**181.1 PURPOSE** To establish agency-wide requirements and procedures
for reporting and investigating accidents/incidents In the BPA system in
compliance with OSHA Part 1960 and Executive Order 12196. Consistent
with Delegation Order No. 0204-161, signed by the Secretary of Energy on
October 7, 1996, this issuance also exempts BPA from the provisions of
any related Department of Energy issuance, including DOE O 225.1A,
Accident Investigation.

**181.2 POLICY** It is BPA policy to thoroughly investigate all serious
accidents and near misses. The purpose of the investigation is to
establish the facts related to the accident, determine the factors that
directly caused or contributed to the accident, and recommend steps to
be taken to prevent a recurrence. Investigation results shall be
reported without attributing individual fault or proposing punitive
measures. The investigation report constitutes an accurate and objective
record that provides complete and accurate details and facts pertaining
to the accident. Analytical results, causes of the accident, conclusions
reached, and recommendations to correct deficiencies that should have or
could have prevented the accident shall be identified.

**181.3 DEFINITIONS**

A.  **Serious Occurrence:** Any unplanned or unexpected event that
    results in a fatality, serious injury or illness to employees,
    contractors or members of the public involving a BPA operation or
    violations of Accident Prevention Manual life or death rules.

**B Near-miss:** An occurrence that had the potential for a fatality,
serious injury, or property damage having system-wide significance.

**C Accident Investigation Board (AIB):** A board consisting of a
Chairperson, Safety Office accident investigators, technical experts,
managers, supervisors, consultants and advisors as necessary to conduct
investigations on the BPA system.

**D Designated Safety and Health Official:** The Senior Vice President
for Employee and Business Resources is BPA's designated Safety and
Health Official. This individual has been appointed by BPA's Chief
Executive Officer to be responsible for the management of BPA's Safety
and Health Program.

**E BPA Accident Investigation Protocol:** Procedures identified in the
Safety and Health Program Handbook, Section C, Chapter 2, for conducting
accident investigations within BPA.

**181.4 ACCIDENT REPORTING RESPONSIBILITIES**

**A. Employees** shall immediately report to their first line
supervisors all accidents and near-misses occurring to or involving them
in the performance of assigned duties, whether on or off BPA property.
If the employee is injured and cannot report, another BPA employee shall
report on their behalf.

**181.4 ACCIDENT REPORTING RESPONSIBILITIES (continued)**

**B. Supervisors** shall immediately report all accidents and
near-misses which may be attributable to the work environment for which
they have supervisory responsibilities to their first line supervisor.

> 1\. In the event of a serious accident, the responsible supervisor
> shall to the extent possible include the name(s) of the individual(s)
> involved, the extent of injuries, the time of the accident, and a
> brief description of the occurrence by telephone to
>
> a\. Their Line Management
>
> b\. The System Dispatcher, and
>
> c\. The BPA Safety Manager
>
> 2\. Supervisors shall complete and submit an Individual
> Accident/Incident Report (BPA F 5480.01e), for all injury/Illness
> accidents through supervisory channels, to the Safety Office within 6
> days of the occurrence.

**C. Safety Office**

> 1\. Reviews Individual Accident/Incident Reports (BPA F 5480.01e),
> investigative reports, narratives, and associated material for
> consolidation into statistical and other reports for use in the BPA
> system (i.e., Safety Alerts, System Accident Data Reports, Recordable
> Injury and Vehicle Accident Statistics, etc.). The Safety Office shall
> provide reporting in accordance with OSHA Part 1960 requirements.
>
> 2\. Immediately publishes system-wide safety alert notifications of
> fatal and serious workplace occurrences. Fatal employee accidents
> shall be immediately reported by the BPA Safety Manager to the Chief
> Executive Officer and Designated Safety and Health Official.
>
> 3\. If a fatality occurs or when three or more employees are
> hospitalized from a single occurrence, notification will be made by
> telephone within 8 hours by the BPA Safety Manager to the US
> Department of Labor (OSHA).

**181.5 ACCIDENT INVESTIGATION RESPONSIBILITY**

**A. The Safety Office** has the responsibility for determining the
appropriate level of investigation required. Serious accidents will be
investigated by a BPA Accident Investigation Board. The Safety Office
will immediately conduct an on-site preliminary investigation and assure
adequate employee safeguards exist. The BPA Safety Manager will initiate
an Accident Investigation Board, provide notification of the accident
and coordinate with the appointed board on behalf of BPA. The Safety
Office is responsible for tracking and reporting the status of
corrective action items implemented by Management's Accident
Investigation Team.

**181.6 ACCIDENT INVESTIGATION BOARD**

**A. The Safety Manager** will facilitate the appointment of the AIB
including preparing the memorandum of appointment for signature by BPA's
Designated Safety and Health Official. The memorandum appointing the AIB
shall include the scope of the investigation, individuals being
appointed, special provisions of the investigation and a specified
completion date for the final report. The AIB will be appointed within 2
working days of the occurrence and will consist of a Board Chairperson
and from three to six members.

**B. Accident Investigation Response Team** shall respond to the
accident site within 24 hours and begin conducting a thorough
investigation. The Board shall determine the facts of the accident by
examining the accident scene, examining documentation, and interviewing
witnesses and other personnel directly associated with the accident. The
scope of the investigation shall include gathering and documenting
facts, analyzing causes, developing conclusions, and making
recommendations to BPA's management. The Board shall report
investigative results without determining individual fault or proposing
punitive measures. The Board shall examine policies, standards,
requirements and safety systems that are applicable to the accident
being investigated that could have contributed to or prevented the
accident. Completed reports will be submitted through BPA's Designated
Safety and Health Official to the appropriate organization for system
review within 30 days of the occurrence.

**C. Accident Investigation Board** Only senior management officials
that have completed the Department of Energy's Chairperson training
shall be authorized to reside over a BPA accident investigation board.
The Chairperson shall not have line management involvement over the
occurrence being investigated and the Safety Manager assigned to that
organization will not participate on the board. The accident
investigation board will not include both a supervisor and their
subordinate. During the investigation, the AIB chairperson and members
will report only to the appointing official.

**D. Management** **Accident Investigation Team** Tier II managers, the
A/I board Chairperson, BPA Safety Manager and Technical Advisors, as
required, will review accident investigation reports. The team is
responsible for reviewing accident investigation recommendations,
implement corrective action plans and assigning the appropriate
organization(s) to address recommendation(s) within 15 days from
receiving the report. The Safety Office shall be responsible for
tracking all recommendations adopted by the Team and report on their
status.

**181.7 REFERENCES**

**A. BPA Safety and Health Program Handbook**

**B. Occupational Safety and Health Administration, 29 CFR 1960.31**

**C. Executive Order 12196, Section 1-401 (I)**