove the length
of the main street near the Field Office in an effort to verify that the
employee was not fueling at one of the local gasoline stations. He
proceeded home and changed clothes to prepare for a field search.

**Monday August 2, 2004**

**Continued**

At 1730 hours the supervisor returned to the Field Office and attempted
to telephone the Field Manager and the Assistant Field Manager with no
success. He left voice messages for both of them. He continued to try to
contact the employee by radio and phone.

At approximately 1800 hours the Field Office Natural Resource Specialist
returned to the Field Office from his work site and offered to assist in
organizing the search effort.

The Natural Resource Specialist contacted the Zone Fire Management
Officer requesting fire personnel to help in the search.

The supervisor contacted the local 911 and spoke with the County
Sheriffs Deputy on duty and reported that an employee had failed to
return at the appointed time and that BLM may need Search and Rescue
assistance.

The supervisor contacted the local BLM Law Enforcement Ranger and
alerted him of the situation. The Ranger came to the office to assist in
the effort.

At 1900 hours the Zone Fire Management Officer contacted Engine #502
Module Leader and informed him of the situation. The Engine Leader
contacted 3 members of his crew and enlisted them in the search effort.

The Natural Resource Specialist had two additional resource specialists
join the search team.

At 1930 hours Dispatch went into service and assisted in the search
effort.

The search parties departed to the project area to begin the search.

At 2000 hours the Dispatch Center Manager came into the office on
unrelated business and was notified of the situation. The Center Manager
contacted the Associate Field Manager who was apprised of the situation.
Center Manager provided management input until the Associate Field
Manager arrived at the Field Office

At 2015 hours the Search Party arrived in the project area and
established a staging area. The Zone Fire Management Officer was
designated as the Incident Commander for the search effort and he
organized the search personnel into 3 teams. The Incident Commander and
an Emergency Medical Technician remained at the staging area providing
coordination.

> Team 1. Conducted their search on motorcycles
>
> Team 2 Utilized ATVs
>
> Team 3 Utilized ATV's

**Monday August 2, 2004**

**Continued**

The search teams were briefed on the search pattern and were instructed
to focus on finding the employee's vehicle or ATV tracks in order to
pinpoint his work location. Areas that were searched and cleared were to
be identified by colored chemical light sticks in order to prevent them
from being searched again.

At 2040 hours the County Sheriffs Deputy arrived at the staging area.

At 2100 hours after receiving a briefing from the Incident Commander on
the situation the Deputy Sheriff called and placed the County Search and
Rescue (SAR) resources on standby.

At 2122 hours the employee's (victim) vehicle was found by Team 2. It
was observed that the ATV had been unloaded and the employee's lunch was
still in the cab of the vehicle. The Deputy Sheriff then activated the
SAR.

The Incident Commander and EMT moved from the staging area and to the
employee (victim) truck location along with search teams 1 and 3.

At 2200 hours Search teams 2 and 3 begin to follow a set of ATV tracks
leading away from where the pickup truck was found.

At 2202 hours the Incident Commander and EMT arrived at the victim's
vehicle (truck) location. Concurrently Team 1 arrived and began to
search the immediate area around the vehicle.

At 2224 hours Team 3 radios the Incident Commander and relays that they
have found the victim and it was the "worst case scenario". The location
was given and it was requested only experienced riders be allowed into
the area.

Search Team 2 arrives and positively identifies the victim.

The victim was found at the bottom of a steep slope and was pinned face
down beneath the ATV he had been operating. The ATV was balanced on its
right side across the victim's upper back. A field first aid assessment
found the victim to be unresponsive and assumed deceased. This
information was relayed back to the Incident Commander.

The County Search and Rescue personnel were notified of the location and
departed for the accident site.

At 2230 hours the Incident Commander notified the Field Manager of the
fatality. She instructed the Incident Commander to notify the Associate
Field Manager.

**Monday August 2, 2004**

**Continued**

At 2240 hours the Incident Commander instructed a member from search
team 2 and 3 to return to the pickup truck location in order to lead
sheriff personnel to the accident scene.

The remaining search team 2 and 3 members remained at the accident site
to ensure security of the area.

At 2300 hours the Field Manager notified the State Director of the
fatality.

At 2400 hours the Associate Field Manager, Center Manager and Field
Office Ecologist proceed to the victim's home and personally notified
the victim's wife of the fatality.

**Tuesday August 3, 2004**

At 0130 hours the County Search and Rescue personnel arrived at the
pickup truck site and were led to the accident site.

0200 hours the County Deputy Sheriff, as well as, SAR personnel arrived
at the accident scene and assumed command of the site.

At 0215 hours BLM search team personnel returned to the pickup truck
location.

At 0215 hours the Deputy Sheriff conducted a visual investigation and
documented the scene with photographs.

The victim was lying on his stomach at the bottom of a steep section of
road. His head was pointing downhill on the left side of the road and
was roughly at a 45 degree angle to the slope.

The victim was wearing appropriate personal protective equipment (PPE)
except for gloves and eye protection.

The victim was wearing a back pack.

A handheld radio was in the vicinity of the body.

The only outward appearances of traumatic injuries were abrasions, some
blood around the mouth and nose, and a possible laceration on his left
wrist.

**Tuesday August 3, 2004**

**Continued**

Returning the ATV to an upright position was easily accomplished by SAR
personnel and did not disturb the position of the victim's body in the
process. An inspection of the ATV did not show any severe damage. The
left hand grip had dirt embedded in it while the right hand grip was
clean, the gear shift lever was found to be between Forward High and
Forward Low, the rear cargo rack was broken, and the vehicle body showed
some abrasions.

At 0315 hours the victim's body was transported from the accident scene
by County Sheriffs Deputies using a recovery trailer and ATV. The body
was released to the Investigator/Deputy Coroner.

The victim's ATV was operable and driven from the accident site by the
Deputy Sheriff.

The accident evidence was loaded for transport as well as ATV equipment
used during the search. All BLM search personnel departed for their home
bases.

At 0415 BLM personnel arrived at Field Office and attended a short
debriefing prior to departing for home.

At 0800 hours a meeting was conducted to inform Field Office personnel
of the accident and death of their fellow employee.

A Type 3 Incident Management Organization was formed to manage and
facilitate the anticipated needs of the investigation.

A Critical Incident Stress Debriefing team was ordered and the
Occupational Safety and Health Administration (OSHA) were notified.

At 1200 hours a Bureau of Land Management Serious Accident Investigation
Team (SAIT) was activated.

At 1330 hours an Occupational Safety and Health Administration (OSHA)
inspector arrived and requested a site visit to the accident area.
Helicopter transportation was arranged and the Center Manager
accompanied him to the site.

**Wednesday, August 4, 2004**

At 0800 hours the Serious Accident Investigation Team began its
investigation of the accident.

**[Investigation Process]{.underline}**

The fatality was reported to the national office of August 03, 2004 and
a BLM Serious Accident Investigation Team (SAIT) was mobilized. The team
consisted of a:

-   Team Leader

-   Chief Investigator

-   Safety Advisor

-   ATV Technical Specialist (Contract)

The team convened at the BLM Field Office on August 03, 2004. The team
in briefed with the Field Office Manager and staff on the morning of
August 04, 2004 and the process of collecting evidence and information
related to the fatality.

The process of information evidence gathering consisted of:

-   Evaluating all human, material, and environmental factors that may
    have contributed to this fatality.

-   Visiting the area where the accident occurred.

-   Establishing the pattern of actions of the victim and the chronology
    of the accident.

-   Reviewing operational guidelines, policies and position
    descriptions.

-   Gathering written statements of personnel which were involved in the
    search and rescue process.

-   Interviewing supervisors, coworkers, law enforcement personnel, who
    were associated with the victim or with the search and rescue
    operations.

There were no eye witnesses to the actual event and the investigation
focused on actions occurring during the search, rescue, and recovery
effort. Focus was also given to operational policies, procedures, and
direction associated with ATV operation at the Field Office. These
included duties, training, and expectations associated with day to day
actions.

**[Findings]{.underline}**

**[Finding 1:]{.underline}** **(Human)**

The victim was conducting Land Health Surveys utilizing an All Terrain
Vehicle (ATV) in the (project area) on August 02, 2004.

[**Finding 2**:]{.underline} **(Human)**

The victim was not trained, certified or experienced to operate All
Terrain Vehicles as required by BLM policy found in the Safety and
Health for Field Operations Handbook 1112-2.

**[Finding 3:]{.underline} (Human)**

No formal qualification process exists to ensure employees are qualified
for All Terrain Vehicle operation at the Field Office.

**[Finding 4:]{.underline} (Human)**

Risk Assessments were not completed for All Terrain Vehicle (ATV)
operations as required by BLM Manual Handbook 1112-2.

**[Finding 5:]{.underline} (Human)**

There is no formal process for the management and accountability of All
Terrain Vehicles (purchasing, maintenance, repair and usage) at the
Field Office

**[Finding 6:]{.underline} (Material)**

The (make and model, VIN) All Terrain Vehicle, has several sensitive
operational characteristics and design limitations.

1.  **Operational problems with throttle response:** The throttle of
    this make and model ATV is very sensitive and responds quickly to
    the slightest touch. This causes the ATV to react immediately
    causing the front suspension to unload and increasing the
    possibility of loss of control that could result in flipping the
    machine over and backwards.

2.  **Shift lever:** This make and model ATV utilizes an automatic
    transmission with the following settings: reverse, neutral, forward
    high, forward low. In order to shift the machine it must be brought
    to a complete stop, release button located on the top of the shift
    lever must be depressed, and the gear change made. This type of
    configuration requires the operator to remove the right hand from
    the handlebar and throttle control. Once the throttle is released
    the machine can begin to roll downhill, or freewheel, forcing the
    operator to rapidly apply the brakes and re-engage the throttle.
    When riding on steep terrain changing gears also requires the rider
    to shift their body weight and position backward on the machine,
    changing the center of gravity. This may cause the operator to lose
    control of the ATV.

[**Finding 7**:]{.underline} **(Material)**

**Tire pressure:** This vehicle had inconsistent tire pressure which
deviated from the manufacturers recommend 5 PSI for each tire. Varying
tire pressures were found on this ATV. The front left tire had 4 PSI,
the front right had 2.5 PSI and the left rear 2.5 PSI, and the right
rear had 3.5 PSI. The manufacturers recommend equal tire pressures on
each axle (based on conditions and use). Unequal pressures may result in
unsafe handling conditions and loss of operator control.

**[Finding 8]{.underline}**: **(Environmental)**

The accident site was located on a single track trail on a steep incline
of 50% slope. The trail was uneven with both loose and stable rocks
throughout.

**[Finding 9:]{.underline} (Environmental)**

Tire tread evidence at the site indicated that the victim was attempting
to navigate over two large embedded rocks in the trail when the accident
occurred.

**[Finding 10:]{.underline}** **(Human)**

Loss of control of the All Terrain Vehicle, culminated in a rollover and
the entrapment of the employee beneath the vehicle. The ATV came to rest
on top of the employee's upper torso in such a way that it resulted in
positional asphyxiation.

**[Finding 11:]{.underline} (Human)**

On Monday August 2, 2004 at 1730 hours the Field Office initiated a
field search for the missing employee (victim). At 2122 hours the
employee's (victim's) vehicle was found. At 2224 hours a search team
found the victim. They conducted a field first aid assessment and
determined the victim to be unresponsive and assumed deceased

**[Finding 12:]{.underline} (Human)**

On Tuesday August 3, 2004 at 0200 hours the County Deputy Sheriff and
Search and Rescue personnel arrived at the accident site and assumed
command. At 0315 hours the victim's body was transported from the
accident scene and was released to the Investigator/Deputy Coroner.

**[Causes]{.underline}**

**[Cause 1:]{.underline} Loss of control of vehicle.**

The loss of control of the (make and model) All Terrain Vehicle
culminated in a roll over and entrapment of the employee beneath the
vehicle. The weight and position of the vehicle across the upper torso
of the employee resulted in positional asphyxiation.

**[Cause 2:]{.underline} Equipment.**

The operational characteristics of the (make and model) All Terrain
Vehicle combined with employee inexperience made traversing rocks on the
steep grade difficult.

**[Contributing Factors]{.underline}**

**[Contributing Factor 1:]{.underline} Training**

The employee was not trained or certified to operate All Terrain
Vehicles as required by BLM policy found in the *Safety and Health for
Field Operations Handbook* 1112-2*.*

The victim had not received any documented training, certification, on
the operation of ATVs.

**[Contributing Factor 2:]{.underline} Qualification Process**

No formal process exists to ensure employees are qualified for operation
of All Terrain Vehicles (ATVs) in the Field Office Unit.

The Field Office Unit has no records of training and certification for
ATV operations. No training records for any employee were reviewed by
the investigation team. The requirement for training and certification
for operating an ATV is known to managers, supervisors, and employees.
However, training is not regularly provided nor is there accountability
to ensure it is completed and documented. While some training is being
provided by individual programs it is still not being documented.

**[Contributing Factor 3:]{.underline} Risk Assessments**

Risk Assessments were not completed for the Field Office Unit All
Terrain Vehicle (ATV) operations as required by *BLM Manual Handbook*
1112-2.

There were no Risk Assessments done or available for the SAIT to review.

**[Contributing Factor 4:]{.underline} Terrain**

The accident site was located on a single track trail on a steep incline
of approximately 50% slope. The stretch of trail at the accident scene
was about 8 feet wide and 100 feet in length. The trail is uneven with
both loose and stable rocks throughout. Tire tread evidence and other
evidence at the site indicated that the victim was attempting to
navigate over two large embedded rocks in the trail when the accident
occurred.

**[Contributing Factor 5:]{.underline} Tire Pressure**

The All Terrain Vehicle had inconsistent tire pressure which deviated
from the manufacturers recommend 5 PSI for each tire. Unequal pressures
may result in unsafe handling conditions and loss of operator control.

**[Maps, Illustrations, and Photographs]{.underline}**

**\[No Maps, Illustrations, or Photographs are included in this Factual
Report Format Example\]**

**[Note:]{.underline}**

**Only include maps, pictures and factual information necessary to
provide an understanding of the accident sequence. Any other remaining
data should be placed in the Accident Investigation Case File.**

**APPENDIX**

**\[No Appendices are included in this Factual Report Format Example\]**

**[Note:]{.underline}**

**Only include appendices necessary to provide an understanding of the
accident, e.g. equipment analysis.**