+-----------------------------------------------------------------------+
| #                                                                     |
|                                                                       |
| **Participants Manual**                                               |
|                                                                       |
| # SERIOUS ACCIDENT INVESTIGATION COURSE                               |
+-----------------------------------------------------------------------+
| **LESSON 14: Reports**                                                |
+-----------------------------------------------------------------------+
| **INSTRUCTOR:**                                                       |
+-----------------------------------------------------------------------+
| **Objectives:**                                                       |
|                                                                       |
| **After completing this lesson the participants will be able to:**    |
|                                                                       |
| -   **Use a template to correctly fill out a 24 - Hour Preliminary    |
|     Report and list all the steps necessary to coordinate the release |
|     of the report.**                                                  |
|                                                                       |
| -   **Use a template to correctly fill out a 72 - Hour Expanded       |
|     Report and list all the steps necessary to coordinate the release |
|     of the report.**                                                  |
|                                                                       |
| -   **Identify the key elements of the Final Report, which contains   |
|     the Factual Report and Management Evaluation Report. Understand   |
|     their purposes, distribution, disposition, and release.**         |
|                                                                       |
| -   **Have knowledge of the BLM Board of Inquiry.**                   |
+-----------------------------------------------------------------------+

+--------------------------------------------+-------------------------+
| **Unit Title: Reports**                    |                         |
+============================================+=========================+
| **Lesson 14:**                             | **Notes**               |
+--------------------------------------------+-------------------------+
| **24 - HOUR REPORT**                       |                         |
|                                            |                         |
| Policy requires us to release three types  |                         |
| of reports, the first being the 24-Hour    |                         |
| Preliminary Report.                        |                         |
|                                            |                         |
| This report preparation is the             |                         |
| responsibility of the local unit to        |                         |
| produce and provide to SAIT Leader.        |                         |
|                                            |                         |
| However, in the event it was not           |                         |
| completed, the Team Leader should:         |                         |
|                                            |                         |
| -   Prepare one using the format in        |                         |
|     Handout 14-1                           |                         |
|                                            |                         |
| -   Obtain information from [Agency        |                         |
|     Administrator]{.underline}             |                         |
|     [in-brief]{.underline} (and other      |                         |
|     sources)                               |                         |
|                                            |                         |
| -   Confirm/[verify]{.underline}           |                         |
|     [information]{.underline} received     |                         |
|                                            |                         |
| -   Avoid [speculation]{.underline}        |                         |
|                                            |                         |
| -   Send copy to:                          |                         |
|                                            |                         |
|     -   [Agency Safety Office]{.underline} |                         |
|                                            |                         |
|     -   [Office of Fire &                  |                         |
|         Aviation]{.underline} BLM for fire |                         |
|         related investigations,            |                         |
|                                            |                         |
|     -   [Fire Director National Park       |                         |
|         Service]{.underline} NIFC for fire |                         |
|         related investigations             |                         |
|                                            |                         |
| -   Coordinate with [PAO]{.underline} for  |                         |
|     release                                |                         |
|                                            |                         |
| -   Prepare for [damage]{.underline}       |                         |
|     [control]{.underline} if report was    |                         |
|     released with incorrect information.   |                         |
|                                            |                         |
| **72 - HOUR REPORT**                       |                         |
|                                            |                         |
| The next required report is the 72 - Hour  |                         |
| Expanded Report. (Although not a DOI       |                         |
| requirement any longer, the Bureau has     |                         |
| chosen to keep this report as a            |                         |
| requirement. This is a requirement for     |                         |
| Forest Service investigations)             |                         |
|                                            |                         |
| This is first product of investigation     |                         |
| team. This report provides more detail     |                         |
| about the accident:                        |                         |
|                                            |                         |
| -   Number of victims                      |                         |
|                                            |                         |
| -   Names of victims (if next of kin has   |                         |
|     been notified)                         |                         |
|                                            |                         |
| -   Severity of injuries or property       |                         |
|     damage                                 |                         |
|                                            |                         |
| -   Synopsis of known facts                |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Send copy to:                          |                         |
|                                            |                         |
|     -   [Agency Safety Office]{.underline} |                         |
|                                            |                         |
|     -   [Office of Fire &                  |                         |
|         Aviation]{.underline} BLM for fire |                         |
|         related investigations,            |                         |
|                                            |                         |
|     -   [Fire Director National Park       |                         |
|         Service]{.underline} NIFC for fire |                         |
|         related investigations             |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Coordinate with PAO for release        |                         |
|                                            |                         |
| -   Confirm/verify information prior to    |                         |
|     release                                |                         |
|                                            |                         |
| **FINAL REPORT**                           |                         |
|                                            |                         |
| > The SAIT will provide its Final Report,  |                         |
| > which consists of the Factual and        |                         |
| > Management Evaluation Reports, to the    |                         |
| > Agency DASHO within 45 calendar days of  |                         |
| > the accident.                            |                         |
| >                                          |                         |
| > If the accident investigation is         |                         |
| > conducted as an interagency              |                         |
| > investigation the final report format    |                         |
| > must be agreed upon by the respective    |                         |
| > agencies.                                |                         |
| >                                          |                         |
| > **NOTE:** For the USDA Forest Service    |                         |
| > the Accident Investigation Report shall  |                         |
| > consist of a factual section and a       |                         |
| > management evaluation section.           |                         |
|                                            |                         |
| **FACTUAL REPORT**                         |                         |
|                                            |                         |
| The purpose of the factual report is to    |                         |
| provide a narrative of the events leading  |                         |
| up to, during, and after the accident.     |                         |
|                                            |                         |
| This information about the factual events  |                         |
| and the findings of the accident will help |                         |
| prevent similar types of accidents from    |                         |
| happening in the future.                   |                         |
|                                            |                         |
| The report should provide:                 |                         |
|                                            |                         |
| -   Executive summary of the event         |                         |
|                                            |                         |
| -   Chronology of the accident sequence    |                         |
|                                            |                         |
| -   Any post-accident actions (e.g.        |                         |
|     emergency response attributed to       |                         |
|     survival of the victim)                |                         |
|                                            |                         |
| -   Attachments or addendums essential to  |                         |
|     support the factual information        |                         |
|                                            |                         |
| **FACTUAL REPORT (continued)**             |                         |
|                                            |                         |
| Report is written by either the Team       |                         |
| Leader or the Chief Investigator--         |                         |
| depending on the complexity of the         |                         |
| accident. It is often done together. In    |                         |
| more complex investigations a writer       |                         |
| editor may be used.                        |                         |
|                                            |                         |
| Only the facts go into this report--no     |                         |
| inferences, conclusions, or                |                         |
| recommendations.                           |                         |
|                                            |                         |
| Each agency has specific direction on the  |                         |
| formatting of the factual and management   |                         |
| evaluation reports, while they are very    |                         |
| similar there are some differences in      |                         |
| terminology, formatting and processes. You |                         |
| should consult your specific agency manual |                         |
| handbook or guide when preparing these     |                         |
| reports during an investigation.           |                         |
|                                            |                         |
| Handout 14-3 provides an explanation of    |                         |
| factual content and format. (Specific      |                         |
| information can be found in:               |                         |
|                                            |                         |
| -   FS Accident Investigation Guide        |                         |
|                                            |                         |
| -   BLM Serious Accident Investigation     |                         |
|     Manual 1112-3                          |                         |
|                                            |                         |
| -   NPS Reference Manual #50B              |                         |
|     Accident/Incident Reporting            |                         |
|                                            |                         |
| **FORMATTING OF THE FACTUAL REPORT**       |                         |
|                                            |                         |
| **Cover:**                                 |                         |
|                                            |                         |
| -   Self explanatory                       |                         |
|                                            |                         |
| **Title Sheet:**                           |                         |
|                                            |                         |
| -   The name and location of the accident  |                         |
|     or incident the date of the accident   |                         |
|     or incident, and the list of           |                         |
|     investigation team members and their   |                         |
|     respective agencies.                   |                         |
|                                            |                         |
| **Table of Contents:**                     |                         |
|                                            |                         |
| -   Use three-ring binders to set up the   |                         |
|     reports with dividers for each         |                         |
|     section. Include page numbers. When    |                         |
|     the report refers to or includes       |                         |
|     supporting documents (such as maps,    |                         |
|     photos, or technical reports refer     |                         |
|     them by exhibits or figures.           |                         |
|                                            |                         |
| **Executive Summary:**                     |                         |
|                                            |                         |
| -   The summary briefly explains how the   |                         |
|     accident occurred. It normally should  |                         |
|     not exceed one page.                   |                         |
|                                            |                         |
| **Narrative:**                             |                         |
|                                            |                         |
| -   The narrative portion explains why the |                         |
|     accident happened. It should provide a |                         |
|     detailed chronology of the facts,      |                         |
|     before, during, and after the          |                         |
|     accident. This section should spell    |                         |
|     out the who, what, when, and where as  |                         |
|     much as possible.                      |                         |
|                                            |                         |
| -   Do not identify involved personnel by  |                         |
|     name in the narrative. Identify        |                         |
|     involved personnel by their position   |                         |
|     (i.e. victim 1 engine leader 6-1).     |                         |
|     Involved personnel are individuals:    |                         |
|                                            |                         |
|     -   Who had an active role in the      |                         |
|         accident                           |                         |
|                                            |                         |
|     -   Who were injured in the accident   |                         |
|                                            |                         |
|     -   Whose actions or inactions         |                         |
|         initiated or sustained the         |                         |
|         accident sequence                  |                         |
|                                            |                         |
| **FORMATTING OF THE FACTUAL REPORT         |                         |
| (continued)**                              |                         |
|                                            |                         |
| **Investigation Process**:                 |                         |
|                                            |                         |
| -   A brief narrative stating that the     |                         |
|     team was assigned to investigate the   |                         |
|     accident.                              |                         |
|                                            |                         |
| -   It should include a standard statement |                         |
|     that human, material, and              |                         |
|     environmental factors were considered. |                         |
|                                            |                         |
| -   If one of these factors is determined  |                         |
|     to be non-contributing to the accident |                         |
|     it should be addressed first and       |                         |
|     discounted, i.e. temperatures          |                         |
|                                            |                         |
| **Findings:**                              |                         |
|                                            |                         |
| -   Each finding is a single event or      |                         |
|     condition.                             |                         |
|                                            |                         |
| -   Each finding is an essential step in   |                         |
|     the accident sequence, but each        |                         |
|     finding is not necessarily causal.     |                         |
|                                            |                         |
| -   Findings are the conclusions of the    |                         |
|     accident investigation team based on   |                         |
|     the facts, weight of evidence,         |                         |
|     professional knowledge and good        |                         |
|     judgment. They are grouped in the      |                         |
|     factual section in the following       |                         |
|     categories: Human, Material, and       |                         |
|     Environment.                           |                         |
|                                            |                         |
| -   All findings should be documented and  |                         |
|     substantiated within the narrative     |                         |
|     section of the report.                 |                         |
|                                            |                         |
| **Maps/Photographs/Illustrations,          |                         |
| graphics, figures, and exhibits:**         |                         |
|                                            |                         |
| -   Graphic information used to document   |                         |
|     and visually portray facts. They need  |                         |
|     to be properly identified throughout   |                         |
|     the reports (i.e. figure-1, figure-2)  |                         |
|                                            |                         |
| **FORMATTING OF THE FACTUAL REPORT         |                         |
| (continued)**                              |                         |
|                                            |                         |
| **Appendices:** Can be used as reference   |                         |
| information. Examples of applicable        |                         |
| appendixes are:                            |                         |
|                                            |                         |
| -   Fire behavior synopsis                 |                         |
|                                            |                         |
| -   Weather forecasts                      |                         |
|                                            |                         |
| -   Human factors analysis                 |                         |
|                                            |                         |
| -   Root cause analysis                    |                         |
|                                            |                         |
| -   Equipment analysis                     |                         |
|                                            |                         |
| -   Personal equipment analysis            |                         |
|                                            |                         |
| -   Tear down analysis                     |                         |
|                                            |                         |
| **Records:** Factual data and documents    |                         |
| used to substantiate facts involving the   |                         |
| accident.                                  |                         |
|                                            |                         |
| **MANAGEMENT EVALUATION REPORT**           |                         |
|                                            |                         |
| The Management Evaluation Report (MER) is  |                         |
| the second part of the Final Report and is |                         |
| intended for *internal use only.* It's     |                         |
| purpose is to review the following:        |                         |
|                                            |                         |
| -   Explores Management Policies           |                         |
|                                            |                         |
| -   Practices                              |                         |
|                                            |                         |
| -   Procedures                             |                         |
|                                            |                         |
| -   Personal Performance related to the    |                         |
|     accident.                              |                         |
|                                            |                         |
| It takes the findings identified in the    |                         |
| factual report and identifies causes.      |                         |
|                                            |                         |
| **MANAGEMENT EVALUATION REPORT**           |                         |
|                                            |                         |
| (continued)                                |                         |
|                                            |                         |
| A cause is a deficiency the correction,    |                         |
| elimination, or avoidance of which would   |                         |
| likely have prevented or mitigated the     |                         |
| accident damage or significant injury.     |                         |
|                                            |                         |
| **Contributing factors** (FS) is any       |                         |
| behavior or omission or deficiency that    |                         |
| contributed to, but did not directly cause |                         |
| or sustain the accident or incidents       |                         |
| occurrence.                                |                         |
|                                            |                         |
| > **NOTE: Remember the FS identifies       |                         |
| > causes as two categories, causes and     |                         |
| > contributing factors.**                  |                         |
|                                            |                         |
| This report may contain:                   |                         |
|                                            |                         |
| -   Findings identified in the factual     |                         |
|     report                                 |                         |
|                                            |                         |
| -   Causes/Contributing factors (FS) of    |                         |
|     the accident                           |                         |
|                                            |                         |
| -   Conclusions and observations           |                         |
|                                            |                         |
| -   Confidential information               |                         |
|                                            |                         |
| -   Recommendations for corrective         |                         |
|     measures                               |                         |
|                                            |                         |
| **(Special Note)**Other findings, which if |                         |
| left uncorrected, could lead to future     |                         |
| accidents (DOI only)                       |                         |
|                                            |                         |
| -   In the BLM/NPS these "Other Findings"  |                         |
|     should be listed in the Management     |                         |
|     Evaluation Report and recommendations  |                         |
|     made.                                  |                         |
|                                            |                         |
| -   **(Note)** In the Forest Service Other |                         |
|     Findings will be a separate letter     |                         |
|     submitted by the Chair of the Accident |                         |
|     Review Board to the appropriate Agency |                         |
|     Administrator                          |                         |
|                                            |                         |
| **Handout 14-4** provides an explanation   |                         |
| of Management Evaluation Report content    |                         |
| and format.                                |                         |
|                                            |                         |
| **FORMATTING OF THE MANAGEMENT EVALUATION  |                         |
| REPORT**                                   |                         |
|                                            |                         |
| **Cover**                                  |                         |
|                                            |                         |
| -   Self --explanatory                     |                         |
|                                            |                         |
| **Title Sheet**                            |                         |
|                                            |                         |
| -   The Freedom of Information Act         |                         |
|     Disclaimer Statement                   |                         |
|                                            |                         |
| -   The name of the accident or incident   |                         |
|                                            |                         |
| -   The date of the accident or incident   |                         |
|                                            |                         |
| -   The list of investigation team members |                         |
|     and their respective agencies          |                         |
|                                            |                         |
| **Table of Contents**                      |                         |
|                                            |                         |
| -   Include page numbers                   |                         |
|                                            |                         |
| **Executive Summary**                      |                         |
|                                            |                         |
| -   A brief summary of the facts involving |                         |
|     the accident                           |                         |
|                                            |                         |
| **Findings**                               |                         |
|                                            |                         |
| -   From the factual report                |                         |
|                                            |                         |
| **Causes**                                 |                         |
|                                            |                         |
| -   A cause is a deficiency that the       |                         |
|     correction, elimination, or avoidance  |                         |
|     of would likely have prevented or      |                         |
|     mitigated the accident or significant  |                         |
|     injury                                 |                         |
|                                            |                         |
| **Contributing Factors** (FS)              |                         |
|                                            |                         |
| -   A contributing factor is any behavior  |                         |
|     or omission or deficiency that         |                         |
|     contributed to, but did not directly   |                         |
|     cause or sustain the accident or       |                         |
|     incidents occurrence.                  |                         |
|                                            |                         |
| **FORMATTING OF THE MANAGEMENT EVALUATION  |                         |
| REPORT (continued)**                       |                         |
|                                            |                         |
| **Recommendations**                        |                         |
|                                            |                         |
| -   Recommendations are the prevention     |                         |
|     measures that management may take to   |                         |
|     prevent similar accidents              |                         |
|                                            |                         |
| -   A recommendation should identify an    |                         |
|     action to be taken.                    |                         |
|                                            |                         |
| -   They must be reasonable, feasible,     |                         |
|     relate to the cause(s) of the          |                         |
|     accident, and allow for definitive     |                         |
|     closure                                |                         |
|                                            |                         |
| -   Every cause need not have a            |                         |
|     recommendation                         |                         |
|                                            |                         |
| -   Number recommendations consecutively   |                         |
|     (for example recommendation 01, 02,    |                         |
|     etc                                    |                         |
|                                            |                         |
| **Other Findings (DOI only)**              |                         |
|                                            |                         |
| -   Other findings that did not contribute |                         |
|     to the accident but, if left           |                         |
|     uncorrected, could lead to other       |                         |
|     accidents                              |                         |
|                                            |                         |
| **Enclosures**                             |                         |
|                                            |                         |
| -   Information used to support the        |                         |
|     recommendations that were not included |                         |
|     in the Factual Report.                 |                         |
|                                            |                         |
| **MINORITY REPORTS**                       |                         |
|                                            |                         |
| Within the DOI we have one other type of   |                         |
| report that should be noted; although      |                         |
| rarely utilized it is called the Minority  |                         |
| Reports.                                   |                         |
|                                            |                         |
| The Forest Service does not utilize this   |                         |
| process.                                   |                         |
|                                            |                         |
| In every team deliberations process the    |                         |
| goal is to have concurrence. The Team      |                         |
| Leader should advise team members that if  |                         |
| they are not in agreement with the factual |                         |
| and management evaluation reports, they    |                         |
| may submit a minority report to the team   |                         |
| leader, which will be included with the    |                         |
| management evaluation report.              |                         |
|                                            |                         |
| This report will:                          |                         |
|                                            |                         |
| -   Only address point of disagreement     |                         |
|                                            |                         |
| -   Recommend alternative conclusions      |                         |
|                                            |                         |
| -   Recommend alternative recommendations  |                         |
|     as appropriate                         |                         |
|                                            |                         |
| -   Be included with the Management        |                         |
|     Evaluation Report and the office file  |                         |
|                                            |                         |
| **DISTRIBUTION OF ACCIDENT REPORTS**       |                         |
|                                            |                         |
| For BLM fire accident investigations the   |                         |
| Team Leader ***may*** send the Draft Final |                         |
| Report to the Office of Fire and Aviation  |                         |
| (OF&A) for formatting and editing (no      |                         |
| content changes will be made).             |                         |
|                                            |                         |
| **However, if you have dedicated           |                         |
| writer/editor, this may not be required.** |                         |
|                                            |                         |
| **DISTRIBUTION OF ACCIDENT REPORTS**       |                         |
|                                            |                         |
| (continued)                                |                         |
|                                            |                         |
| > Once the Team Leader is satisfied with   |                         |
| > the report, distribution and             |                         |
| > disposition, should be as follows:       |                         |
|                                            |                         |
| **BLM:**                                   |                         |
|                                            |                         |
| -   **Within 45 days** of the accident,    |                         |
|     the original and two copies of all     |                         |
|     reports except fire fatalities will be |                         |
|     sent, by traceable means to the Bureau |                         |
|     Safety Manager.                        |                         |
|                                            |                         |
| -   **Within 45 days** of the accident,    |                         |
|     reports of fire fatalities will be     |                         |
|     sent to the Director, Office of Fire   |                         |
|     and Aviation. These documents must be  |                         |
|     mailed by a traceable means.           |                         |
|                                            |                         |
|     **National Park Service:**             |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   **Within 45 days** of the accident,    |                         |
|     the original and two copies of all     |                         |
|     reports except fire related            |                         |
|     investigations will be sent, by        |                         |
|     traceable means to the Associate       |                         |
|     Regional Director of Operations        |                         |
|     (ARD-O) of the affected region.        |                         |
|                                            |                         |
| -   **Within 45 days** of the accident,    |                         |
|     reports of fire related investigations |                         |
|     will be sent to the Fire Director,     |                         |
|     National Park Service. NIFC. These     |                         |
|     documents must be mailed by a          |                         |
|     traceable means.                       |                         |
|                                            |                         |
|     **FOREST SERVICE:**                    |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   **Within 45 days** of the accident the |                         |
|     Team Leader contacts the appropriate   |                         |
|     safety manager to determine the number |                         |
|     of draft copies that should be         |                         |
|     forwarded for the Accident Review      |                         |
|     Board. These must be mailed by a       |                         |
|     traceable means.                       |                         |
|                                            |                         |
| **DISTRIBUTION OF ACCIDENT REPORTS**       |                         |
|                                            |                         |
| (continued)                                |                         |
|                                            |                         |
| **CASE FILES**                             |                         |
|                                            |                         |
| Case files including factual data that was |                         |
| generated during the investigation but not |                         |
| contained with the report will be          |                         |
| forwarded, by traceable means, to the      |                         |
| Agency Safety Office. The Agency Safety    |                         |
| Office is the office of record for the     |                         |
| official copy of the report and the case.  |                         |
| (Non-fire or fire).                        |                         |
|                                            |                         |
| Physical evidence may be returned to the   |                         |
| property owner or insurance company under  |                         |
| signed receipt. Return of contractor       |                         |
| property will be coordinated through the   |                         |
| appropriate Contracting Officer.           |                         |
|                                            |                         |
| The Team Leader should check with any      |                         |
| other investigative entities before        |                         |
| releasing any evidence gathered during the |                         |
| investigation.                             |                         |
|                                            |                         |
| Upon completion of the Final Report, the   |                         |
| Team Leader will collect **all draft**     |                         |
| Factual Reports, Management Evaluation     |                         |
| Reports, and notes and ensure that they    |                         |
| are **destroyed**.                         |                         |
|                                            |                         |
| **RELEASE OF ACCIDENT REPORTS**            |                         |
|                                            |                         |
| **Release of accident reports and          |                         |
| documentation.**                           |                         |
|                                            |                         |
| -   These documents contain material       |                         |
|     intended for internal agency use only. |                         |
|                                            |                         |
| -   Any request for copies of accident     |                         |
|     Factual Reports, Management Evaluation |                         |
|     Reports and supporting documents shall |                         |
|     be forwarded immediately to the        |                         |
|     Agencies Freedom of Information Act    |                         |
|     Officer.                               |                         |
|                                            |                         |
| -   These documents may contain privacy    |                         |
|     information or another agency's        |                         |
|     documents and must be reviewed before  |                         |
|     release to the public.                 |                         |
|                                            |                         |
| **BOARD OF INQUIRY/BOARD OF SURVEY**       |                         |
|                                            |                         |
| In instances where responsibility or       |                         |
| disciplinary action needs to be assigned,  |                         |
| a **Board of Inquiry (BLM)/Board of Survey |                         |
| (NPS)** may be established. (e.g., Lowden  |                         |
| Fire) While this is not one of your        |                         |
| responsibilities as a member of a SAIT     |                         |
| assignment it is important for you to know |                         |
| that these types of reviews can take place |                         |
| during or after your investigation.        |                         |
|                                            |                         |
| Boards of Inquiry/Board of Survey are used |                         |
| to follow-up on serious accident           |                         |
| situations and can determine               |                         |
| responsibility and make recommendations    |                         |
| ranging from no action to termination.     |                         |
| Only the Bureau Director or Deputy         |                         |
| Director may request a Board of Inquiry.   |                         |
+--------------------------------------------+-------------------------+