######### Bureau of Land Management 

##### Serious Accident Investigation

####### Draft BLM Manual Handbook 1112-3

####### 

####### Table of Contents

Preface 1

Chapter 1---Administrative Information and Overview 2

Chapter 2---Team Preparation and Activation 12

Chapter 3---Opening Conference 18

Chapter 4---Initial Site Investigation 22

Chapter 5---Maps, Sketches, Drawings, and Diagrams 24

Chapter 6---Photographs and Videos 27

Chapter 7---Interviews and Witness Statements 31

Chapter 8---Evidence Gathering and Documentation 36

Chapter 9---Wildland and Prescribed Fire Accident Investigation 52

Chapter 10---Deliberations, Findings, and Recommendations 59

Chapter 11---Reports and Briefings 65

Chapter 12---Accident Review Board (Forest Service Only) 82

Chapter 13---Follow Up 85

####### 

####### 

####### Preface

As a member of a Serious Accident Investigation Team (SAIT), you will
face one of the most significant challenges in your career. Your
responsibility is to establish the facts and develop the findings and
causal factors of an accident that has resulted in a loss of life,
significant injuries, or substantial damage to property. You must then
make recommendations that will help prevent similar accidents from
occurring in the future. It is imperative that you remain totally
unbiased, keeping an open mind to all situations that you may encounter.
The event that you are trying to understand has had an enormous
emotional impact on those involved and may have an emotional impact on
you and your team. You must remain cognizant of that fact throughout
your investigation, and take the necessary time to ensure that the
impact of the investigation remains minimal to your team members, the
unit's employees, and the families of those involved.

A full review of all evidence by the Chief Investigator is essential.
However, there will be circumstances where it is necessary to control
disclosure of confidential and sensitive matters (e.g., HIV infection,
disciplinary action not related to the accident) with the team and in
the final report. Each of these exceptions and the consequences of
nondisclosure should be fully discussed with the Team Leader to
determine appropriate actions.

One last but very important item: If criminal activity is suspected, the
SAI Team **must to notify the agency DASHO, the FBI, and other
appropriate law enforcement agencies.** Do not resume the investigation
unless a determination is made that there was no criminal activity.

#######  

####### Chapter 1---Administrative Information and Overview

1.1. PURPOSE

A. An accident investigation is the methodical collection of evidence
(facts), and the analysis and interpretation of the evidence. The
fundamental purpose is to identify the cause(s) of the accident and to
recommend corrective actions to prevent or minimize the chance of a
reoccurrence.

B. This Serious Accident Investigation Handbook provides guidance on how
to conduct a serious accident investigation and perform the associated
administrative tasks. It also includes an investigation protocol for
wildland fire shelter deployments, entrapments, and fatalities.

1.2. OBJECTIVE

A. An investigation must be initiated promptly and properly to ensure
that important evidence is not lost, misplaced, or contaminated. This
handbook provides essential steps for serious accident investigations,
regardless of the organizational level involved. It teaches Serious
Accident Investigation Team (SAIT) members how to:

> 1\. Conduct a comprehensive accident investigation.
>
> 2\. Identify findings and causes that led to the accident..
>
> 3\. Make recommendations for corrective actions to prevent similar
> accidents from occurring in the future.

B. This handbook also shows how to prepare and submit briefings and
documents required by the Department of the Interior (DOI) and the
Bureau of Land Management (BLM).

1.3. AUTHORITY

The authority to investigate accidents is established in the Code of
Federal Regulations - 29 CFR 1960, Executive Order 12196, DOI 485 DM,
and Bureau of Land Management Manual 1112.

1.4. SCOPE

A. This handbook is primarily designed to provide guidelines for SAITs.
However, the process outlined in this guide can be applied, in whole or
in part, to all accident investigations regardless of severity.

B. Training on the use of this handbook meets the DOI and BLM
requirements for Chief Investigator training.

1.5. TYPES OF ACCIDENTS AND INVESTIGATIONS

A. DOI Serious Accidents. DOI defines a serious accident as a
Department-related incident that is a result of an employee action or
Departmental condition that results in:

> 1\. One or more job-related fatalities or imminently fatal injuries or
> illnesses to employees, or
>
> 2\. Three or more persons hospitalized as a result of the same
> accident, or
>
> 3\. Property damage (including site mitigation or cleanup) and/or
> operating loss of \$250,000 or more, or
>
> 4\. Consequences that the Bureau Designated Agency Safety and Health
> Official (DASHO) or Bureau Safety Manager judges to warrant further
> investigation using these serious accident investigation procedures.
>
> 5\. There are fire-related accidents that do not meet the requirements
> of a serious accident that are investigated by an SAIT. Wildland and
> prescribed fire accident investigation is covered in Chapter 9.

B. BLM Serious Accidents. In accordance with BLM Handbook 1112-1,
accidents meeting the DOI definition of a serious accident, which occur
solely as a result of BLM operations, will be investigated using this
guide. If the serious accident occurs during wildland fire management
operations, BLM Handbook 9213-1 (Standards for Fire and Aviation
Operations--commonly referred to as the Red Book) will also be used.

C. Interagency Wildland Fire Accidents. DOI and Forest Service (FS)
wildland firefighting that results in a "serious fire-related accident"
are investigated in accordance with the Memorandum of Understanding
(MOU) between the U.S. Department of the Interior and the U.S.
Department of Agriculture. The procedures outlined in this handbook are
consistent with that memorandum.

D. Other Interagency Accidents. The degree of BLM participation in joint
investigations or the involvement of other Federal, State, or municipal
agencies in BLM accident or incident

investigations depends on the circumstances of the accident or incident
and any MOUs or interagency agreements in effect.

E. Aviation Accidents. Aviation accidents are investigated by the DOI
Office of Aircraft Services (OAS) or by the National Transportation
Safety Board (NTSB) in accordance with the Office of Fire and Aviation
Manual, 352 DM - Aviation Safety, and Federal Aviation Administration
regulations. BLM does not get involved in those accidents. Smokejumping,

helicopter rappelling, and aviation short-haul accidents are considered
aviation accidents until such time as the employee or equipment is
safely on the ground.

F. Collateral Investigations. Collateral investigations are conducted
independently and apart from the serious accident investigation to make
a record of the facts for use in litigation, claims, and other
administrative and disciplinary actions. Collateral investigations may
include the following: Board of Inquiry, Occupational Safety and Health
Administration (OSHA) Inspection, or a law enforcement investigation.

G. SAIT Investigation Priority. BLM serious accident investigations take
precedence over all other investigations.

H. Criminal Investigations. If criminal activity is suspected, the SAI
Team **must to notify the agency DASHO, the FBI, and other appropriate
law enforcement agencies.** Do not resume the investigation unless a
determination is made that there was no criminal activity.

1.6. SERIOUS ACCIDENT INVESTIGATION TEAM COMPOSITION

A. Authority to authorize the formation of an SAIT rests with the
Bureau\'s DASHO. This authority has been delegated to the Bureau Safety
Manager and the Director, Office of Fire and Aviation (OF&A) (for
fire-management-related accidents only).

B. Once authorized, a nationally appointed SAIT will be composed of a
Team Leader, Chief Investigator, and Accident Investigation Advisor. A
Delegation of Authority Memorandum documents the official appointment of
the Team Leader. See Exhibit 1-1 for an example. For complex
investigations, technical specialists, a documentation specialist,
subject matter experts, and interagency representatives are added as
requested by the Team Leader or the Chief Investigator.

C. Use of a Trained Investigator. A Trained Investigator (contractor) is
someone from outside the affected agencies who is brought in under
contract to investigate the accident. The SAIT is the desired approach
for the investigation of serious accidents. However, in isolated events,
where the accident causes appear to be unrelated to Departmental
management processes and controls, the Bureau DASHO may elect to use a
Trained Investigator in lieu of the SAIT. The Bureau Safety Manager and
OF&A also have the option of using a Trained Investigator instead of a
BLM Chief Investigator on any accident investigation.

D. Qualifications, duties, and responsibilities of team members are:

> 1\. Team Leader. The Team Leader is normally a line officer or
> higher-level agency official, GS-14 or above. Individuals are selected
> based upon the severity of the accident and the level of management
> representation needed, and should be of equivalent or higher grade
> than the manager of the organizational unit incurring the accident.
> The Team Leader must be
>
> knowledgeable about BLM policy and should be selected from outside the
> State incurring the accident.
>
> a\. Qualifications. Must be a senior management official, GS-14 or
> above. Must have completed the BLM Serious Accident Investigation Team
> Leader Training Course.

b\. Duties and Responsibilities.

-   Organizes, conducts, and controls the investigation effort with the
    assistance of the Chief Investigator.

-   Contacts the unit that had the accident to determine the status of
    the local investigation and to obtain other pertinent information.

-   Provides entrance briefings and closeout briefings with affected
    personnel and agency officials.

-   Conducts investigation team meetings and coordinates information
    exchange between team members.

-   Maintains liaison with the Field/District Office Manager, State
    Director, and Washington Office.

-   Approves requests for resources from the Chief Investigator and
    approves team member release from or inclusion in the investigation.

-   Forwards the 24 Hour Preliminary Report and the 72 Hour Expanded
    Report to the Bureau Safety Manager, State Director, and Director,
    Office of Fire and Aviation (Fire Accidents).

-   Arranges local transportation, obtains a suitable local workplace,
    provides for the safety of the team, and ensures the security of the
    meeting place and the investigation information gathered.

-   Coordinates with local law enforcement, the coroner\'s office, and
    others as required.

-   Confirms that drug testing, autopsies, medical reports, and other
    appropriate tests are initiated when required.

-   Arranges Critical Incident Stress Debriefing (CISD) for
    investigation team members when necessary.

-   Coordinates with the unit Public Information Officer for all media
    releases.

-   Prepares and presents the Factual Report and Management Evaluation
    Reports to the Bureau Safety Manager and the Director, Office of
    Fire and Aviation if it is a fire investigation.

> 2\. Chief Investigator. The Chief Investigator is responsible for the
> direct management of the technical investigation activities.

a.  Qualifications.

-   A fully qualified Safety and Health Specialist, GS-0018 or 0803
    series. Must have completed a basic accident investigation course
    (e.g., National Safety Council or OSHA accident investigation
    course); served as an Accident Investigation Advisor on an accident
    investigation team; and satisfactorily completed the BLM Chief
    Investigator Training Course.

-   The Chief Investigator may, upon approval of the Bureau Safety
    Manager, be a qualified accident investigator from outside the
    Bureau.

b\. Duties and Responsibilities.

-   Documents the sequence of events leading up to, during, and
    following the accident; assists the team in identifying findings and
    developing causes of the accident; and recommends possible solutions
    to prevent this type of accident from occurring in the future.

-   Identifies additional team staffing and resource needs, such as
    technical specialists, documentation specialists, law enforcement,
    communications, and forensic experts (based upon the technical
    complexity of the investigation).

-   Ensures that the investigation addresses pertinent safety issues and
    concerns.

-   Works with the organization having jurisdiction over the accident
    site to ensure security and control of the accident site.

-   Works closely with the Team Leader to draft the 72-Hour Report, the
    Factual Report, and the Management Evaluation Report.

> 3\. Accident Investigation Advisor. The Accident Investigation Advisor
> is a safety and occupational health professional responsible for
> advising the team on safety issues pertinent to the investigation in
> accordance with OSHA and BLM policies.
>
> a\. Qualifications.

-   Must be a fully qualified Safety and Health Specialist, GS-0018 or
    0803 Series. Must have completed a basic accident investigation
    course (e.g., National Safety Council or OSHA accident investigation
    course).

> b\. Duties and Responsibilities.

-   Advises the team on the conduct of the investigation to ensure
    compliance with OSHA and BLM requirements.

-   Ensures a Risk Assessment is completed for the investigation team\'s
    operations and activities.

-   Ensures team members have the necessary equipment and training for
    any activity they will be performing.

-   Ensures team members utilize the required personal protective
    clothing and equipment as prescribed by the Risk Assessment.

4\. Technical Specialists. Technical Specialists are individuals with
specific technical skills needed to support the accident investigation.

> a\. Qualifications. Possess sufficient technical skills in a specialty
> area required to provide expert advice in support of the
> investigation.
>
> b\. Duties and Responsibilities. Work directly with the Chief
> Investigator to provide technical support to the investigation until
> released by the Team Leader.

Note: The need for a documentation specialist in complex investigations
should not be overlooked when requesting the support of Technical
Specialists. The documentation specialist is an individual assigned to
the Serious Accident Investigation Team to provide document management
and to provide writer/editor support. Their qualifications should
include skill in writing, editing, word processing, and records
management. Their duties and responsibilities include working directly
for the Team Leader to provide document management support to the
investigation until released and to work with the Chief Investigator to
develop a system to ensure that all evidence collected by the
investigation team is safeguarded.

1.7. INVESTIGATION PROCESS

While each accident investigation is different, the following steps will
almost always occur in BLM accident investigations: (A flowchart of the
Accident Investigation Process is provided in Exhibit 1-2)

A. On-call preparation

B. Notification and travel to the city nearest to the accident

C. Initial meeting with other team members

D. Initial meeting with manager of the unit sustaining the accident

E. Initial site survey

F. Witness interviews and statements

G. Evidence collection

H. Development of accident sequence, findings, causes and
recommendations

I. Report preparation

J. Close-out briefings with management

1.8. INVESTIGATION PRODUCTS

When complete, the investigation needs to have produced the following:

A. A chronology of the events leading up to the accident, the accident
sequence, and the events that occurred after the accident

B. Findings that sustained the accident sequence

C. Causes of the accident

D. Recommendations for correcting all causes and findings

E. Other findings, which if left uncorrected, could lead to another
accident

1.9. INVESTIGATION REPORTS

A number of briefings and reports are required by DOI and BLM
regulations. This section discusses them briefly; however, more detailed
discussion can be found in Chapter 11.

A. Preliminary Report (24-Hour Report). This document contains the first
details of the accident. It provides preliminary factual information
about the accident and may contain preventive measures or
recommendations of an emergency nature.

B. Expanded Report (72-Hour Report). This document contains a brief
narrative of the accident based on factual information gathered onsite.

C. Safety Alert. If a safety hazard or action item is identified during
the course of the accident investigation that requires immediate action,
a Safety Alert will be developed to address the concern and recommend
corrective action.

D. Factual Report. This document contains a chronology of the events
leading up to, during, and after the accident; findings that sustained
the accident sequence and the causes of the accident.

E. Management Evaluation Report. This document contains an executive
summary of the factual report, the Findings from the Factual Report,
Causes identified, any conclusions that the SAI Team makes, and
recommendations to prevent similar accidents. Other findings that, if
left uncorrected, could lead to future accidents are also included in
this report.

1.10. REPORT USE

Information collected and developed during the course of an accident
investigation is to be used for accident prevention purposes only. It
shall not be used for purposes such as:

A. Evidence (or to obtain evidence) to determine the misconduct of
agency personnel

B. Evidence to determine the disciplinary responsibility of agency
personnel

C. Evidence to assert affirmative claims on behalf of the Government

D. Evidence to determine the liability of the Government for property
damage, injuries, or death

#######  

####### Chapter 1---Administrative Information and Overview

### EXHIBIT 1-1 

### Sample Delegation of Authority Letter

Date:

Memorandum

To: , Team Leader

From:

Subject: Delegation of Authority - Serious Accident Investigation

This memorandum formalizes your appointment as Team Leader to
investigate the accident that occurred on (location and date). Your
duties include, but are not limited to:

1\. Organizing, conducting, and controlling the accident investigation.

2\. Providing for in-briefings and out-briefings with affected personnel
and agency officials.

3\. Coordinating information exchange between team members, local law
enforcement, the

> coroner's office, and others.

4\. Maintaining liaison with affected units.

5\. Approving requests and allocating funding for resources.

6\. Requesting technical, logistical, or other support as required to
conduct the investigation.

7\. Providing daily briefings to the Bureau Safety Manager and the
Director, Office of Fire

> and Aviation.

8\. Providing the following formal briefings/reports:

a\. Preliminary Report (24 hours)

b\. Expanded Report (72 hours)

c\. Factual and Management Reports (45 days)

You will be provided a charge code to pay for all travel and associated
costs.

(Name of official authorizing the investigation)

(Title)

cc:

Official case file

Bureau Safety Manager (if appropriate)

#######  

####### Chapter 1---Administrative Information and Overview

### EXHIBIT 1-2 

### Accident Investigation Process

####### Chapter 2---Team Preparation and Activation

2.1. INTRODUCTION

The hours after a major accident can be confusing and stressful for most
of the people involved. As a member of an activated Serious Accident
Investigation Team (SAIT), you should be prepared to dispatch to the
location of the incident as soon as possible. The first responsibility
of all emergency response team members is to arrive expeditiously and
safely to the site of the incident. (Team composition is covered in
Chapter 1.)

2.  PREPARATION

As a team member, you should preplan what you will do if activated. On
Call SAI Team members should contact their Team Leader at the start of
the on-call period just to touch base. You should have a list of
personal items you will need and a list of the most common accident
investigation tools you will likely use. Exhibit 2-1 provides a list of
items that may be needed during an investigation. Depending upon the
agency, accident investigation kits may be available in regional or
State offices. If this is the case, the safety manager will
automatically send the kit to the accident site. Alternately, you can
prepare your own kit to take with you or contact BLM's Office of Fire
and Aviation (OF&A) Safety Manager and have a kit sent from there to the
accident site.\
\
2.3. NOTIFICATION

> A. Upon activation, record the following information on the
> Preliminary Notice Worksheet (Exhibit 2.2).

-   Accident/incident specifics: what happened, where, and when accident
    occurred

-   Point of Contact (POC) telephone/call back number

-   Record OF&A, BOS, or NICC POC (who and what they said)

-   Contact information for onsite POC

-   Team report location

-   Team report time

-   How to get there (who will be making travel arrangements)

-   Confirmation of other team members' status (estimated time of
    arrival - ETA, etc.)

-   Confirm "Just in Time" training video is available. If not, you will
    need to bring one

-   Confirm accident investigation kit is enroute or available. If not,
    you will need to bring or get one from NIFC.

> Note: All of the information may not be available immediately.

B. Once mobilized, you should make immediate plans to depart so that, if
possible, you arrive at the scene within 24 hours of the call. Do not
delay your departure while attempting to contact other team members or
to gather additional information on the incident.

2.4. TRAVEL PLANS

If travel plans are not already made for the team, you should make your
own plans, using the most efficient approved method. Charge all
authorized expenses to your Government credit card. The organization
sustaining the accident will provide reimbursement charge codes.

5.  INITIAL TEAM MEETING

The Team Leader should get the team together before the initial briefing
with the affected unit. It is preferable to do this offsite. It allows
team members to meet each other, organize their thoughts, and get an
understanding of their roles. At this meeting, the Team Leader will ask
you to explain how you plan to proceed. Provide the team members with an
overview of your approach to the investigation (e.g., getting
preliminary information from the agency, documenting the site,
interviewing witnesses, collecting other evidence). If you plan to use a
formal analytical process such as MORT or Fault Tree Analysis, tell the
team and give them a short explanation of how that process works. Either
you or the Team Leader should ensure the following information is
conveyed to the team:

-   Make sure the team understands the need for confidentiality of the
    findings until the investigation is complete and the report is
    released.

-   Make sure the team knows they should not take any independent
    actions without prior approval of the Chief Investigator.

-   Have the Accident Investigation Advisor remind team members of the
    need to maintain their own personal safety.

-   Have the Accident Investigation Advisor discuss any known hazards
    and protective measures that will be required. Include both the
    local area and work sites.

-   Make sure team members understand each other's roles and general
    duties.

-   Discuss the immediate plan of action.

-   Discuss expectations regarding performance and conduct.

-   Discuss need to be sensitive to local personnel and their feelings
    of loss.

-   Be careful when discussing the investigation in public settings
    (e.g., hallways and other common areas, such as restaurants).

-   Discuss the standards for confidentiality/freelancing ("freelancing"
    is following your own investigative trail without coordinating with
    the Chief Investigator).

-   Do not disturb any physical evidence at the accident site.

-   Keep written information secure.

2.6. TEAM ORGANIZATION

The team cannot be effective if it is not organized. Lodging,
transportation needs, work areas, and other logistical needs should be
taken care of as soon as the team arrives at the incident site. The Team
Leader should contact the unit POC assigned to assist the SAI Team. Ask
the POC to arrange for the items you need.

#######  

####### Chapter 2---Team Preparation and Activation

### Exhibit 2-1

### Accident Investigation Kit Contents

Basic Administrative Requirements
---------------------------------

Serious Accident Investigation Manual Handbook 1112-3

Agency Administrator's Guide to Critical Incident Management, PMS
926/NFES 1356

Standards for Fire and Aviation Operations (Red Book)

Glossary of Fire Terminology (PMS 205/NFES 1832)

BLM Supervisor's Employee Casualty Guide

Laptop computer/pocket computer/calculator

Voice recorder (spare batteries and cassettes)

Flashlight (spare batteries)

Camera, 35-mm with date/time stamp (zoom/close-up, spare film slide and
print)

Clipboard

Notepad

Pencils/pens/markers

100-foot measuring tape

Ruler

Compass

Optional Equipment
------------------

Polaroid camera

Inclinometer

Optical range finder

Handheld GPS unit

Magnifier, small

Pocket multi-tool with case

Screwdriver, flat tip

Screwdriver, Phillips

Pliers

Graph paper

#######  

####### Chapter 2---Team Preparation and Activation

### Exhibit 2-2

### Preliminary Notice Worksheet

  ------------------ ----------------------
  Date of Accident   Location of Accident
  ------------------ ----------------------

Who is Contacting You

  ------------ ---------- -------------------------------------------------------
  Name/Phone   Position   Organization (i.e., Bureau Safety Office, OF&A, NICC)
  ------------ ---------- -------------------------------------------------------

Injuries/Fatalities Details (if available)

  --------- -------------- --------
  Name(s)   Home Unit(s)   Age(s)
  --------- -------------- --------

  --------------------------- ----
  Estimated Property Damage   \$
  --------------------------- ----

  -------------------------------------------------------------
  Brief Description of Accident (who, what, when, where, how)
  -------------------------------------------------------------

  ---------------------------------
  Initial Actions by Local Office
  ---------------------------------

Who is the Local Point of Contact (POC)

  ------ ---------- ---------------
  Name   Position   Phone Numbers
  ------ ---------- ---------------

Delegation of Authority letter

  ----------------- ----------
  Signed (yes/no)   Sent To:
  ----------------- ----------

Get the following information:
==============================

Where do I go?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How am I traveling?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Confirm other team members' travel plans (if known).
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

\_\_\_\_\_Call the local POC and confirm that the "Just-in-Time"
training package is available or on the way.

\_\_\_\_\_ Determine if there will be a co-team lead. Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_ Confirm who from or how you will be getting the Delegation of
Authority letter.

Get a cost/charge code from OF&A/NICC (if known)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Note: Temporary charge codes from NICC are used only if a permanent
charge code is not available at the time of Team deployment.
Investigation costs will be charged to the respective State Office for
non-fire-related accidents and to the specific fire for fire-related
accidents.

####### Chapter 3---Opening Conference

3.1. INTRODUCTION

The opening conference is an opportunity for you to get to know the
managers and supervisors involved in the incident and for them to get to
know you. This is an extremely valuable meeting.

3.2. OPENING CONFERENCE

A. The Team Leader should ask the Agency Administrator to give a
complete and candid briefing to the team. All known facts,
circumstances, and theories that the unit may have on the cause of the
accident should be thoroughly covered. Begin to fill out the
investigation documentation form located at Exhibit 3.1, with the facts
provided by the Agency Administrator and agency staff.

B. The Team Leader should use the Investigation Team in-brief to conduct
the formal part of the briefing. During the briefing, cover the general
approach that the team will take, and explain the duties of the team
members and what they will be looking for. State that recommendations
will be made at the end of the investigation.

C. Any collateral investigations that are underway or planned should be
discussed at this time. The BLM Serious Accident Investigation Team
(SAIT) investigation takes priority over all other internal BLM
investigations. Other investigations being conducted (e.g., OSHA, NTSB,
FAA, local law enforcement) may be ongoing. Many times these agencies
have seasoned investigators who will provide valuable information to the
SAIT. The Team Leader must ensure that the SAI Team works with, not
against, other authorized investigatioins.

D. Any evidence that has been collected by the unit to date should be
turned over to the investigation team to be cataloged. The Team Leader
will assign one of the SAIT members the responsibility of cataloging
evidence. The Chain of Custody of any evidence collected during the
course of the investigation must be maintained.

E. Senior representatives of the unit sustaining the loss may ask that
the team address certain specific areas or issues. These should always
be taken into consideration, but should not guide the investigation or
interfere with the basic purpose of the investigation.

F. The team should request a safety briefing from the unit. The briefing
should cover local conditions, such as weather, special field
precautions, driving conditions, vehicle usage (e.g., use of four-wheel
drive, ATVs, snow machines), political climate (e.g., as it may affect
Government employees), and any other areas the team should be aware of.

G. The team should confirm who their Team Liaison with the unit is. The
Team Liaison is the team's local point of contact (POC) with the unit
for logistical needs. As much as possible,

all requests for equipment, information, and other resources should be
directed to that person. The team should strive to reduce the impact of
the investigation on the unit as much as possible.

H. The team should identify any working space, specialized equipment,
office supplies, and administrative support that they know they will
need at the time of the in-brief to the unit. Obtaining resource
requirements for the investigation team should be a priority, but should
also be consistent with the unit's requirement to continue/complete
their mission.

3.3. SITE SECURITY

The team should obtain all information possible on the condition of the
accident site; determine if any evidence has been removed or moved from
its position; and determine if any special site entry requirements have
been put into place. If any evidence has been removed, its location and
the name of the POC should be given to the Team Leader or the Chief
Investigator.

3.4. FAMILY LIAISON/PUBLIC AFFAIRS OFFICER

A. The unit should provide the Team Leader with the names and phone
numbers of the Family Liaison and the Public Affairs Officer (PAO), as
well as copies of any press releases or preliminary up-channel reports
(e.g., the 24 Hour Report or Law Enforcement Serious Incident Reports)
that may have been generated.

B. All information given by the team to non-BLM entities should come
from a PAO, if possible. The Team Leader, working closely with the PAO,
will need to make public announcements in some cases. Team members,
including the Chief Investigator, should not make public announcements
unless directed to do so by the Team Leader.

3.5. CRITICAL INCIDENT STRESS DEBRIEFING\
\
As a general rule, it is best for the team to interview witnesses before
the Critical Incident Stress Debriefing (CISD). The Team Leader should
ascertain if a CISD has been conducted or is planned, how the employees
are doing in general, and if the CISD liaison has any serious concerns.
The Team Leader should also get the name of the CISD liaison in case
members of the Investigation Team need counseling assistance during or
after the investigation.

3.6. AUTOPSIES

A. The Team Leader should find out if an autopsy is planned. If so,
request that samples of body fluids be analyzed for alcohol and drugs.
The rules on autopsies vary from State to State. Most States require an
autopsy if the death was unattended by a physician.

B. If an autopsy is not planned, determine if the family would agree to
one if it is determined that the information gained would benefit the
investigation.

Note: Survivors of firefighters who die in the line of duty are entitled
to death benefits; normally, an autopsy is required. This fact should be
presented to the family if they are uncertain about approving an
autopsy. Refer to Chapter 9 for additional information.

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####### Chapter 3---Opening Conference

### Exhibit 3-1

### Investigation Documentation Form

+------------------+------------------+------------+---------------+
| USDI - BLM       | INVESTIGATION    |            |               |
|                  | DOCUMENTATION    |            |               |
|                  | FORM             |            |               |
+==================+==================+============+===============+
| Personal Data -- |                  |            |               |
| Victim           |                  |            |               |
+------------------+------------------+------------+---------------+
| Name:            | Address:         | Telephone: |               |
+------------------+------------------+------------+---------------+
| Age:             | Sex: M F         | Job Title: | Grade/Series: |
+------------------+------------------+------------+---------------+
| Date of          | Time in          |            |               |
| employment:      | position:        |            |               |
+------------------+------------------+------------+---------------+
| Training for job |                  |            |               |
| being performed  |                  |            |               |
| at time of       |                  |            |               |
| accident:        |                  |            |               |
+------------------+------------------+------------+---------------+
| Employee status: |                  |            |               |
+------------------+------------------+------------+---------------+
| Nature of        |                  |            |               |
| injuries:        |                  |            |               |
+------------------+------------------+------------+---------------+
| Accident Data    |                  |            |               |
+------------------+------------------+------------+---------------+
| How and why did  |                  |            |               |
| the accident     |                  |            |               |
| occur?           |                  |            |               |
+------------------+------------------+------------+---------------+
| Physical layout: |                  |            |               |
+------------------+------------------+------------+---------------+
| Measurements:    |                  |            |               |
+------------------+------------------+------------+---------------+
| Sk               | Videos/Photos:   |            |               |
| etches/Drawings: | Yes No           |            |               |
| Yes No           |                  |            |               |
+------------------+------------------+------------+---------------+
| Equipment        |                  |            |               |
| Involved or      |                  |            |               |
| Process          |                  |            |               |
+------------------+------------------+------------+---------------+
| Machine type:    | Manufacturer:    | Model:     |               |
+------------------+------------------+------------+---------------+
| Kind of process: |                  |            |               |
+------------------+------------------+------------+---------------+
| Manufacturer's   | Warning devices  |            |               |
| instructions:    | (detectors): Yes |            |               |
| Yes No           | No               |            |               |
+------------------+------------------+------------+---------------+
| Condition: Good  | Misuse: Yes No   |            |               |
| Fair Poor        |                  |            |               |
+------------------+------------------+------------+---------------+
| Maintenance      | Equipment        |            |               |
| program: Yes No  | inspection       |            |               |
|                  | (logs, reports): |            |               |
|                  | Yes No           |            |               |
+------------------+------------------+------------+---------------+
| Tasks performed: |                  |            |               |
+------------------+------------------+------------+---------------+
| How often is     |                  |            |               |
| equipment used?  |                  |            |               |
+------------------+------------------+------------+---------------+
| Energy sources   |                  |            |               |
| and              |                  |            |               |
| disconnecting    |                  |            |               |
| means            |                  |            |               |
| identified: Yes  |                  |            |               |
| No               |                  |            |               |
+------------------+------------------+------------+---------------+
| Supervision or   |                  |            |               |
| instruction      |                  |            |               |
| provided to      |                  |            |               |
| employees        |                  |            |               |
| involved in      |                  |            |               |
| accident: Yes No |                  |            |               |
+------------------+------------------+------------+---------------+
| Witnesses        |                  |            |               |
+------------------+------------------+------------+---------------+
| Public           |                  |            |               |
|                  |                  |            |               |
| Fellow Employees |                  |            |               |
|                  |                  |            |               |
| Management       |                  |            |               |
+------------------+------------------+------------+---------------+
| Safety and       |                  |            |               |
| Health Program   |                  |            |               |
+------------------+------------------+------------+---------------+
| Does             |                  |            |               |
| org              |                  |            |               |
| anization/office |                  |            |               |
| have a safety or |                  |            |               |
| health program?  |                  |            |               |
| Yes No           |                  |            |               |
+------------------+------------------+------------+---------------+
| Does the program |                  |            |               |
| address the type |                  |            |               |
| of hazard that   |                  |            |               |
| resulted in the  |                  |            |               |
| fatal            |                  |            |               |
| ity/catastrophe? |                  |            |               |
| Yes No           |                  |            |               |
+------------------+------------------+------------+---------------+

####### Chapter 4---Initial Site Investigation

4.1. INTRODUCTION

The initial site investigation is the most important and revealing
visit. The accident site must be secured and made safe before entering
or visiting the site and evidence must be protected. The team should
approach the site slowly and get the overall picture of what was going
on and what the conditions were at the time of the accident. Landscape
features, shadows, roadways, space allocation, type/location of
equipment and people, should all be looked at from a distance to help
establish the overall complexity of the scene.

4.2. COORDINATION WITH LAW ENFORCEMENT

Prior to departure to the site, the team should coordinate with law
enforcement to see what their interest in the incident is and if they
have any evidence that should be considered. If BLM law enforcement has
sent out any preliminary reports, a copy should be given to the team.
Should the investigation at any time identify any evidence that may
indicate that a crime has occurred; the SAI Team **must to notify the
agency DASHO, the FBI, and other appropriate law enforcement agencies.**
Do not resume the investigation unless a determination is made that
there was no criminal activity.

4.3. PREPARATION FOR SITE VISIT

The first priority is always to visit and return safely from the site.
The team should wear any required personal protective equipment (PPE)
when entering any work area or accident site and comply with all other
site safety requirements. Ensure that all necessary equipment is
identified and obtained prior to departing for the site. Adequate
transportation, water, and protective clothing should be provided for
each team member. Items such as adequate film for all cameras and
adequate blank cassette tapes for tape recorders should be on hand.
Prepare yourself mentally and emotionally for the site visit.

4.4. INITIAL SITE INVESTIGATION

A. Site Security. Any site security procedures that have been
established prior to the Serious Accident Investigation Team's (SAIT)
arrival should be complied with. The team may change these procedures
once they evaluate the scene.

B. As Chief Investigator, you will usually want to look at the accident
scene early in the investigation. Upon arriving, STOP. Your first
observations and analysis of the scene are critical. Slow your team's
approach and observe the overall picture. Do not move anything. Take
photographs and make sketches. All site evidence must be documented on
an evidence log.

It is very important to get an overall look of the accident area and at
the exact site of the accident before any evidence is disturbed. The
site should be approached from the same direction as the site is
normally approached. The entire site should be taken into account. The
position of major structures, utilities, roadways, benches, machinery,
tools, and other items should be considered. The main tasks and the flow
of work should be established. If there is evidence that may be easily
disturbed, only the Chief Investigator and Team Leader should enter the
area.

C. Pictures. All pictures taken must be logged or identified on a
sketch. The type of film, exposure number, date/time of photo, the
person taking the photo, angle of photo, location, and photo description
should be included for each shot taken.

D. Entrance to the Site. People not on the SAIT or not invited into the
site for assistance should be prohibited from entering the site.

E. Evidence Removal. Anything taken from the accident site should be
logged in on the evidence log and a chain of custody established.
Chapter 8 discusses evidence gathering and documentation.

F. Extent of Site and Controls. The extent of the accident site---its
physical dimensions---should be established and boundaries identified
and marked. The entire site needs to be controlled and evidence
protected until released back to the unit by the Chief Investigator.

G. Initial Description of Site. The site description needs to be
prepared very carefully to ensure that it is accurate and well defined.
Drawings, photographs, and historical records may all prove useful.
Chapters 5 and 6 discuss site documentation.

H. Contamination of Site. If the site has been disturbed, witnesses
should be used to determine how the site looked at the time of the
incident or how it typically looks during a similar operation. The Chief
Investigator should always consider the possibility that the site has
been disturbed when considering the position of the evidence.

I. Grid Plan for Sketches/Photographs. On large or complex accident
sites, the site should be divided into grids so that photographs and
sketches can be easily logged and their locations and angles easily
understood when looking at them later.

####### Chapter 5---Maps, Sketches, Drawings, and Diagrams

5.1. INTRODUCTION

A. The purpose of maps, sketches, drawings, and diagrams is to aid the
investigation team and management in understanding the conditions
existing at the time of the accident, and to reconstruct the
circumstances leading up to the accident. Critical information may be
lost forever due to inadequate documentation by the investigation team.
Such information may be necessary later on in the investigation when
analysis of causal factors shows that the position of items held a
greater importance than originally thought. Accuracy in measurements,
mapping, sketches, and drawings is so important to a successful
investigation, that prior to entering a site, a thoughtful and
deliberate planning process must occur.

B. The initial development of maps, sketches, drawings, and diagrams
should begin as soon as possible following the Agency Administrator's
briefing. It is necessary to identify and document any personal items
that left the scene of the accident with the victim(s) or response
personnel. Do not rely on photographs alone for "site layout" due to
problems encountered with photography perspectives (and the occasional
bad roll of film).

5.2. PRELIMINARY WORK

A. The first step upon arriving at the scene is to, from a distance,
determine the extent of the accident site. Note specific geographic and
spatial "benchmarks" in order to establish common points of reference. A
spatial benchmark may be the big boulder just to the left of the
accident site that helps give you an idea of the proportions of the
accident.

B. A baseline often needs to be established so that all other
measurements can be based from a point along the baseline. Roads,
sidewalks, exterior building walls, and ridge or tree lines make good
baselines since their positions are fixed and unlikely to change if
follow up site inspections are required. Identify all of the common and
proper names of the boundary marks so that interview questions can be
developed for witnesses who may be unfamiliar with the terms used by
long-term residents.

5.3. INITIAL SKETCHES

A. The first sketch should be a rough general area sketch encompassing
the accident site, debris field, location of readily identifiable
structures or land features, general orientation to the north arrow, and
approximate measurements by estimation. It should show the orientation
of the victim(s), equipment, machinery parts, and debris field.

B. Obvious marks such as skid marks, damaged foliage, damaged surfaces
or structures, spills or contaminated areas, and the position of safety
equipment should be noted.

C. The intent is not to prepare a detailed drawing of the site, but to:

1\. Identify where more precise measurements should be taken

2\. Establish the general orientation of investigation photographs

3\. Identify hazardous locations

4\. Note key areas likely to contain forensic evidence

D. A team member should be assigned as recorder to take notes for the
Chief Investigator and/or Technical Advisor.

5.4. EVIDENCE PRESERVATION

The Chief Investigator must determine what evidence is fragile or
perishable and may be destroyed or lost due to weather, theft, or moved
in order to protect valuable equipment or evidence. After conferring
with the personnel responsible for site security, arrange for site,
equipment, and material preservation. This may require flagging or
barricading the area, increasing security personnel, expanding the site
security perimeter, covering the site with plastic, obtaining a secured
storage facility, or carefully packaging and removing evidence.

5.5. MEASUREMENTS AND MAPPING

A. Upon establishing a baseline, determine which measurements must be
taken to provide definitive information showing the scope and size of
the site. An easy method to accomplish this is by establishing a grid
pattern for a debris field, and identifying each grid in its x-axis and
y-axis. Care must be taken when entering the debris field so as not to
disturb evidence during measurements. Photographs taken by the Chief
Investigator inside the debris field may be necessary prior to moving
objects. Videotapes taken outside the debris field may be useful during
the measurement process. A critical measurement is the point of contact
and the distance and angle from the point of contact where persons or
objects may have been thrown. Specific points must be identified and
recorded from the notes. From the first sketch and the measurements
taken, a map is sketched on grid paper and the notes from the recorder
are added into a "map symbol key" or directly onto the position map.

B. Many organizations have access to global positioning systems (GPS).
This tool can be very helpful in mapping accident sites. There are two
types of GPS, navigational and engineering.

> 1\. Navigational GPS data and software are usable for quick, accurate
> mapping for spatial locations and gross distances between areas of
> interest. DO NOT rely on navigational GPS units to provide accurate,
> minute detail.
>
> 2\. Engineering GPS units used with geographic information system
> (GIS) programs (e.g., ArcView) will provide accurate, minute detail,
> as well as data documentation and multiple mapping opportunities to
> more accurately display the accident scene and occurrences.
>
> 3\. Use of detailed GPS and GIS information will require a technical
> specialist, who can often be provided by the unit sustaining the
> accident.

5.6. RECORD KEEPING

During the initial measurement and initial photography stage, specific
notes should be taken indicating which items may reveal important clues
and should be removed immediately for protective storage (eventually all
items will be removed from the site). Indicate items that were disturbed
or removed during the emergency response efforts, and items that should
be at the site but are missing, such as personal protective equipment
(PPE) or broken parts. Information critical to the investigation may
include: environmental and site conditions that have changed from the
time of the accident; events like rainfall or fire that may have
destroyed perishable evidence such as tire tracks; and equipment that
may have been repaired.

5.7. RECONSTRUCTION

Reconstruction of an accident scene or re-creation of an accident is
generally not recommended for BLM SAITs due to the complexities and
potential theoretical errors, as well as the re-creation of the hazards.
If a scene reconstruction or re-creation of an accident is necessary, it
is recommended that a professional accident investigator/engineering
firm versed in accident reconstruction be brought into the investigation
as early as possible before fragile evidence is compromised. The use of
placards, traffic cones, ribbon, twine, and spray paint to indicate
paths of travel or trajectories is recommended to highlight physical
evidence that may not be readily apparent through photographs.

####### Chapter 6---Photographs and Videos

6.0. GENERAL

A. One of the most useful tools the investigator can bring to the
accident scene is a camera. The camera shows the view seen by a witness
and can record accident scene details for future reference. There is
almost no limit to its usefulness.

B. Depending upon the complexities of the accident, a professional
photographer may be needed to document the accident.

C. Digital, 35-mm, and self-processing film cameras can all be used for
this application. Remember that self-processing cameras are hard to
duplicate. You can have 35-mm film digitized on a CD when the film is
processed.

D. While video cameras have their uses, photographs are more useful
because they can be enlarged and printed in multiple copies and placed
in the Factual Report; videos are difficult to integrate into the final
report.

E. If law enforcement personnel investigated the accident, they may have
photos of the undisturbed scene that will be of value.

F. Video of the accident scene may be available from the media.

6.1. PHOTOGRAPHY

A. Photographs do not have to be taken in the order the investigator
intends to look at them. Shoot all the distant and medium shots first
and then move on to close-up shots. Use a tripod, flash, or cable
release if needed. This method may save time by not having to go back
and forth between the two types of photography.

B. Types of photographs that can be used to document the scene.

> 1\. Perishable Evidence. These are photographs of things that are
> likely to change or disappear altogether if not photographed
> immediately. They can include, but are not limited to, photographs of
> the accident aftermath or rescue in progress, the victim'(s) position,
> gauge readings, ground scars, radio settings, fire damage, body fluids
> or parts, and switch/control positions on equipment.
>
> 2\. Aerial Views. When using an aircraft to shoot aerial photography
> an aviation plan approved by the Unit Aviation Officer will be needed.
> If possible, photograph aerial views early. The appearance of the
> accident site from the air will change rapidly as investigators move
> through it. Important locations on the ground can be marked using
> yellow flagging or other suitable material (e.g., yellow fire shirt).
> Shoot from multiple angles and distances aboveground.
>
> 3\. Overviews of the Scene. Photograph the accident site equipment
> wreckage from the eight points of the compass. If the accident scene
> is spread out over a long distance, try a series of overlapping
> pictures. The prints can be edge-matched creating a montage (panoramic
> view). It is important not to adjust the camera between shots and take
> the shots from about the same distance.
>
> 4\. Significant Scene Elements. Try to establish the terrain gradient
> through photographs. Photograph ground scars in such a manner that
> will allow future analysis of size and depth.
>
> 5\. Site Inventory. The camera is a useful tool to inventory the
> accident site and document personal protective equipment (PPE), other
> safety equipment, personal effects, and the location and condition of
> victims. The location of each item may be plotted on a scaled map
> using a fixed point of reference.
>
> 6\. Closeups. Bracket exposures for closeups by taking two pictures
> with slightly different focus adjustments (f-stops). Use a tripod or
> monopod, as appropriate.
>
> 7\. Documents. The camera can be used to photograph documents that
> otherwise cannot be retained or copied. This includes licenses and
> logbooks, or even a map or chart on someone's wall.
>
> 8\. Witness Views. It may be important to document the witness' view
> of the accident. Because the witness may have a very wide-angle view,
> use a tripod and take overlapping pictures to duplicate the view.
>
> 9\. Exemplars. An exemplar is a model or pattern for an actual object.
> Sometimes it is difficult to tell from wreckage photographs what the
> part or component is supposed to look like. In some investigations, it
> is worth a roll of film to have pictures of an identical undamaged
> object for comparison.
>
> 10\. Reference. Use something of a known size like a ruler, pen, or
> your hand in pictures for a reference.
>
> 11\. Wildland Fire Photos. In addition to the types of photographs
> previously discussed, the following items are specific to fire
> management accidents:
>
> a\. Final resting position of victims, equipment, trees, and other
> relevant items
>
> b\. Fireline construction at the accident site
>
> c\. Equipment carried or worn by personnel (personal and official
> gear)
>
> d\. Fire personal protective clothing and equipment

e\. Safety equipment

> f\. Vegetative conditions (before and after)
>
> g\. Surrounding terrain, structures, and orientation photographs
>
> h\. Fire origin and build-up photographs
>
> i\. Shelter deployment (shelter, packaging, and location carried by
> personnel)\
> j. Operating base unit/facilities/equipment

6.2. PRESENTATION

Photographs used in the Factual Report should be mounted and captioned.
A caption example could be: "View of damaged driver's door looking
north." Each photo taken should be entered into a log and should include
the name of the photographer and date taken (Accident Photographic
Documentation Form, Exhibit 6-1).

#######  

####### Chapter 6---Photographs and Videos

### Exhibit 6-1

### Accident Photographic Documentation Form

  ACCIDENT PHOTOGRAPHIC DOCUMENTATION FORM   
  ------------------------------------------ ---------------------------------
  Accident:                                  Location:
  Name of Photographer:                      Date and Time Photograph Taken:
  Camera Type:                               Film:
  Description of Photograph:                 
  MOUNT PHOTOGRAPH HERE                      

####### Chapter 7---Interviews and Witness Statements

7.1. GENERAL

A. After the site visitation, it is generally best to continue the
investigation by interviewing the "eyewitnesses." Those involved in the
accident are included in the "eyewitness" category. Eyewitnesses may be
your best or only source of information for determining the accident
sequence of events. It is important for investigators to hold interviews
as soon as possible.

B. The mental state of the witnesses in regard to critical incident
stress should be taken into account. They may be in shock or traumatized
following the accident. They may also be on medication and require the
approval of the attending physician before making statements or being
interviewed. On the other hand, they are frequently anxious to talk
about the accident to anyone who will listen. Providing them with an
opportunity to talk about the events surrounding the accident may be
helpful to their psychological recovery.

C. It is best to interview the witnesses before any Critical Incident
Stress Debriefing (CISD) takes place. However, should the events of an
accident cause a severe psychological burden on a witness, it may be
necessary to secure the services of a CISD counselor before interviews
are conducted. In these cases, try to get a written statement from the
witness prior to attending the CISD. Contact the local Employee
Assistance Program (EAP) coordinator to arrange for CISD counseling on
scene, as necessary.

7.2. STATEMENTS

A. To ensure candor, witnesses should be isolated from each other when
making their individual statements.

B. Investigators taking statements need to inform witnesses that the
Serious Accident Investigation Team (SAIT) will only use their
statements for accident prevention purposes. An assurance of
confidentiality cannot be given.

C. Exhibit 7-1, Memorandum of Interview, is the form recommended for
documenting witness interviews.

7.3 INTERVIEWS

A.  The Chief Investigator should take the lead in preparing questions
    for interviews, but may not necessarily always be the interviewer.
    Interview duties can be assigned to other investigation team
    members. Interviews need to be taken in quiet, private, comfortable
    locations that are free of disruption. Provide frequent breaks.
    Depending on the amount of information needed, an interview may need
    to be divided up and held in subsequent sessions. It is recommended
    that the

interview be taped so that a complete record of the interview exists.
Whenever an interview is taped, the tape becomes a part of the accident
investigation record.

B. Control questions should be developed and used. Control questions
provide consistency and ensure that pertinent information is collected
in all interviews. Paragraph 7.6 describes some types of control
questions.

C. Ensure the name, work address, phone number, date, and name of the
interviewee are included in the document.

D. In some instances, witnesses may have to be taken to the accident
site after the initial interview for clarification of their statements.

E. If employees are concerned the interview may result in disciplinary
action being taken against them, a request for union representation may
be made before or during the interview (Weingarten Right) as stated in
the Master Agreement. Anytime a representative is requested, the
interview will be discontinued until representation is obtained.

7.4. CONDUCT OF INTERVIEW

A. The objective of the interview is to get the individual to tell you
everything he or she knows without being influenced by either the
question or by what he or she thinks you want to hear. Usually, it is
more productive to move from general to specific questions and from the
known to the unknown.

B. The interview begins by asking the individual for his or her name,
work address, phone number, position (job title), and location during
the accident. The best approach is to ask the person to explain, in his
or her own words, what happened. Ask them to start with when they first
noticed something. This usually helps put the person at ease and gives
you a pretty good idea of what they know.

> 1\. Avoid interviewing more than one witness at a time.
>
> 2\. Do not prejudge a witness. Keep an open mind and be receptive to
> all information regardless of its nature. Be serious. Maintain control
> of the interview. Don't make promises you can't keep.
>
> 3\. Place the witness at ease. Explain that the purpose of the
> interview is for accident prevention purposes and that you only seek
> the facts related to the accident.
>
> 4\. Inform the witness that a promise of confidentiality cannot be
> given.
>
> 5\. Read the witness\'s written statement (if available) before the
> interview.
>
> 6\. Permit witnesses to tell the story in their own words (do not
> interrupt).
>
> 7\. Be a good listener. Be unobtrusive in note taking. Maintain
> self-control during the interview. Don't become emotionally involved
> in the investigation.
>
> 8\. Investigation team members should coordinate their questions at
> the direction of the Chief Investigator.
>
> 9\. The interviewer should ask follow up interview questions of the
> witness. Do not assist the witness in answering questions.
>
> 10\. Avoid revealing to the witness items discovered during the
> investigation.
>
> 11\. Avoid contemptuous attitudes. Avoid controversial matters.
> Respect the emotional state of the witness.

7.5. TYPES OF QUESTIONS

A. General Questions. General questions are open-ended, broad questions
that are useful in getting the witness to talk. Examples are: "What did
you see?" "Tell me everything you can recall." "Tell me more about
that."

B. Directed Questions. Directed questions address the subject in a
direct manner and get the witness to focus on a specific subject without
guiding him or her to what he or she may have seen. For example: "Did
you notice any lights on the vehicle?"

C. Specific Questions. Specific questions are needed for specific
information. For example: "Did you notice any flashing lights?" "What
color was the light?"

D. Summary Questions. Summary questions help the witness organize his or
her thoughts and draw attention to possible additional information.
Restate what you think the witness told you in your words and ask if
that's correct. Frequently, the witness will add more information.

E. Leading Questions. Avoid leading questions. A leading question is one
that contains or implies the desired answer. Once you ask a leading
question, you have forever frozen an idea about what the witness is
supposed to have seen. For example: "Was a red light flashing?"

F. Techniques That Do Not Require Questions. Some interview techniques
do not require questions. A nod of your head or an expectant pause may
encourage the witness to talk. To keep a witness talking, say something
like "uh-huh," "really," or "go ahead." Another non-question technique
is to mirror or echo what the witness says. Repeat back to the witness
what they have just said without either agreeing or disagreeing with
them, such as "You say you saw smoke coming from the vehicle?"

7.6. SAMPLE WITNESS QUESTIONS

A. What is your name, work address, and phone number?

B. What is your duty station (location) and position (job title)?

C. Tell us, in your own words, what happened. Try to begin with when you
first noticed something?

D. What is your technical background, skills, or knowledge?

E. What is your connection with those involved in the accident?

F. At what time did you see the accident happen?

G. What attracted your attention to the accident?

H. What was the position of the vehicle or equipment and individual
involved in the accident when first seen?

I. What was the direction of travel, fall, or final resting place of the
vehicle or equipment and individual involved in the accident? (Have the
witness draw a diagram, if appropriate.)

J. What was the weather like at the time of the accident? (Determine if
it was clear, sunny, rainy or smoky; what the wind conditions were, such
as gusty).

K. What actions did you take at the accident site?

L. Were there any other eyewitnesses around? Do the police have other
witnesses\' names?

M. Do you wear glasses, other corrective lenses, or a hearing aid? What
type? Did you have your glasses or hearing aid on?

N. Is there any additional information you would like to provide?

####### Chapter 7---Interviews and Witness Statements

### Exhibit 7-1

### Memorandum of Interview

+---------------------------+---------------------------+------------+
|                           | Page \_\_\_\_\_ of        |            |
|                           | \_\_\_\_\_\_              |            |
+===========================+===========================+============+
| USDI - BLM                | MEMORANDUM OF INTERVIEW   |            |
+---------------------------+---------------------------+------------+
| 1\. Nature Of             |                           |            |
| Investigation:            |                           |            |
+---------------------------+---------------------------+------------+
| 2\. Name Of Person        |                           |            |
| Interviewed:              |                           |            |
+---------------------------+---------------------------+------------+
| 3\. Home Address (St.,    | 4\. Phone (H) (Area       |            |
| City, State, Zip Code):   | Code):                    |            |
+---------------------------+---------------------------+------------+
| 5\. Employer (Name And    | 6\. Phone (W) (Area       |            |
| Address):                 | Code):                    |            |
+---------------------------+---------------------------+------------+
| 7\. Location Of           | 8\. Name Of Interviewer:  |            |
| Interview:                |                           |            |
+---------------------------+---------------------------+------------+
| 9\. Others Present:       | 10a. Started              | 10b. Ended |
|                           |                           |            |
|                           | Date:                     | Date:      |
|                           |                           |            |
|                           | Time:                     | Time:      |
+---------------------------+---------------------------+------------+
| 11\. Remarks:             |                           |            |
+---------------------------+---------------------------+------------+
| 12\. Interviewer's        | 13\. Witness' Signature:  |            |
| Signature:                |                           |            |
+---------------------------+---------------------------+------------+

####### Chapter 8---Evidence Gathering and Documentation

8.1. GENERAL

A. Evidence is gathered for two primary reasons: 1) to help you
determine what happened and, 2) to provide documentation to support your
findings and causes. Evidence takes many forms (e.g., photos, witness
statements, site diagrams, technical references, equipment parts,
personnel records, and tear-down analysis).

B. The collection of this information begins almost immediately after
you arrive at the accident site. During the Agency Administrator's
Briefing, you should determine if they received a fax from the Bureau
Safety Manager or National Interagency Fire Center (NIFC) requesting
them to collect evidence. If they did, determine how much of the
requested evidence has been collected and take possession of it. For all
pertinent documentation that has not been collected, request that it be
secured until your team can retrieve it.

C. Once collected, all evidence must be logged in and tracked through
detailed Evidence and Chain-of-Custody Logs (Exhibits 8-1 and 8-2). If
one of the Serious Accident Investigation Team (SAIT) members takes a
piece of evidence away from the work area, its removal should be noted
on the chain-of-custody log.

8.2. TYPES OF EVIDENCE

A. Evidence is categorized into three types: human, material, and
environmental. As the investigation starts, begin to list the items you
want the team to acquire. One good way to do this is to take three
sheets of flipchart paper and place them on the wall in the team room.
Place one of the three evidence headings on each sheet. As you identify
items you want to acquire or check on, place that item on the
appropriate sheet. As items are acquired or discarded as not relevant,
place a check mark in front of that item or draw a line through it.

B. Sections 8.3, 8.4, and 8.5 give examples of types of evidence that
will help provide a thorough understanding of the systems in place prior
to the accident, and identify the inherent strengths and weaknesses in
management controls. In requesting the information, care must be taken
so as to not destroy, alter, or lose documentation, and to preserve
documentation for any subsequent legal proceeding.

8.3. TYPES OF HUMAN FACTORS EVIDENCE

A. Qualification and Training. Determine the qualifications and training
of individuals directly involved in the accident (e.g., operator,
passenger, supervisor). Identify any contributing factors, such as the
lack of operator certifications or insufficient training.

B. Duties. Identify the duties (e.g., primary and additional duties,) of
the individuals directly involved in the accident. Note any accident
contributing factors (e.g., work/rest schedules, employee fatigue).

C. Management. Management policies and procedures, manufacturers'
operator manuals, and standard operating procedures are written with the
intention of placing controls on human behavior. If these documents are
inadequate for the job to be performed by a given employee, the employee
may perform the job task unsafely. Determine organization, supervision,
and external control of the individuals directly involved in the
accident. Identify any accident contributing factors (e.g., supervisory
or organizational lack of safety emphasis or support).

D. Compliance. Note deviations from policies, procedures, practices, and
contract specifications directly involved in the accident (e.g., risk
assessments/job hazard analysis (JHA), safety equipment, and other items
pertinent to the accident).

E. Documents. Identify whether directives, operating guides, and
contracts were current, readily available, and properly used by
individuals associated with the accident. Review records specific to the
accident (e.g., inspections, dispatch and equipment logs, time and
attendance records).

F. Communications. Establish what the pre-accident, accident, and
post-accident communications were. Identify any communication factors
that contributed to the accident (e.g., coverage, faulty equipment).

G. Services. Determine whether contractual services, such as road
guards, traffic signs, or dispatch procedures contributed to the
accident.

H. Fatigue. At a minimum, a 72-hour pre-accident, work/rest analysis
should be conducted. This analysis should include an examination of time
and attendance records, as well as input from respective supervisors on
tasks completed and actual time worked (may not necessarily be reflected
on time and attendance records), off-duty activities, and sleep
duration/cycles.

I. Risk Management. Determine whether a risk assessment, JHA, or other
workplace analysis was developed and establish the role they played in
the work project or activity. Determine if a safety briefing was
conducted prior to beginning work. Exhibit 8-3 is a Human Factors
Accident and Incident Analysis checklist.

J. The following are examples of specific human factors evidence.

> 1\. Official personnel records/official medical records
>
> 2\. Private medical records
>
> 3\. Position descriptions
>
> 4\. Resumes
>
> 5\. Driver's license checks
>
> 6\. Training records
>
> 7\. Management policy statements
>
> 8\. Accident records
>
> 9\. OSHA log
>
> 10\. Time cards, work shift schedules
>
> 11\. Safety briefings
>
> 12 Employee reports of unsafe/unhealthful working conditions
>
> 13\. Safety communications
>
> 14\. Executive and safety committee minutes
>
> 15\. Employee suggestions
>
> 16\. Inspection reports
>
> 17\. Risk assessments
>
> 18\. Job hazard analyses
>
> 19\. System safety analyses
>
> 20\. Facility inspections
>
> 21\. Standard operating procedures
>
> 22\. Job or contract specifications
>
> 23\. Purchasing records (contracts, change orders, invoices)
>
> 24\. Regulatory standards
>
> 25\. Professional, trade, and union standards
>
> 26\. Emergency medical system records
>
> 27\. Coroner and medical examiner's reports
>
> 28\. Public affairs news releases
>
> 29\. News media reports
>
> 30\. Radio communication reports/transcripts
>
> 31\. Law enforcement reports

8.4. TYPES OF MATERIAL EVIDENCE

A. Equipment. Equipment evidence includes the tools, machinery, and
vehicles that employees use to perform job tasks. A number of accidents
are the result of improper use of equipment, not using equipment as
designed by the manufacturer, confusing designs or layouts, improper
maintenance, manufacturing design flaws, defeated guards, or abuse of
equipment.

B. Systems. Determine what equipment was involved in the accident and
its suitability to perform the work project or activity. Include any
pertinent maintenance records, preventive maintenance, inspections, and
approvals of maintenance personnel.

C. Survivability. Evaluate the ability and suitability of the
vehicle/system/equipment to perform the work project or activity and the
occupant compartment's structural integrity. Examples include:

> 1\. Impact conditions and crash (dynamic) forces
>
> 2\. Restraint and roll-over protection systems (used/non-used,
> equipped/non-equipped, seatbelts used/not used)

3\. Personal protective clothing and equipment, and safety equipment

4\. Backup and emergency systems

5\. Safety design

D. Position of all dials and gages. Note position of operating controls,
such as the gear shifter, parking brake, and lift/tilt controls.

E. Laboratory/Tear down Analysis. Special studies or tests may be needed
to determine the cause of the failure. These tests are usually conducted
by another agency or private laboratory to ensure impartiality. Review
the results of the equipment component analysis, if conducted.

F. Here are some examples of specific material evidence:

> 1\. Equipment, parts, and structures
>
> 2\. Manufacturer's operating instructions
>
> 3\. Equipment inspections
>
> 4\. Condition reports and operation logs
>
> 5\. Repair reports (documenting previous equipment failures)
>
> 6\. Building blueprints
>
> 7\. Facility design documents
>
> 8\. Facility layout diagrams
>
> 9\. Engineering orders
>
> 10\. Construction project files
>
> 11\. Equipment installation manuals
>
> 12\. Parts lists
>
> 13\. Maintenance schedules
>
> 14\. Maintenance procedures
>
> 15\. Building contract provisions
>
> 16\. Fabrication and design records
>
> 17\. Manufacturer's warranties
>
> 18\. Material consensus standards (ANSI, ATSM)
>
> 19\. Material safety data sheets

8.5. TYPES OF ENVIRONMENTAL EVIDENCE

A. Weather. Verify the weather conditions before, during, and after the
accident.

Identify any contributing factors, such as precipitation, temperature,
lighting, and visibility.

B. Physical Environment. Identify any contributing factors, such as
terrain features, working space, walking surfaces, altitude, vegetation,
slope, accessibility, dust, and smoke.

C. Types of environmental evidence include:

> 1\. Weather reports
>
> 2\. Meteorological analysis
>
> 3\. Weather damage analysis (lightning strike points, wind damage)
>
> 4\. Terrain maps
>
> 5\. Altitude
>
> 6\. Environmental hazards (smoke, fire, asbestos, radiation)
>
> 7\. River volume and speed
>
> 8\. Surface slip resistance
>
> 9\. Noise levels

8.6. EVIDENCE COLLECTION

A. It is your responsibility as Chief Investigator to identify what
evidence is required and see that it is collected and cataloged.

B. All members of the team may collect and catalog evidence.

C. Physical evidence, such as equipment and parts, needs to be \"bagged
and tagged\" at the time of collection. Large items such as vehicles or
construction items should be secured.

D. Exhibits 8-1 and 8-2 are examples of an evidence collection log and a
chain-of-custody log. The chain-of-custody log helps keep track of
pieces of evidence taken by team members for further testing or study.

E. The original or copies of all important paper evidence should be
placed in the permanent file.

####### Chapter 8---Evidence Gathering and Documentation

### Exhibit 8-1

### Evidence Log 

**EVIDENCE LOG (for Non-Photographic Evidence)**

**Incident Identification:**

**Evidence Custodian:**

+---------+---------+---------+---------+---------+---------+---------+
| **E     | *       | **Co    | **Desc  | **Re    | *       | **Date  |
| vidence | *Date** | llected | ription | marks** | *Person | S       |
| ID      |         | By**    | of      |         | Logging | igned** |
| N       |         |         | Evi     | **(l    | E       |         |
| umber** |         |         | dence** | ocation | vidence | **In**  |
|         |         |         |         | found,  | In**    |         |
|         |         |         |         | etc.)** |         |         |
|         |         |         |         |         | **(Si   |         |
|         |         |         |         |         | gnature |         |
|         |         |         |         |         | Requ    |         |
|         |         |         |         |         | ired)** |         |
+=========+=========+=========+=========+=========+=========+=========+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+

####### Chapter 8---Evidence Gathering and Documentation

### Exhibit 8-2

### Chain-of-Custody Log

**CHAIN-OF-CUSTODY LOG (for Non-Photographic Evidence)**

**Incident Identification:**

**Evidence Custodian:**

+---------+---------+---------+---------+---------+---------+---------+
| **Evi   | **Desc  | **Name  | **Name  | **Date  | **Name  | **Date  |
| dence** | ription | of      | and     | Item    | and     | Item    |
|         | of      | Person  | Sign    | Rec     | Sign    | Rec     |
| **ID**  | Item**  | Logging | ature** | eived** | ature** | eived** |
|         |         | Item    |         |         |         |         |
| **N     |         | Out**   | **of    |         | **of    |         |
| umber** |         |         | Person  |         | Person  |         |
|         |         |         | Re      |         | Re      |         |
|         |         |         | ceiving |         | ceiving |         |
|         |         |         | Item**  |         | Item    |         |
|         |         |         |         |         | Back    |         |
|         |         |         |         |         | In**    |         |
+=========+=========+=========+=========+=========+=========+=========+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+

####### 

####### Chapter 8---Evidence Gathering and Documentation

### EXHIBIT 8-3

### Human Factors Accident and Incident Analysis

**1. Sensory and Perceptual Factors**

Misjudgment of distance, clearance, speed, etc.

False perception caused by visual illusion

*Conditions that impair visual performance:*

Featureless terrain (such as a desert, dry lake, water, snow)

Darkness and poor visibility

Smoke and changing smoke patterns

Mountainous terrain or sloping runway

Anomalous light effects that cause flicker vertigo

Low contrast of objects to background or poor illumination

View into bright sunlight or moonlight

Shadows

Whiteout snow conditions

Spatial disorientation and vertigo

*Conditions that affect sense of body position:*

Loss of visual cues

Adverse medical condition or physiological condition (alcohol and drug
effects, hangover, dehydration, fatigue, etc.)

Moving head up and down, looking in and out to change radios, answering
or using cell phones

*Loss of situational awareness types:*

Geographic disorientation (such as deviation from route, loss of
position awareness)

General loss of situational awareness (such as failure to perceive
hazardous condition)

Erroneous situational assessment (misinterpretation of situation or
condition)

Failure to predict or anticipate changing conditions

False hypothesis confirmation bias (persistent false perception or
misconception of situation)

*Attention failure types (such as failure to monitor or respond when
correct information is available)*

Failure to visually scan outside the vehicle or equipment for hazards

Omission of checklist items

Failure to respond to communication or warning

*Control-action error:*

Failure to set, move, or reset control switch (lapse)

Unintentional activation of control switch (slip)

Control-substitution error (slip)

Control-reversal error (slip)

Control-adjustment or precision error (slip)

*Conditions that affect attention and situational awareness:*

Inattention (focus on information unrelated to tasks)

Channelization, fixation (psychological narrowing of perception)

Distraction (preoccupation with internal mental event or with external
event)

Task overload due to systems (such as communications)

Task overload due to equipment systems assignment factors

Cognitive workload (problem-solving concentration or information
overload)

Habit influence or interference

Excessive crew stress or fatigue

Excessive workload or tasking

Inadequate briefing or preparation

Inadequate training or experience for assignment

Negative learning transfer (such as during transition to new assignment)

Adverse meteorological conditions

Tactical-situation overload or display-information overload

Inadequate crew motivation or inadequate vigilance

Inadequate equipment design

**2. Medical and Physiological Factors**

Carbon monoxide poisoning

Self-medication (without medical advice or against medical advice)

Motion sickness

Incompatible physical capabilities

Overexertion while off duty

Influence of drugs or alcohol

Cold or flu (or other known illness)

Excessive personal stress or fatigue

Inadequate nutrition (such as omitted meals)

Hypoxia (lack of oxygen)

Heat

Cold

Stress induced by heightened state of alertness

Effects of smoke

Dehydration

Other medical or physiological conditions

*Conditions that may cause adverse medical or physiological state:*

Assignment tasking or job fatigue (such as on duty more than 14 hours,
late-night or early morning operations)

Cumulative fatigue (such as excessive physical or mental workload,
circadian disruption, or sleep loss)

Cumulative effects of personal or occupational stress (beyond
stress-coping limit)

Emergency condition or workload transition (from normal operation to
emergency operation)

Medical or physiological preconditions (health and fitness, hangover,
dehydration, etc.)

**3. Knowledge and Skill Factors**

*Inadequate knowledge of systems and procedures:*

Use of improper procedure

Ill-structured decisions

Failure in problem solving

Inadequate equipment control or inadequate accuracy and precision of
equipment maneuvering (skill-based error)

Breakdown in visual scan

Failure to see and avoid

Over or under reacting

Over or under controlling

Inadequate experience for complexity of assignment

*Misuse of procedures or incorrect performance tasks (rule-based
error):*

Failure to perform required procedure

Use of wrong procedure(s) or rule(s)

Failure to conduct step(s) in prescribed sequence

*Conditions that lead to inadequate operational performance:*

Lack or variation of standards

Loss of situational awareness in varying environment

Demonstration of performance below required proficiency standards or
current certification standards

Demonstration of inadequate performance or documented deficiencies

Inadequate essential training for specific task(s)

Inadequate recent experience or inadequate overall experience

Lack of sensory input

Limited reaction time

**4. Assignment Factors**

Failure of dispatch to provide correct critical information (such as
frequencies, location, other equipment or resources)

Poor communication with other assets (such as ground or aircraft)

Inadequate or faulty supervision from ground or tactical aircraft

Lack or variation of standards

Non-participant or non-communicative equipment or resources at the scene

Loss of situational awareness in varying environment

Changing plans tactics (change of teams on incidents)

Unanticipated change of radio frequencies

Intentional deviation from procedures

Unintentional deviation from procedures

Demonstration of performance below required proficiency standards or
currency standards

Demonstration of inadequate performance or documented deficiencies

Inadequate essential training for specific task(s)

Inadequate recent experience or inadequate experience for assignment

Transition (learning new equipment or operational systems)

Inadequate knowledge of tactical situation

Lack of sensory input

Limited reaction time

Smoke

Wind shifts

Changes in fire behavior

Low visibility

Unexpected or non-participant equipment, resources, or aircraft

Assignment intensity

Assignment creep

Assignment urgency

Failure to recognize deteriorating conditions

Time compression

Excessive communication demands

Past assignment success based on high-risk behavior

**5. Personality and Safety Attitude Factors**

Demonstration of overconfidence

Demonstration of excessive motivation to achieve assignment

Reckless operation

Demonstration of anger or frustration on the job

Demonstration of stress-coping failure (such as anger)

Overly assertive or non-assertive

Inadequate confidence to perform tasks or activities

Acquiescence to social pressure (from organization or peers) to operate
in hazardous situation or condition

Failure to report or act upon incidents of misconduct

Toleration of unsafe acts and behaviors

Poor equipment or assignment preparation

**6. Judgment and Risk Decision Factors**

Acceptance of a high-risk situation or assignment

Misjudgment of assignment risks (complacency)

Failure to monitor assignment progress or conditions (complacency)

Use of incorrect task priorities

Intentional deviation from safe procedure (imprudence)

Intentional violation of standard operating procedure or regulation

Violation of orders, regulations, or standard operating procedures
(SOPs)

Crew rest requirements

Inadequate training

Violated agency policy or contract

Failed to comply with agency manuals

Supervisor knowingly accepted unqualified crew

Failed to obtain valid weather brief

Accepted unnecessary hazard

Not current or qualified for assignment

Intentional disregard of warnings

Noncompliance with personal limits

Noncompliance with published equipment limits

Noncompliance with prescribed assignment parameters

*Conditions leading to poor safety attitude and risky judgment:*

History of taking high risks (personality-driven)

Pattern of overconfidence

Personal denial of wrongdoing

Documented history of marginal performance or failure

Excessive motivation (did not know limits)

Reputation as a reckless individual

Failure to cope with life stress (anger or frustration)

Overly assertive or non-assertive (interpersonal style)

Influenced by inadequate organizational climate or safety culture (such
as lack of adequate supervision)

**7. Communication and Crew Coordination Factors**

Inadequate assignment plan or brief

Inadequate or wrong assignment information conveyed to crew (dispatch
errors or supervisor errors)

Failure to communicate plan or intentions

Failure to use standard or accepted terminology

Failure to work as a team

Inability or failure to contact and coordinate with ground or aviation
personnel

Inadequate understanding of communication or failure to acknowledge
communication

Interpersonal conflict or crew argument during assignment

*Conditions leading to inadequate communication or coordination:*

Inadequate training in communication or crew coordination

Inadequate standard operating procedures for use of crew resources

Inadequate support from organization for crew coordination doctrine

Failure of organizational safety culture to support crew resource
management

**8. System Design and Operation Factors**

Use of wrong switch or lever or control

Misinterpretation of instrument indication

Inability to reach or see control

Inability to see or interpret instrument or indicator

Failure to respond to warning

Selection or use of incorrect system operating mode (mode confusion)

Over reliance on automated system (automation complacency)

*Conditions that contribute to design-induced crew errors:*

Inadequate primary equipment control or display arrangement

Inadequate primary display data or data format

Inadequate hazard advisory or warning display

Inadequate system instructions or documentation

Inadequate system support or facilities

Inappropriate type or level of automation, or excessive mode complexity

**9. Supervisory and Organizational Factors**

Not adhering to rules and regulations

Inappropriate scheduling or crew assignment

Failure to monitor crew rest or duty requirements

Failure to establish adequate standards

Failure to provide adequate briefing for assignment

Failure to provide proper training

Lack of professional guidance

Failure to support or negative support of crews

Failure to monitor compliance with standards

Failure to monitor crew training or qualifications

Failure to identify or remove a known high-risk employee

Failure to correct inappropriate behavior

Failure to correct a safety hazard

Failure to establish or monitor quality standards

Failure of standards, either poorly written, highly interpretable, or
conflicting

Risk outweighs benefit

Poor crew pairing

Excessive assignment tasking or workload

Inadequate assignment briefing or supervision

Intentional violation of a standard or regulation

*Failure to perceive or to assess correctly assignment risks, with
respect to:*

Hazards go unseen or unrecognized

Environmental hazards or operating conditions

Assignment tasking and crew skill level

Equipment limitations

*Conditions leading to supervisory failures:*

Excessive operations or organizational workload (imposed by the
organization or imposed by

organizational chain)

Inadequate organizational safety culture

Supervisor over-tasked

Supervisor untrained

Inattention to safety management (inadequate safety supervision)

Inadequate work standards or low performance expectations

Inadequate or bad example set by supervisors

Inadequate safety commitment or emphasis by supervisors

Organization lacked an adequate system for monitoring and correcting
hazardous conditions

Supervisors did not promote and reward safe behavior or quickly correct
unsafe behaviors

Organization did not have adequate policies and procedures to ensure
high-quality work performance

Organization had inadequate job qualification standards or training
program

Organization had inadequate internal communication

Organization had no system or an inadequate system for management of
high-risk employees

Organization had inadequate process or procedures for operational risk
management

Organization did not provide adequate human factors training

Organization did not ensure sufficient involvement of medical and
occupational health specialists

Organization did not establish or enforce acceptable medical or health
standards

**10. Maintenance Factors**

*Procedures:*

Unwritten

Unclear, not defined, or vague

Not followed

*Records:*

Discrepancies entered, but not deferred or cleared

Entries not recorded or not recorded in correct book(s)

Improper entries or unauthorized signature or number

Falsification of entries

*Publications, manuals, guides:*

Not current

Were not used for the procedure

Incorrect manual or guide used for procedure

Not available

*Training:*

Not trained on procedure

Training not documented

Falsified

Not current

*Personnel:*

Not properly licensed

Insufficient (staffing)

Improper or insufficient oversight

Not properly rested

*Management:*

Non-existent

Ineffective

Understaffed

Ineffective organization chart

Insufficiently trained

*Quality Assurance:*

Non-existent

Insufficiently trained

Ineffective

Not used when available

*Inspection Guides:*

Not available

Procedures not followed

Insufficient

Not current

Not approved

Not signed off

Falsified

Unapproved signature or number

*Tools or Equipment:*

Improper use or procedure

Not calibrated

Not used properly

Not trained for the special equipment or tool

Not used

No tool control program

####### 

####### Chapter 9---Wildland and Prescribed Fire Accident Investigation

9.1. GENERAL

A. Wildland firefighters work under extreme conditions and are exposed
to many hazards and associated risks. The wildland fire organization
operates under a concept of total interagency mobilization that moves
firefighters across the country as easily as rural departments move
across county lines. Because of this mobilization, it is imperative that
information about specific entrapments and the lessons learned from
these situations be disseminated to all wildland firefighters in a
thorough and timely manner. For this reason, most wildland fire agencies
that experience a burnover or fatality conduct a fire entrapment
investigation to review the circumstances of the incident. Such a review
can provide important insights and recommendations to improve wildland
fire safety.

B. Fire entrapments and/or deployments that do not result in a fatality
or the hospitalization of three or more individuals are not considered
serious accidents; however, they will be investigated at a lower level
(usually State level).

C. The investigation process, Factual Reports, and Management Evaluation
Reports are the same as for any other serious accident investigation.
This chapter addresses the terms and procedures that are unique to
wildland fire accidents.

9.2. WILDLAND FIRE DEPLOYMENTS, ENTRAPMENTS, AND FATALITIES PROTOCOL

The following information is specific to wildland fire deployments,
entrapments, and fatalities in conjunction with the previously stated
general information. In a wildland fire environment:

A. A deployment refers to the use of a fire shelter for protection
against fire.

B. "An entrapment is a situation where personnel are unexpectedly caught
in a fire behavior-related, life-threatening position where planned
escape routes or safety zones are absent, inadequate, or have been
compromised. An entrapment may or may not include deployment of a fire
shelter for its intended purpose. This situation may or may not result
in injury. They include near misses" (Reference: Investigating Wildland
Fire Entrapments, MTDC 9551-2845).

C. All motorized fire equipment vehicles involved in a burnover (e.g., a
fire engine) will be considered as an entrapment when personnel are
involved; otherwise, it will be considered damaged or destroyed property
and investigated as determined by local or State management.

D. A fatality is any death that occurs in the line of fire duty. This
includes travel to and from assigned incidents.

9.3. INITIAL RESPONSE

A. The unit or Incident Management Team that has experienced a fire
entrapment, deployment, or fatality needs to take some immediate
actions.

B. As soon as an entrapment, deployment, or fatality is verified, the
local unit agency dispatcher should initiate the contacts necessary to
meet legal and logistical requirements.

> 1\. Agency law enforcement personnel should be requested to assist in
> securing the site.

2\. The National Interagency Coordination Center (NICC) should be
notified.

3\. Higher level headquarters (Director/National/State Safety Managers)
should be notified.

4\. Contact any other agencies and individuals as required by local
incident response plans.

C. The unit or Incident Management Team shall report preliminary
information about a fire entrapment, deployment, or fatality associated
with wildland fire operations on the Wildland Fire Entrapment/Fatality
Initial Report Form NFES 0869. This form needs to be forwarded to the
agency administrator and NICC within 24 hours of the accident or
incident.

D. The unit or Incident Management Team should use the On-Site Wildland
Fire Injury and Fatality Protocol Checklist to ensure all required
actions have been taken.

9.4. TEAM COMPOSITION

A. As soon as a fire entrapment, deployment, or fatality occur the
agency having jurisdiction moves to establish an investigation team for
the specific incident.

B. Any fire-related serious accident investigation requires interagency
Serious Accident Investigation Team (SAIT) participation per the
Memorandum of Understanding (MOU) between the United States Department
of the Interior and the United States Department of Agriculture (Exhibit
9-1), meaning there will be at least one interagency representative from
the Department of Agriculture on Department of Interior incidents and
vice-versa.

C. Co-lead Investigations. Co-lead investigations will be conducted in
accordance with the MOU between the United States Department of the
Interior and the United States Department of Agriculture (Exhibit 9-1).

D. When a serious fire-related accident occurs affecting only personnel
of one agency, the Chief Investigator may be assigned by the responsible
agency. Chief Investigators must be outside the office that sustained
the accident.

E. Other individuals normally assigned to an entrapment, deployment, or
fatality investigation are:

> 1\. Fire operations specialist (normally at the Operations Section
> Chief level)
>
> 2\. Fire safety officer
>
> 3\. Fire behavior analyst (with experience in the incident fuel type)
>
> 4\. Fire weather meteorologist from the National Oceanic and
> Atmospheric Administration (NOAA) Fire Weather Service
>
> 5\. Fire equipment specialist from the Missoula Technology and
> Development Center
>
> 6\. Technical (professional) photographer
>
> 7\. Incident information officer

F. Investigators visiting the fireline should be escorted and trained in
the use of and have the following personal protective equipment (PPE):

> 1\. 8--inch high, lace-type work boots with non-slip (Vibram type),
> melt-resistant soles and heels
>
> 2\. Aramid (Nomex) shirts and trousers
>
> 3\. hard hat with chinstrap
>
> 4\. leather gloves
>
> 5\. fire shelter
>
> 6\. hand tool
>
> 7\. water canteen
>
> 8\. personal first aid kit

9.5. INVESTIGATION ELEMENTS

The investigation team will use procedures that apply to all serious
accident investigations. However, they will pay particular attention to
the following elements as they relate to this fire event.

A. Fire behavior

B. Environmental factors

C. Incident management

D. Control mechanisms

E. Involved personnel profiles

F. Equipment

9.6. ON-SCENE ACTIVITIES

A. When a fatality occurs on an entrapment, the victim should not be
moved without the specific permission of the sheriff or coroner/medical
examiner. Injured persons should receive emergency medical treatment and
transportation to a medical facility as soon as possible.

B. Tools, vehicles, personal equipment, and PPE (to include fire
shelters and other associated items) should be left where they are until
cleared for removal by the Chief Investigator. Law enforcement personnel
should be used to secure the site from outside disturbance and from
unauthorized visits by the media. Information gathered at the site of an
entrapment is often critical in reconstructing the events that occurred
and for identifying lessons learned so that recurrence can be avoided.

C. Once the investigation team arrives on the site (usually within 12
hours), the following tasks are undertaken:

> 1\. Photograph the entire scene before any items are removed. Specific
> areas requiring photographic documentation include overviews of the
> entrapment scene from the air. Aerial photographs show critical
> factors such as fuel types and burn patterns that may have contributed
> to the entrapment. When photographing from helicopters, be cognizant
> of rotor downwash that could disturb the site.
>
> 2\. Take general area photographs of the scene from the ground and
> large-format close-ups of damage to PPE and other fire fighting
> equipment. (Note: Laying a new yellow Nomex shirt and green Nomex
> trousers where an individual was burned over helps a photograph better
> show conditions as they were found.)
>
> 3\. Make a detailed site diagram showing the specific locations of
> individuals, equipment, roads, structures, and other important
> features. Small entrapment scenes can be mapped using a compass and
> pacing method from known landmarks or control points. On larger scale
> entrapments, which occur over areas covering more than a 3/8-mile
> area, global positioning system (GPS) may be a useful tool. A detailed
> site diagram is an essential part of the final investigation report.
>
> 4\. Observe the position of all items to help reconstruct the events
> that took place. After the visual review is complete, individual items
> of personal protective clothing and other equipment should be
> collected, tagged to indicate which person used them, and removed to
> the investigation team headquarters. These items should be protected
> and secured in the same manner as evidence.
>
> 5\. Natural terrain features at entrapment scenes can provide valuable
> information. Slope, aspect, drainage, fuel type, fuel loading,
> heat-set on grass and needles, and evidence of winds can all aid the
> investigator in determining the events that led to the entrapment.

9.7. ANALYSIS OF PROTECTIVE EQUIPMENT

A. PPE should be inspected for compliance with BLM policies on mandatory
and optional equipment for wildfires. It should also be inspected to
determine the manufacturer and if it was constructed in accordance with
accepted standards. The National Fire Protection Association

(NFPA) 1977 compliance label is a good indicator of compliance. Note:
BLM Standards may or may not be NFPA compliant.

B. Clothing subjected to radiant heat or direct flame contact should be
compared with industry examples to show temperature ranges in the
entrapment. Comparing after-burn conditions of equipment with the design
standard for the individual items can often help determine the
survivability of an entrapment. The Missoula Technology and Development
Center should analyze all PPE.

9.8. FIREFIGHTER AUTOPSY PROTOCOL

A. This protocol was developed by the U.S. Fire Administration for the
purpose of providing medical examiners and pathologists with uniform
recommended procedures for investigating the causes and contributing
factors related to firefighter deaths.

B. Family members are entitled to benefits under the U.S. Department of
Justice, Public Safety Officer Benefits Program, when \"public safety
officers found to have died as the direct and proximate result of a
personal injury sustained in the line of duty.\" (28 CFR 32.1)

C. To acquire these benefits, claimants are required to demonstrate that
the injury resulting in death was the direct result of activities
performed in the line of duty (as opposed to personal health, such as
coronary artery disease).

D. While every attempt will be made to provide this protocol to the
medical examiner at the same time the SAIT is dispatched, you should
follow up with the medical examiner to ensure it was received and is
being utilized.

#######  

####### Chapter 9---Wildland and Prescribed Fire Accident Investigation

### Exhibit 9-1

### Memorandum of Understanding

MEMORANDUM OF UNDERSTANDING

Between the

United States Department of the Interior

and the

United States Department of Agriculture

I. Purpose. This Memorandum of Understanding establishes the basis for
interagency investigation of serious fire-related accidents.

II\. Introduction. If the causal factors of a serious fire-related
accident are identified, effective corrective actions to prevent a
recurrence can be taken. Interagency investigations add perspective and
enhance the mix of skills and knowledge on the investigation team.
Interagency investigations are especially important where there are
common management and corrective action issues.

III\. Policy. Interagency investigations will be conducted whenever a
serious fire-related accident occurs on a USDA Forest Service managed
fire, Department of the Interior managed fire, or a jointly managed
fire. The National Transportation Safety Board, the USDA Forest Service,
and the Department of the Interior in accordance with established laws
and agreements will investigate aircraft accidents occurring during
wildland fire operations.

IV\. Definitions.

a\. Serious Fire-Related Accidents. Accidents occurring to personnel
participating in wildland fire suppression or prescribed burning
operations, or to personnel working in direct support of those
activities, which result in one or more fatalities or the
hospitalization of three or more personnel.

b\. Co-Lead Investigations. Team Leaders from both Departments and team
members from both Departments.

c\. Agency-Lead Investigations. Single team leader and team members from
both Departments.

V. Procedures. Interagency investigation teams will include personnel
from both the Department of the Interior and the Department of
Agriculture. Representatives of the Department of Labor, Occupational
Safety and Health Administration, will be invited to

participate in these investigations, or will be given full support to
conduct their own investigation.

a\. Co-Lead Investigations will be conducted whenever:

> 1\. A serious fire-related accident occurs on a USDA Forest
> Service/Department of the Interior jointly managed fire, or,
>
> 2\. A serious fire-related accident involving USDA Forest Service
> personnel occurs on a Department of the Interior managed fire, or,
>
> 3\. A serious fire-related accident involving Department of the
> Interior personnel occurs on a USDA Forest Service managed fire.

b\. Agency-Lead Investigations will be conducted whenever only one
agency is responsible for managing a fire, and a serious fire-related
accident occurs affecting only personnel of that same agency. The agency
responsible for managing the fire will lead the investigation.

VI\. Timeframes. The report should be completed and a copy submitted to
the appropriate Departmental Designated Safety and Health Official(s)
within 45-calendar days of the accident.

VII\. Training and Qualifications. Team Leaders, Investigators, and
Specialists will meet minimum training and qualification standards as
jointly established by the Department of Agriculture, the Department of
the Interior, and the National Wildfire Coordinating Group.

Assistant Secretary Operations Director of Operations

Director of U.S. Department of Agriculture U.S. Department of the
Interior

10/26/95

#######  

####### Chapter 10---Deliberations, Findings, Causes and Recommendations

10.1. GENERAL

At some point during the investigation, you will decide that all the
relevant data has been collected. The next task is to analyze the data
and to structure the results into a format that clearly shows the
relationship between the causal factors (human errors/material
failures/environmental factors) and the system inadequacies or root
causes that permitted them to occur. The process used to conduct this
analysis is termed \"deliberations\" and will be conducted with all team
members present.

10.2. DELIBERATIONS

A. The Team Leader is responsible for the supervision of deliberations
and, at a minimum, should discuss the following areas with the team
prior to beginning:

> 1\. Deliberation process that will be used.
>
> 2\. The products that the team will need to produce as a result of the
> deliberations.

a\. Accident chronology

> b\. Findings that sustained the accident sequence
>
> c\. Causes of the accident
>
> d\. Findings that did not contribute to the accident but could lead to
> other accidents if uncorrected
>
> e\. Recommendations to correct the causal findings identified

B. All appointed team members will attend the deliberations. (Note:
Advisors are not considered voting members, but may be included in the
deliberations.)

10.3. DELIBERATION PROCESS

> A. As Chief Investigator, you will help lead the deliberations in
> conjunction with the Team Leader. There are several different ways to
> effectively conduct deliberations. The following method is suggested
> for use if you don't have another preference. It ensures that all
> deficiencies are addressed, establishes the timeline, produces a
> written record of the deliberations, and provides a framework from
> which to write the analysis portion of the Report, which is the
> documentation of the team\'s deliberations.

B. Develop an accident chronology. This chronology will include events
leading up to the accident, the accident sequence, and actions taken
after the accident. This chronology will

probably have already been outlined during the investigation. Go through
it one more time to make sure that the timeline is complete and there
are no unexplained gaps. Consider the following in your chronology:

> 1\. Pre-Accident. Establish the sequence of events leading to the
> accident to answer the questions: who, what, when, where, why, and
> finally how the operation was to be conducted. Identify any
> pre-accident contributing factors. These may be things like an
> inappropriate sense of urgency, known weather issues that were not
> taken into consideration, equipment conditions or terrain, or
> management pressure to complete a job or task.
>
> 2\. Accident. Determine the accident sequence of events. Identify any
> accident contributing factors (e.g., use of seatbelts, worn tires,
> lack of information, mistakes). If a fire was involved, establish
> when, where, and how the fire started if possible. Determine flame
> propagation and if attempts were made to extinguish the fire. (Note:
> Fire in this subparagraph does not mean wildland fire.)
>
> 3\. Post-Accident. Identify the post accident sequence of events
> (e.g., search and rescue efforts, medical efforts), how the accident
> was first reported, and the locations of personnel/equipment at the
> conclusion of the accident. Describe rescue, first aid, and evacuation
> efforts. Identify all medical facilities that provided treatment. Note
> any disturbance to the accident site, security/preservation measures
> taken, and any post-accident contributing factors, (e.g.,
> rescue/medical response).
>
> 4\. Injuries. Record all injuries. Document the condition of the
> patients, and summarize autopsy reports, if applicable.
>
> 5\. Damage. Estimate the extent and cost of the equipment or property
> damage and define as minor, major, destroyed, or repairable.

C. Identify the findings. You will have looked at all the Human,
Material, and Environmental evidence. You probably have flipchart paper
on the wall or a whiteboard with these three headings and all findings
listed under them. At this point the team will identify findings. A
finding is a single event or condition. Each finding is an essential
step in the accident sequence, but each finding is not necessarily
causal. These findings have been placed on these sheets throughout the
investigation as they were discovered.

D. Identify the causes of the accident. A cause is a deficiency that the
correction, elimination, or avoidance of would likely have prevented or
mitigated the accident or significant injury.

E. After you determine the causes of the accident, go to the human,
material and environment lists on the flip charts described earlier.
Place all the findings in sequential order on a whiteboard or pieces of
flip chart paper. They are generally laid out in the following
categories:

-   Pre-Accident: historical (e.g., improper training); events preceding
    the accident (e.g., the deceased had only three hours of sleep the
    previous night)

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-   Accident: during the accident sequence (e.g., the right front tire
    blew out)

-   Post-Accident: post-accident actions (e.g., because of weather it
    took 25 minutes for emergency assistance to arrive at the scene of
    the accident)

> 1\. As you place them in sequential order, scratch them off the human,
> material, and environmental sheets.
>
> 2\. Some of the findings will not fit in the sequential list. If you
> are not sure about a finding, ask yourself this question, \"Would the
> accident still have occurred if this finding was not present?\" If the
> answer is no, leave this item out of the sequential order you are
> preparing. (Note: It is of utmost importance to impress on each team
> member that every finding, regardless of perceived individual
> importance, be brought to the attention of the entire board during
> deliberations.)

F. Listed below are examples of findings that are frequently found
during investigations.

1\. History

> • Medical problems
>
> • Personnel records (discrepancies)
>
> • Driving records (discrepancies with DA Form 348, training records,
> and SF-46)
>
> • The unit driver's training program was inadequate.
>
> • The activity wasn\'t approved.
>
> • There wasn't adequate preparation.
>
> • The employee wasn\'t qualified.
>
> • The employee\'s work/rest schedule did not comply with standards.
>
> • The equipment condition/maintenance trends indicated problems.
>
> • The written guidance was inadequate.
>
> • The operator had a number of previous accidents.
>
> • Risk management procedures weren\'t applied or weren\'t adequate
> (e.g., hazards identified and controls in place followed).
>
> 2\. Preparations
>
> • Vehicle checks were not completed properly.
>
> • Vehicle was not dispatched properly.
>
> • Written policies were not followed.
>
> • Other discrepancies

3\. Activity

> • Work not conducted as planned.
>
> • Material/maintenance problems
>
> • Logistical support problems
>
> • Weather conditions
>
> • Didn\'t adhere to written requirements.
>
> • Communication and coordination inadequate

4\. Post-accident

> • Egress, seat belt, or rollover protection system problems
>
> • Compromise, penetration, or reduction of occupiable space
>
> • Rescue (timeliness, problems with rescue)
>
> • Pre-accident plan (written instructions on what to do if an accident
> occurs)
>
> • Security of accident site

G. After completing this process, you will have a sequential listing of
all the findings that contributed to the accident.

H. Now go back to your original human, material, and environmental
lists. The remaining abnormalities will be classified as \"Other\"
findings because they were present, but did not contribute to, the
accident (e.g., unsafe equipment or operations you observed during your
investigation that could lead to a serious accident if not corrected).

10.4. ANALYSIS

A. After all of the findings have been identified, the team needs to
analyze each finding to determine the why. WHY did it happen?

B. The Team must continue to ask the question "why" to determine what
findings are causes. Many investigative teams do not do this, which
results in flawed recommendations that do not get to the root of the
problem.

> 1\. The \"why\" of human errors can be divided into four categories:
> standards failure, training failure, leader failure, and individual
> failure.
>
> a\. Standards Failure - Policies do not exist, or policies exist, but
> are not clear or practicable.
>
> b\. Training Failure - Policies exist, but are not known, or ways to
> achieve the policies are not known.
>
> c\. Leader Failure - Policies are known, but not enforced.
>
> d\. Individual Failure - Policies are known, but not followed.
>
> 2\. Material failures must also be investigated closely. Why did the
> material fail? While it is possible to have a totally unexpected
> failure, many times there are contributing factors that were known
> before the accident.
>
> 3\. Environmental conditions occasionally are the cause of an
> accident. A lightning strike is a classic example. When this occurs,
> look for human errors that may have exposed the employee to the
> environmental hazard.

10.5. RECOMMENDATIONS

A. For each cause or \"other\" finding identified, the team recommends a
course of action which has the best potential for correcting or
eliminating it. It is rare to not have a recommendation for a finding
that contributed to or caused an accident. It is also important to
specify who should take the corrective action. These recommendations,
once validated and approved by the Designated Agency Safety and Health
Official (DASHO), will be assigned to the appropriate parties for action
and their progress tracked.

B. Recommendations can vary widely in their scope and who is assigned
responsibility for implementing them. The Bureau level or organization
assigned responsibility for the corrective action should have sufficient
authority to implement the correction. In some cases, more than one
level in the Bureau or even other agencies will have action
responsibility.

C. The don'ts of making recommendations:

> 1\. Recommendations should not focus on punitive steps addressing an
> individual's failure in a particular case.
>
> 2\. Do not recommend briefing unit personnel on the accident. Such
> briefings are a basic management responsibility and a normal function
> of safety and health managers at all organizational levels.
>
> 3\. Do not recommend sweeping or general recommendations that cannot
> be closed out at the assigned action level(s).
>
> 4\. Do not recommend that a new policy, regulation, or SOP be written
> when existing guidance exists, but was not followed.
>
> 5\. Vague recommendations addressing the importance of simply doing
> one\'s job properly are also inappropriate. Allow for definitive
> completion of each recommendation.

D. If a recommendation depends on test results or analyses that are
incomplete when the Factual Report is sent in, explain this and
reference the test or analysis.

E. If the test results are critical to the completion of the Factual
Report, the team leader should request an extension from the individual
authorizing the accident investigation (failure to incorporate critical
information could result in reconvening the Serious Accident
Investigation Team (SAIT) at a later date).

10.6. DELIBERATION PRODUCTS

A. Upon completion of the deliberations, the team should have identified
the following:

1\. A chronology of the accident that includes findings that outline:

a\. Events leading up to the accident

b\. The accident sequence

c\. Rescue and recovery actions after the accident

2\. The events that were directly responsible for the fatality, injury,
or damage (Causes)

> 3\. Recommendations for correcting the causes and \"other\" findings
> identified

4\. A list of findings that were present, but did not contribute to the
event

#######  

####### Chapter 11---Reports and Briefings

11.1. INVESTIGATION REPORTS

This chapter discusses the various reports that are generally prepared
during an accident investigation. Exhibits at the end of the chapter
provide sample formats for your use.

A. Preliminary Report (24-Hour Report). This document contains the first
details of the accident. It is normally prepared by the manager of the
office sustaining the accident and transmitted to the Bureau Safety
Manager and to the Director, Office of Fire and Aviation (for fire
accidents), within 24 hours. If there is a delay in sending this report,
the Team Leader can prepare and transmit it within 24 hours after the
team arrives. It provides preliminary, factual information about the
accident and may contain preventive measures or recommendations of an
emergency nature. This information does not become part of the Factual
Report, but is retained as part of the case file (See Exhibit 11-1).

B. Expanded Report (72-Hour Report). This document contains a brief
narrative of the accident based on factual information gathered onsite.
It usually contains the number of victims, names of victims (if next of
kin notified), severity of injuries or property damage, and status of
the investigation (e.g., site surveyed, data collection ongoing,
witnesses being interviewed). It is drafted by the Chief Investigator,
working closely with the Team Leader, within 72-hours after arriving at
the accident site and is released under the signature of the Team
Leader. The Team Leader sends the Expanded Report to the Bureau Safety
Manager and to the Director, Office of Fire and Aviation (for fire
accidents). This information does not become part of the Factual Report,
but is retained as part of the case file (See Exhibit 11-2).

C. Safety Alert. If a safety hazard or action item is identified during
the course of the accident investigation that requires immediate action,
a Safety Alert will be developed to address the concern. Proposed safety
alerts will be submitted to the Bureau Safety Manager or Office of Fire
and Aviation (for fire related alerts) for consideration and national
distribution as applicable. (See Exhibit 11-3).

D. Final Report. After completion of the deliberations, the Team Leader,
along with the Chief Investigator, will draft the final report.
Depending upon the severity and complexity of the event, it may be wise
to have the report reviewed by an editor. If one is available locally,
or has been assigned to the team, use that person. Otherwise, the report
may be sent to the Office of Fire and Aviation, External Affairs Office,
for review and formatting. When an editor is used, the Serious Accident
Investigation Team (SAIT) should review and approve the revised version.
The final report consists of two parts, the Factual Report and the
Management Evaluation Report.

11.2. FACTUAL REPORT

A. The purpose of the Factual Report is to provide a narrative of the
events leading up to, during, and after the accident. It is based on an
examination of technical and procedural issues. Only the facts go into
this report; do not include inferences, conclusions, causes, or
recommendations. The report should provide:

1\. An executive summary of the event

2\. A chronology of the accident sequence

3\. Any post-accident actions (e.g., emergency response attributed to
survival of

victim)

> 4\. Attachments or addendum essential to support the factual
> information

B. The Team Leader or the Chief Investigator will prepare the Factual
Report using the following format (see Exhibit 11-4).

1\. Cover. Self-explanatory.

> 2\. Title Sheet. The Freedom of Information Act Disclaimer Statement
> ("This document contains materials for internal agency use only and is
> not releasable under the Freedom of Information Act"), the Privacy Act
> Statement, the name of the accident or the incident, the date of
> accident or incident, and the list of investigation team members and
> their respective agencies.

3\. Table of Contents. Include page numbers.

4\. Executive Summary. A brief description of the facts involved in the
accident.

> 5\. Narrative. A detailed chronological narrative of the events
> leading up to and including the accident, as well as rescue and
> medical actions taken after the accident. This section should spell
> out the who, what, when, and where in as much detail as possible.
>
> 6\. 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. For example, if the investigation revealed that there were
> no environmental findings that contributed to the accident, simply
> state that fact and move on to the next factor. Human factors or
> material factors paragraphs should not be formulated so as to draw
> conclusions, nor should they contain adjectives or adverbs to describe
> and thus render opinion into pertinent facts. Keep it simple. If the
> particular system or factors were not involved, say it simply.
>
> 7\. 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.
>
> 8\. Maps/Illustrations/Photographs. Graphic information used to
> document and visually portrays facts.
>
> 9\. Appendices. Excerpts, test results, factual data, and documents
> used to support the facts surrounding the accident that were used as
> reference information.
>
> 10\. Records. Factual data and documents used to substantiate facts
> involving the accident.

11.3. MANAGEMENT EVALUATION REPORT

A. The Management Evaluation Report is intended for internal use only
and explores management policies, practices, procedures, and personal
performance related to the accident. It takes the findings identified in
the factual report and categorizes them for management. This report may
contains:

1\. Executive Summary

2\. Findings identified in the Factual Report

> 3\. Causes of the accident
>
> 4\. Conclusions and observations
>
> 5\. Confidential information
>
> 6\. Recommendations for corrective measures
>
> 7\. Other findings, which if left uncorrected, could lead to future
> accidents.

B. The Team Leader or Chief Investigator will prepare the Management
Evaluation Report using the following format (see Exhibit 11-5).

> 1\. Cover. Self-explanatory.
>
> 2\. Title Sheet. The Freedom of Information Act Disclaimer Statement -
> "This document contains materials for internal agency use only and is
> not releasable under the Freedom of Information Act," the Privacy Act
> Statement, the name of the accident or incident, the date of the
> accident or incident, and the list of investigation team members and
> their respective agency.
>
> 3\. Table of Contents. Include page numbers.
>
> 4\. Executive Summary. Consists of a brief summary of the facts
> involving the accident.

5\. Findings. From the Factual Report.

6\. Causes. A cause is a deficiency that the correction, elimination, or
avoidance of would likely have prevented or mitigated the accident or
significant injury.

> 7\. Recommendations. Recommendations are prevention measures that
> management may take to prevent similar accidents. 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.
>
> 8\. Other Findings. Other findings that did not contribute to the
> accident but, if left uncorrected, could lead to other accidents.
>
> 9\. Enclosures. Information used to support the recommendations that
> were not included in the Factual Report.

11.4. MINORITY REPORT

Team members should be advised that, if they are not in agreement with
the factual and management reports, they may submit a minority report to
the Team Leader, which will be included with the Management Evaluation
Report. This report will:

> A. Only address points of disagreement
>
> B. Recommend alternative conclusions\
> C. Recommend alternate recommendations as appropriate\
> D. Be included with the Management Evaluation Report and the office
> file.

11.5. REPORT DUE DATE

The SAIT will provide its Final Report, which consists of the Factual
and Management Evaluation Reports, to the Bureau Designated Agency
Safety and Health Official (DASHO) within 45 calendar days of the
accident. In extreme circumstances, the Team Leader may request a short
extension from the Bureau Safety Manager.

11.6. DISTRIBUTION OF REPORTS

Upon completing the investigation, the Team Leader will forward three
copies of the Factual and Management Evaluation Reports to the Bureau
Safety Manager, Director, Office of Fire and Aviation for fire Serious
Accident Investigation Teams. The report will be processed in accordance
with DOI 485 DM.

11.7. DISPOSITION OF REPORT/CASE FILE.

A. The Factual Report may be released to the public and other agencies
for use as an accident prevention tool.

B. The Management Evaluation Report (MER) will not generally be released
to other agencies or the public because it contains opinions and
recommendations for internal use only. The MER of Fire investigation
reports will generally be released within the interagency fire
community.

C. The Bureau Safety Office is the "office of record" for accident
files. A case file containing the Factual Report, Management Evaluation
Report, and data that was gathered during the investigation, but is not
included in the report, will be sent to the Bureau Safety Office by
traceable means.

D. Physical evidence will be returned to the property manager, insurance
company, or owner under signed receipt. Return of contractor property
will be coordinated through the appropriate contracting officer. All
items that should be kept as evidence will be sent to the Bureau Safety
Office and kept with the case file.

11.8. RELEASE OF ACCIDENT REPORTS AND DOCUMENTS

Any request made under the Freedom of Information Act (FOIA) for copies
of accident Management Evaluation Reports and supporting documents shall
be forwarded immediately to the appropriate FOIA Officer. These
documents may contain privacy or other information that may be exempt
from mandatory disclosure under FOIA.

11.9. INVESTIGATION TEAM CLOSEOUT BRIEFING

A. The purpose of the closeout briefing is to tie up loose ends and
critique the team's performance. The Team Leader should facilitate the
closeout briefing. Exhibit 11-6 is a checklist that should help ensure
that the closeout covers the appropriate items. The closeout should
cover:

1\. Collection and destruction of all field notes

> 2\. Cleaning and turning in all equipment
>
> 3\. Follow on assignments for members after leaving the scene
>
> 4\. Critique of the investigative process(es) used
>
> 5\. Critique of the team's performance

B. The critiques are performed to ensure that any lessons learned from
the investigation can be captured. One effective way to do this is to
simply have each member of the team identify three things they liked
about the process and three things they would like to see improved.

C. Suggestions for process improvement should be sent to the Bureau
Safety Office and/or the Office of Fire and Aviation.

D. The possible need for critical incident stress debriefing (CISD) for
team members should be discussed. If there is an interest, the Team
Leader is responsible for ensuring that a CISD is scheduled and that
team members attend.

11.10. CLOSEOUT BRIEFINGS WITH EXTERNAL (TO THE TEAM) ENTITIES

A. The Team Leader will conduct the closeout briefing; however, the
Chief Investigator will likely be involved in a support role (see
Exhibit 11-7).

B. The Team Leader should stress the fact that the purpose of the
investigation, the report, and the supporting material is accident
prevention only.

C. The closeout briefing with the unit sustaining the accident should
cover:

> 1\. Unit support to the investigation. It would be appropriate to
> address any outstanding support that you received from the unit.
>
> 2\. The timeline of the accident
>
> 3\. Significant findings; particularly those that the unit should take
> immediate action on
>
> 4\. The cause(s) of the accident
>
> 5\. Other findings, which if left uncorrected, could lead to future
> accidents and any recommendations that have been identified.

D. The Team Leader should describe the process and timeline that is
required to get the report to the appropriate agencies for
approval/signature, and when they should see a signed report. The Team
Leader should also add that there is no need for the unit to wait until
the report is signed to take appropriate action on identified
recommendations.

E. The Team Leader and/or Chief Investigator may be requested by the
Bureau Director to make oral presentations to management on the opinions
and recommendations included in the report.

1\. Upon request by other agencies (e.g., OSHA, State organizations), a
formal presentation may be provided, detailing the findings of the
investigation.

2\. Upon completion of the investigation, the Bureau Director may be
requested to personally brief the Secretary to explain the accident and
corrective actions.

3\. It is likely that the Team Leader and the Chief Investigator will be
asked to participate in these briefings.

#######  

####### Chapter 11---Reports and Briefings

### Exhibit 11-1

### 24-Hour Report Cover Letter and Format

To: (Official Authorizing the Investigation)

Subject: Preliminary (24-Hour) Report

**THE FOLLOWING INFORMATION IS PRELIMINARY AND SUBJECT TO CHANGE**

LOCATION:

DATE OF OCCURRENCE:

TIME OF OCCURRENCE:

TEAM LEADER:

ACTIVITY:

NUMBER OF INJURIES:

NUMBER OF FATALITIES:

PROPERTY DAMAGE (such as to vessels, equipment, and structures):

NARRATIVE:

/s/ (Team Leader)

cc:

BLM Safety Manager

Official Case File

Office of Fire and Aviation Safety Manager (if a fire accident)

####### 

####### Chapter 11---Reports and Briefings

### Exhibit 11-2

### 72-Hour Report Cover Letter and Format

To: (Official authorizing the investigation)

Subject: Expanded (72-Hour) Report

NAME OF INJURED OR DECEASED (IF THE NEXT OF KIN HAVE BEEN NOTIFIED):

NARRATIVE (INCLUDE ALL OF THE 24-HOUR REPORT INFORMATION PLUS
MISSION/ACTIVITY INFORMATION):

PRELIMINARY FACTUAL FINDINGS:

/s/ (Team Leader)

cc:

BLM Safety Manager

Office of Fire and Aviation Safety Manager (if a fire accident)

#######  

####### Chapter 11---Reports and Briefings

### Exhibit 11-3

### Safety Alert Format

To: Bureau of Land Management Safety Manager

Subject: Safety Alert

NARRATIVE: IDENTIFY THE BASIC CIRCUMSTANCES SURROUNDING THE INCIDENT.

FINDINGS: IDENTIFY THE FINDINGS OF FACT THAT WARRANT A SAFETY ALERT.

RECOMMENDATIONS: IDENTIFY APPROPRIATE RECOMMENDATIONS.

(The Bureau Safety Manager or the Director of the Office of Fire and
Aviation will coordinate with appropriate staff and issue the Safety
Alert.)

/s/ (Team Leader)

cc:

BLM Safety Manager

Official case file

Office of Fire and Aviation Safety Manager (if a fire accident)

####### 

####### Chapter 11---Reports and Briefings

### Exhibit 11-4

### Accident Investigation Factual Report

######## - FOR OFFICIAL USE ONLY -

This document contains materials for internal agency use only and is not
releasable under the Freedom of Information Act.

####### Accident Investigation Factual Report

(Type of Accident

(Unit, Location)

(Region/Station/Area/Institute)

(City, State)

(Date of Accident or Incident)

Privacy Act

This report contains information protected by the Privacy Act.
Disclosure of protected information is a violation of the Privacy Act of
1974, as amended, (5U.SC. § 552a).

Copy \_\_\_\_of\_\_\_\_

### Exhibit 11-4 (cont)

### Accident Investigation Factual Report

Accident: (type of accident or incident and name of involved individual)

Location: (unit and location where accident occurred)

Date: (date of accident)

Investigation Team Leader: (name, title, location of home unit)

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

Signature Date

Investigation Chief Investigator: (name, title, location of home unit)

Investigation Team Members:

(name, title, location of home unit)

(name, title, location of home unit)

(name, title, location of home unit)

(name, title, location of home unit)

Investigation Technical Consultants:

(name, title, location of home unit)

(name, title, location of home unit)

### Exhibit 11-4 (cont)

### Accident Investigation Factual Report

Table of Contents. Include page numbers.

Executive Summary. Briefly summarize the factual report in a paragraph
or two.

Narrative. Place the accident chronology you developed in the
deliberation phase here.

Investigation Process. Summarize the appointment of the team and what
you did. Emphasize that you evaluated all of the human, material, and
environmental factors surrounding the event.

Findings. Identify all of the findings that support the accident
sequence. (DO NOT include causes and other findings that are not related
to this accident. They both go in the Management Evaluation Report)

Maps/Illustrations/Photographs. Graphic information used to document and
visually portrays facts.

Appendices. Excerpts, test results, factual data, and documents used to
support the facts surrounding the accident that were used as reference
information.

Records. Factual data and documents used to substantiate facts involving
the accident.

#######  

####### Chapter 11---Reports and Briefings

### Exhibit 11-5

### Management Evaluation Report

######## - FOR OFFICIAL USE ONLY -

This document contains materials for internal agency use only and is not
releasable under the Freedom of Information Act.

####### Management Evaluation Report

(Type of Accident)

(Unit, Location)

(Region/Station/Area/Institute)

(City, State)

(Date of Accident or Incident)

Privacy Act

This report contains information protected by the Privacy Act.
Disclosure of protected information is a violation of the Privacy Act of
1974, as amended, (5U.SC. § 552a).

Copy \_\_\_\_of\_\_\_\_

### Exhibit 11-5 (cont)

### Management Evaluation Report

Accident: (type of accident or incident and name of involved individual)

Location: (unit and location where accident occurred)

Date: (date of accident)

Investigation Team Leader: (name, title, location of home unit)

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

Signature Date

Investigation Chief Investigator: (name, title, location of home unit)

Investigation Team Members:

(name, title, location of home unit)

(name, title, location of home unit)

(name, title, location of home unit)

(name, title, location of home unit)

Investigation Technical Consultants:

(name, title, location of home unit)

(name, title, location of home unit)

### Exhibit 11-5 (cont)

### Management Evaluation Report

Table of Contents. Include page numbers.

Executive Summary. Briefly summarize the entire report in a paragraph or
two. The factual data portion should be identical to what is in the
Factual Report.

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.

Causes. A cause is a deficiency that the correction, elimination, or
avoidance of would likely have prevented or mitigated the accident or
significant injury.

Other Findings. Include the \"other findings\" not related to the
accident here along with your recommendations.

Recommendations. There will normally be a recommendation for each
finding. List the findings in the same order as the Factual Report has
them listed. Put the Team\'s recommendations under that finding and
specify who has the responsibility for implementing the recommendations.

Other Information (Optional). This paragraph can contain opinions by the
investigators, conclusions and observations, and confidential
information that the team feels is relevant for management's
consideration.

Enclosures. Enclose witness statements and other non-factual data needed
to support your recommendations that you did not put in the Factual
Report.

####### Chapter 11---Reports and Briefings

### Exhibit 11-6

### Investigation Team Closeout Briefing

### 

INVESTIGATION TEAM CLOSEOUT BRIEFING

The purpose of the closeout is to tie up loose ends and critique the
team's performance. Typically the following items are covered:

-   Collection and destruction of all field notes

-   Cleaning and turning in all equipment

-   Follow on assignments for members after leaving the scene

-   Critique accident process used

-   Critique team performance

-   Discuss need for critical incident stress debriefing (CISD) for
    members

Suggestions for process improvement that comes out of the closeout with
the team should be sent to the Bureau Safety Office or the Office of
Fire and Aviation.

Discuss the possibility of another closeout after the report is
published.

####### 

####### Chapter 11---Reports and Briefings

### Exhibit 11-7

### Closeout Briefing with Management

CLOSEOUT BRIEFING WITH MANAGEMENT

(Note: This briefing will be prepared by the Team Leader with the
assistance of the Chief Investigator.)

The most important thing to remember about closeout briefings is to use
a presentation method you are comfortable with. The Chief Investigator
may present a portion of the outbrief if you like. However, remember
that this briefing is yours. Many times you will make an impression on
management that is far more powerful than the one a Chief Investigator
can make.

You should reemphasize that the purpose of the investigation, the
report, and the supporting material is for accident prevention purposes
only.

The outbrief with the unit should cover the timeline of the accident,
any significant findings identified, and any preliminary recommendations
made by the SAI Team that need to be implemented immediately. Briefings
with groups other than the unit sustaining the accident will generally
not include recommendations.

Disciplinary actions should not be discussed---at all. Questions and
solicitations for your opinion in this matter should be handled very
carefully. A separate investigation (e.g., Board of Inquiry) may be
initiated by the Bureau Director to determine if any disciplinary
actions are appropriate.

It would be appropriate to address any outstanding support that you
received from the unit during the outbrief. Be careful about addressing
any negative issues with this subject; it may not be productive.

You should describe the process and timeline that you will follow to get
the report to the appropriate agencies for approval/signature, and when
they should see a signed report. You should also add that there is no
need for the unit to wait until the report is signed to take appropriate
action on the identified recommendations.

You have developed some opinions, thoughts, or ideas about the incident
by this time. Use your judgment in what to include and not include. Your
opinions and insights may have a significant

impact on the unit's ability to ensure that this type of accident never
occurs again. On the other hand, if you ramble on over a pet peeve, you
could also damage your credibility.

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####### 

####### Chapter 12---Accident Review Board (Forest Service Only)

12.1. ACCIDENT REVIEW BOARD

When investigating Forest Service accidents, the Factual Report and
Management Evaluation Report are not final. They are sent to an Accident
Review Board. The purpose of the Accident Review Board is to review the
draft Factual and Management Evaluation Reports. They review, accept,
reject, or modify recommendations contained in the Management Evaluation
Report. Development of the Accident Prevention Action Plan is the last
task of the Board. This action plan is based on the recommendations
approved by the Accident Review Board.

Note: The BLM\'s Board of Inquiry is completely different than the
Forest Service Accident Review Board. The Board of Inquiry has nothing
to do with safety or accident prevention; it examines the possibility of
employee misconduct.

12.2. ACCIDENT REVIEW BOARD COMPOSITION

A. The approving authority at the level authorizing the investigation
will designate a Chair and Accident Review Board Members within 21 days
of the completion date of the Factual Report and Management Evaluation
Report.

B. The Accident Review Board is made up of representatives with
expertise and knowledge in applicable areas. Accident Review Board
membership is held to a minimum (usually about five). There will be
times when non-board members will need to be present and make comments
during the Accident Review Board proceedings. Such participation is at
the discretion of the Chair. However, attendees must be limited to
individuals who have a connection to the accident or incident and who
can contribute in a positive manner to the process. Parties to
litigation, insurance representatives, and news media are specifically
prohibited from attending any portion of the proceedings.

12.3. DUTIES AND RESPONSIBILITIES

A. Chair. The Chair, who is a voting member of the Board, is appointed
by the approving authority at the level authorizing the investigation
and is charged with managing the Accident Review Board proceedings. The
Chair will transmit the final Factual Report and Management Evaluation
Report, recommendations, and action plans from the Accident Review Board
to the approving official.

B. Management Officials. Management Officials are voting members of the
Board who are selected from outside the unit where the accident
occurred. They provide information and advice to the Accident Review
Board on management-specific policies and procedures as related to the
accident.

C. Safety and Health Manager. The Safety and Health Manager is from the
organizational unit that initiated the investigation. This person is not
a member of the Board and, therefore, does not vote. The Safety and
Health Manager provides advice on safety and health matters as they
relate to the accident and facilitates the process of the Board.

D. Local Management Representative. A Local Management Representative is
selected to provide information and advice to the Accident Review Board
on local management-specific policies and procedures as related to the
accident. The Local Management Representative is not a member of the
Board and, therefore, does not vote.

E. Team Leader. The Team Leader presents the draft Factual and
Management Evaluation Reports to the Accident Review Board, and provides
assistance with the Accident Prevention Action Plan development. He or
she is not a member of the Board and does not vote.

F. Chief Investigator. The Chief Investigator assists the Team Leader in
the presentation of the draft Factual and Management Evaluation Reports.
He or she is not a member of the Board and does not vote.

G. Technical Specialists. Technical Specialists are selected to provide
technical assistance to the Accident Review Board within their area of
expertise as needed. They are not voting members of the Board.

H. Recorder. The Recorder will document the decisions and action plans
of the Accident Review Board and submit that documentation to the Chair
of the Accident Review Board. The Recorder is not a member of the Board
and, therefore, does not vote.

12.4. CONVENING THE ACCIDENT REVIEW BOARD

A. The Chair calls the Accident Review Board to order, introduces the
Accident Review Board Members and attendees, and discusses the purpose
and objectives of the accident review process.

B. The Team Leader and Chief Investigator present the draft Factual
Report. The Chair opens the draft Factual Report for discussion and
comment by the Accident Review Board Members. The Accident Review Board
Members either accept or reject the draft Factual Report.

C. The Team Leader and Chief Investigator present the draft Management
Evaluation Report to be finalized by the Accident Review Board. The
Accident Review Board accepts, rejects, modifies, or makes new
recommendations. Recommendations must be reasonable, feasible, and
relate to the cause(s) of the accident. However, every cause need not
have a recommendation. A reasonableness test must be applied to each
recommendation. Resources required to implement a recommended corrective
action must be weighed against value received, practicality, and allow
for definitive closure. Examples of possible recommendations:

> 1\. Referral to a management official for corrective action(s) related
> to hazardous conditions or practices
>
> 2\. Referral to a staff area (e.g., Health and Safety, MTDC, or a
> Resource Staff) for corrective design of equipment or job procedures
>
> 3\. Referral to a specialized team for further analysis to determine
> why specific causal factors existed (such a team would include
> specialists in the areas of concern, e.g., management, contracting,
> procurement, personnel, budget and finance, resource specialists,
> health and safety, engineering)

D. Vague recommendations, which address the importance of simply doing
one's job properly, are inappropriate. Issues not directly related to
the accident's cause must be administratively separated from the
accident prevention recommendations. These issues shall be addressed in
a separate transmittal letter from the Chair to the approving authority,
recommending that a collateral investigation be conducted to look into
the issue(s).

E. From the recommendations contained in the Management Evaluation
Report, the Accident Review Board develops a draft Accident Prevention
Action Plan to prevent similar accidents. The final Management
Evaluation Report includes probable cause(s), contributing factors, and
recommendations.

#######  

####### Chapter 13---Follow Up

13.1. GENERAL

All accident reports must be followed up on and closed out in accordance
with 485 DM Chapter 7, Appendix 1. Although this occurs after the
Serious Accident Investigation Team (SAIT) has completed its work, and
is not a function of the SAIT, it is important that the process be
understood.

13.2. REQUIREMENTS

A. The SAIT Investigation Final Report, consisting of the Factual Report
and the Management Evaluation Report, is due to the Bureau Safety
Manager within 45 calendar days of the accident occurrence, the Bureau
Safety Manager will review the report and forward it to the Designated
Agency Safety and Health Official (DASHO).

B. Within 21 working days of receipt of the Final Report, the First
Executive Level Manager (a Region, State, Area, or Division Director who
reports directly to the Bureau head) whose organization incurred the
accident must develop a corrective action plan and forward it to the
Bureau Safety Manager who will review it and forward it to the Bureau
DASHO. This individual is also responsible for implementing the
corrective action plan.

C. The Bureau DASHO, or their designee, must forward the reports, along
with the corrective action plan, to the Departmental DASHO. The
transmittal will include a statement of concurrence or non-concurrence
with the SAIT opinions and recommendations, identify any corrective
actions already taken or proposed, and identify recommendations for
actions by higher management and/or other agencies. This constitutes the
final, complete, serious accident report to the Department.

D. Within 90 days of the accident, the First Executive Level Manager,
whose organization incurred the accident, will personally brief the
Agency head on the accident, with an emphasis on identifying and
correcting any management deficiencies contributing to the accident.

E. The Agency Administrator will provide a status report to the Bureau
DASHO, through the First Executive Level Manager, at least every 90 days
until the appropriate corrective actions are implemented.

F. Once all corrective actions have been accomplished, the Bureau
Director, in conjunction with the Bureau DASHO, will notify the
Departmental DASHO, the Office of the Solicitor, and others as
appropriate. At this point the case is closed.