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### *U.S. Geological Survey Manual*

# Appendix 7-1 Part 445-2-H, Chapter 7

# Department of the Interior 485 DM 7 - Appendix 1

# Serious Accident Investigation

1\. **Purpose**.

A. To establish a process for investigating serious accidents and
identifying 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).

2\. **Scope**.

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

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

C.  The investigation establishes the facts and 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.

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 DM Part 485) the Office of the Secretary.

B.  *Agency Administrator*. The Bureau facility/organization manager
(e.g., 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) having
direct line authority over employee activities when and where a serious
accident occurs.

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

D.  *Serious Accident*. Department-related activities which result in:

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

(2)  Three or more employees, volunteers, contractors, emergency
firefighters, 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 and prescribed fire-related
activity, or to personnel working in direct support of these activities.

F.  *Preliminary Notice*. A written notice to the Departmental DASHO
prepared by the involved Bureau 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 from the Bureau
safety manager, chosen to investigate a serious accident and to report
the accident facts and corresponding conclusions and recommendations.
The team is comprised of a Team Leader, an Accident Investigation
Advisor, a Chief Investigator, and a Technical Specialist(s). These
individuals are described in Section 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 at
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 basic 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
Occupational Health and Safety (OHS).

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 not only all of the basic facts that are
contained in the Factual Report but also the results of the
investigation; e.g., the SAIT or TI opinions as to why
management-control systems did not prevent the accident (if applicable)
and recommendations for preventing similar accidents.

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

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 that 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 having jurisdiction over 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
OHS are notified in a timely manner.

B. The Bureau will immediately file with OHS a telecommunications report
on the serious accident. 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 and/or three or more
employees hospitalized. If the report cannot be made during OSHA regular
business hours Monday through Friday, then the report can be made
through the OSHA telephone hotline at 1-800-321-6742. The DOI Watch
Office can be contacted on the telephone hotline at 1-877-246-1373,
available on a 24-hour daily basis.

C.  The telecommunications report is followed by a written Preliminary
Notice to the Bureau DASHO, with a copy to OHS, and 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, OHS will notify
the Departmental DASHO, the Office of the Secretary, the Office of the
Solicitor, the Departmental Information Office, the OSHA Office of
Federal Agency Programs, and others as appropriate.

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 7-2 and 7-3***.**

B. *Bureau DASHO*.

\(1\) Immediately authorize and appoint, with the assistance from the
Bureau safety manager, an SAIT or a TI for the Bureau head and (see
Sections 6D and 6E of this appendix). The SAIT composition is described
in Section 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.

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

(4)  Ensures that the OSHA Area Office having jurisdiction over the
accident site is offered the opportunity to participate in the
investigation. OSHA 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.

**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
to OHS 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 either 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 4A, B, and C above.

\(2\) Provides for and emphasizes treatment and care of employees
involved or affected by the accident.

\(3\) Briefs the SAIT or TI upon arrival and facilitates and supports
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, through the First Executive Level Manager, will provide a
status report to the Bureau DASHO at least every 90 days until all
appropriate corrective actions are implemented.

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
who is 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 the 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 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 8 of this appendix.

C. If the TI option described in Section 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.

7\. **Conduct of the Investigation**.

A. *The Agency Administrator*.

\(1\) Secures the accident site and identifies 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 in 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 in 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 immediately notify the Federal Bureau of Investigation
and local law enforcement authorities, Office of the Inspector General
(OIG), and the Bureau DASHO. 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.

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 Safety Manager though the Bureau DASHO will provide to the
Departmental DASHO a written preliminary notice within 48 hours of the
accident on the basic facts (no opinions or recommendations) surrounding
the accident.

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

D.  The SAIT or TI will also provide to the Bureau head, through the
Bureau DASHO and the Bureau safety manager, an original and a copy of
the completed Factual and Management Reports 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
immediately to OHS 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
non-concurrence 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 receipt of the SAIT or TI
Management Report by the Bureau DASHO 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 non-concurrence for each report
recommendation. The memorandum will also include an explanation for each
"non-concurrence" 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 be submitted to the Bureau head for
inclusion in the package that will be forwarded to the Departmental
DASHO.

G. The Bureau Safety and Environmental Management Branch will prepare an
Abstract of a Serious Accident Investigation for the Departmental DASHO
within 30 working days from the receipt of the Factual and Management
Reports. The Abstract provides a summary of what happened, without
identifying the specifics of the accident, and discusses direct and
indirect contributing causes as well as recommendations for preventing
similar accidents. 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. OHS
becomes the Office of Record for the report.

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 will be provided by the
requested Bureau individual(s) and/or the SAIT or TI, on the accident
that details 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.

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 and Environmental
Management Branch, as the Office of Record, for retention, unless
determined otherwise by the Office of the Solicitor.