**NATIONAL OCEANIC and ATMOSPHERIC ADMINISTRATION (NOAA)**

**NOAA's INCIDENT INVESTIGATION PROGRAM (NIIP)**

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**MANUAL FOR MAJOR ACCIDENT/INCIDENT**

**INVESTIGATIONS GO TEAM**

OCTOBER 2005

**RECORD OF REVISIONS**

This manual and its appendixes have been revised significantly, and any
previous versions of these documents should be replaced in their
entirety. Future revisions will be logged using the table below.

  ------------------------- -------------------------- ----------------------- -----------------------
  **~REVISION\ NUMBER:~**   **~DATE\ OF\ REVISION~**   **~AFFECTED\ PAGES~**   **~REMARKS/PURPOSE~**

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               

                                                                               
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  ------- ---------------------------------------------------------- ----------
          **CONTENTS**                                               **Page**

          Record of Revisions                                        2

          Contents                                                   3

          Appendixes                                                 5

          Foreword                                                   6

          Accident/Incident Investigation Review Requirements        7

          NOAA Accident/Incident Investigation NIIP Flow Chart For   8
          Major Accident/Incident                                    

  1\.     Notification and Initial Response                          9

  1.1     The Investigation Begins/Fact-Finding and Party Selection  9

  1.2     Domestic Investigations                                    10

  1.3     International Investigations                               10

  2\.     Pre-Investigation Preparation                              10

  2.1     The Go Team                                                10

  2.2     The Go Team Roster                                         11

  2.3     Regional Office Responsibilities and Procedures ID         12
          locations regions (Pacific, Mountain, Central and          
          Atlantic)                                                  

  2.3.1   Regional located SECO personnel Responsibilities Related   12
          to a Go Team Deployment                                    

  2.3.2   Stakedown Guidelines                                       12

  3       Pre-Investigation Preparations                             13

  3.1     Initial Notification and Status Reports                    13

  3.2     Selection, Notification and Assignment of GO TEAM Subject  13
          Matter Expert (TSME)                                       

  3.3     NOAA Public Affairs Officer Briefings NOAA PAO             13

  4       Party Notification                                         13

  4.1     Domestic Participants                                      13

  4.2     International Participants                                 14

  5       Travel Arrangements                                        14

  5.1     Commercial Aircraft                                        14

  5.2     Rental Cars                                                14

  5.3     Hotels                                                     14

  6       On-Scene Activities                                        14

  6.1     Command Post/Meeting Room                                  14

  7       Press Briefing Room                                        15

  7.1     Telephone and Communications                               15

  7.2     Equipment/Supplies                                         15

  7.3     Administrative Support                                     15

  7.4     Contracting for Services or Supplies                       15

  7.5     Support Equipment                                          16

  8       Organizational Meeting                                     16
  ------- ---------------------------------------------------------- ----------

  ------ ---------------------------------------------------------- ------
         **Content**                                                

  8.1    Progress Meeting                                           17

  8.2    Final Progress Meeting                                     18

  9      Briefing                                                   18

  9.1    Headquarters Briefing                                      18

  9.2    Press Briefing                                             19

  10     Identification and Assignment of Personnel                 19

  10.1   Forms and Badges                                           19

  11     Accident Site Safety Precautions                           19

  12     Investigation-In-Charge (IIC) Duties for Work Planning     20

  12.1   Daily Activities of the IIC                                21

  12.2   IIC Site Visit                                             22

  12.3   Observers                                                  22

  12.4   Lines of Authority                                         22

  2.5    Group Chairperson Responsibilities                         22

  13     Filed Notes                                                23

  14     Follow-up Activities                                       24

  15     Laboratory and Medical Findings                            24

  16     Closing the Command Post                                   25

  17     Post-On-Scene Activities                                   25

  17.1   Administrative Task Upon Return To Headquarter             25

  18     Public Hearing Action Memo                                 25

  18.1   Investigator or Group Chairperson Factual, Studies and     25
         Analysis                                                   

  18.2   FOIA Requests                                              26

  18.3   The Public Docket                                          26

  18.4   Technical Review                                           26

  18.5   Party Submissions                                          27

  18.6   Report Planning Meeting                                    28

  18.7   Report Draft                                               28

  19     Report and Safety Recommendations                          29

  19.1   Intended Audience                                          29

  19.2   Conclusions and Recommendations                            29

  19.3   Document Preservation/Archiving                            30

  19.4   Petition For Reconsideration                               30

  20     Other Investigations                                       30

  20.1   International Investigations                               30

  20.2   Underwater Recovery of Wreckage                            30

  21     Role and Responsibilities                                  31

  21.1   Roles of the Director of (SECO)                            31

  21.2   Role of the Office of NOAA Public Affairs                  31

                                                                    
  ------ ---------------------------------------------------------- ------

**APPENDIXES**

+---+-------------------------------------------------------------------+
| * | STAKEDOWN DUTIES OF FIELD INVESTIGATORS                           |
| * |                                                                   |
| A |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | IIC Incident Investigation Commander Checklist                    |
| * |                                                                   |
| B |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | On-Scene Organizational Chart                                     |
| * |                                                                   |
| C |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Incident Investigation Commander (IIC\'s) Opening Statement at    |
| * | Organizational Meeting                                            |
| D |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Forms for the GO Team Kit                                         |
| * |                                                                   |
| E |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | On-Site Safety                                                    |
| * |                                                                   |
| F |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Group Chairmen Checklists                                         |
| * |                                                                   |
| G |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Sample Group Chairperson Progress Meeting Brief                   |
| * |                                                                   |
| H |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Group Chairperson Factual/Analysis Report Outlines                |
| * |                                                                   |
| I |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Materials Laboratory Examinations                                 |
| * |                                                                   |
| J |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | CHIEF ADMINISTRATION Officer (CAO's) Response Checklist for       |
| * | Preparing                                                         |
| K |                                                                   |
| . | Public Hearing                                                    |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Exhibit Cover Sheet and Identification Numbers                    |
| * |                                                                   |
| L |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Prehearing Conference Proceedings                                 |
| * |                                                                   |
| M |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Public Hearing Proceedings                                        |
| * |                                                                   |
| N |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | IIC\'s Incident Investigation Commander Opening Statement to      |
| * | Board Meeting                                                     |
| O |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Petition for Reconsideration Procedures                           |
| * |                                                                   |
| P |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Policy on Freedom of Information Act                              |
| * |                                                                   |
| Q |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Occupational Safety and Health Information                        |
| * |                                                                   |
| R |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | INVESTIGATION ORGANIZATION CHART, ON-SCENE ROSTER AND PARTY FORM  |
| * |                                                                   |
| S |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+
| * | Office of NOAA Public Affairs Officer Task List                   |
| * |                                                                   |
| T |                                                                   |
| . |                                                                   |
| * |                                                                   |
| * |                                                                   |
+---+-------------------------------------------------------------------+

**FOREWORD**

This manual is a NATIONAL OCEANIC and ATMOSPHERIC ADMINISTRATION (NOAA)
Safety and Environmental Compliance Office (SECO) staff product intended
to provide information and guidance to NOAA employees involved in
organizing and conducting NOAA major accident/incident investigations.

The purpose of the (NIIP) is to understand the underlying and
contributing conditions that led to or contributed to the occurrence of
an accident or incident, identify appropriate corrective actions, and
recommend the timely implementation and effective corrective actions.

All major accidents/incident shall be reported within 8 hours of the
accident/incident to the management official responsible for managing
the accident/incident investigation and to SECO. Particularly
fatalities, serious accidents/incident; however, shall be reported
***[no later than (8) eight working hours]{.underline}*** of
accident/incident occurrence.

The procedures in this *NOAA Incident Investigation Program NIIP
Manual--- MANUAL FOR MAJOR NOAA ACCIDENT/INCIDENT INVESTIGATION apply*
to "Go Team" investigations of NOAA major accidents/incidents. An
investigation of this type could involve a number of technical
specialists, representing as many as a dozen parties and multiple
Federal and local government agencies.

This manual provides general information to assist the Chief
Administration Officer (CAO) or designee of SECO, the Director of SECO,
Investigator-In-Charge (IIC) Supervisor, and others who may participate
in a major accident/incident investigation. It is intended to provide
guidance on the process of conducting a major accident/incident
investigation, from initial notification to the adoption of the final
report, probable cause, and recommendations by the Members of the "GO
Team".

Although this publication includes some technical information related to
investigative activities in major accidents/incidents, it is primarily
intended to provide guidance of a procedural or administrative nature.
Investigators should refer to other sources, such as Coast Guard, DOT,
NTSB and the military investigation manuals, that can also be used to
supplement information in the NOAA's *Investigation Manual*.

The SECO will be responsible for keeping this manual updated. The
"Record of Revisions" on the preceding page should be used to
acknowledge receipt of new or amended pages. The manual's original
printing date will be indicated in the lower left corner of the cover
page. The effective date of any page change will be indicated by the
entry on the revision sheet. All recipients of this manual are
encouraged to submit information to be considered for inclusion.

**Major Accident/Incident Investiga**tion Review Requirements

+----------------+--------------+------------+----------+-------------+
|                | **Management |            | **Time   |             |
|                | Level        |            | frames** |             |
|                | A            |            |          |             |
|                | ccountable** |            |          |             |
+----------------+--------------+------------+----------+-------------+
| **Severity of  | **In         | **Review   | *        | *           |
| Major          | vestigation, | of Major   | *Initial | *Completion |
| Accid          | Development  | Accident/  | Noti     | of Major    |
| ent/Incident** | of           | Incident   | fication | Accide      |
|                | Accid        | Report,    | to Next  | nt/Incident |
|                | ent/Incident | and        | Ma       | Report and  |
|                | Reporting,   | Approval   | nagement | Corrective  |
|                | and          | of         | Level**  | Action      |
|                | Im           | Corrective |          | Plan**      |
|                | plementation | Action     |          |             |
|                | of           | Plan**     |          |             |
|                | Corrective   |            |          |             |
|                | Action       |            |          |             |
|                | Plan**       |            |          |             |
+----------------+--------------+------------+----------+-------------+
| Major s        | Deputy AA or | NOAA       | 8        | 2 months,   |
| accidents /    | Staff Office | Executive  | working  | unless      |
| incidents      | Director     | Council,   | hours    | exception   |
| involving:     | **and** the  | with       |          | granted by  |
|                | Director of  | support    |          | CAO \[NOTE: |
| \- Employee    | SECO         | from SECO  |          | It is       |
| fatality       |              |            |          | recognized  |
|                |              |            |          | that some   |
| \-             |              |            |          | incidents   |
| H              |              |            |          | may require |
| ospitalization |              |            |          | more        |
| of 3 or more   |              |            |          | extensive   |
| employees      |              |            |          | and         |
|                |              |            |          | tim         |
| \- Permanent   |              |            |          | e-consuming |
| employee       |              |            |          | inve        |
| disability     |              |            |          | stigations. |
|                |              |            |          | The         |
| \- Five or     |              |            |          | 2-months    |
| more lost      |              |            |          | timeframe   |
| workdays       |              |            |          | is designed |
|                |              |            |          | to ensure   |
| \- Conditions  |              |            |          | that        |
| that could     |              |            |          | readily     |
| pose an        |              |            |          | i           |
| imminent and   |              |            |          | dentifiable |
| severe threat  |              |            |          | corrective  |
| of serious     |              |            |          | actions are |
| injury to      |              |            |          | identified  |
| other          |              |            |          | and         |
| employees, or  |              |            |          | corrected   |
|                |              |            |          | timely.\]   |
| \- Property    |              |            |          |             |
| losses of \$1  |              |            |          |             |
| million        |              |            |          |             |
+----------------+--------------+------------+----------+-------------+
| All other      | Second level | Deputy AA  | 24 hours | 2 weeks     |
| (less serious) | manager,     | or Staff   |          |             |
| accide         | with support | Office     |          |             |
| nts/incidents, | from their   | Director   |          |             |
| and unsafe     | Safety       |            |          |             |
| conditions     | Manager as   |            |          |             |
| reported by    | appropriate  |            |          |             |
| employees      |              |            |          |             |
+----------------+--------------+------------+----------+-------------+

**NOAA's MAJOR ACCIDENT/INCIDENT INVESTIGATION PROGRAM NIIP**

**FLOW CHART FOR MAJOR ACCIDENTS/ INCIDENTS**

**Exhibit 3**

**1. Notification and Initial Response**

Early notification is essential to initiate and organize the
investigation. Initial information concerning the facts and
circumstances of the occurrence will often be incomplete and erroneous.
For this reason, early factual information transmitted for alerting
purposes must be handled with considerable discretion. Parties notified
are to be cautioned about the preliminary nature of the data.

**1.1 The Investigation Begins/Fact-Finding and Party Selection**

> **Phase 1- The Investigation Begins:** The initial task is to define
> the scope of the accident investigation in terms of the nature and
> proportions of the event reported. Upon notification to the CAO and
> the SECO Director, as the case may be, determines whether the full GO
> TEAM or an Investigator-In- Charge (IIC), should be assigned to the
> event that was reported or whether the event is one that should be
> investigated by the another federal agency, under delegated authority
> or the CAO may have a parallel investigation in lien of delegation of
> authority (i.e. DOT, Coast Guard and/or NTSB, etc.).
>
> **Phase 2- Fact-Finding and Party Selection:** In the event that an
> NOAA major accident/incident investigation is required based on the
> following:

1\. Triggers that automatically launch the GO TEAM include:

a.  Fatality

b.  Three (3) or more employees hospitalized

c.  Property loss in excess of \$1,000,000

    2\. Triggers that might launch the GO TEAM, as determined by the
    CAO:

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a.  Matters of potentially high public/media interest

b.  Permanent employee disabilities

c.  Conditions that could pose an imminent and severe threat of serious
    injury

d.  Although the likelihood of a GO TEAM investigation is remote,
    accidents/incidents that are a result of criminal actions, riots,
    civil disorders, radical terrorist acts or felonious acts, as well
    as suicides will be evaluated on a case-by-case basis by the CAO to
    determine whether a GO TEAM investigation is warranted.

    3\. A major accident/incident investigation shall not be used to
    determine culpability, nor will the investigation statements or
    information be used to assist with a culpability investigation.

Once a SECO Safety Manager is assigned as IIC to conduct an on-site
major accident/incident investigation his/her first concern is, in most
cases, is the securing of all relevant evidence. In this endeavor,
he/she should first refer to the section on preservation of wreckage
etc., and decide whether he will take custody of the wreckage

which may already have been secured by local law enforcement officers?
In the event the NOAA investigator does assume custody of the wreckage,
the problem of wreckage release arises when the investigator has no more
need of the wreckage.

Proper wreckage release involves use of a wreckage release form and, in
some cases, will require that the owner of record be located and
informed that the accident has occurred. Ideally, after inspection has
been completed, the wreckage is returned to the owner of record who
acknowledges receipt by signing the official wreckage release form.

**1.2 Domestic Investigations**

The CAO and the SECO Director will receive initial notification of a
major accident/incident within (8) eight hours. The SECO Director or the
Chief Safety Division will then notify the Safety Manager who will begin
to form a Go Team and advice the members to be on stand by status. The
CAO and SECO Director will decide whether to deploy the Go Team.

Following a decision to dispatch the Go Team, the CAO, SECO Director or
Chief of the Safety Division will:

> \(1\) notify the appropriate NOAA officials;
>
> \(2\) notify NOAA's Government and Public Affairs;
>
> \(3\) SECO Director or Chief of the Safety Division will assist the
> IIC with selection and notification of the Team Members;

**1.3 International Investigations**

The SECO Director will advise the CAO of any major NOAA
accidents/incident outside the United States. If the NTSB Board is
sending a U.S. Accredited Representative NOAA's CAO or his designee will
determine whether it is appropriate for a NOAA employee to be an NTSB
observer.

**2. Pre-Investigation Preparation**

The Go Team is a group of investigators who are on-call for immediate
assignment to major accident investigations. SECO assigns the IIC for
the Go Team.

**2.1 The Go Team**

The NOAA Administrator will normally appoint the CAO as the appointing
official for a GO TEAM investigation; however, another designee may be
appointed at the Administrator's discretion.

Chief, NOAA Safety Division shall ensure an appropriate number of
trained GO TEAM IICs are available should an incident investigation be
required and will maintain a list of qualified GO TEAM IICs.

To ensure impartiality, the GO TEAM IIC will normally be a qualified
SECO staff member selected by the Director of SECO. GO Team membership
will normally also include Line Office and/or Staff Office individuals
who have subject matter expertise related to the incident under
investigation. The total number of members will vary depending on type
of incident being investigated.

A full GO TEAM may consist of the following members:

-   SECO Chief of Safety and/or Environmental Division

-   SECO Field Safety Manager

-   SECO Field Environmental Compliance Officer

-   Site Facilities Manager

-   NOAA Public Affairs Officer (NPAO)

-   Technical Subject Matter Expert (TSME)

-   Site Supervisor

Note: Some members are only deployable under the most catastrophic
conditions. Site Supervisor will make initial call as the initial IIC,
following up the chain of management or command.

These GO TEAM members will normally be deployed first; SECO Field Safety
Managers, Field Environmental Compliance Officers, Site Facilities
Managers, Site Supervisors.

Due to the critical nature of an accident/incident investigation, it is
important that the onsite Supervisor will stake down the site and
function as the onsite IIC until relieved by the formal investigation
team or SECO IIC. Note that CAO will appoint a member of the SECO staff
to act as the IIC (in most cases a Field Safety Manager will be
selected) and assume control of the investigation.

Also due to the critical nature of an accident/incident investigation,
it is important that all GO TEAM members focus fully on the timely
completion of the accident/incident investigation above all other
duties. The active time frame for an accident/incident investigation
will vary, but is anticipated to last from two to five days.

**2.2 The Go Team Roster**

The Go Team roster is a spreadsheet of names and telephone numbers,
email addresses and pager numbers, etc., of all SECO personnel assigned
standby duty for major accident/investigations. A new list is prepared
on an as needed basis after a change of duty officers or the launch of a
prior group of Go Team members.

All personnel on call should arrange their personal affairs such that
they are able to depart for the scene of an accident with a minimum of
delay. Regardless of when they are notified about an accident, Go Team
members should be able to arrive at the airport within approximately 8
hours of being notified. For incidents that occur during duty

hours, Go Team members who live too far to travel home and return to the
airport within this timeframe should bring clothing and other essentials
to the office. Go Team

members should always ensure that their information listed on the Go
Team Roster is correct.

In addition, personnel should always ensure that they can be reached
when on call. This includes "testing" the phone tree for proper
operations, forwarding alternate phone numbers to SECO, and supervisors
in advance of expected travel, and maintaining contact with the SECO.
When changes to Go Team assignments are made, the persons involved shall
ensure that SECO is notified and provided updated phone and pager
numbers.

***2.3 Regional Office Responsibilities and Procedures ID locations
regions (Pacific, Mountain, Central and Atlantic Regions)***

During duty hours, Regional Offices will notify headquarters via the
SECO whenever an accident (or safety incident with serious implications)
occurs that involves the following:

> • fatalities,
>
> • three (3) or more employees, volunteers, contractors, etc., are
> hospitalized,
>
> • property damage in excess of \$1,000,000 one million dollars or
> more,
>
> • matters of potentially high public interest.

During non-duty hours, the designated Regional Office duty official
shall notify the SECO Director by the most expeditious means after
receiving notification of a major accident or safety incident of the
type described above. Travel to the accident scene will be initiated
without delay.

**2.3.1 SECO Responsibilities Related to a Go Team Deployment**

The SECO Field Safety Manager closest to the accident will typically
travel immediately to the site, perform, and assist with "stakedown"
coordination duties. The Field Safety Manager will continue to function
in this role until relieved by the IIC.

**2.3.2 Stakedown Guidelines**

Personnel assigned to the initial Stakedown of a major accident have
important duties that contribute to the overall success of the
investigation. Those personnel include investigators dispatched to the
scene, as well as those handling administrative affairs. Personnel
assigned to respond to the accident scene are obligated to reach the
scene as quickly and as safely as possible and to remain at the scene
until properly relieved.

The only information released to the media should be that the Go Team is
en route, name of the media contact, and when the team is expected to
arrive. Initial activities, in addition to those listed herein, should
be aimed at gathering as much pertinent information as possible to brief
the Go Team upon their arrival.

**3 Pre-Investigation Preparations**

**3.1 Initial Notification and Status Reports**

While the Go Team is conducting the on-scene phase of the investigation,
an official use only notification memo will be provided which briefly
describes the circumstances of the accident and lists the members of the
Go Team.

**3.2 Selection, Notification and Assignment of Go Team Technical
Subject Matter Experts (TSME)**

Once the initial notification of an accident has been received and the
decision to deploy Go Team members has been made, the composition of the
Go Team must be determined. This decision will be based on the probable
scope of the investigation and

the magnitude of the tasks but will also include the following factors:
the number of injuries/fatalities, type of accident, previous accidents
of this type, location of the accident, extent of property or ground
damage, weather, public interest, and specialist workloads. These
factors will guide the IIC's determination about the need for
**Technical Subject Matter Experts** (TSME).

**3.3 NOAA Public Affairs Officer Briefings** **NOAA PAO**

The NOAA PAO representative will coordinate with the IIC to determine
the factual information about the investigation that will be released
during the evening news media briefing. Simultaneously with the news
media release, NOAA PAO staff members will provide families with the
appropriate synoptic information about the investigation.

**4 Party Notification**

**4.1 Domestic Participants**

The SECO typically extends party status to those organizations that can
provide the necessary technical assistance to the investigation. The IIC
typically confers party status to the operator, vessel, systems, and
power plant manufacturers, and labor organizations involved because of
the accident circumstances. The NOAA SECO Director should ensure that
the appropriate parties are informed of the accident, the location of
the command post, and the time and location of the organizational
meeting.

Police, firefighters, National Guard, Department of Defense (DoD),
Federal Bureau of Investigation (FBI), Federal Emergency Management
Agency (FEMA), National Disaster Mortuary Team (D-MORT), Red Cross,
Salvation Army, and other agencies can provide assistance at the scene
and attend on scene meetings but are not made parties to the
investigation.

**4.2 International Participants**

NOAA does not anticipate international participant interest, but the CAO
will consider the participation of international parties on a
case-by-case basis.

**5 Travel Arrangements**

Typically, the SECO will have sufficient support from their staff and
other personnel for much of the initial coordination effort necessary to
make arrangements for the Go Team deployment. Whenever possible, the
entire Go Team will travel together to the accident site. It is
important that all Go Team members begin the investigative process as
soon as possible and with the most current and accurate information.

**5.1 Commercial Aircraft**

The GO TEAM will arrange airline tickets and rental cars through the
approved government travel agencies. Because return times may vary among
the team members, open returns should be requested. Normally, prepaid or
electronic tickets should be requested for GO TEAM members to pick up at
the airport. This will allow everyone to obtain his or her tickets,
particularly during off hours, with relative ease.

**5.2 Rental Cars**

Rental cars should be reserved for "NOAA GO TEAM" personnel when initial
travel arrangements are made.

**5.3 Hotels**

The following factors should be considered when selecting a hotel:

> • Proximity to the accident site,
>
> • Availability and adequacy of guest rooms for Safety and
> Environmental
>
> Compliance Office (SECO) personnel,
>
> • Cost of accommodations and meeting room, and
>
> • Compliance with government hotel/motel requirements

The Safety and Environmental Compliance Office (SECO) cannot "guarantee"
rooms for other agencies or organizations.

**6. On-Scene Activities**

**6.1 Command Post/Meeting Room**

The Line Office where the accident/incident occurred is responsible for
providing a meeting room and meeting supplies. The number of people
expected to participate in the investigation will dictate the size of
the meeting room.

**7 Press Briefing Room**

NOAA Public Affairs will coordinate with the respective Line Office
representatives if a press briefing room is desired.

**7.1 Telephones and Communications**

All Go Team members have cell phones, which should always be turned ON
when on site (GO Team members should ensure that their cell phone
batteries are charged and should carry a spare set.) In remote locations
where cell phone coverage is inadequate or in situations where secure
communications are necessary, the IIC can request the Line Office where
the accident/incident occurred or SECO Director to provide on-site

communications support.

**7.2 Equipment/Supplies**

The Command Post/Meeting Room should be equipped with many of the tools
of the modern office. Because it may be unreasonable to ask the hotel to
acquire this equipment on short notice, the IIC should be prepared to
coordinate with the local Line Office representative for needed
supplies.

The IIC should ensure that the following items are available in the
Command Post:

> • NOAA laptop computer with internet access
>
> • Commerce Department form CD-137 (rev 2004)
>
> • NOAA Major Accident Investigation Form
>
> • Statement of Witness SF 94-105
>
> • Motor Vehicle Accident Report SF91
>
> • Attendance rosters
>
> • Wreckage Release forms
>
> • Party Coordinator Signature form,
>
> • Guidance to Party pamphlet (See Appendix F)
>
> • On-Scene Organizational chart (see Appendix S)

All of these forms can be downloaded from the SECO intranet site.

**7.3 Administrative Support**

Depending on the size of the team, the scope of the investigation, and
the availability of administrative support personnel the IIC may require
on-scene support from the respective Line Office.

**7.4 Contracting for Services or Supplies**

Contracting for services or supplies will be coordinated through SECO's
budget officer and credit card holder.

**7.5 Support Equipment**

**GO TEAM kit:** will be available for use during the investigation. The
two GO TEAM kits contain such things as:

+-----------------------------------+----------------------------------+
| -   Video camera                  | • NOAA laptop computer with      |
|                                   | internet access                  |
| -   Digital camera                |                                  |
|                                   | • Commerce Department form 137   |
| -   Tape recorder                 |                                  |
|                                   | • Statement of Witness SF 94-105 |
| -   Causation tape                |                                  |
|                                   | • Motor Vehicle Accident Report  |
| -   Tape measurer                 | SF91                             |
|                                   |                                  |
| -   Flash light                   | • Attendance rosters             |
|                                   |                                  |
| -   Printer                       | • Wreckage Release forms         |
|                                   |                                  |
| -   various charging devices      | • Party Coordinator Signature    |
|                                   | form,                            |
| -   Film, flash cards, etc.       |                                  |
|                                   | • Guidance to Party pamphlet     |
| -   Administrative supplies (i.e. | (See Appendix F)                 |
|     pens, pencils, etc.           |                                  |
|                                   | • On-Scene Organizational chart  |
| -   copies of the investigator\'s | (see Appendix D)                 |
|     manual.                       |                                  |
|                                   | • NOAA Major Accident            |
|                                   | Investigation Form               |
|                                   |                                  |
|                                   | • Personal Protective Equipment  |
+-----------------------------------+----------------------------------+

Mailing labels attached to the kits allow them to be mailed quickly to
an accident scene upon direction by the Incident Investigation Commander
IIC.

The kits are intended for use with Major accident/incident
investigations, where purchase of considerable amount of supplies or
equipment might be needed. The IIC is responsible for the equipment in
the kits and for mailing them back to SECO after the on-scene phase of
the investigation has been completed.

**8 Organizational Meeting**

The manner in which the IIC conducts the organizational meeting will
establish the tone of the investigation. Therefore, the importance of
being organized, articulate, assertive, composed, and understanding
cannot be overstated.

As the formal opening of the investigation into an accident, the
organizational meeting serves several purposes. It will:

> • Provide the opportunity to share preliminary information on the
> accident;
>
> • Introduce the participants of the investigation to each other and
> identify those eligible to participate;
>
> • Organize participants into investigative groups;
>
> • Establish rules of conduct for the investigation; and
>
> • Reiterate safety and health considerations for all participants.

All on scene activities should be shut down pending the organizational
meeting. If search and recovery operations are still in progress, the
IIC should designate an NOAA representative to remain at the site during
the organizational meeting. The organizational meeting should be held as
soon as practicable upon arrival of the Go Team at the accident site
according to the time of day and the number of parties that have
arrived. For example, if the Go Team members arrived at the site during
the night, key personnel from the parties may not arrive until the next
morning.

Therefore, the meeting should not be held until after the key parties
have arrived. If the team has arrived in mid afternoon and most of the
parties will be expected to arrive in late afternoon, the meeting should
be in the early evening.

The IIC will prepare an outline of the issues to be covered in the
organizational meeting. The IIC will identify himself/herself and, after
calling the meeting to order, ask reporters, attorneys, and others not
technically qualified or needed for the investigation (e.g., an
accountant with the airline) to leave the room. The IIC should then
distribute the

attendance roster for each person to sign and make sure that business
cards (or equivalent information) have been collected.

After introductions, the IIC should state that the primary purpose of
the meeting is to explain operating procedures and to assign specialists
to the investigative groups. The facts of the accident/incident will be
reviewed and should include the following:

> • Operator (medical history, laboratory results, etc.);
>
> • Type vehicle, craft, vessel, etc., and registration/serial number;
>
> • Type of vehicle, craft, vessel, etc., origin and intended
> destination;
>
> • Type of vehicle, craft, vessel, etc., maintenance history;
>
> • Number of fatalities (or best information presently known);
>
> • Condition and location of crewmembers (if applicable);
>
> • Extent of vehicle, craft or vessel damage; and
>
> • Other information considered relevant (e.g., hazardous material
> (HAZMAT), weather conditions and site considerations)

After preliminary information about the accident has been given, the IIC
will discuss the information contained in the \"IIC's Opening Statement
at Organizational Meeting\". This statement advises the participants of
SECO policies relevant to the investigation.

The IIC's opening statement will include the following points:

> • SECO authority to conduct the investigation
>
> • Role of all the parties involved in the investigation;
>
> • Organization of the team;
>
> • Expected duration of on-site activities and follow-up activities;
>
> • Dissemination of information among investigation participants;
>
> • Public release of information about the investigation;
>
> • Site safety and security;
>
> • Who will be allowed at the progress meetings;

The IIC should adjourn the organizational meeting (and all progress
meetings) by stating the time of the next meeting.

**8.1 Progress Meetings**

On-site Progress meetings are held daily to disseminate information
obtained during the day\'s activities and to discuss plans for
subsequent investigative activities. The

meetings also provide factual information to the IIC and NOAA PAO
representative for dissemination to the media at press briefings and
family meetings.

The IIC will schedule progress meetings as he or she sees fit. However,
when possible, progress meetings should be scheduled to begin late
enough for participants to clean up after spending time on site but
early enough for everyone to have dinner afterwards and get sufficient
rest for the next day\'s activities. Generally, 1800 is a good time to
start the first progress meeting.

The IIC will begin the meeting by calling the group to order and asking
any reporters and attorneys representing possible claimants to leave.
The IIC will then distribute the attendance roster and ask those who are
new to the investigation to stand and identify

themselves, their organizations, and their roles in the organizations.
For the first few meetings, all attendees must identify themselves at
the start of the meeting. Questions or discussions on group
chairpersons' presentations should be limited to factual material only.
Analytical questions to the group chairpersons on the implications of
their findings will not be allowed. The progress meetings should not be
used for a discussion of accident causation. Each group chairperson's
report should take 5 to 10 minutes, unless it is absolutely necessary to
relay more facts to the audience.

After all team/group chairpersons have completed their presentations,
the IIC should remind participants not to discuss the investigation in
public areas or in places in which their conversations can be overheard.
Participants should also be reminded to remove their personal belongings
and notes from the Command Post overnight or at other times when the
room is unattended or served.

**8.2 Final Progress Meeting**

As work progresses, the groups will begin to present less information.
Some groups will complete their activities and be released by the IIC.
When the IIC determines that little new information remains to be
obtained from the remaining groups, it is appropriate to

end the progress meetings and wrap up the on-site activities. During the
final progress meeting, the IIC should update the participants on the
status of the investigation, advise them of any proposed follow up
activities, and approve and distribute field notes to the group members
with a complete set of notes to the party coordinators.

**9 Briefing**

**9.1 Headquarters Briefing**

The IIC is expected to brief headquarters personnel on a daily basis.
These briefings provide headquarters staff with the following
opportunity:

1\) obtain an update of the recent findings

2\) assess the progress of the investigation,

3\) communicate relevant technical information to the on-scene team, and

4\) HQ will provide assistance to the IIC as needed. The Director, SECO
Division will provide notice to other Division Chiefs and Directors to
allow for their participation in the briefings.

The IIC should schedule the briefing for a time that is mutually
convenient for the IIC and headquarters personnel. The IIC should allow
at least 1 hour for the briefing and ensure that he/she will not be
needed at the Command Post or other location during that time. The
briefing should be held in a location where there will be no
disturbances and where sensitive material may be discussed. A hotel room
or an office with complete privacy is recommended.

The IIC will review notes carefully before the briefing and be prepared
to discuss in detail each team's/group's activities and findings. If any
of the reported findings are

unclear, contact the appropriate group chairperson before the briefing
for clarification. During the briefing, the IIC should note suggestions
or questions from the headquarters staff for which answers must be
researched.

**9.2 Press Briefing**

Press briefings will be coordinated and conducted by NOAA Public
Affairs.

**10. Identification and Assignment of Personnel**

The IIC determines who will be parties to the investigation and should
be selective when making these designations. Only technically qualified
individuals with the necessary expertise will be permitted to
participate in the investigation. Specialists typically include
representatives of the operator, manufacturers of the vehicle's, craft's
or vessel's equipment, power plant, and accessories, labor associations,
and other parties who can contribute knowledge and expertise. The IIC
will assess the qualifications of proposed members. The final decision
regarding the assignment of specialists will be made by the IIC.

**10.1 Forms and Badges**

As the investigative groups are being formed and party personnel are
being assigned, the IIC should use an "On Scene Organizational Chart" to
assist in registering the investigative members. The IIC should also
distribute the form \"Statement of Party

Representatives to NOAA Investigation\" to each party coordinator and
obtain their signatures (see Appendix D). Explain that, by signing the
form, the coordinators are obligating and indicating the organizations
they represent and all personnel assigned to

the investigative groups that they understand the rules and that they
are willing to abide by them. All participants should sign the form or a
similar nondisclosure form as a condition of their participation.

The IIC has the option of distributing identification badges. If
identification badges are used, the IIC may delegate the responsibility
for keeping track of badges.

**11 Accident Site Safety Precautions**

Any Accident/Incident site may expose investigators to certain risks,
including biohazards, airborne hazards, adverse terrain and adverse
climatic conditions. The IIC will coordinate with the local police,
National Guard, or fire and rescue, if present, to

determine hazards at the accident site and safety resources available to
the investigative staff. Personnel involved in the recovery,
examination, and documentation of wreckage may be exposed to physical
hazards from such things as hazardous cargo, flammable or toxic
materials and vapors, sharp or heavy objects, pressurized equipment, and
disease. The IIC will be responsible for conducting a risk assessment of
the accident site, which will identify possible hazards, and determine
the level of risk

(high, medium, low) at the work site. An environmental risk assessment
can be conducted while en route and a more detailed assessment
accomplished following the initial visit to the accident site. The IIC
will then develop countermeasures to identified risks and ensure that
the appropriate countermeasures are applied at the accident/incident
site. The IIC will conduct daily safety briefings with all individuals
who are working at the accident/incident site. Throughout the on-scene
phase of the investigation, the IIC and the group chairperson will
monitor everyone to exercise good judgment, use necessary protective
devices and clothing, and use extreme caution when working in and around
the accident/incident site.

During the IIC's opening statement, the IIC will state that the SECO
will not assume responsibility for any personal injuries incurred during
the course of an investigation by representatives of organizations
participating in the investigation as a party or by an authorized
observer. Any safety concerns should be promptly expressed to the IIC.
Parties not properly protected will not be allowed on site.

All SECO personnel traveling to an area with certain known public health
risks or suspected diseases will be cleared by their IIC before
departure. The supervisor will ensure that adequate personal protective
equipment (PPE) is provided and the employee is medically qualified for
the work to be done. Those who work in or around the accident/incident
site must use extreme caution to minimize direct contact with bloodborne
viruses. At a minimum, heavy leather work gloves over non permeable
rubber gloves should be used and in some case will be required when
touching the wreckage at the accident/incident site. Under certain
conditions, investigators may come into contact with blood or human
remains, full face masks, protective goggles, and disposable overalls
and booties shall be worn. Occupational Safety and Health

Administration (OSHA) requirements concerning training and on-scene
protection procedures and equipment are included in the SECO's Blood
Borne Pathogens (BBP) Exposure Control Plan.

The SECO's BBP Committee is responsible for maintaining the plan and
ensuring that it is updated annually; copies of the plan may be obtained
from the intranet. Each investigator who will be working on-scene will
have two packages of biohazard equipment as part of his or her go-team
equipment.

**12. Investigator-In-Charger (IIC) Duties for Work Planning**

The purpose of the work planning meetings is to discuss activities that
will follow the on-scene phase of investigation (e.g., component
teardowns, follow-up interviews, etc.). It also allows all involved
staff to agree on realistic schedules to complete required work
products.

The IIC shall prepare a memo announcing the meeting, its location, date,
and time. The memo should be accompanied by a summary outlining the
major issues of the investigation and distributed to each group.

The IIC should anticipate the investigative activities that each group
should pursue and suggest avenues for follow-up investigation, if
necessary. By the end of the meeting, the

groups should agree to the accident-related issues, the general
activities that remain the type of report to be generated, the
recommendation on whether to convene a public hearing, and the deadlines
for the factual and analysis reports. Report completion deadlines may
need to be negotiated with the groups depending on their workloads and
priorities.

The IIC will prepare a memo summarizing items of agreement achieved
during the meeting, a revised issue outline, and any unresolved issues.
All deadlines for report submissions and anticipated milestones should
be included. The memo should be distributed to each group.

The IIC will maintain contact with the group during the course of the
investigation and be aware of the progress of their follow-up
activities. The group will notify the IIC if they can not meet report
deadlines and provide a new date for completion of their reports. The
IIC will integrate the activities of related investigative groups if it
is determined that they are proceeding in similar directions.

The IIC should ensure that he or she is informed of all group activities
and group findings. The IIC is responsible for ensuring that the
appropriate group will cover all relevant issues. The IIC is also
responsible for keeping abreast of potential discrepancies, loopholes
and conflicts about the findings of the various groups and either
resolve these issues or bring them immediately to the attention of upper
management.

**12.1 Daily Activities of the IIC**

The IIC is responsible for directing and/or controlling resources by
virtue of explicit legal, agency, or delegated authority. As part of the
responsibility for oversight of the investigation, the IIC will serve as
a liaison between SECO headquarters and the investigative team and the
accident/incident site. Liaison with headquarters is primarily carried
out through the daily briefing; however, the IIC should always be
available for additional headquarters inquiries.

The IIC is responsible for all aspects of the response, including
developing incident objectives and managing all incident operations. The
IIC sets priorities and defines the

IIC's organization for the particular response. Even if other positions
are not assigned, the IIC will always be designated.\
\
The IIC may assign deputies, who may be from the same agency, or from
assisting agencies. Other personnel may also be used at section and
branch levels of the IIC's organization. Other personnel may not have
the same qualifications as the person for whom they work, as they must
be ready to take over that position at any time.

**12.2 IIC Site Visit**

The IIC should visit the site regularly to get a good understanding of
the nature of the accident; twice a day is preferable. The visits enable
the IIC to learn about the progress of the investigation and any
particular problems, to observe working conditions of the

team, and to provide supervision, as necessary, to ensure that the
investigation is making satisfactory progress.

**12.3 Observers**

The CAO may allow properly accredited members of Congressional
oversight, designated military personnel, representatives of other
Federal agencies, or representatives of foreign governments to be
observers to the investigation. Training and familiarization with the
SECO investigative process is the sole purpose of the observer status.
Observers should not have any self-interest in the investigation, and
they will be permitted access to only those portions of the
investigation deemed appropriate by the IIC. Observer status must be
coordinated and approved in advance. Although observers will sometimes
work with one of the investigative groups, they will be under the
overall authority of the IIC and will be given factual information on a
\"need to know basis.\" The restrictions concerning public dissemination
of accident information apply to all observers.

**12.4 Lines of Authority**

The IIC is the senior trained person on-scene and all investigative
activity at the site are under his/her control. The IIC has the overall
authority and responsibility to resolve any difficulties that may arise
on scene. Members will first attempt to resolve problems directly with
their respective group chairperson if any difficulties arise among the
team

members during the on-scene investigation. If a resolution is not
reached, the group members should alert their respective party
coordinators. Concurrently, the group chairperson will notify the IIC.
The IIC and the party coordinator will discuss the problem and attempt
to resolve it, informing the group member and group chairperson of the
decision.

If the IIC and party coordinator cannot reach resolution of a problem,
they will then discuss it with the Director of the SECO. If the issue
cannot be resolved at that level, it will be elevated to the CAO.

**12.5 Group Chairperson Responsibilities**

If the accident/incident event is larger than normal the team maybe
broken into groups, than each group will be headed by a chairperson.
Immediately following the organizational meeting, each group chairperson
should meet with his/her group members. Since some group members will be
unfamiliar with the procedures of an NOAA accident/incident
investigation, several things should be discussed with the group,
including the scope of the group\'s investigation, assignment of duties
and NOAA protocol concerning field notes.

It should be explained that for all matters related to the
accident/incident and the investigation, the team members' primary
responsibility is to their working group and

respective group chairperson---not to their respective organization.
They must arrange their personal schedules to conform to the schedule
determined by the respective group chairperson and commit to staying
with the group until released by the IIC and their respective group
chairperson.

**13 Field Notes**

Each investigator and/or group chairperson is required to compile field
notes documenting the on-site activities of his/her group. Field notes
represent the summation of factual material gathered and information
obtained by each investigative group participating in the investigation.
Each investigator and/or group chairperson will have one official set of
field notes. The field notes will contain applicable information
outlined in a set of checklists, as well as other information collected
or documented by the group.

At the end of each day of the on-site investigation, each investigator
should discuss its efforts and review the progress of its field notes.
This is most conveniently accomplished before the daily progress
meeting. At the end of the on-scene investigation, every member of each
working group must sign the group's field notes.

These signatures indicate and clearly convey that each member of the
group has read all of the field notes and either agrees with the
information included in the notes or has indicated, in writing, specific
areas of disagreement and the reasons for that disagreement. If group
members do not attach written statements of disagreement to

the field notes, it will be assumed that they agree with the content and
completeness of the information contained in the field notes.

The IIC will draft a summary of the accident for each group chairperson
to use in his or her field notes. At the conclusion of the on-scene
investigation, each investigator or the group chairperson will present
the group\'s field notes to the IIC for review and signature. After the
IIC\'s approval, the group chairperson should make copies of the field
notes for his/her group members. The IIC should inform each
investigator/the group chairperson

that factual information will be shared with all parties unless it is
proprietary in nature or there is other concern for the dissemination of
sensitive material.

**The group chairperson and, therefore, the group members will not be
released until the field notes have been approved and distributed.**

The IIC should be aware of the team/group's future plans and provide
direction, as required, to obtain information that has not been included
in the field notes. Following the on-scene phase of the investigation,
the IIC may reconvene the team/group in whole or in part to conduct
follow-up work such as witness/crew/operator interviews, maintenance,
medical, laboratory records reviews, testing/teardown of power plants,
equipment, instruments, and other system components. Field notes will
also be required to document any such additional investigative work.

**14 Follow-up Activities**

Follow-up activities may or may not include the team/group. The IIC or
group chairperson should ensure that the team/group discusses in advance
the scope of any planned follow-up work. Upon reconvening, the group
chairperson should meet with the group and, if necessary, other
technicians who might be assisting in the activity to review the planned
activity and resolve any remaining questions. Team/Group members should
be reminded that only the SECO may release information about the
investigation. The IIC should receive periodic updates during the
follow-up activity.

If the follow-up work involves representatives from an organization that
is not a party to the investigation and the IIC authorizes the
organization to become a party, the group chairperson should have the
party's coordinator (or one of the party's representatives) sign the
"Statement of Party Representatives" form. Status as a party allows an
organization to participate in certain SECO meetings and to receive all
public docket material generated during the investigation. This allows
the organization access to specific information that it might not
otherwise have, as well as information it could use to initiate
preventive or corrective action quickly. The IIC may grant limited party
status, such that a party will only receive specific factual information
and not all factual reports produced during the investigation.

If an organization is not a party to the investigation but will only
provide assistance necessary for the investigation (e.g., testing
facility or specific technical expertise) the

form will not be signed. However, the representatives and the
organization(s) should be informed about limitations regarding
discussion with anyone outside the investigation and/or dissemination of
any investigative information.

As with the on-scene investigation, signed field notes of the follow-up
work will be required. A closeout meeting should be held to review the
field notes and to discuss future activities involving the group's work.
It might also be helpful to discuss the Team's/Group's process regarding
the overall investigation and the preparation of the final report and to
seek opinions from the group regarding conclusions or corrective actions
related to the team's/group's work.

**15 Laboratory and Medical Findings**

In the event that a material failure is suspected or that detailed
examinations of a part are desired, group chairperson should enlist the
assistance of first a NOAA Laboratory **Technical Subject Matter
Expert** (TSME) and then an outside laboratory. Medical evaluations
might be conducted at a NOAA health care clinic or private health care
provider. Even if an outside laboratory or manufacturer\'s facility is
used for an examination, the Laboratory should be consulted. Appendix J
contains recommended procedures to submit parts, as well as certain
steps to preserve their condition. Review all laboratory reports such
as:

-   Autopsy

-   Medical treatment

-   Clinical Examination, and all laboratory works to include drug
    testing

-   Outside Laboratory for material's failure testing

-   Manufacture's Laboratory testing for materials/parts failure

    **16 Closing the Command Post**

The IIC will read and approve all field notes. Group Chairmen and their
groups are not to be released from the site until after the IIC approves
their field notes. After the field notes are completed, approved, and
distributed, the IIC is responsible for closing the

Command Post. Arrangements should be made to return rented supplies and
equipment and to settle vendor accounts. The IIC should expect to pay or
arrange to

pay for such things as telephones, photocopy machines, computers and
accessories, meeting room, and supplies.

**17. Post-On-Scene Activities**

Following the on-scene phase of an investigation, the IIC will schedule
a debrief meeting after the go-team's return to headquarters to discuss
a tentative schedule of activities based on guidance provided in and
other respective offices. These items include meetings to discuss the
progress of the investigation, due dates of the group chairpersons
factual and analysis reports, preparation of the final report.

**17.1 Administrative Tasks Upon Return to Headquarters**

Once the IIC returns to headquarters, he or she will check to make sure
the incident and investigation were entered into SECO's database,

**18 Public Hearing Action Memos**

The IIC shall draft an action memo to the CAO recommending whether or
not to convene a public hearing within 20 days of returning from the
accident site. The memo should present a logical discussion supporting
the hearing recommendation based on previous accidents and subsequent
follow-up actions, public interest, local and national

media attention, and Congressional and local government interest. A
summary of the major issues and the key findings of the investigation
should be included. The memo

should also include the views of the parties regarding the need for a
public hearing. All parties to the investigation are given the
opportunity to record in writing whether or not they want a public
hearing to be conducted on the accident. Accordingly, the IIC should

ask each of the parties to indicate via fax, e-mail, or regular mail
whether they believe a public hearing should be conducted for a
particular accident.

**18.1 Investigator or Group Chairperson Factual, Studies, and Analysis
Reports**

The IIC will maintain a list of open action items or issues for the
investigation and ensure the completion of each item by coordinating
with the all investigators/groups chairperson.

Upon completion of a factual documentation, the group will prepare a
**factual report** based on the field notes and subsequent investigation
activities. A **draft of the factual**

**report** should be made available to all the group members for
comments that can be incorporated into the factual report.

**18.2 Freedom of Information Act (FOIA) Requests**

The IIC should not discard any documentation related to the
investigation, including paperwork, photographs, videotapes, audiotapes,
electronic files (email) and electronic correspondence. The IIC and
Board employees should not attempt to determine which items in their
possession are subject to the FOIA request. Following notification of a
**Freedom of Information Act (FOIA)** request, the IIC should deliver
the originals of all investigation material to NOAA FOIA personnel,
except that material that has been placed in the public docket. Be aware
that it will be extremely difficult to retrieve items once they have
been surrendered, so it is important that investigative staff make
copies of whatever they will need. Following the initial delivery of
material to FOIA personnel, the IIC should make copies, as necessary, of
all material that he or she receives for use during the remainder of the
investigation and provide the originals to FOIA personnel immediately
thereafter.

**18.3 The Public Docket**

Note: all factual information, proposed findings that parties have
submitted (that is, submissions), and petitions for reconsideration will
be placed in the public docket, which will be made available to the
public. The IIC is responsible for assembling the public docket and will
retain the original copy of all docket material for one year from the
date that the accident report is adopted. If it is unclear whether to
place material into the docket, the Office of the General Counsel will
make a determination. The manner in which material is entered into the
docket is the same regardless of the circumstances; however, the
timeframe for opening the docket is determined by whether a public
hearing is convened on the accident (see below). When the docket is
opened, the IIC should also update the record to "Factual" status.

Generally, copies of the following shall be entered into the docket:
factual reports, addenda to the factual reports, errata sheets,
photographs, and pertinent correspondence from the parties (other than
routine requests for information). Photographs are acceptable from
either digital cameras or scanned prints, but should

meet minimum defined quality standards (see Docket Procedures manual);
until further notice, associated negatives should also be provided
whenever they exist. It is NOAA

policy to retain materials, such as documents and photographs scanned
into the docket, for 1 year after the final report is adopted before
their disposal.

**18.4 Technical Review**

The Technical Review is normally the final step in the factual phase of
the investigation and provides the parties with the opportunity to
perform a final review of all factual material obtained during the
investigation. It allows the parties to raise any investigation problem
areas so the issues can be resolved or at least addressed in the report
preparation process. In addition, the Technical Review provides a formal
review of the

accuracy of information contained in the group chairpersons' factual
reports. The Technical Review should be held as soon as possible after
completion of the public hearing or fact-gathering. The Technical Review
will be held after group chairpersons have completed their investigative
activities, written their factual reports, and collected the documents
that will complete the public docket of the investigation. The IIC shall
notify the parties of the date, time, and location of the Technical
Review in writing.

This correspondence should establish the limits of the party review
process, noting that discussions will focus on fact-finding only and
that no analysis will be discussed. Group members should be present at
the Technical Review. All factual reports should be provided to the
party coordinators with sufficient time to allow their thorough review
before the date of the Technical Review. The IIC should begin the
Technical Review by calling upon each group chairperson, as necessary,
to discuss the work of his or her group(s) during the investigation.
Next, each party coordinator will be asked whether he or she has
questions concerning the material presented in the particular factual
report.

Finally, party coordinators will be given the opportunity to suggest
additional avenues of investigation or to submit additional factual
information for inclusion into the public

docket to ensure that the information is considered. Discussions that
are not substantive, such as minor wording and grammatical changes, or
that do not deal with factual material should be avoided.

All formal correspondence should be retained for possible inclusion in
the public docket. After the meeting, the IIC shall write a memo to
parties and group chairpersons listing agreed upon changes, deletions or
additions to the factual reports.

**18.5 Party Submissions**

Although the Technical Review provides parties with the opportunity to
offer comments on the factual material, parties should be strongly
encouraged to submit their proposed

conclusions, recommendations, and probable cause. If a hearing is held,
closing comments by the CAO will contain instructions on submitting
proposed findings and conclusions.

The IIC will write each party coordinator before the Technical Review,
informing him or her of the opportunity to present submissions. It
should be explained that the submissions should contain their proposed
conclusions, probable cause, and recommendations relating to the
accident. The coordinators should be given 30 days from the day of the
Technical Review to provide submissions and be reminded that they are
required to send a copy of their submission to each of the other
parties. Parties should submit an electronic document in Microsoft Word.
Submissions should be addressed to the CAO.

The IIC should distribute submissions to the Safety Team Members as soon
as they are received. Additional copies should also be sent to Safety
Team Members at the same time that as the draft of the final report. The
party submissions will be considered during development of the final
report.

**18.6 Report Planning Meeting**

A **confidential report^1^** planning meeting should be convened to
discuss the report outline and to resolve any outstanding issues
identified during the work planning meeting. The IIC shall draft a memo
announcing the date, time, and location of the meeting and distribute it
(along with a list of major areas of discussion), to all group members
and SECO staff. At the conclusion of the meeting, all participants
should agree on the major issues to be discussed in the report,
recommendation topics, the thrust of the probable cause, and remaining
deadlines. The IIC shall draft a memo or email after the meeting that
summarizes the major points that were agreed to and distribute it to all
participants.

**18.7 Report Drafts**

**The initial confidential drafts report^1^** of a major
accident/incident report will be circulated to the Members of the Safety
and Environmental Compliance Office (SECO) for their consideration and
may be explained to NOAA's Environmental Compliance and

Safety Committee and NOAA's Safety Council. During the Initial draft
stage, several drafts will likely be distributed, sometimes in various
states of completion, before the document is ready to progress to **the
SECO Director's draft**. At each level of review, reviewers are
encouraged to correct any known discrepancies and to suggest textual
improvements, which may range from minor changes to substantive
revisions. The report writer will evaluate each suggestion and, when
necessary, will discuss potential conflicts with the group chairperson
or IIC. During this stage, the report writer will internally distribute
the report to the group members assigned to the investigation and other
personnel as appropriate. In the early drafting stages, statements of
probable cause may not be included.

After comments and corrections from parties\' submissions and those who
reviewed **the Initial confidential draft report** have been
incorporated, the Initial draft becomes the Directors\' draft. The
report writer then distributes this draft to the Director of SECO. The
Director will then schedule a Directors' Review meeting to discuss the
report. After the day, location, and time of the Director's review have
been set, the IIC or report writer is responsible for sharing
information with the group members. Before the Directors'

Review meeting, the IIC in coordination with the report writer should
identify any dissenting opinions from or between group chairpersons and
senior staff, keeping in mind that consensus is a goal but not a
requirement. After the accident, report has been revised to address
issues that may have been identified during the Directors' Review
meeting, the **Directors' draft report^3^** becomes **the Notation draft
report^2^**

The **Notation draft report** is transmitted to the Safety Team Members
via the Director of SECO with a notation memo, which is generally
drafted by the report writer. The notation memo summarizes the principal
issues of the investigation and the final report and outlines unresolved
areas of staff disagreement. It also contains the names of the
organizations receiving safety recommendations and the respective NOAA
officials who will most likely be responsible for initiating the
recommended action. The notation package should include a proposed NOAA
Safety Council meeting agenda that lists the

principal issues discussed in the report and notes the pages in the
factual and analysis sections where these issues are discussed. The
agenda should also note the corresponding conclusion and recommendation
numbers.

**19 Reports and Safety Recommendations**

Director of SECO will track the status of recommendations contained
within the report and periodically inform NOAA's Safety Councils of the
status of each confidential recommendation into the **NOAA Municipal
Report^5^** for NOAA management.

**19.1 Intended Audience**

Confidential Reports and recommendation letters should be written so
that they are comprehensible to and contain enough explanation to be
understood by interested persons who are **not** technical experts.

**19.2 Conclusions and Recommendations**

Recommendations for actions shall be directed to all affective parties
to include but not limited to (Line Offices/Staff Offices) for their
review, petition for reconsideration are due within 2 weeks of receiving
the report and plan of action for implementation with time lines shall
be forwarded to the Director of SECO within 7 days of approving the
report.

Note in particular the guidelines regarding use of the words "concludes"
and "believes": Conclusions:

-   The words "the SECO concludes..." should not be used in the text of
    a report unless they precede a formal conclusion.

-   Do not make a conclusion a statement of fact but, rather, a
    declaration of what we have drawn from the facts.

-   Ensure that each point that is analyzed in the report logically
    leads to a conclusion that summarizes the SECO's view or position on
    that issue.

Even if the issue under discussion turns out not to have been a factor
in the accident/incident, construct a conclusion indicating that it was
not a factor.

Recommendations:

-   The words "the SECO believes..." should not be used in the text of a
    report unless they precede a formal recommendation.

-   Generally, follow a conclusion with a recommendation. Some
    conclusions do not call for a recommendation. For example, very
    innocuous conclusions ("the driver was properly certified") or
    conclusions that rule something out ("windshield was not a factor in
    the accident") do not suggest the need for a recommendation.

-   However, when conclusions raise an actual or potential safety issue
    that requires some sort of follow-up, either propose a
    recommendation to correct

> or address the problem or document that some sort of corrective action
> has already been initiated or completed (by the operator,
> manufacturer, FAA, etc.)

**19.3 Document Preservation/Archiving**

After an accident report has been adopted, the IIC should place original
factual and analysis reports in a cardboard box, seal the box, and
clearly mark it regarding its contents. NOAA's Chief of the Safety
Division should retain the box for 1 year from the date of the report's
adoption.

**19.4 Petition for Reconsideration**

After the Safety Team Members have adopted an accident report,
recommendations, and probable cause, a party or any other persons with a
direct interest in the accident

investigation can formally petition SECO to reconsider all or part of
the analysis, conclusions, or probable causes within 30 days of
receiving the confidential municipal report.

**20 Other Investigations**

**20.1 Accidents/Incidents Involving Known or Suspected Criminal Acts**

Vehicle/Aircraft/Vessel accidents/incident in which criminal activity is
suspected may involve the participation of law enforcement officials in
the investigation. In such cases, law enforcement agencies are not
parties to the investigation; however, the CAO should

provide the law enforcement agencies with necessary access to evidence.
If evidence indicates that a criminal activity was involved, the NOAA
investigation will be conducted to the extent necessary to determine
probable cause, address any safety concerns, and, where appropriate, to
furnish requested assistance to law enforcement agencies. In the absence
of any such evidence, the NOAA investigation will continue in its normal
scope.

In any event, the importance of cooperation and communication cannot be
overstated. Because the criminal investigation may overlap NOAA's
investigation, the IIC should

explain NOAA's procedures and the criticality of preserving and
documenting certain forms of evidence. If any problems are encountered
in this type of accident investigation, NOAA's General Counsel should be
consulted.

**20.2 Underwater Recovery of Wreckage**

Locating and recovering vehicle, vessel, aircraft, etc., wreckage in the
water will require a well coordinated plan. Depending on the
circumstances of the accident, locating the wreckage might require that
the SECO obtain such things as witness statements, weather data, and
radar tracking data for the accident vessel, vehicle, aircraft, etc.
Trajectory analyses may also be necessary to aid in locating the
wreckage.

Should the recovery of underwater wreckage be required, the IIC will
coordinate these efforts through NOAA liaisons. For example, NOAA has
several fulltime Department of Defense liaison officers representing
most of the military services.

Once wreckage is raised to the surface, immediate treatment with the
appropriate solvents is necessary to prevent rapid corrosion of parts.
Planning for such treatment must be done in advance.

It may be necessary for the SECO staff IIC to be on the recovery boat(s)
for several hours. Therefore, proper attire should be packed.

**21 Roles and Responsibilities**

**21.1Role of the Director of SECO**

The Director of SECO will provide a centralized operation to support all
modes of transportation at critical periods during the accident
investigative process. Before a Go Team deploys, the Communications
Center can provide important initial accident

information through alphanumeric pagers and logistical support through
arrangements for air travel and rental car and hotel accommodations.
After the deployment, it can

assist the IIC with setting up the on-scene command post, configuring
cellular telephones, laptop computers, and pagers, and providing
satellite telephone capabilities and language translation services. The
IIC is responsible for coordinating with the Communications Center on
logistics.

**21.2 Role of the Office of NOAA Public Affairs**

As quoted from **Department Administrative Order (DAO)** 219-2. As NOAA
is an agency within the **U.S. Department of Commerce (DOC)**, clearance
of releasable information is the ultimate responsibility of the
Secretary of Commerce and his/her designated Public Affairs Director.
Information on the DOC program is outlined in

**Department Administrative Order (DAO)** 219-2, Release of News,
Clearance of Publications, and Media Coverage.

 

**Office of Public, Constituent, and Intergovernmental Affairs (OPCIA)**
is responsible for coordinating and approving media communications
involving NOAA, including advisories, press releases, interviews, and
other related media contacts. OPCIA's responsibilities include media
communications concerning the following:

 

a.  announcement of the release of official NOAA data, research,
    positions, and statements;

b.  announcement of activities of NOAA or Department leadership which
    pertain to NOAA policy, science, research, missions, projects, and
    partnerships;

c.  announcement of the release of contracts, grants, and grants-in-aid
    of \$500,000 or more, or others of any amount which may have
    significant public interest or other public value or significance;

d.  activities that may have policy-making implications; and

e.  announcing official scientific and technical papers authored or
    co-authored by NOAA employees that result or may result in media
    interest.

 

The Director, OPCIA, may grant exceptions to the provisions of this
Order as circumstances warrant.

NOAA public affairs professionals are responsible for ensuring that
reporters get timely and accurate answers to pertinent questions.

 

Officials in Line and Staff Offices will ensure their organizations
coordinate their activities in accordance with this Order. Media
inquiries, or issues and events that may be expected to lead to media
inquiries, should be referred to the Line or Staff Office's servicing
**NOAA Public Affairs Officer (PAO)**.