REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 365

1 Chapter 18

2 Reviews and Investigations 

3 Introduction

4 When an accident occurs, each agency will meet their agency-specific accident 

5 investigation (AI) reporting requirements (e.g., Department of the Interior [DOI] 

6 Safety Management Information System (SMIS) or USDA eSafety).

7 Reviews and investigations are used by wildland fire and aviation managers to 

8 assess and improve the effectiveness and safety of organizational operations.

9 Information (other than factual) derived from safety reviews and AIs should 

10 only be used by agencies for accident prevention and safety purposes.

11 Multiagency Cooperation

12 Many reviews and investigations involve cooperation between Federal, State, 

13 county, and municipal agencies. To comply with each agency’s authorities, 

14 policies, and responsibilities, a multiagency review or investigation may be 

15 necessary. A multiagency delegation of authority should be provided to outline 

16 roles, responsibilities, and expected deliverables.

17 The team leader or delegating official(s) should establish cooperative 

18 relationships with the other agencies involved in the review or investigation to 

19 ensure policies and responsibilities are met. This may involve negotiations, 

20 cooperative agreements, and coordination with the agency designated agency

21 safety and health official (DASHO) or the agency official who signs the 

22 delegation of authority.

23 Federal Interagency Investigations

24 Close calls or accidents that involve interagency (Forest Service [FS] or DOI) 

25 personnel and/or jurisdiction (e.g., FS firefighter injured on Fish and Wildlife 

26 Service [FWS] jurisdictional wildland fire and vice versa) shall be reviewed or 

27 investigated cooperatively and conducted at the appropriate level as outlined in 

28 this chapter.

29 Agency administrators will ensure that affected agencies are involved 

30 throughout the review/investigation process.

31 When an incident does not meet the serious accident criteria, the affected agency 

32 administrators should jointly decide what type and level of investigation will be 

33 conducted based on agency processes outlined in this chapter. Questions should 

34 be addressed to your agency wildland fire safety program manager.

35 Reviews

36 Reviews are methodical examinations of system elements, such as program 

37 management, safety, leadership, operations, preparedness, training, staffing, 

38 business practices, budget, cost containment, planning, and interagency or intra39 agency cooperation and coordination. Reviews do not have to be associated with 
CHAPTER 18 REVIEWS AND INVESTIGATIONS

366 Release Date: January 2023

1 a specific incident. The purpose of a review is to ensure the effectiveness of the 

2 system element being reviewed, and to identify deficiencies and recommend 

3 specific corrective actions. Established review types are described below and 

4 include:

5 • Preparedness review

6 • After action review (AAR)

7 • Fire and Aviation Safety Team (FAST) review

8 • Safety Assistance Team (SAT) visit

9 • Aviation Safety and Technical Assistance Team (ASTAT) review

10 • Wildland Fire Management Annual Report and Large Fire Review – (FS)

11 • Significant wildland fire review or (SWFR) - (DOI)

12 • Individual fire review

13 • Lessons learned review (LLR)

14 • Rapid lesson sharing (RLS)

15 • Declared wildfire review 

16 • Air Quality Exceedance Notice of Violation (NOV) review

17 Review Types and Requirements

Type When Conducted Delegating or 

Authorizing Official

Preparedness review Annually, or management 

discretion

Local/state/region/ 

national

After action review Management discretion N/A

Fire and Aviation Safety 

Team review

As fire activity dictates Geographic Area 

Coordinating Group

Safety Assistance Team 

visit

As fire activity dictates Local/state/region/ 

national

Aviation Safety and 

Technical Assistance 

Team review

As aviation activity 

dictates

State/regional aviation 

manager or MACG

Wildland Fire 

Management Annual 

Report and Large Fire 

Review (FS)

Washington Office

discretion

Washington Office

Significant wildland fire 

review (DOI)

Refer to Office of 

Wildland Fire (OWF)

Policy Memorandum 

2016-013

Agency director, agency 

administrator, or 

individual bureau 

direction

Individual fire review Management discretion Local/state/region/ 

national
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 367

Type When Conducted Delegating or 

Authorizing Official

Lessons learned review 

• NPS/FS – FLA may 

be used

Management discretion Local/state/region/ 

national

Rapid lesson sharing Management discretion N/A

Declared wildfire review See Interagency

Prescribed Fire Planning 

and Implementation 

Procedures Guide (PMS 

484)

See Interagency

Prescribed Fire Planning 

and Implementation 

Procedures Guide (PMS 

484)

Air Quality Exceedance

Notice of Violation

(NOV) 

See Interagency

Prescribed Fire Planning 

and Implementation 

Procedures Guide (PMS 

484)

See Interagency

Prescribed Fire Planning 

and Implementation 

Procedures Guide (PMS 

484)

1 Preparedness Review

2 Preparedness reviews assess fire programs for compliance with established fire 

3 policies and procedures outlined in the current Interagency Standards for Fire 

4 and Fire Aviation Operations and other pertinent policy documents.

5 Preparedness reviews identify organizational, operational, procedural, personnel, 

6 or equipment deficiencies, and recommend specific corrective actions. 

7 Interagency preparedness review checklists can be found at 

8 https://www.nifc.gov/standards. 

9 After Action Review

10 An after action review (AAR) is a learning tool intended for the evaluation of an 

11 incident or project in order to improve performance by sustaining strengths and 

12 correcting weaknesses. An AAR is performed as soon after the event as possible 

13 by the personnel involved. An AAR should encourage input from participants 

14 that is focused on:

15 • What was planned?

16 • What actually happened?

17 • Why it happened?

18 • What can be done the next time?

19 An AAR is a tool that leaders and units can use to get maximum benefit from 

20 the experience gained on any incident or project. When possible, the leader of 

21 the incident or project should facilitate the AAR process. However, the leader 

22 may choose to have another person facilitate the AAR as needed and 

23 appropriate. 

24 AARs may be conducted at any organizational level. However, all AARs 

25 involve the exchange of ideas and observations, and focus on improving 
CHAPTER 18 REVIEWS AND INVESTIGATIONS

368 Release Date: January 2023

1 proficiency. The AAR should not be utilized as an investigational review. The 

2 format can be found in the Interagency Response Pocket Guide (IRPG), PMS 

3 461, NFES 1077. Additional AAR information is available at 

4 https://www.nwcg.gov/wfldp/toolbox/aars.

5 Fire and Aviation Safety Team Review

6 A Fire and Aviation Safety Team (FAST) assists agency administrators during 

7 periods of high fire activity by assessing policy, rules, regulations, and 

8 management oversight relating to operational issues. They can also do the 

9 following:

10 • Provide guidance to ensure fire and aviation programs are conducted safely;

11 • Assist with providing immediate corrective actions;

12 • Review compliance with OSHA abatement plan(s), reports, reviews, and 

13 evaluations; and

14 • Review compliance with Interagency Standards for Fire and Fire Aviation 

15 Operations.

16 FAST reviews can be requested through Geographic Area Coordination Centers 

17 (GACC) to conduct reviews at the state/regional and local level. If a more 

18 comprehensive review is required, a national FAST can be ordered through the 

19 National Interagency Coordination Center (NICC).

20 FASTs include a team leader, who is either an agency administrator or fire 

21 program lead with previous experience as a FAST member, a safety and health 

22 manager, and other individuals with a mix of skills from fire and aviation 

23 management.

24 FASTs will be chartered by their respective Geographic Area Coordinating 

25 Group (GACG) with a delegation of authority, and report back to the GACG.

26 FAST reports will include an executive summary, purpose, objectives, 

27 methods/procedures, findings, recommendations, follow-up actions (immediate, 

28 long-term, national issues), and a letter delegating authority for the review. 

29 FAST reports should be submitted to the GACG with a copy to the Federal Fire 

30 and Aviation Safety Team (FFAST) chair within 30 days. See appendix L for 

31 sample FAST delegation of authority.

32 Safety Assistance Team Visit

33 In addition to FAST reviews, Safety Assistance Team (SAT) visits emphasize 

34 engaging individual firefighters, managers, and administrators to grasp potential 

35 issues, with a focus on firefighting safety fundamentals. SAT visits are not 

36 inspections. SATs are often ordered when activity within an area escalates 

37 rapidly, or when a high level of activity has been occurring for a long time. 

38 SATs can be single agency or interagency in scope and composition.

39 The goals of a SSAT are to:

40 • Assist fire managers and IMTs with site visits with firefighters, fire 

41 managers, and program leaders.

42 • Be service oriented, assisting the local units.
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 369

1 • Provide early warning of potentially hazardous conditions or situations.

2 Direct intervention, circumventing normal chain of command, is authorized 

3 when necessary; however, the overall objective is to create a work environment 

4 where the normal operating procedures are responsible for safe practices.

5 Aviation Safety and Technical Assistance Team Review

6 Refer to chapter 16 for Aviation Safety and Technical Assistant Team (ASTAT) 

7 information.

8 Wildland Fire Management Annual Report and Large Fire Review (FS)

9 The Washington Office, Director of Fire and Aviation Management, will select 

10 a subset of fires for review based on complexity and national significance, 

11 ensuring the selected fires provide a cross-sectional representation of cost, size, 

12 and oversight complexity. The reviews will be multi-tiered and foster a working 

13 environment that will improve the decision-making process and develop a 

14 capacity for organizational learning. If a site visit is required, the Washington 

15 Office, Deputy Chief, State and Private Forestry, will notify the regional 

16 forester. The national review process can include real time analysis of fire 

17 information, informal discussions with fire managers and regional personnel, 

18 and/or site visits by a cadre of specialists to individual incidents and or 

19 geographic areas. For more detail, see FSM 5139.2.

20 Significant Wildland Fire Review (DOI)

21 A significant wildland fire review (SWFR) will be conducted when an incident 

22 (single-fire or complex) meets or exceeds Federal combined expenditures of $15 

23 million in suppression costs, and more than 50% of the burned acres are 

24 managed by one or more DOI bureaus. The DOI is responsible for advising the 

25 appropriate individual(s) within their agency of the need for a SWFR. When a 

26 multi-jurisdictional fire requires review, the DOI bureaus will determine which 

27 agency will be designated as the lead in the review process. The agency will 

28 provide a delegation of authority to the SWFR team authorizing the 

29 implementation of a review. When possible, SWFRs should be conducted when 

30 the incident management team (IMT) is still in place to allow prompt access to 

31 records and incident personnel. For more information, see 

32 https://www.doi.gov/sites/doi.gov/files/elips/documents/owf_policy_memo_201

33 6-13_criteria_for_review_wildfire_incidents.pdf. 

34 • BLM – The will initiate, facilitate, and provide oversight for the SWFR 

35 process when BLM is the lead DOI agency. Upon determination of the need 

36 for a SWFR, the Assistant Director, FAD, will coordinate with the 

37 appropriate state director and assemble a SWFR team, provide a delegation 

38 of authority, and initiate the SWFR using the BLM guidance found at 

39 https://web.blm.gov/internal/fire/budget/Reference_docs/reviews/reviews.ht

40 ml. The Assistant Director, FAD, will provide briefings to the BLM 

41 Director, as appropriate. 

42 • NPS – Management discretion determines when SWFRs will be conducted; 

43 the delegating official may be at the local, regional, or national level. See 
CHAPTER 18 REVIEWS AND INVESTIGATIONS

370 Release Date: January 2023

1 the agency administrator and fire management performance tables in

2 chapter 3 and the “Review Types and Requirements” table for further 

3 information.

4 Individual Fire Review

5 An individual fire review may also be conducted on incidents that do not rise to 

6 the level of a SWFR. Individual fire reviews examine all or part of the 

7 operations on an individual fire. The fire may be ongoing or controlled. These 

8 reviews may be local, state/regional, or national. These reviews evaluate 

9 decisions and strategies, correct deficiencies, identify new or improved 

10 procedures, techniques, or tactics, determine cost-effectiveness, and compile and 

11 develop information to improve local, state/regional, or national fire 

12 management programs. 

13 • BLM – Any fire that burns more than 50,000 acres of sagebrush rangelands 

14 will be evaluated by the FAD to determine if an individual fire review is 

15 warranted. If an individual fire review is warranted, the Assistant Director, 

16 FAD, will organize a review and provide oversight for the review team. 

17 Individual fire reviews may also be conducted when there are significant 

18 natural resource concerns or there are policy, political, social, or economic 

19 concerns, including significant impacts to infrastructure and energy-related 

20 corridors or there are significant and complicated cost-share or multi21 jurisdictional issues. 

22 Lessons Learned Review

23 The purpose of a lessons learned review (LLR) is to explore, investigate, or 

24 review unintended outcomes or near misses in order to learn from the event and 

25 prevent future occurrences. In order to learn from these events, conduct an LLR 

26 in an open, non-punitive manner. LLRs are intended to provide educational 

27 opportunities that foster open and honest dialog and assist the wildland fire 

28 community in sharing lessons learned information. LLRs provide an outside 

29 perspective with appropriate technical experts assisting involved personnel in 

30 identifying conditions that led to the unexpected outcome and sharing findings 

31 and recommendations.

32 An LLR should be tailored to the event being reviewed. The scope of the review 

33 should be commensurate with the severity of the incident. An LLR will not be 

34 substituted for a serious accident investigation (SAI) or other agency-specific AI

35 reporting requirements (e.g., DOI Safety Management Information System 

36 [SMIS] or United States Department of Agriculture [USDA] eSafety). 

37 • NPS – A facilitated learning analysis (FLA) may be used for incidents 

38 meeting the AI criteria.

39 • FS – A facilitated learning analysis (FLA) may be used for incidents 

40 meeting the AI criteria or if a coordinated response protocol (CRP) is not 

41 being utilized for an incident meeting SAI criteria. A guide for the FLA 

42 process is available at 

43 https://www.wildfirelessons.net/viewdocument/facilitated-learning-analysis44 and-l. The FS’s formal learning review processes are the FLA which may 
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 371

1 be used for unintended outcomes of all types and the CRP reserved for FS 

2 employee fatality events. Both processes are explicitly non-punitive and 

3 must have a delegation signed by a line officer so stating. Where 

4 appropriate, and for less serious incidents the FS may also use the rapid 

5 lesson sharing (RLS) process or other review process such as AARs which 

6 typically do not have a line officer’s delegation. In some cases, an FLA and 

7 an RLS may be produced for the same incident to quickly highlight lessons 

8 revealed in the learning process while the larger narrative is still being 

9 compiled. The FS does not use the SAI process but may assist other 

10 agencies in an SAI for incidents involving the FS interests or personnel. FS 

11 Aviation accidents and incidents utilize the FS aviation mishap 

12 investigation process. Current versions of the FLA and CRP guides can be 

13 found on the Wildland Fire Lessons Learned Center’s (LLC) website 

14 (https://www.wildfirelessons.net/viewdocument/facilitated-learning15 analysis-imple-1).

16 A LLR will be led by a facilitator not involved in the event. A facilitator should 

17 be an appropriate fire management expert who possesses skills in interpersonal 

18 communications, organization, and be unbiased to the event. Personnel involved 

19 in the event will be participants in the review process. Depending upon the 

20 complexity of the event, the facilitator may request assistance from technical 

21 experts (e.g., fire behavior, fire operations).

22 The LLR facilitator will convene the participants and:

23 • Obtain a delegation of authority from appropriate agency level. See 

24 appendix J for a sample LLR delegation of authority;

25 • Identify facts of the event (sand tables maybe helpful in the process) and 

26 develop a chronological narrative of the event;

27 • Identify underlying reasons for success or unintended outcomes;

28 • Identify what individuals learned and what they would do differently in the 

29 future;

30 • Identify any recommendations that would prevent future similar 

31 occurrences;

32 • A 24- and 72-hour report should be produced as an acknowledgement that 

33 an incident has occurred and to distribute initial facts about what happened. 

34 These preliminary reports are a valuable element of the many learning35 focused products that LLR teams may produce; and

36 • Provide a final written report, including the above items to the pertinent 

37 agency administrator(s) within two weeks of event occurrence unless 

38 otherwise negotiated. Names of involved personnel should not be included 

39 in this report (reference them by position).

40 A copy of the final report will be submitted to the respective agency’s national 

41 fire safety lead who will provide a copy to the LLC. Refer to 

42 https://www.wildfirelessons.net/aboutus. 
CHAPTER 18 REVIEWS AND INVESTIGATIONS

372 Release Date: January 2023

1 Rapid Lesson Sharing

2 RLS is a type of lessons learned review (LLR) for field personnel to quickly 

3 share lessons with others. An RLS can be used to document and share lessons 

4 learned as a result of close calls, minor accidents, successes, efficient ways of 

5 performing work, adaptations, or anything from which wildland fire personnel 

6 can learn.

7 To visit a searchable database with RLS documents, go to 

8 https://www.wildfirelessons.net/irdb.

9 To submit or view RLS documents, go to 

10 https://www.wildfirelessons.net/resources/rapidlessonsharing.

11 Declared Wildfire Reviews

12 Every prescribed fire resulting in a wildfire declaration will receive an outcome 

13 review. Declared wildfire outcome review direction is found in these agency

14 documents:

15 • Interagency Prescribed Fire Planning and Implementation Procedures 

16 Reference Guide (PMS 484)

17 ○ BLM – Refer to Fuels Management Manual 9214 and Handbook 9214-

18 1, chapter 5.

19 ○ NPS – Refer to RM-18, chapter 7 and 17.

20 ○ FWS – Refer to Fire Management Handbook, chapter 17.

21 ○ FS – Refer to FSM 5140.

22 ○ BIA – Refer to Bureau of Indian Affairs Fuels Management Program 

23 Supplement to the Interagency Prescribed Fire Planning and 

24 Implementation Procedures Reference Guide (December 2008), 

25 chapter 3.

26 Declared wildfire reviews will be submitted to the LLC by the agency fuels 

27 program lead. Submissions should be sent to kelly_woods@nps.gov. 

28 Air Quality Exceedance Notice of Violation Reviews

29 An Air Quality Exceedance Notice of Violation (NOV) review supports 

30 understanding of the planning, decisions, and actions taken that contributed to 

31 the NOV. Refer to https://www.nwcg.gov/publications/484. 

32 Investigations 

33 Investigations are detailed and methodical efforts to collect and interpret facts 

34 related to an incident or accident, identify causes or conditions that contributed 

35 to the accident (organizational factors, local workplace factors, unsafe acts), and 

36 develop control measures to prevent recurrence.

37 In addition to agency-specific AI reporting requirements (SMIS/eSafety), 

38 distinct types of wildland fire incidents and accidents have specific investigation 

39 requirements.
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 373

1 Wildland Fire Incident and Accident Types and Definitions

2 • Serious Wildland Fire Accident – An unplanned event or series of events 

3 that resulted in death, injury, occupational illness, or damage to or loss of 

4 equipment or property. For wildland fire operations, a serious accident 

5 involves any of the following:

6 ○ One or more job-related fatalities or imminently fatal injuries or

7 illnesses to employees, volunteers, contractors, or the public;

8 ○ The in-patient hospitalization of three or more employees, volunteers,

9 or members of the public due to departmental operations;

10 ○ Amputation(s) or loss of an eye(s);

11 ○ Property damage (including site mitigation or cleanup) or operating

12 loss of $500,000 or more, or (6) accident, illness; and/or

13 Incident that a Bureau DASHO judges to warrant further investigation

14 using the serious accident investigation procedures.

15 • Wildland Fire Accident – An unplanned event or series of events that 

16 resulted in injury, occupational illness, or damage to or loss of equipment or 

17 property to a lesser degree than defined in a “serious wildland fire 

18 accident.”

19 • Near-miss – An unplanned event or series of events that could have 

20 resulted in death, injury, occupational illness, or damage to or loss of 

21 equipment or property but did not.

22 • Entrapment – A situation where personnel are unexpectedly caught in a 

23 fire behavior-related, life-threatening position where planned escape routes 

24 or safety zones are absent, inadequate, or compromised. Entrapment may or 

25 may not include deployment of a fire shelter for its intended purpose. 

26 Entrapment may result in a serious wildland fire accident, a wildland fire 

27 accident, or a near-miss.

28 • Burnover – An event in which a fire moves through a location or overtakes 

29 personnel or equipment where there is no opportunity to utilize escape 

30 routes and safety zones, often resulting in personal injury or equipment 

31 damage.

32 • Fire Shelter Deployment – The removing of a fire shelter from its case and 

33 unfolding it to use as protection against heat, smoke and burning embers.

34 • Fire Trespass – The occurrence of unauthorized fire on agency-protected 

35 lands where the source of ignition is tied to some type of human activity.

36 AI types and final reports should be commensurate with the complexity and/or 

37 severity of the accident and focus on organizational learning and the prevention 

38 of reoccurrence. Investigations and reports may range from large investigation 

39 teams producing comprehensive AI reports to first-level supervisors initiating 

40 investigations and reporting injury/property damage in their agency-specific 

41 reporting systems (SMIS/eSafety). Final AI reports may range between agency42 specific accident reports, small one-page RLSs, LLR reports (simple or 

43 complex), to extensive investigation reports that follow the same format as a 

44 serious accident.
CHAPTER 18 REVIEWS AND INVESTIGATIONS

374 Release Date: January 2023

1 Investigation and Review Types and Requirements

Wildland Fire 

Event

Investigation or 

Review Type

Management Level 

Requiring 

Notification1

Management level 

that determines 

review type and 

authorizes review2

Serious wildland fire 

accident 

SAI

FS –FLA process or 

the CRP for FS 

employee fatality 

events.

National National

Wildland fire 

accident

SAI, AI, LLR, RLS, 

depending on 

severity. This is in 

addition to agencyspecific accident 

report (e.g., 

SMIS/eSafety)

NPS/FS – FLA may 

be used

BLM/NPS–National

FS/FWS –

Management 

discretion

Region/state/local

Entrapment/

burnover

SAI, AI, LLR, RLS

depending on 

severity

National National/regional/

state

Fire shelter 

deployment

SAI, AI, LLR, RLS 

depending on 

severity

National National/regional/

state

Near-miss LLR, AAR, RLS Management 

discretion

Region/state/local

Fire trespass Fire cause 

determination and 

trespass investigation

Local Local

1In the event that a wildland fire entrapment or fatality occurs, immediate notification to 

NICC is required. A Wildland Fire Fatality and Entrapment Initial Report (PMS 405-1) 

should be submitted to NICC within 24 hours. Submit this report even if some data is 

missing. The PMS 405-1 is located at https://www.nwcg.gov/publications/405-1. 2

Higher level management may exercise their authority to determine the type of review or 

investigation.

2 • BLM – When a BLM employee is involved, investigations will occur 

3 regardless of land jurisdiction. BLM agency administrators may jointly 

4 delegate authority to investigate accidents in cases of mixed jurisdiction or 

5 employee involvement. Joint delegations must ensure that BLM AI reporting 

6 requirements are met.

7 • FS – FS line officers are the deciding officials regarding what type of AI or 

8 analysis method is to be used for accidents or near misses occurring under 

9 FS jurisdiction.
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 375

1 Investigation Processes

2 Processes Common to All Wildland Fire Accident Investigations

3 • Site Protection – The site of the incident should be secured immediately 

4 and nothing moved or disturbed until the area is photographed and visually 

5 reviewed by the investigation team. Exact locations of injured personnel, 

6 entrapments, injuries, fatalities, and the condition and location of personal 

7 protective equipment (PPE), property, and other equipment must be 

8 documented.

9 • Management of Involved Personnel – Treatment, transport, and follow-up 

10 care must be immediately arranged for injured and involved personnel. The 

11 agency administrator or delegate should develop a roster of involved 

12 personnel and supervisors and ensure all personnel are available for 

13 interviews by the investigation team. The agency administrator should 

14 consider relieving involved supervisors from fireline duty until the 

15 preliminary investigation has been completed. Attempt to collect initial 

16 statements from the involved individuals prior to a critical incident stress 

17 management (CISM) session.

18 • Delegation of Authority – A delegation of authority shall be issued by the 

19 agency administrator to the investigation team leader. The delegation of 

20 authority will outline roles, responsibilities, and expected deliverables. 

21 Delegation of authority templates are available from agency fire safety 

22 program managers.

23 • Critical Incident Stress Management (CISM) – CISM is the 

24 responsibility of local agency administrators, who should have individuals 

25 preidentified for critical incident stress debriefings. Also refer to the Agency

26 Administrator’s Guide to Critical Incident Management (PMS 926), 

27 available at https://www.nwcg.gov/publications/926. Individuals or teams 

28 may be available through employee assistance programs (EAP) or GACCs. 

29 Wildland Fire Accident Investigation Process

30 • FS – The wildland fire AI process is not applicable to FS accidents. The 

31 FS’s formal learning review processes are the FLA which may be used for 

32 unintended outcomes of all types and the CRP reserved for FS employee 

33 fatality events. Both processes are explicitly non-punitive and must have a 

34 delegation signed by a line officer so stating. Where appropriate, and for 

35 less serious incidents the FS may also use the RLS process or other review 

36 process such as AARs which typically do not have a line officer’s 

37 delegation. The FS does not use the SAI process but may assist other 

38 agencies in an SAI for incidents involving the FS interests or personnel. FS 

39 aviation accidents and incidents utilize the FS aviation mishap investigation

40 process. 

41 Accident investigations and reports should be commensurate with the 

42 complexity and/or severity of the accident and focus on organizational learning 

43 and the prevention of reoccurrence. Investigations and reports may range from 
CHAPTER 18 REVIEWS AND INVESTIGATIONS

376 Release Date: January 2023

1 large investigation teams producing comprehensive reports to first-level 

2 supervisors initiating investigations and reporting injury/property damage in 

3 agency reporting systems (e.g., SMIS/eSafety). Final accident investigation 

4 reports may range between agency-specific accident reports, small one-page 

5 RLS, LLR reports (simple or complex), to extensive investigation reports that 

6 follow the same format as a serious accident.

7 Notification

8 When an accident occurs, agency notification requirements will be followed. 

9 Notification requirements universally include:

10 • Local dispatch center

11 • Unit fire management officer (FMO)

12 • Agency administrator

13 • Occupational Safety and Health Administration (OSHA) (Refer to chapter 7 

14 for reporting criteria.)

15 Investigation Team Membership

16 Investigation team membership should be commensurate with the complexity 

17 and/or severity of the accident. An investigation team should consist of a team 

18 leader and an adequate number of technical specialists and subject matter 

19 experts. For complex investigations, team membership may also include a chief 

20 investigator, a safety advisor/manager, and additional technical specialists, and a 

21 writer/editor. Team members may have dual roles (e.g., chief investigator/safety 

22 advisor).

23 Investigation Methodology

24 Accident investigations are detailed and methodical efforts to collect and 

25 interpret facts related to an accident and to provide specific recommendations to 

26 prevent recurrence. The AI may include the following actions:

27 • Visual inspection of involved site, equipment, or material;

28 • Detailed analysis of equipment or material, as necessary;

29 • Interviews with involved personnel, witnesses, managers, and other 

30 pertinent persons;

31 • Collection and review of written statements;

32 • Review of records, archives, plans, policies, procedures, and other pertinent 

33 documents;

34 • Consideration of environmental, equipment, material, procedural, and 

35 human factors as they related to the incident; and

36 • Development of specific findings and related recommendations for the AI 

37 report.

38 Accident Investigation 24- and 72-Hour Reports

39 The 24- and 72-hour reports should be completed when an AI will be conducted. 

40 Final 24- and 72-hour reports will be approved by the AI delegating official, 

41 then sent to the agency fire safety/risk management lead who will provide a 

42 copy to the LLC. Submissions should be sent to kelly_woods@nps.gov.
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 377

1 • 24-Hour Preliminary Report – This report contains known basic facts 

2 about the accident and will be completed and forwarded by the responsible 

3 agency administrator to the next higher level (e.g., district manager 

4 forwards to state director). Names of injured personnel will not be included 

5 in this report. Personnel may be referenced by position.

6 • 72-Hour Expanded Report – This report provides additional factual 

7 information, if available. The information may include the number of 

8 victims and severity of injuries. The focus should be on information that 

9 may have immediate impact on future accident prevention. The AI team 

10 will complete and forward the report to the AI delegating official. Names of 

11 injured personnel will not be included in this report. Personnel may be 

12 referenced by position.

13 Accident Investigation Final Report

14 Within approximately 60 calendar days of the accident, a final report shall be 

15 submitted to the senior manager dependent upon the level of investigation (e.g., 

16 local agency administrator, state/regional director, and agency fire director or 

17 their designee). If a lower-level investigation is conducted, a courtesy copy of 

18 the final report shall be sent to the respective agency’s national fire safety/risk 

19 management lead.

20 The final report (minus names of employees—they should be referenced by 

21 position) will be submitted to LLC by the respective agency’s national fire 

22 safety leads. Submissions should be sent to kelly_woods@nps.gov.

23 Accident Investigation Report Standard Contents

24 AI reports will vary in length, format, and complexity. Each report should be 

25 commensurate to the complexity of the incident and focus on organizational 

26 learning and the prevention of reoccurrence. The following list is common or 

27 standard contents often found in accident investigation reports.

28 • Executive Summary – A brief narrative of the facts involving the accident 

29 including dates, locations, times, name of incident, jurisdiction(s), number 

30 of individuals involved, etc. Names of injured personnel or personnel 

31 involved in the accident are not to be included in this report (reference them 

32 by position).

33 • Narrative – A detailed chronological narrative of events leading up to and 

34 including the accident, as well as rescue and medical actions taken after the 

35 accident. This section will contain who, what, and where.

36 • Investigation Process – A brief narrative of actions taken by the 

37 investigation team. This narrative should include investigation team 

38 membership, delegation of authority information (from who and contents, 

39 include a copy as an appendix), investigative actions and timeline (when the 

40 team conducted interviews, inspections, site visits, etc.), and if other sources 

41 were consulted (e.g., professional accident reconstruction experts, 

42 equipment manufacturers). This section may also address if environmental, 

43 equipment, material, procedural, and human factors were present, and state

44 how findings/recommendations were developed.
CHAPTER 18 REVIEWS AND INVESTIGATIONS

378 Release Date: January 2023

1 • Findings/Recommendations

2 ○ Findings – Developed from the factual information. Each finding is a 

3 single event or condition. Each finding is an essential step in the 

4 accident sequence, but each finding is not necessarily causal or 

5 contributing, and each finding may not have an associated 

6 recommendation. Findings should only include information necessary 

7 to explain the specific event or condition. Findings must be 

8 substantiated by the factual data. Findings should not include opinion 

9 or speculation.

10 ○ Discussion – This provides explanation or information pertinent to a 

11 specific finding.

12 ○ Recommendations – Recommendations are proposed actions intended 

13 to prevent similar accidents. Recommendations should be directly 

14 related to findings, should not contain opinion or speculation, and when 

15 appropriate, should identify the specific organization responsible for 

16 completing the recommended action. Recommendations will be 

17 evaluated and may be incorporated into future operational direction 

18 through established processes.

19 • Conclusions and Observations – Investigation team’s opinions and 

20 inferences, and lessons learned may be captured in the section.

21 • Reference Materials

22 ○ Maps/Photographs/Illustrations – Graphic information used to 

23 document and visually portray facts.

24 ○ Appendices – Reference materials (e.g., fire behavior analysis, 

25 equipment maintenance reports, agreements).

26 Examples of AI reports are available from agency fire safety program managers.

27 Wildland Fire Serious Accident Investigation Process 

28 For interagency serious accident investigations (SAI), a multi-agency delegation 

29 of authority to conduct the investigation may be issued. The delegation will 

30 ensure that the investigation meets the policy requirements of involved agencies.

31 • BLM/FWS – The Interagency Serious Accident Investigation Guide 

32 establishes core direction for BLM, FWS, and interagency SAIs (exceptions 

33 for aviation accidents are stated in the guide). The guide provides SAI

34 teams (SAIT) a standardized and comprehensive process for conducting 

35 SAIs. The guide is available at 

36 https://www.nps.gov/subjects/fire/upload/interagency-serious-accident37 investigation-guide.pdf. SAI reports will be completed, routed, and 

38 disseminated according to processes established in the guide. Reports may 

39 contain information supplemental to the requirements of the guide if it 

40 augments the BLM/FWS's ability to learn and to develop further 

41 improvements. The guide may be used entirely or in part for accidents that 

42 do not meet the serious accident definition.

43 • FS – The FS’s response to serious accidents includes the FLA which may 

44 be used for unintended outcomes of all types and the CRP reserved for FS 
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 379

1 employee fatality events. Both processes are explicitly non-punitive and 

2 must have a delegation signed by a line officer so stating. FS aviation 

3 accidents and incidents utilize the FS aviation mishap investigation process. 

4 Current versions of the FLA and CRP guides can be found on the LLC’s

5 website https://www.wildfirelessons.net/viewdocument/facilitated-learning6 analysis-and-l.

7 Fire Director Responsibilities

8 The fire director(s) or designee(s) of the lead agency, or agency responsible for 

9 the land upon which the accident occurred, will:

10 • Ensure the agency safety manager and DASHO have been notified;

11 • Immediately appoint, authorize (through delegation of authority), and 

12 deploy an accident investigation team;

13 • Provide resources and procedures adequate to meet the team’s needs;

14 • Receive the factual and management evaluation reports and take action to 

15 accept or reject recommendations;

16 • Forward investigation findings, recommendations, and corrective action 

17 plan to the DASHO (the agency safety office is the “office or record” for 

18 reports);

19 • Convene an accident review board/board of review (if deemed necessary) to 

20 evaluate the adequacy of the factual and management reports and suggest 

21 corrective actions;

22 • Ensure a corrective action plan is developed, incorporating management 

23 initiatives established to address accident causal factors; and

24 • Ensure SAIs remain independent of other investigations.

25 Agency Administrator Responsibilities

26 • Develop local preparedness plans to guide emergency response.

27 • Identify agencies with jurisdictional responsibilities for the accident.

28 • Provide for and emphasize treatment and care of survivors.

29 • Ensure the incident commander (IC) secures the accident site.

30 • Conduct an in-briefing to the investigation team.

31 • Facilitate and support the investigation as requested.

32 • Determine need and implement CISM.

33 • Notify home Tribe leadership in the case of a Native American fatality.

34 • Prepare and issue the required 24-hour preliminary report unless formally 

35 delegated to another individual.

36 Notification

37 Agency reporting requirements will be followed. As soon as a serious accident 

38 is verified, the following groups or individuals should be notified:

39 • Agency administrator;

40 • Public affairs;

41 • Agency law enforcement;

42 • Safety personnel;

43 • County sheriff or local law enforcement as appropriate to jurisdiction;
CHAPTER 18 REVIEWS AND INVESTIGATIONS

380 Release Date: January 2023

1 • NICC through the local dispatch center and GACC. Provide a Wildland 

2 Fire Fatality and Entrapment Initial Report (PMS 405-1) directly to NICC 

3 within 24 hours;

4 • Agency headquarters; and

5 • OSHA will be notified according to agency policy when an employee is 

6 killed on the job or suffers a work-related hospitalization, amputation, or 

7 loss of an eye. Refer to https://www.osha.gov/report.html.

8 ○ A fatality must be reported within 8 hours.

9 ○ An in-patient hospitalization, amputation, or eye loss must be reported 

10 within 24 hours.

11 Notification to the respective agency’s fire national safety/risk management lead 

12 is required.

13 Designating the Investigation Team Lead

14 The 1995 Memorandum of Understanding (MOU) between the U.S. Department 

15 of the Interior and the U.S. Department of Agriculture states that serious 

16 wildland fire-related accidents will be investigated by interagency investigation 

17 teams.

18 The Memorandum of Agreement (MOA) between Department of Agriculture 

19 Forest Service and Department of Interior augments and provides clarification 

20 to the 1995 MOU for investigation type and team lead/deputy team 

21 lead/interagency representative designation. The MOA also provides an 

22 interagency template for joint delegation of authority. The MOA is available 

23 from agency fire safety program managers.

24 Following initial notification of a serious accident, the agency DASHO will 

25 designate a SAI team leader(s) and provide that person(s) with a written 

26 delegation of authority to conduct the investigation and the means to form and 

27 deploy an investigation team.

28 • BLM/NPS/FWS – The agency DASHOs have delegated this responsibility 

29 to the respective agency fire directors.

30 • BLM – The FAD Safety Program Manager mobilizes SAITs in coordination 

31 with the SAI team leader.

32 Accidents involving more than one agency will require a collaboratively 

33 developed delegation of authority that is signed by each of the respective 

34 agencies.

35 Serious Accident Investigation Team Composition

36 Serious accident investigation team (SAIT) members should not be affiliated 

37 with the unit that sustained the accident.

38 Team Leader (Core Team Member)

39 The team leader is a senior agency management official, at the equivalent 

40 associate/assistant regional/state/area/division director level. The team leader 

41 will direct the investigation and serve as the point of contact to the designated 

42 agency safety and health official (DASHO).
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 381

1 Chief Investigator (Core Team Member)

2 The chief investigator is a qualified accident investigation specialist is 

3 responsible for the direct management of all investigation activities. The chief 

4 investigator reports to the team leader.

5 Accident Investigation Advisor/Safety Manager (Core Team Member)

6 The accident investigation advisor/safety manager is an experienced safety and 

7 occupational health specialist or manager who acts as an advisor to the team 

8 leader to ensure that the investigation focus remains on safety and health issues. 

9 The accident investigation advisor/safety manager also works to ensure strategic 

10 management issues are examined. Delegating officials or their designee may, at 

11 their discretion, fill this position with a trained and qualified National Wildfire 

12 Coordinating Group (NWCG) safety officer, line (SOFR), safety officer, type 2 

13 (SOF2), safety officer, type 1 (SOF1), or safety officer complex (SOFC).

14 Interagency Representative

15 An interagency representative will be assigned to every fire-related SAIT. The

16 interagency representative will assist as assigned designated by the team leader 

17 and will provide a perspective from outside the agency.

18 Technical Specialists

19 Technical specialists are qualified and experienced in specialized occupations, 

20 activities, skills, and equipment, addressing specific technical issues such as 

21 specialized fire equipment, weather, and fire behavior.

22 Public Affairs Officer

23 For investigations with high public visibility and significant news media 

24 interest, a public affairs officer (PAO) should be considered a part of the team. 

25 The PAO should develop a communications plan for the team, be a designated 

26 point of contact for news media, and oversee all aspects of internal and external 

27 communications. Ideally, the PAO should be qualified as a complex, type 1, or 

28 type 2 public information officer and be familiar with SAIT organization and 

29 function.

30 • BLM – All media-related documents (news releases, talking points, etc.) 

31 should be cleared through NIFC Public Affairs prior to external release.

32 Core SAIT members are required to take the Interagency Serious Accident 

33 Investigation Course (1112-05) prior to an SAI assignment. This training is 

34 required every 5 years to maintain currency unless the core SAIT member has 

35 completed an SAIT assignment within the last 5 years.

36 • BLM/FWS/FS – This training is required every 5 years to retain currency. 
CHAPTER 18 REVIEWS AND INVESTIGATIONS

382 Release Date: January 2023

1 Serious Accident Investigation 24- and 72-Hour Reports

2 The final 24-hour report will be approved by the agency administrator in 

3 concurrence with the SAI delegating official. The 72-hour report will be 

4 approved by the SAI delegating official. Both reports are sent to the agency fire 

5 safety/risk management lead who will provide a copy to the LLC. Submissions 

6 should be sent to kelly_woods@nps.gov.

7 • 24-Hour Preliminary Report – The 24-hour preliminary report contains 

8 known basic facts about the accident. The responsible agency administrator

9 will complete the report and forward to the SAI delegating official. Names 

10 of injured personnel will not be included in this report. Personnel may be 

11 referenced by position.

12 • 72-Hour Expanded Report – The 72-hour report provides additional 

13 factual information, if available. The information may include the number 

14 of victims and severity of injuries. The focus should be on information that 

15 may have immediate impact on future accident prevention. The SAIT will

16 complete and forward the 72-hour expanded report to the SAI delegating 

17 official. Names of injured personnel will not be included in this report; 

18 positions may be referenced.

19 Serious Accident Investigation Final Report

20 Within 60 calendar days of the incident, the SAIT will produce a final report 

21 consisting of a factual report and a management evaluation report and forward to 

22 the DASHO through the agency fire director(s).

23 • Factual Report (FR) – The FR contains a brief summary or background of 

24 the event and facts based only on examination of technical and procedural 

25 issues related to equipment and tactical fire operations. The FR does not 

26 contain opinions, conclusions, or recommendations. Names of injured 

27 personnel are not to be included in this report; positions may be referenced. 

28 Post-accident actions (emergency response attribute to survival of a victim, 

29 etc.) should be included in this report. FRs will be submitted to LLC by the 

30 respective agency’s fire safety/risk management leads. Submissions should 

31 be sent to kelly_woods@nps.gov.

32 • Management Evaluation Report (MER) – The MER is intended for 

33 internal use only and explores management policies, practices, procedures, 

34 and personal performance related to the accident. The MER categorizes 

35 findings identified in the FR and provides recommendations to prevent or 

36 reduce the risk of similar accidents.

37 Accident Review Board/Board of Review

38 An accident review board/board of review is used by some agencies to evaluate 

39 recommendations and develop a corrective action plan. Refer to the respective 

40 agency’s safety and health policy.
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 383

1 Fire Cause Determination and Trespass Investigation

2 Introduction

3 Agency policy requires determination of cause, origin, and responsibility for all 

4 wildfires. Accurate fire cause determination is a critical first step for a 

5 successful fire investigation and for targeting fire prevention efforts. Proper 

6 investigative procedures, which occur concurrent with initial attack, more 

7 accurately pinpoint fire causes and can preserve valuable evidence that would 

8 otherwise be destroyed by suppression activities. Fire trespass refers to the 

9 occurrence of unauthorized fire on agency-protected lands where the source of 

10 ignition is tied to some type of human activity.

11 Initiation of fire cause determination must be started with notification of an 

12 incident. Initial attack dispatchers are responsible for capturing all pertinent 

13 information when the fire is reported and throughout the incident. The initial 

14 attack IC and the initial attack forces are responsible for protecting the origin 

15 area and initiating fire cause determination and documenting observations 

16 starting with their travel to the fire. If probable cause indicates human 

17 involvement, an individual qualified in fire cause determination (wildland fire 

18 investigator [INVF] or cooperator equivalent) should be dispatched to the fire.

19 Policy

20 The agency must pursue cost recovery, or document why cost recovery is not 

21 required, for all human-caused fires on public lands. The agency will also pursue 

22 cost recovery for other lands under fire protection agreement where the agency

23 is not reimbursed for suppression actions, if stipulated in the agreement.

24 For all human-caused fires where negligence can be determined, trespass actions 

25 are to be taken to recover cost of suppression activities, land rehabilitation, and 

26 damages to the resource and improvements. Only fires started by natural causes 

27 will not be considered for trespass and related cost recovery.

28 The determination whether to proceed with trespass action must be made on 

29 “incident facts,” not on “cost or ability to pay.” Trespass collection is both a cost 

30 recovery and a deterrent to prevent future damage to public land. Pursue 

31 collection of costs, regardless of amount. This determination must be 

32 documented and filed in the unit office’s official fire report file.

33 Unless specified otherwise in an approved protection agreement, the agency that 

34 has the land management jurisdiction/administration role is accountable for 

35 determining the cause of ignition, responsible party, and for obtaining all 

36 billable costs, performing the billing, collection, and distribution of the collected 

37 funds. The agency with the fire protection responsibility role must provide the 

38 initial determination of cause to the agency with the land management 

39 jurisdiction/administration role. The agency providing fire protection shall 

40 provide a detailed report of suppression costs that will allow the jurisdictional 

41 agency to proceed with trespass procedures in a timely manner.
CHAPTER 18 REVIEWS AND INVESTIGATIONS

384 Release Date: January 2023

1 Each agency’s role in fire trespass billing and collection must be specifically 

2 defined in a relevant cooperative fire protection agreement between Federal and 

3 State cooperators. Federal agencies will follow established procedures for each 

4 agency and utilize the Intra-Governmental Payment and Collection (IPAC) 

5 system to transfer funds. 

6 Agency references:

7 • BLM – 9238-1 

8 • NPS – RM-18, chapter 6 and RM-9 

9 • FWS – 621 FW 1

10 • FS – FSM 5130 and FSM 5300

11 • BIA – For guidance regarding origin and cause determination on lands 

12 under the jurisdiction of the Bureau of Indian Affairs, see 90 IAM 1.4C (10) 

13 Wildland Fire Management - National Fire Investigation Handbook 

14 available at 

15 https://www.bia.gov/sites/default/files/dup/assets/public/raca/handbook/pdf/

16 90_iam_6-

17 h_wildfire_investigations_hb_final_signed_5.16.22_w.footer_508.pdf. 

18 • BIA – For guidance regarding fire trespass and damage to Indian forest 

19 products on lands under the jurisdiction of the Bureau of Indian Affairs, see 

20 53 IAM, chapter 7-H, Indian Forest Management Handbook – Forest 

21 Trespass, available at 

22 https://www.bia.gov/sites/bia.gov/files/assets/bia/ots/dfwfm/pdf/idc23 022535.pdf and https://www.bia.gov/policy-forms/handbooks.

24 Related Policy Documents

25 These documents provide specific direction related to incident and accident 

26 investigations.

Safety Prescribed Fire

DOI 485 DM, chapter 7

BLM DOI Occupational Safety and Health 

Program – Field Manual, 1112-1

NPS DO/RM-50B, RM-18, chapter 3 RM-18, chapter 7

FWS 240 FW 7

FS FSH-6709.11 FSM-5140

FSM-5100 and FSH-6709.11, FSM 5720 

(Aviation), FSM 5130 (Ground 

Operations), FSM 6730 (Specific 

Policy), FSH 6709.12 chapter 30 

(General Guidance), and most recent 

Accident Investigation Guide, for 

specific guidance.

Same as “Safety”
REVIEWS AND INVESTIGATIONS CHAPTER 18

Release Date: January 2023 385

Safety Prescribed Fire

Interagency Information on accident investigations 

may be found at 

https://www.nps.gov/subjects/fire/upload

/interagency-serious-accidentinvestigation-guide.pdf. For reporting 

use Wildland Fire Fatality and 

Entrapment Initial Report (PMS 405-1),

https://www.nwcg.gov/sites/default/files/p

ublications/PMS%20405-1.pdf

Same as “Safety”
CHAPTER 18 REVIEWS AND INVESTIGATIONS

386 Release Date: January 2023

(This page intentionally left blank.)