Supersedes 240 FW 7, FWM 441, 03/19/04
Series: Occupational Safety and Health
Part 240:Safety Program
Originating Office: Division of Safety and Health
TABLE OF CONTENTS
7.1 What is the purpose of this chapter? This chapter describes the U.S. Fish and Wildlife Service's (Service) policies and procedures for investigating and reporting accidents and incidents (employees should read it in conjunction with 054 FW 1, Serious Incident Notification Procedures).
7.2 What is the scope of this chapter?
A. This chapter applies when one of the following situations occurs due to operations that we conduct:
(1) Whenever anyone is injured, becomes ill, or dies;
(2) When property is damaged as a result of an accident; and
(3) Whenever an incident or near miss occurs that had the potential for serious injuries or significant property damage.
B. This chapter does not apply to aviation-related accidents. If an aviation-related accident occurs, report it in accordance with the Region’s Aviation Plan or the field station's Aviation Mishap Response Plan. See Part 330 for aviation-related accident reporting requirements.
A. The authorities for this chapter are:
(1) Occupational Safety and Health Act, Federal Agency Safety Programs and Responsibilities (Public Law 91-596 Sec.19).
(2) Executive Order 12196, Occupational Safety and Health Programs for Federal Employees.
(3) Executive Order 12564, Drug-Free Federal Workplace.
(4) Basic Program Elements for Federal Employee Occupational Safety and Health Programs and Related Matters (29 CFR 1960).
(5) Recording and Reporting Occupational Injuries and Illnesses (29 CFR 1904).
(6) Reporting Marine Casualties (46 U.S.C. Chapter 61).
(7) 485 DM 7, Incident/Accident Reporting/Serious Accident Investigation.
B. Table 7-1 provides links to other relevant Service Manual chapters that include information about responding to and reporting accidents.
Table 7-1: Other Relevant Service Manual Chapters
Serious Incident Notification Procedures
Motor Vehicle Accident Reporting
Aviation Safety and Mishap Prevention and Reporting
Physical Security in Service Facilities
Management of Officer-Involved Critical Incidents
A. Accident. The accidents we discuss in this chapter are those unplanned or unsought events that result in human injury, illness, or death to the people described in 29 CFR 1904.31 or in property damage.
(1) A serious accident involves:
(a) A death,
(b) Three or more people being hospitalized overnight,
(c) $250,000 or more in property loss, or
(d) An accident that the Assistant Director – Business Management and Operations believes warrants more investigation. We use the Interagency Serious Accident Investigation Guide to investigate serious accidents.
(2) Non-serious accidents are all other accidents not meeting the definition in 7.4A(1) above.
B. Incident. We use ‘incident’ in this chapter to describe an unplanned event that could have resulted in an accident, but did not. An incident is typically referred to as a “near miss,” and it is critical that we investigate them to determine contributing factors and record them in the Department of the Interior’s (Department) Safety Management Information System (SMIS). We must also account for them in preventive measures to ensure that an incident doesn’t turn into an accident with more severe consequences.
C. Shelter deployment. Shelter deployment is when someone removes a fire shelter from its case and uses it as protection against fire. A fire shelter may be deployed during a serious wildland fire accident, a non-serious wildland fire accident, or a near miss.
D. Entrapment. Entrapment is when someone is unexpectedly caught in a fire-related, life-threatening situation where planned escape routes or safety zones do not exist, are inadequate, or are compromised. Entrapment may involve deployment of a fire shelter and may result in a serious wildland fire accident, a non-serious wildland fire accident, or a near miss (see section 7.13A for more information).
Table 7-2: Responsibilities for Accident Investigations and Reports
Are responsible for…
A. The Director
Approving or declining to approve policy for accident investigations and reports.
B. The Assistant Director – Business Management and Operations [serving as our Designated Agency Safety and Health Official (DASHO)]
(1) Ensuring that we conduct serious accident investigations in accordance with 485 DM 7 and the Interagency Serious Accident Investigation Guide;
(2) Ensuring that the Director, the Department’s DASHO, and the Office of Occupational Safety and Health (OSH) are notified of serious accidents in a timely manner;
(3) Appointing serious accident investigation teams or trained investigators;
(4) Funding support for travel and expenses associated with serious accident investigations; and
(5) Convening an accident review board, if necessary.
C. Regional Directors
(1) Ensuring we have national level expertise in serious accident investigations by sending an adequate number of employees to the Interagency Serious Accident Investigation Training;
(2) Providing administrative or logistical support to serious accident investigation teams and trained investigators when requested;
(3) Ensuring the impacted program provides administrative, financial, and logistical support to any non-serious accident investigations that are necessary;
(4) Ensuring that staff develop a corrective action plan that addresses the serious accident investigation team’s or trained investigator’s recommendations in their Regions; and
(5) Ensuring that employees complete any corrective action plan requirements associated with serious accident investigations and share any lessons learned within their Regions, as appropriate.
D. The Chief, Division of Safety and Health
(1) Periodically reviewing the Department's SMIS reports to analyze relevant statistical information and using this information to determine relevant accident trends;
(2) Notifying the Assistant Director - Business Management and Operations (AD-BMO) when a serious accident occurs;
(3) Recommending to the AD-BMO when to appoint a serious accident investigation team or a trained investigator to conduct an investigation;
(4) Serving as the liaison between the Service and the Department to ensure that we provide and disseminate information, reports, and corrective action plans as required in 485 DM 7;
(5) Considering and approving or disapproving requests for extensions of the due date of the Factual and Management Reports from the serious accident investigation team’s leader or trained investigator, reviewing those reports, and sending them to the AD-BMO;
(6) Validating that the investigation team or trained investigator reports provide a complete account of the accident, that the facts support the causes identified, and that the recommendations for corrective action are realistic and attainable; and
(7) Preparing and disseminating summaries of serious accident investigation findings as lessons learned.
E. Regional Safety Managers
(1) Ensuring a member of their safety staff completes the Interagency Serious Accident Investigation Training course and serves as a trained investigator, chief investigator, accident investigation advisor, or technical advisor, if requested;
(2) Ensuring that within 7 calendar days of an SMIS report entry, Regional personnel review and edit them, if necessary, and then processing the reports into “Permanent Record” status in SMIS;
(3) At their discretion, conducting investigations of non-serious accidents and incidents, or assigning a trained investigator to conduct the investigation and call in subject matter experts; and
(4) Recommending focused safety training events, e.g., safety stand-down operations, as necessary.
F. Regional Fire Management Coordinators
Ensuring that employees report fire shelter deployments or fire entrapments (other than for training purposes) to the Deputy Chief of Fire Operations, National Fire Management Branch.
G. Project Leaders/Supervisors
(1) Notifying line management and the Regional Safety Office about serious accidents;
(2) Ensuring that allaccidents and incidents are reported as required in SMIS;
(3) Ensuring that staff report the types of incidents listed in 054 FW 1 to the Staff Duty Officer by calling the National Serious Incident Reporting line at 1-888-519-3606;
(4) Ensuring that employees report fire shelter deployments or fire entrapments (other than for training purposes) to the Fire Operations Program Chief, National Fire Management Branch; and
(5) Serving as a liaison or support person to members of serious accident investigation teams or trained investigators who are conducting investigations at their duty stations
7.6 Why does the Service investigate and report accidents and incidents? We investigate and report accidents and incidents to determine the facts and causes and develop corrective measures to prevent recurrences. The Occupational Safety and Health Administration (OSHA) and the Department also mandate that we investigate and report accidents and incidents. Employees and supervisors submit and complete accident reports electronically using SMIS, usually as part of the Department’s workers’ compensation claims filing process. This central collection of information allows Headquarters safety personnel and Regional Safety Officers to analyze accidents and incidents and identify why they happened.
A. What the employee does: Employees must immediately report to their supervisor every job-related accident and all incidents that had the potential to be serious accidents. Accidents may include:
(1) An occupational injury, illness, or death;
(2) An injury or death to a member of the public;
(3) Property damage related to Service operations, including:
(a) Private property damage;
(b) Property damage or injury resulting from the operation of General Service Administration (GSA) leased, privately owned, Service owned, or commercially leased/rented vehicles or motorized equipment; and
(c) Other property under Service control that is damaged by accident, whether or not it is to be repaired or replaced, and regardless of who caused the damage.
(4) Shelter deployments and entrapments that are the result of wildfire or prescribed fire-related operations. The Chief, National Fire Management Branch determines what type of team will investigate fire entrapments and fire shelter deployments and any other wildland fire accident or incident (see section 7.13A).
B. What the supervisor does:
(1) For serious accidents, the supervisor must:
(a) As soon as possible, notify line management and the Regional Safety Office. This initial notification should include the following information:
(i) Facility name,
(ii) Location of the accident,
(iii) Date/time of the accident,
(iv) Number of fatalities or people hospitalized,
(v) Local contact person and phone number, and
(vi) Brief description of the accident.
(b) Enter the accident in SMIS as soon as possible, but within 6 calendar days.
(2) For non-serious accidents or incidents:
(a) The supervisor must investigate and report the accident or incident electronically in SMIS as soon as possible but within 6 calendar days. The SMIS is the official Departmental method for reporting accidents and incidents.
(b) The field station’s Collateral Duty Safety Officer or Safety Committee may assist in the investigation to ensure that all relevant factors are identified and corrective actions are implemented.
(3) If the accident/incident meets the reporting requirements in 054 FW 1, either call the National Serious Incident Reporting line at 1-888-519-3606 or make sure someone else does.
C. What the Regional Safety Office does:
(1) For serious accidents, the Regional Safety Office notifies:
(a) The Division of Safety and Health, who notifies the AD-BMO;
(b) The Deputy Chief of Fire Operations, National Fire Management Branch if it’s wildlandfire-related;
(c) The appropriate OSHA area office by calling 1-800-321-OSHA (6742) within 8 hours if the accident involves:
(i) The death of an employee, or
(ii) One or more people being formally admitted to the in-patient service of a hospital or clinic for care or treatment as a result of a work-related accident.
(2) For non-serious accidents or incidents:
(a) The Regional Safety Manager may conduct an investigation of any accident or incident within his/her Region.
(b) Managers in the chain-of-command above the immediate supervisor may request a more thorough investigation be conducted at either the unit/station level or through the Regional Safety Manager. All costs associated with investigations conducted under this section are the responsibility of the Region where the accident occurred. Accident investigations and written reports other than those documented in SMIS should be conducted in accordance with the Interagency Serious Accident Investigation Guide.
D. When on travel:
(1) Some larger Service facilities, like the National Conservation Training Center, have procedures in place that require someone locally (such as an instructor) to fulfill the supervisor’s investigation and reporting responsibilities while employees are at the facility on travel status. In these cases, follow the facility’s procedures. Employees need to ensure their regular supervisor is also informed of the accident or incident and made aware of investigation and reporting actions taken by facility personnel.
(2) For all other accidents and incidents while in a travel status, follow the routine investigation and reporting requirements.
E. Reporting insect bites: We do not categorize insect bites as an accident or injury unless there is a reaction to the bite, or the employee seeks medical treatment.
(1) Some Regional Safety Offices have established a process for the supervisor to document reported insect bites, but the supervisors do not enter them into SMIS unless symptoms develop or medical treatment is obtained.
(2) In the absence of a Regional procedure, supervisors may enter insect bites into SMIS as a minor accident with no injury.
A. Without delay, obtain emergency aid for the injured and protect others from injury and property from unnecessary damage.
B. Notify line management and the Regional Safety Office as soon as possible. Provide the following information:
(1) Facility name,
(2) Location of the accident,
(3) Date/time of the accident,
(4) Number of fatalities or people hospitalized,
(5) Local contact person and phone number, and
(6) A brief description of the accident.
C. After the initial emergency response is complete, the manager in charge of the area where the accident occurred must call the National Serious Incident Reporting line at 1-888-519-3606 or make sure someone else does, and prepare for the arrival of the serious accident investigation team or trained investigator by:
(1) Ensuring the accident site is secured and remains secure. If necessary, barricade or isolate the scene with ropes, barrier tape, cones, guards, etc., to warn people and restrict access to the area.
(2) Ensuring that evidence is preserved. Record the location of evidence at the accident site with videotape, photos, or sketches. Do not disturb, collect, or remove evidence from the accident scene unless it is the only way to preserve it.
(3) Identifying witnesses and recording their contact information. Identify those who witnessed the event and anyone else who was in the accident area. Ask them to write down what they recall about the accident.
(4) Responding to requests for information from the Division of Safety and Health and preparing the 24-Hour Initial Report in accordance with the Interagency Serious Accident Investigation Guide.
A. For employees and volunteers who are killed or seriously injured while performing duties for the Service, whenever practical, we should notify the family in-person.
(1) We prefer that at least two Service representatives notify them. This team should consist of one member of the deceased employee’s discipline and a member of the management staff, at least one of whom should be in Service uniform.
(2) If the victim had identified someone to do this (e.g., through an emergency contact form), we must follow those wishes whenever possible.
(3) It may be necessary for local law enforcement officers to notify the family initially, but they should do this in coordination with Service representatives.
(4) If the family reside outside the local area, the supervisor should contact a law enforcement agency representative and a local Service representative to coordinate the death/injury notification.
(5) Service employee(s) who were close to the victim may also participate, with supervisory approval.
(6) Managers should direct other employees not to reveal any information outside appropriate Service channels concerning the victim until they are advised otherwise.
(7) Critical incident stress management personnel may be available or standing by to respond. The family should be advised about the availability of the free Employee Assistance Program for confidential counseling.
B. When an employee or volunteer dies, the servicing Human Resources/Capital Office prepares a letter for the signature of the Secretary of the Interior. The servicing Human Resources/Capital Office sends a draft to the Headquarters Division of Human Capital, and that office sends it through management channels to the Secretary for signature.
C. When the person who dies or is injured is not an employee or a volunteer, the investigating law enforcement authority having jurisdiction contacts the victim’s family.
A. Employees are entitled to payment of medical bills and reimbursement of lost wages associated with a work-related injury or illness. Filing for these benefits is optional and the choice of the injured/ill employee. Should the employee choose to file, the U.S. Department of Labor Office of Workers Compensation Program (OWCP) approves the claim if the employee provides sufficient evidence substantiating the injury or illness as job-related.
B. To initiate a claim, the employee must log on to SMIS, click on “Accident Reporting and Compensation Claims,” and complete the employee's module of the electronic Form CA-1as soon as possible. SMIS automatically notifies the employee’s supervisor by electronic mail that the employee’s module is complete. The supervisor must complete the supervisor’s module as soon as possible.
C. If the employee developed an illness due to recurring workplace exposures, the employee logs on to SMIS, clicks on “Accident Reporting and Compensation Claims,” and completes Form CA-2 for Occupational Disease. The employee and supervisor complete their modules as soon as possible.
D. The supervisor should print and provide the employee copies of the CA-1 or CA-2 and Receipt of Notice of Injury upon completion of the supervisor’s module in SMIS.
E. Employees must send medical evidence that they sustained a work-related injury to the Regional Injury Compensation Specialist (usually in the Human Resources/Capital Office or the Safety Office) within 10 calendar days from the date of the injury.
F. The employee or the supervisor must also send the Regional Injury Compensation Specialist the signed, hard copy original CA-1 or CA-2 for recordkeeping purposes.
G. The supervisor must also complete the “Supplemental Accident Report” in SMIS as soon as possible after completing the CA-1 and CA-2.
A. Appointing members to a serious accident investigation team: Within 24 hours of notification of a serious accident, the AD-BMO appoints a serious accident investigation team or a trained investigator to perform the investigation. The investigator(s) should be on the scene within 48 hours.
B. Composition of the serious accident investigation team: The team must have at least three members whose expertise will depend on the type of accident to be investigated. Each member must be from a Region other than the one where the accident happened, and they must not have functional responsibility for the activity or people involved. Team members should have completed the Interagency Serious Accident Investigation Training course within the past 5 years. The team consists of the following:
(1) Team leader: The team leader is normally a line officer or higher-level agency official, GS-14 or above. The AD-BMO selects leaders based on the severity of the accident and the level of management representation needed. The team leader should be of equivalent or higher grade than the manager of the organizational unit where the accident happened.
(2) Chief investigator: The chief investigator is responsible for managing the technical investigation activities and should be a fully qualified Safety and Health Specialist. Chief investigators should have served as an accident investigation advisor on a serious accident investigation team or have other accident investigation experience.
(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. The advisor should be a qualified Safety and Health Specialist who has completed, at a minimum, a basic accident investigation course (e.g., National Safety Council or OSHA accident investigation course) and the Interagency Serious Accident Investigation course.
(4) Technical specialists: Technical specialists may be requested by the AD-BMO; the Chief, National Fire Management Branch; the team leader; or the chief investigator to assist the team with technical details or skills needed for the investigation.
C. How the investigation runs:
(1) At the first meeting of the team, the team leader briefs the members on the following:
(a) The delegation of authority memorandum from the AD-BMO that establishes the team and explains that the reason for the investigation is for accident prevention purposes only.
(b) Background and known preliminary details of the accident, including the status of the accident scene (security, existing hazards, personal protective equipment required, etc.).
(2) The team investigates and completes reports according to the requirements in the Interagency Serious Accident Investigation Guide.
(3) The team (and other Service officials) use the information gathered during a serious accident investigation to determine the accident’s causes and do not use the information for punitive action.
A. The supervisor must investigate the accident and report the findings in SMIS.
B. The field station's Collateral Duty Safety Officer or Safety Committee may assist in the investigation to ensure that they identify all relevant factors.
C. The following officials may also choose to investigate the accident:
(1) The Regional Safety Manager may conduct an investigation of any non-serious accident or incident occurring within the Region.
(2) Managers in the chain-of-command above the immediate supervisor may request a more thorough investigation be conducted at either the unit/station level or through the Regional Safety Manager.
D. All accident investigations and written reports that are conducted beyond the basic SMIS report must follow the requirements in the Interagency Serious Accident Investigation Guide.
E. Costs associated with investigations of non-serious accidents are the responsibility of the Region where the accident happened.
A. Fire: The Interagency Serious Accident Investigation Guide, which is consistent with 485 DM 7 Appendix 2, describes the investigation process for wildland fire-related serious accidents. The Chief, National Fire Management Branch, National Wildlife Refuge System:
(1) Has the authority to investigate all wildland fire accidents within the scope of this chapter, and
(2) Must provide a copy of his/her delegation of authority for all wildland fire serious accident investigation teams to the AD-BMO.
B. Motor vehicles: Motor vehicle accidents in Service-owned, leased, rented or otherwise managed vehicles that involve injury or damage must be reported (consistent with Part 320 of the Service Manual). Each Service vehicle must have a DI-135 Accident Packet containing appropriate forms and guidance to follow in case of an accident (see 243 FW 1 and 320 FW 8).
(1) The employee or his/her supervisor must complete and submit the forms listed below to their Regional Property Manager. (These reports are in addition to the SMIS report.)
(a) The motor vehicle operator must complete a Motor Vehicle Accident Report, Standard Form (SF)-91.
(b) Passengers and any other involved individuals must complete a Statement of Witness form, SF-94, if applicable.
(c) The motor vehicle operator must complete a Board of Survey form, DI-103, describing damage to the vehicle and any other Service property.
(2) If the vehicle is GSA property, the supervisor must notify the GSA Fleet Manager and provide him/her with applicable required reports.
(3) If the vehicle is a rental car owned by a car rental agency, the motor vehicle operator must notify the car rental agency and complete any required reports in addition to completing a property damage accident report in SMIS.
(4) The motor vehicle operator must comply with all State and local reporting requirements.
(5) Employees must not make statements about who is responsible for the accident, except to their supervisor or to a Government investigating officer. Making statements to others could result in the Service being wrongly incriminated.
(1) An SMIS report is required for all boating accidents or incidents that are the result of Service operations.
(2) The Regional Safety Office must ensure the Regional Watercraft Safety Coordinator is informed of boating accidents. For non-serious accident/incident investigations, the Regional Safety Office and the Project Leader/supervisor must give the Regional Watercraft Safety Coordinator the opportunity to participate in investigations as a technical specialist or review the accident report and provide feedback to the Regional Safety Manager
(3) The Project Leader or supervisor must complete a U.S. Coast Guard Form 3865 whenever an accident involving boats we own or lease occurs in U.S. or territorial waters if it results in:
(a) A person dying,
(b) A person disappearing from the boat under circumstances that indicate death or injury,
(c) A person being injured and requiring medical treatment beyond first aid,
(d) Damage to boats and other property totaling $2,000 or more, or
(e) The boat is destroyed.
7.14 Is drug testing required after an accident or incident? Supervisors may initiate testing for an employee who has an on-the-job accident or whose unsafe acts pose a danger to other people if the supervisor gets the approval of the Director or his/her designee. Accident or unsafe behavior drug testing can look for any drug.
A. Within 45 calendar days of the accident, the serious accident investigation team or trained investigator must send the Factual Report and Management Report and any supporting documentation or materials to the Chief, Division of Safety and Health using a traceable method (e.g., overnight express service, certified mail, etc.). The Chief, Division of Safety and Health, reviews the reports to ensure that they are in the appropriate format and sends them to the AD-BMO.
B. For complex investigations and recommendations, the AD-BMO may convene an accident review board, as outlined in the Interagency Serious Accident Investigation Guide, to determine if the identified causes are supported by the facts, and if the recommendations related to the identified causes are realistic and attainable. Similar to the serious accident investigation team, the purpose of the board is accident prevention only. The AD-BMO appoints senior level managers from the affected programs and appropriate administrative programs to the board.
C. For less complex investigations, the Chief, Division of Safety and Health reviews the reports and makes recommendations to the AD-BMO.
D. Within 15 working days of receiving the two reports, the AD-BMO or accident review board must review and concur or not concur with the serious accident investigation team’s or trained investigator’s recommendations. The responsible Regional Director or Assistant Director must provide a corrective action plan to the AD-BMO or accident review board for review. The AD-BMO or the board may add corrective actions that are either Servicewide or Regional in scope.
E. Within 21 working days of receiving the reports, the AD-BMO must send the reports, the AD-BMO’s or accident review board’s comments on the reports, and the proposed corrective action plan to the Director. The Director may request that the Regional Director or Assistant Director, the serious accident investigation team or trained investigator, the AD-BMO, or the board provide a briefing.
F. The Director reviews the reports and proposed corrective action plan and sends the following to the Department’s DASHO:
(1) The reports,
(2) A statement of concurrence or non-concurrence with the serious accident investigation team’s or trained investigator’s opinions and recommendations,
(3) The final corrective action plan, and
(4) As an option, suggestions for Departmental or other agency actions.
G. The people who are assigned responsibility for corrective action plan items must provide the AD-BMO a status report at least every 90 days until the appropriate corrective actions are implemented. The AD-BMO must report this to the Department.
H. Once all corrective actions have been accomplished, the AD-BMO must notify the Department’s DASHO. At this point the case is closed.
I. You can find more information on the followup actions required for serious accident investigations in the Interagency Serious Accident Investigation Guide.
For information on the content of this chapter, contact the Division of Safety and Health. For information about this Web site, contact Krista Bibb in the Division of Policy, Performance, and Management Programs.